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The Modified Richmond Agitation-Sedation Scale-Alcohol Withdrawal and the revised Clinical Institute Withdrawal Assessment for Alcohol scale

Nov 01, 2017, By: Jane de Lemos, Pharm.D., M.Sc. (Epid) , Renée Liu, R.Ph., B.Sc. (Pharm) , June Cho, B.Sc. (Pharm) , Catherine Marshall, BScN, RN , Fiona Francis, BScN, RN , Silvia Nobrega, BScN, RN, MSN , Richard Dillon, BScN, RN , Lawrence Hoeschen, MD, FRCPC

Abstract

Objective: This study was designed to evaluate nurses’ perceptions of the Modified Richmond Agitation-Sedation Scale-Alcohol Withdrawal (mRASS-AW) and the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar) as tools to manage patients with alcohol withdrawal.

Methods: We conducted a five-question online survey of nurses who (1) had previously used CIWA-Ar and (2) had completed an educational module on mRASS-AW and/or had used mRASS-AW with patients with alcohol withdrawal. We assessed the usability (ease and speed of use) of mRASS-AW and its face validity as a tool to measure severity of alcohol withdrawal (we asked which tool is more accurate and which one provides a better way to decide if a benzodiazepine dose should be given). Data were analyzed using the chi-square statistic adjusted for multiple comparisons, with p < 0.01 considered significant.

Results: In this study with 120 nurses, 42-54 per cent of respondents preferred or strongly preferred mRASS-AW, whereas 11-13 per cent preferred or strongly preferred CIWA-Ar (p < 0.001 for all comparisons).

Conclusion: Nurses perceived mRASS-AW to provide a more accurate assessment of the severity of alcohol withdrawal and to be a better way to decide whether a benzodiazepine should be given. They perceived mRASS-AW to be easier and quicker to use than CIWA-Ar, and they preferred it overall as an assessment tool.

In hospital, nurses often use symptom-triggered protocols to manage the care of patients experiencing alcohol withdrawal symptoms (Maldonado, Nguyen, Schader, & Brooks, 2012). These protocols typically include an assessment tool such as the widely used revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar) to help the nurse decide whether a benzodiazepine dose is indicated (Sullivan, Sykora, Schneiderman, Naranjo, & Sellers, 1989). CIWA-Ar contains 10 symptom domains derived from the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders that are intended to capture the range of symptoms patients can exhibit when they are experiencing alcohol withdrawal. We used to use CIWA-Ar at our institution to assess the severity of alcohol withdrawal and to guide symptom-triggered benzodiazepine dosing, but this tool has three key limitations. First, we believe that four of the 10 symptom domains (tremor, sweating, nausea or vomiting, fullness in head or headache) are not necessarily alleviated by benzodiazepine treatment in a time- or dose-dependent way. Second, if patients are agitated or experiencing delirium, it is usually not possible to ask them questions, which means scores cannot be produced for several of the domains, such as anxiety, nausea and fullness in head. Third, CIWA-Ar has not been validated in settings such as the emergency department and is regarded as burdensome to use in acute care contexts (Stehman & Mycyk, 2013; Williams, Lewis, & McBride, 2001).

Because of these concerns, we developed and introduced a new protocol at our hospital for evaluating and treating patients with alcohol withdrawal. This protocol uses the Richmond Agitation-Sedation Scale (RASS) to assess both the severity of agitation caused by alcohol withdrawal and the level of sedation potentially caused by treatment (Sessler et al., 2002). RASS is a valid and reliable tool that is widely used in critical care settings to measure the level of agitation and sedation of mechanically ventilated patients. Its use in managing patients with alcohol withdrawal symptoms has not been previously reported, although some authors have advocated using it when such patients are difficult to assess (Hoffman & Weinhouse, 2016). We made some minor changes to the text of RASS to reflect the fact we were using it in patients who were not mechanically ventilated (see figure). We subsequently refer to our revision of this scale as the Modified RASS-Alcohol Withdrawal (mRASS-AW).

