{"id":28336,"date":"2019-12-23T10:01:13","date_gmt":"2019-12-23T17:01:13","guid":{"rendered":"https:\/\/www.uchealth.org\/today\/?p=28336"},"modified":"2020-01-03T09:32:30","modified_gmt":"2020-01-03T16:32:30","slug":"alcohol-withdrawal-in-hospitals-care-tool","status":"publish","type":"post","link":"https:\/\/www.uchealth.org\/today\/alcohol-withdrawal-in-hospitals-care-tool\/","title":{"rendered":"How ICU patients with alcohol withdrawal are getting better, faster"},"content":{"rendered":"
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Tremors. Sweating. Severe anxiety. Confusion. Seizures.<\/p>\n

These symptoms of potentially-fatal alcohol withdrawal frequently torment a hospital\u2019s sickest patients: the ones in the ICU.<\/p>\n

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Kristen Boettcher, an ICU nurse at UCHealth Poudre Valley Hospital, received a 2019 National Magnet Nurse of the Year Award for her work helping patients experiencing alcohol withdrawal in hospitals. Photo by Robert Allen.<\/figcaption><\/figure>\n

\u201cIt\u2019s not what they intended, but their life caught up with them,\u201d UCHealth Poudre Valley Hospital<\/a> ICU nurse Kristen Boettcher said. \u201cThere\u2019s a lot of stigma that goes with alcohol and alcoholism. I just truly have a heart for those patients.\u201d<\/p>\n

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.<\/p>\n

About 40% of hospital patients<\/a> in the United States have an alcohol use disorder, and half of them may experience alcohol withdrawal symptoms.<\/p>\n

\u201cWe see these patients all the time,\u201d said Melanie Roberts, the critical care clinical nurse specialist who advised Boettcher on the project. \u201cThese patients use a lot of resources because they\u2019re complicated patients to care for. They\u2019re often violent, making it difficult to keep the patient safe and the staff safe.\u201d<\/p>\n

The program started as a pilot in spring 2018 in the ICUs at UCHealth Medical Center of the Rockies<\/a> and Poudre Valley Hospital, and it\u2019s now the standard in the critical care units at the two hospitals. It expanded to UCHealth Greeley Hospital<\/a> and work is underway to bring the program to other UCHealth hospitals and units.<\/p>\n

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<\/a>, in the empirical outcomes category.<\/p>\n

Fewer intubations, more precise care<\/strong><\/h3>\n

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.<\/p>\n

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.<\/p>\n

\u201cIt\u2019s just not great to have this population intubated,\u201d said Brandi Koepp, supervisor of pharmacy services at Medical Center of the Rockies. \u201cThey require a lot of drugs to keep them sedated, which makes it difficult to assess when the breathing tube can be removed.\u201d<\/p>\n

Boettcher\u2019s approach focused with more precision on alleviating the symptoms: Start with lorazepam (a sedative), and monitor the patient every 15 minutes, adjusting dosages \u2013 and possibly switching to phenobarbital (another type of sedative) \u2013 up to several hours until the symptoms are under control.<\/p>\n

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\u2019re only given when symptoms demand the need for medication.<\/p>\n

\u201cWe\u2019re actually a lot more aggressive with symptom management,\u201d Koepp said.<\/p>\n

Without heavy sedation and intubation up front, she said, the patients have better outcomes.<\/p>\n

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\u201cBefore, we would put them on a continuous infusion of medication,\u201d Boettcher said. \u201cPatients could potentially be getting medications when they didn\u2019t need it, and for longer periods of time.\u201d<\/p>\n

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.<\/p>\n

\u201cThe problem with humans is we\u2019re all different,\u201d Koepp said. \u201cI 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.\u201d<\/p>\n

‘The right tool for the patient’<\/h3>\n

A system called Clinical Institute Withdrawal Assessment for Alcohol (CIWA) has traditionally been used to assess the severity of a patient\u2019s withdrawal symptoms. But Boettcher, through her research, found a different assessment tool, the Alcohol Withdrawal Clinical Assessment (AWCA)<\/a> scale developed by Dr. Colin Feeney<\/a> in Oakland, California, that led to more consistent scoring.<\/p>\n

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.<\/p>\n

The program is now in everyday use at the three hospitals.<\/p>\n

\u201cIn each of the ICUs, at any given point in time, we have at least one person on this protocol,\u201d Koepp said.<\/p>\n

The program\u2019s results, for ICU patients on alcohol withdrawal protocol:<\/p>\n