Clinical Institute Withdrawal Assessment (CIWA) Based Protocols for Alcohol Withdrawal: A Clinical Decision Support Tool to Address Common Misunderstandings and Avoid Misuse

Abstract

Rationale Alcohol use disorder is more common in hospitalized patients than the general population and alcohol withdrawal syndrome may precipitate or complicate the hospitalization. The Clinical Institute Withdrawal Assessment (CIWA-Ar) was developed in the 1980s to measure severity of alcohol withdrawal symptoms. Utilizing the CIWA-Ar tool, benzodiazepines were only delivered in a scaled "symptom-triggered" fashion without traditional benzodiazepine prophylaxis. This method of treating alcohol withdrawal was initially shown to be beneficial and safe in detoxification units. However, CIWA-Ar based symptom-triggered therapy protocols have migrated into the general hospital setting and are now being used for patients with numerous comorbidities and active medical conditions. We previously demonstrated that providers have a knowledge deficit regarding the limitations of CIWA-Ar, resulting in inappropriate patient selection and placing patients at risk for delays in diagnosis and unnecessary sedation. We hypothesized that the creation of a clinical decision support tool at the point of order entry would decrease the number of inappropriate withdrawal protocol orders without increasing the likelihood of intensive care admission for severe alcohol withdrawal syndrome. Methods A clinical decision support tool was created within the electronic order entry system to guide the provider on appropriate use of the CIWA-Ar protocol. Using a cascade of four yes/no questions, patients were categorized as being appropriate for the traditional CIWA-Ar based protocol or an alterative "CIWA scoring only" option. The CIWA scoring only provides serial CIWA assessments with physician notification for elevated scores rather than benzodiazepine administration. Following deployment of the tool and a one-year wash-in period, the electronic medical record was queried for inpatient hospital encounters associated with a CIWA-Ar order between April 24, 2019, and October 24, 2019. These cases were reviewed to determine frequency of CIWA-Ar scoring only orders, CIWA-Ar protocol orders, and conversion between CIWA-Ar scoring and protocol. Results A total of 1387 unique CIWA-Ar orders placed during inpatient encounters were identified. Of these, 618 were CIWA-Ar scoring without escalation to CIWA-Ar protocol and 270 were CIWA-Ar protocol without preceding CIWA-Ar scoring. An additional 143 CIWA-Ar scoring orders were escalated to CIWA-Ar protocol. An additional 49 CIWA-Ar protocol orders were de-escalated to CIWA-Ar scoring only. There was insufficient data to determine if rates of ICU transfer were significantly different compared to historical rates. Conclusion Development of a clinical decision support tool to guide appropriate CIWA-Ar ordering decreased potential benzodiazepine exposure by greater than 50% compared to a historical cohort.