With our new protocol, nurses base their treatment decisions mainly on the patient’s mRASS-AW score, but the protocol also directs them to assess the patient for three other elements of alcohol withdrawal: the presence of delirium (assessed using the Confusion Assessment Method), hallucinations (tactile, visual or auditory) and abnormal vital signs (heart rate, blood pressure, respiratory rate) (American Psychiatric Association, 2013; Inouye et al., 1990). Although RASS has not been previously reported to be used to assess patients with alcohol withdrawal, Hoffman and Weinhouse (2016) suggested that it be used for this purpose in mechanically ventilated patients.

Before the introduction of the protocol, about 220 nurses at our hospital completed an online educational module. Adoption of the protocol throughout our institution was 100 per cent. The aim of our study was to evaluate the perceptions of nurses who (1) had used CIWA-Ar and (2) had completed the online education module on mRASS-AW and/or used it in practice. The questions were designed to assess the usability and face validity of mRASS-AW as a tool to measure the severity of alcohol withdrawal.

The objectives were to compare nurses’ perceptions of mRASS-AW and CIWA-Ar by surveying those who had prior experience using CIWA-Ar. The questions were designed to assess the usability (ease and speed of use) and face validity of mRASS-AW as a tool to measure severity of alcohol withdrawal (e.g., Which tool is more accurate? Which tool is a better way to decide if a benzodiazepine dose should be given?).

Methods

Setting. This study was conducted at Richmond Hospital, a 190-bed community hospital with approximately 9,100 admissions and approximately 46,000 emergency department visits per year. The total bedside nursing staffing pool is about 600. At the time of the study, some 220 nurses had completed an educational module outlining the use of mRASS-AW as a tool for measuring alcohol withdrawal, and the hospital’s protocol employing mRASS-AW had been in use for 15 months. Patients are generally treated for alcohol withdrawal in the emergency department or an inpatient medical or surgical unit (with the exception of the intensive care, palliative care and maternity units).

Design. Nurses employed at the hospital completed an online survey at work. Institutional and university ethics board approval was obtained.

Exclusion criteria. Nurses working in the intensive care unit, palliative care unit, maternity unit and special care nursery were excluded (these nurses were not sent the survey).

Sample size. We estimated that 200 staff nurses completed the online educational module, given that some of the nurses who completed the module were engaged in temporary student placements. To obtain a survey response rate of 60 per cent among these 200 staff nurses, we therefore calculated an a priori target sample size of approximately 120 respondents.

Nursing survey. The intent of the survey was to compare perceptions of mRASS-AW and CIWA-Ar among nursing staff. The five questions in the survey addressed (1) ease of use, (2) speed of use, (3) which tool the respondent believed to provide a more accurate assessment of the severity of alcohol withdrawal, (4) which tool the respondent believed to offer a better way to decide whether a dose of benzodiazepine should be given, and (5) which tool the respondent preferred overall. The third and fourth questions addressed the face validity of mRASS-AW for use with patients experiencing alcohol withdrawal.

Each question was associated with a seven-point Likert scale, with a neutral option flanked by three options favouring CIWA-Ar on one side and three options favouring mRASS-AW on the other. The survey was uploaded to SurveyMonkey.com.

Nurse recruitment. A letter of initial contact was e-mailed by the nurse educators to all nurses (not only those who had completed the online module) working on all patient units in the hospital, except those units listed in the exclusion criteria. The letter contained a link to the online survey and included a statement explaining which nurses were eligible to proceed with the survey, so that nurses could determine their own eligibility. The survey was completed anonymously. Nurses were initially allowed four weeks to complete the survey. To improve the participation rate, two followup reminders were sent out: one at two weeks and one at four weeks after the letter of initial contact was e-mailed. Typically, nurse educators also reminded nurses to complete the survey at daily nursing huddles. Nurses were encouraged to inform their nurse educator when they completed the survey, for the purpose of tracking patient care area representation.

Analysis. The proportions of respondents favouring mRASS-AW over CIWA-Ar were compared with the one-sample chi-square statistic for independent observations with one degree of freedom. For this analysis, the two extreme responses for each scale were combined and the Bonferroni correction was used to account for the five comparisons for each question. Therefore, a p value less than 0.01 was required for significance.

Results

One hundred and twenty nurses responded to the survey, but two of them skipped questions. Therefore, the number of responses for each question ranged from 118 to 120. The respondents broadly represented the target nursing population, with at least 45 of the 120 (37.5%) working in the emergency department and the remaining ones working in psychiatry, medical and surgical patient care areas.

