Appropriateness, feasibility, and adoption of a nurse-driven CIWA-Ar symptom-triggered protocol for alcohol withdrawal syndrome in New York City public hospitals.

BACKGROUND

Effective management of alcohol withdrawal syndrome during hospitalization is paramount to patient safety and quality care. NYC Health + Hospitals initiated a quality improvement project to pilot an electronic health record (EHR) integrated, nurse-driven CIWA-Ar symptom-triggered protocol, including recommendations for medications for alcohol use disorder (MAUD), in medical and surgical units at 3 public hospitals.

OBJECTIVE

To describe implementation processes and to report related implementation outcomes (appropriateness, feasibility, and adoption) of the updated CIWA-Ar protocol in a safety net hospital setting.

METHODS

NYC Health + Hospitals implemented a standardized CIWA-Ar symptom-triggered, nurse-driven EHR protocol on March 15, 2022. The protocol included order sets, practice advisories, task lists, and reminders for assessments and orders. We measured nursing perspectives on feasibility and appropriateness at 6 months via a survey. We measured provider adoption as the proportion of admissions with a CIWA-Ar protocol ordered among admissions that triggered a recommendation, and MAUD use as the proportion of admissions with a MAUD order during hospitalization among all patients with a protocol ordered.

RESULTS

During 13 months of implementation, providers ordered a CIWA-Ar protocol for 59.1% (n = 887/1500) of recommended admissions. Adoption increased over time from 46.0% in month 1 to 63.2%-78.9% in months 11 to 13 (P = .0004). Most nurses agreed that the protocol was suitable, fitting for medicine, easy to use, and improved clinical care for patients experiencing alcohol withdrawal syndrome. MAUD was ordered in 19.2% of admissions, however, did not change over the course of implementation (P = .249).

CONCLUSIONS

The CIWA-Ar protocol was appropriate, feasible, and adopted at NYC public hospitals. Quality improvements to ensure protocol fidelity with benzodiazepine dosing and MAUD prescribing are needed.