Roseburg Conducts Clinical Institute Withdrawal Assessment - VHA SimLEARN
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Roseburg Conducts Clinical Institute Withdrawal Assessment

By Amanda Morrow BSN, RN
Education Consultant
Roseburg VA Health Care System

ROSEBURG, Ore. – Staff in the Roseburg VA Health Care System conducted a Clinical Institute Withdrawal Assessment (CIWA) and related simulation training. CIWA is a ten-item scale used in the assessment and management of alcohol withdrawal. Each item on the scale is scored independently, and the summation of the scores yields an aggregate value that correlates to the severity of alcohol withdrawal.

During the assessment, discrepancies were identified in the nursing documentation of CIWA scores that could potentially affect the patient’s level of care. It was identified that nursing staff tended to score patients differently depending on the area where they worked and even the shift they worked. The Nurse Manager from the Medical Telemetry Unit (MTU) worked with the education department staff to develop a survey to both elicit interest and promote learning in the topic of CIWA. Staff was asked to complete the survey, review the station CIWA policy and documentation, then attend a CIWA simulation offered in the sim lab.

The six survey questions were issued:
1. What are the appropriate medications for providers to consider for Alcohol Withdrawal? Choose the correct answer or answers. A. Chlordiazeposide B. Lorazepam C. Diazapam

One skipped the question, five staff chose Lorazepam, but ten staff chose chlordiazeposide and lorazepam.

2. Would a patient’s age affect the choice of medication? Yes or no

One skipped the question, while 15 answered yes

3. Would you be concerned about a patient with a score of 29? 16 answered yes.

4. At what CIWA score would you hold medication and reassess in 8 hours or if patient has a change in condition?

Choices were: less than 10, less than 15, less than 20. 100 percent chose less than 10-point scores.

5. If your detoxing patient describes and demonstrates arm scratching, itching, burning, and numbness how would you rate the tactile disturbances? Out of 0-7 possible, 13 chose 5 points and 3 chose 3 points toward the total score.

6. All patients detoxing on the inpatient setting are expected to be on seizure precautions. True/false

Ten staff chose true but only 6 chose false.

This small group of questions helped staff know where to focus and develop objectives: Introduce more simulations to validate learning; increase awareness of area and shift differences in scoring tendencies; and reduce the risk to the Veterans presenting with possible detox.

With a minimum of three nurses each from MTU, the emergency room and the acute psychiatric area, simulation was held several times per week for two weeks. It was important to include all acute care areas and all tours. The simulation consisted of a standardized patient who was disheveled, demonstrating multiple symptoms and signs of alcohol withdrawal. Staff were prebriefed and given the CIWA scoring tool. Each person in a group was given approximately five minutes to complete their assessment.

As a group, each simulation was debriefed and scores reviewed and compared. By debriefing and discussing the differences in the scores, the staff came away with a better understanding of the scores and the risk to patients if not done properly and with consistency. Staff members were encouraged to talk to their coworkers. This was especially true if there was a two or more-point score difference. It could mean an unnecessary transfer, or it could mean putting the patient at risk of not being in an area equipped to handle the acute withdrawal emergencies.

Data was correlated from the CIWA scores done by each group where a difference of up to 10 points was demonstrated. This pointed out and verified the potential for inappropriate levels of care.

To follow up, the survey questions were resent after two months to participants for reinforcement, and a follow up simulation is being scheduled.