Question 1: Which assessment tool do you find easier to use, CIWA-Ar or RASS?
One hundred and nineteen nurses answered this question. Sixty-five of them (54.6%) indicated that mRASS-AW is easier or much easier to use, whereas 14 (11.8%) indicated that CIWA-Ar is easier or much easier to use (chi-square 53.9, p < 0.001). Seventeen respondents slightly preferred mRASS-AW (14.3%), and eight slightly preferred CIWA-Ar (6.7%). Overall, 66.4% of the nurses who answered this question favoured mRASS-AW and 18.5% favoured CIWA-Ar. The remaining 15 (12.6%) respondents had a neutral opinion.

Question 2: Which assessment tool takes less time to use, CIWA-Ar or RASS?
One hundred and nineteen nurses answered this question. Sixty-one of them (51.3%) indicated that mRASS-AW takes less time or a lot less time to use; 13 (10.9%) indicated CIWA-Ar takes less time or a lot less time to use (chi-square 45.3, p < 0.001). Twenty-seven respondents slightly preferred mRASS-AW (22.7%), and three respondents slightly preferred CIWA-Ar (2.5%). Overall, 74.0% of the nurses who answered this question favoured mRASS-AW and 13.4% favoured CIWA-Ar. The remaining 15 (12.6%) respondents had a neutral opinion.

Question 3: Which assessment tool do you think is a more accurate assessment of the severity of alcohol withdrawal?
All 120 nurses answered this question. Fifty-one of them (42.5%) indicated that mRASS-AW is more accurate or much more accurate, whereas 16 (13.3%) indicated that CIWA-Ar is more accurate or much more accurate (chi-square 12.1, p < 0.001). Twenty (16.7%) respondents slightly preferred mRASS-AW and 11 (9.2%) slightly preferred CIWA-Ar. Overall 59.2% of the nurses who answered this question favoured mRASS-AW and 22.5% favoured CIWA-Ar. The remaining 22 (18.3%) respondents had a neutral opinion.

Question 4: Which tool do you think is a better way to decide whether a dose of benzodiazepine should be given?
One hundred and nineteen nurses answered this question. Fifty-five of them (46.2%) indicated that mRASS-AW is either better or a lot better, whereas 16 (13.4%) indicated CIWA-Ar is better or a lot better (chi-square 29.9, p < 0.001). Twenty-four (20.2%) respondents slightly preferred mRASS-AW, and six (5.0%) slightly preferred CIWA-Ar. Overall, 66.4% of the nurses who answered this question favoured mRASS-AW and 18.5% favoured CIWA-Ar. The remaining 18 (15.1%) respondents had a neutral opinion.

Question 5: Overall, which assessment tool do you prefer?
One hundred and eighteen nurses answered this question. Fifty-nine of them (50.0%) preferred or strongly preferred mRASS-AW, whereas 15 (12.7%) preferred or strongly preferred CIWA-Ar (chi-square 27.1, p < 0.001). Twenty-one (17.8%) respondents mildly preferred mRASS-AW and 10 (8.5%) mildly preferred CIWA-Ar. Overall, 67.8% of the nurses who answered this question favoured mRASS-AW and 21.2% favoured CIWA-Ar. The remaining 13 (11.0%) respondents expressed no preference.

Discussion

This is the first study to compare CIWA-Ar and mRASS-AW in terms of user experience and preference. The cohort of nurses we surveyed consistently favoured mRASS-AW over CIWA-Ar as a tool to measure the severity of alcohol withdrawal across each of the five questions we asked; all comparisons exhibited a significant difference (p < 0.001).

