Tremors. Sweating. Severe anxiety. Confusion. Seizures.

These symptoms of potentially-fatal alcohol withdrawal frequently torment a hospital’s sickest patients: the ones in the ICU.

“It’s not what they intended, but their life caught up with them,” UCHealth Poudre Valley Hospital ICU nurse Kristen Boettcher said. “There’s a lot of stigma that goes with alcohol and alcoholism. I just truly have a heart for those patients.”

She recently developed a program to better care for them. It succeeded: Lives were saved, intubations decreased, and patients were able to transfer sooner out of the ICU.

About 40% of hospital patients in the United States have an alcohol use disorder, and half of them may experience alcohol withdrawal symptoms.

“We see these patients all the time,” said Melanie Roberts, the critical care clinical nurse specialist who advised Boettcher on the project. “These patients use a lot of resources because they’re complicated patients to care for. They’re often violent, making it difficult to keep the patient safe and the staff safe.”

The program started as a pilot in spring 2018 in the ICUs at UCHealth Medical Center of the Rockies and Poudre Valley Hospital, and it’s now the standard in the critical care units at the two hospitals. It expanded to UCHealth Greeley Hospital and work is underway to bring the program to other UCHealth hospitals and units.

For her work, Boettcher received one of the highest honors a nurse can receive during their career: the 2019 National Magnet Nurse of the Year Award, in the empirical outcomes category.

Fewer intubations, more precise care

For severe alcohol-withdrawal cases, hospitals often respond with heavy sedation, sometimes to the extent that the patient has to breathe through a tube on a ventilator.

This takes care of the symptoms and prevents patients from causing harm to themselves or others. But intubation introduces risks for additional potential complications, such as pneumonia, delirium or damage to vocal cords, which can last long after the patient leaves the hospital.

“It’s just not great to have this population intubated,” said Brandi Koepp, supervisor of pharmacy services at Medical Center of the Rockies. “They require a lot of drugs to keep them sedated, which makes it difficult to assess when the breathing tube can be removed.”

Boettcher’s approach focused with more precision on alleviating the symptoms: Start with lorazepam (a sedative), and monitor the patient every 15 minutes, adjusting dosages – and possibly switching to phenobarbital (another type of sedative) – up to several hours until the symptoms are under control.

The process requires more work for nurses. In many cases, over the course of treatment, sedatives are now used in higher amounts than before. But they’re only given when symptoms demand the need for medication.

“We’re actually a lot more aggressive with symptom management,” Koepp said.

Without heavy sedation and intubation up front, she said, the patients have better outcomes.

“Before, we would put them on a continuous infusion of medication,” Boettcher said. “Patients could potentially be getting medications when they didn’t need it, and for longer periods of time.”

She said the previous approach involved subjective questions and treatment processes varied based on which physician was present. Further, the effects of alcohol cessation vary widely.

“The problem with humans is we’re all different,” Koepp said. “I could drink a couple glasses of wine and you could have a case of beer every night, and I might have a (more severe) alcohol withdrawal experience than you would.”

‘The right tool for the patient’

A system called Clinical Institute Withdrawal Assessment for Alcohol (CIWA) has traditionally been used to assess the severity of a patient’s withdrawal symptoms. But Boettcher, through her research, found a different assessment tool, the Alcohol Withdrawal Clinical Assessment (AWCA) scale developed by Dr. Colin Feeney in Oakland, California, that led to more consistent scoring.

Boettcher next developed a decision tree to help nurses understand the use of the scale to determine medication dosing until effectiveness is reached. She collaborated on the project with an interdisciplinary team that included physicians, pharmacists and a clinical nurse specialist.

The program is now in everyday use at the three hospitals.

“In each of the ICUs, at any given point in time, we have at least one person on this protocol,” Koepp said.

The program’s results, for ICU patients on alcohol withdrawal protocol:

• Rate of intubation dropped from 19% to 8%.
• Percent of deaths decreased from 9.46% to 5.86%.
• Patients transfer out of ICU, on average, 19 hours earlier, leading to substantial cost savings.

“That’s what we do as nurses: We want to do our best, and we want to take care of people and to help this population get through withdrawal a little bit faster,” Boettcher said. “To get out of the ICU and be able to get back to their families is awesome.”

Roberts, who previously received the National Magnet Nurse of the Year Award in empirical outcomes for a project to help save patients in cardiac arrest, said work is underway to further extend Boettcher’s program to intermediate units and to fully integrate it with electronic health records.

“We hope to have it increase throughout the system, because we believe it is the right tool for the patient,” Roberts said.

Boettcher has 15 years of nursing experience, all with Poudre Valley Hospital. In part through this evidence-based project, she was promoted to a Level IV nurse under UCHealth’s UEXCEL Nursing Practice and Credentialing Model. She’s the first nurse in the UCHealth Northern Colorado Region to receive that distinction and one of only about 21 Level IV nurses in the system, which includes about 7,800 registered nurses.

“Kristen’s work has had a profound impact on patients in the ICU,” said Lydia Baldwin, ICU nurse manager at Poudre Valley Hospital. “I am so proud of the work that Kristen has done. I admire her perseverance, her kindness and her humble approach to improving lives for patients.”