Typically, the decision to administer a benzodiazepine is based on a nursing assessment using symptom-triggered protocols (Maldonado et al., 2012). The CIWA-Ar is commonly used to assess alcohol withdrawal severity and, in particular, to determine whether a benzodiazepine dose should be given. For example, a combined CIWA-Ar score of more than 10 would indicate that the nurse should administer a dose. Understanding the perceptions of the nursing staff as they relate to ease and speed of use and the usefulness of the tool for decision-making may be a key determinant of an institution’s decision about which tool to use, if the psychometric properties of the tools are considered similar. The RASS tool has not been studied for use in the management of alcohol withdrawal. However, the studies that have validated the use of CIWA-Ar for this purpose are sparse and are limited to experienced users in research settings and, importantly, none of them have been conducted in the emergency department (Stehman & Mycyk, 2013; Williams et al., 2001). In the absence of robust data making a strong case for using CIWA-Ar, and given the attractiveness of RASS for measuring level of agitation and depth of sedation in non-communicative patients (adult patients who are mechanically ventilated), we considered RASS to be a feasible tool for assessing the severity of alcohol withdrawal (by measuring level of agitation) and the consequences of alcohol withdrawal treatment (by measuring depth of sedation).

In this study, we present the first findings that mRASS-AW is preferred over CIWA-Ar by actual users. These data should prompt further research into the reliability and validity of mRASS-AW for assessing the severity of alcohol withdrawal. Moreover, our respondents’ answers to the questions about which tool they thought provided a more accurate assessment of alcohol withdrawal and which tool was a better way to decide whether a benzodiazepine should be given have provided the first evidence of face validity for mRASS-AW as a tool to measure the severity of alcohol withdrawal. Asking people experienced in using CIWA-Ar these questions is a novel way of testing the face validity of mRASS-AW. Further work can be done to assess reliability and construct validity.

Our rationale for using RASS was based on three key points. First, we believe that at least four of the 10 domains assessed with CIWA-Ar are perhaps not very responsive to benzodiazepine treatment (fullness in head or headache, nausea or vomiting, sweating, tremor), but the combined CIWA-Ar score is used to indicate whether the patient should be given a benzodiazepine and if so, how frequently. Instead, we felt that it makes more physiologic sense to use a scale that focuses on psychomotor agitation (which clearly responds to benzodiazepine treatment) and sedation (a side effect of treatment). Second, the CIWA-Ar score requires the clinician to ask the patient questions to elicit information for a number of the domains, such as anxiety. Often, patients experiencing alcohol withdrawal are not able to respond or may be manipulative because they are seeking drug treatment. Finally, CIWA-Ar has never been validated as a clinical tool in a busy emergency department; it is widely regarded by clinicians as burdensome and not easy to use (Stehman & Mycyk, 2013). In many instances, it is just not possible to ask an agitated patient the questions contained in CIWA-Ar. Instead, nurses at the bedside are left to use their clinical judgment or perhaps document a score that permits them to give a treatment dose. In fact, it is recommended that patients with delirium tremens be treated on the basis of their level of agitation (Mayo-Smith et al., 2004). RASS is an observational tool that was designed to be used with critically ill patients who are not able to communicate verbally. We suggest that use of this tool in the setting of alcohol withdrawal to measure psychomotor agitation and sedation is a valid and logical extension of its use in critical care settings.

It is important to note that our alcohol withdrawal protocol integrates the assessment of delirium and hallucinations and consideration of vital signs (heart rate, blood pressure, respiratory rate). We felt it was important that these features (not captured by RASS) be assessed and documented as present or absent so that this information would be highly visible to the physician and other care providers rather than lost in a summated score. Depending on how CIWA-Ar is used and the resulting score is documented, the fact that patients are experiencing hallucinations or delirium (referred to as clouding of sensorium in CIWA-Ar) may be masked. We felt that knowing whether the patient is experiencing hallucinations facilitates better nursing care and will enable the care team to reassure the patient and provide appropriate treatment, possibly with low-dose antipsychotics. Similarly, it is important to document development of new delirium so that the physician can consider whether it represents progression to delirium tremens or instead represents delirium caused by benzodiazepine treatment or other medical conditions. Identifying the presence of abnormal vital signs or unstable hemodynamics will help trigger assessment for the possibility of another medical condition, such as sepsis. We therefore felt that mRASS-AW had stronger content and face validity for use as a tool for assessing agitation in patients with alcohol withdrawal and the expected side effects (e.g., sedation) of alcohol withdrawal treatment. The mRASS-AW combined with an assessment of presence of delirium and hallucinations and consideration of elevated vital signs formed the basis of our revised protocol.

Conclusion

In this survey of 120 nurses, mRASS-AW was perceived as providing a more accurate assessment of the severity of alcohol withdrawal and as offering a better way to decide whether a benzodiazepine should be given. The respondents also perceived that mRASS-AW was easier and quicker to use and, overall, they preferred it over CIWA-Ar as an assessment tool for the management of alcohol withdrawal. This is the first report comparing user experiences with mRASS-AW and CIWA-Ar as tools to evaluate patients with alcohol withdrawal. The respondents’ strong preference for mRASS-AW in the domains tested suggests that further research to demonstrate the reliability of RASS for this purpose could be useful. We have provided the first evidence of user preference for RASS and its face validity as a tool for assessing alcohol withdrawal severity. Reducing nursing burden by avoiding the use of CIWA-Ar would be desirable in the acute care setting, as this would allow nursing time to be released for other direct nursing care responsibilities.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association Publishing.

Hoffman, R. S., & Weinhouse, G. L. (2016, May). Management of moderate and severe alcohol withdrawal syndromes. In S. J. Trab (Ed.), UptoDate.

Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: The confusion assessment method: A new method for detection of delirium. Annals of Internal Medicine, 113, 941-948. doi:10.7326/0003-4819-113-12-941M

Maldonado, J. R., Nguyen, L. H., Schader, E. M., & Brooks, J. O. (2012). Benzodiazepine loading versus symptom-triggered treatment of alcohol withdrawal: A prospective, randomized clinical trial. General Hospital Psychiatry, 34(6), 611-617.

Mayo-Smith, M. F., Beecher, L. H., Fischer, T. L., Gorelick, D. A., Guillaume, J. L., Hill, A.,…Melbourne, J. (2004). Management of alcohol withdrawal delirium. An evidence-based practice guideline. Archives of Internal Medicine, 164(13), 1405-1412.

Sessler, C. N., Gosnell, M. S., Grap, M. J., Brophy, G. M., O’Neal, P. V., Keane, K. A.,…Elswick, R. K. (2002). The Richmond Agitation-Sedation Scale: Validity and reliability in adult intensive care unit patients. American Journal of Respiratory and Critical Care Medicine, 166(10), 1338-1344.

Stehman, C. R., & Mycyk, M. B. (2013). A rational approach to the treatment of alcohol withdrawal in the ED. American Journal of Emergency Medicine, 31(4), 734-742.

Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A., & Sellers, E. M. (1989). Assessment of alcohol withdrawal: The revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). British Journal of Addiction, 84(11), 1353-1357.

Williams, D., Lewis J., & McBride, A. (2001). A comparison of rating scales for the alcohol-withdrawal syndrome. Alcohol and Alcoholism, 36(2), 104-108.

*Italicized text reflects modifications made to the original RASS scale

Adapted with permission of the American Thoracic Society. Copyright © 2017 American Thoracic Society.

C. N. Sessler, M. S. Gosnell, M. J. Grap, G. M. Brophy, P. V. O’Neal, K. A. Kean,…R. K. Elswick/2002/The Richmond Agitation-Sedation Scale: Validity and Reliability in Adult Intensive Care Unit Patients/American Journal of Respiratory and Critical Care Medicine/Volume 166/Pages 1338-1344.

The American Journal of Respiratory and Critical Care Medicine is an official journal of the American Thoracic Society.

Jane de Lemos, Pharm.D., M.Sc. (Epid), is a clinical pharmacy specialist, emergency department, Richmond Hospital, in Richmond, B.C.

Renée Liu, R.Ph., B.Sc. (Pharm), is a community pharmacist in Vancouver.

June Cho, B.Sc. (Pharm), is a pharmacist, Richmond Hospital.

Catherine Marshall, BScN, RN, is a clinical nurse educator, Richmond Hospital.

Fiona Francis, BScN, RN, is a clinical nurse educator, Richmond Hospital.

Silvia Nobrega, BScN, RN, MSN, is a clinical nurse educator, Vancouver General Hospital.

Richard Dillon, BScN, RN, is director, client relations and risk management, Richmond Hospital.

Lawrence Hoeschen, MD, FRCPC, is the former director of the drug and alcohol resource team, Richmond Hospital.