NRS 441v 10R: Constructing the Written Evidenced-Based Proposal

SIGNIFICANCE OF EARLY ASSESSMENT AND INTERVENTION ON THE
SEVERITY OF ALCOHOL WITHDRAWAL
By (Student Name)
Grand Canyon University
NRS-441V: Professional Capstone Project
Exemplar of Evidence-Based Practice
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Date
DECLARATION
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Table of Contents TOC \o "1-3" \h \z \u DECLARATION PAGEREF _Toc467157256 \h 2Abstract PAGEREF _Toc467157257 \h 4Problem Statement PAGEREF _Toc467157258 \h 5Solution Description PAGEREF _Toc467157259 \h 5Implementation Plan PAGEREF _Toc467157260 \h 7Incorporated Theory PAGEREF _Toc467157261 \h 7Evaluation Plan PAGEREF _Toc467157262 \h 12Dissemination Plan PAGEREF _Toc467157263 \h 14Review of Literature PAGEREF _Toc467157264 \h 16Conclusion PAGEREF _Toc467157265 \h 22References PAGEREF _Toc467157266 \h 24APPENDIXES PAGEREF _Toc467157267 \h 26
Abstract
Based on documented studies, the prevalence of alcohol dependence in medical settings indicates that as many as 1 in 5 patients may require treatment for alcohol withdrawal (AW) while hospitalized for a concurrent illness. Research has indicated a definitive problem in recognizing and treating those patients at risk for AW. Symptom-triggered treatment, based on the use of appropriate assessment tools and treatment protocols, has been shown to be safe, and it is associated with a decrease in the quantity of medication required and the duration of treatment. Implementing standardized screening tools and initiating treatment based on established protocols, can prevent disease progression and an increased complication rate. These interventions can potentially decrease length of stay and health care costs.
This project aims to demonstrate a potential strategy to use in timely treatment of alcohol withdrawal patients, with the aim of reducing hospital stay and costs. As noted by Lussier-Cushing et al. (2007), a quarter of AW patients are alcohol-dependent, making their hospital stay longer. Establishing an assessment method to ascertain the onset of symptoms development in AW patients is imperative in reducing mortality and morbidity. Therefore, proper detection and management procedures for the AW patients is essential. In this study, data from the patients shall be useful in determining the prevalence of the patients to the conditions, and disseminating the data among group members to aid in spreading awareness concerning the management of AW. The proposal relays the implementation, evaluation and dissemination plans required during development of the appropriate nursing care method for assessing and assisting AW patients in the health continuum.
Key words: alcohol withdrawal, assessment, CAGE, CIWA-Ar, symptom-triggered, protocol.
Significance of Early Assessment and Intervention on the
Severity of Alcohol Withdrawal
Problem Statement
Patients admitted to the acute care setting with a secondary diagnosis of alcohol abuse carry a significant risk of alcohol withdrawal (AW) when there is a failure to recognize and treat their alcoholism. Early recognition of AW is essential to early intervention, which, in turn, has the potential to prevent or decrease serious complications associated with AW.
Solution Description
Alcohol withdrawal has been described as a syndrome that affects those people accustomed to regular alcohol intake, who suddenly stop drinking and subsequently develop those clinical manifestations associated with AW (Saitz, 1998). An estimated 15-20% of hospitalized patients are dependent on alcohol, putting them at risk for prolonged or complicated hospital stays (Lussier-Cushing, Repper-DeLisi, Mitchell, Lakatas, Mahmoud, & Lipkis-Orlando, 2007).
Dependence on alcohol usually remains undetected in the hospitalized patient until withdrawal signs appear, secondary to cessation of their alcohol intake. Nursing staff must recognize the warning signs and symptoms of AW. Without an established assessment process, it is difficult to predict withdrawal symptoms or assess risk factors associated with an increased severity of withdrawal symptoms and subsequent impact on the patient’s treatment plan. An established assessment process/protocol has the potential to reduce patient morbidity and mortality as well as health care costs.
One fifth of the total national expenditure for hospital care is related to alcohol dependence, as evidenced by prolonged hospital stays (particularly in the Intensive Care setting) and characterized by major complications for patients progressing through AW, with an increase in utilization of health care resources/services (Phillips, Haycock, & Boyle, 2006). In addition to the increase in required health care resources, patient and staff safety must be considered; consideration for the physical safety of the patient during a withdrawal episode and for the safety of the health care worker exposed to patient behaviors during a withdrawal episode is paramount. Further significant issues related to AW are found/indicated in the progression of symptoms during the course of AW including the increased use of restraints and the increased use of sitters during the progression period (Chaney & Gerard, 2003).
The determination of need for a program directed at identifying and addressing AW within a population should begin with retrospective chart audits of identified patients, and data collection related to cost and length of stay (LOS). Development of an audit tool for an initial risk assessment and the development of an ongoing assessment process should follow. Development of treatment protocols/interventions would be the final step in addressing the identification and treatment of the patient with AW.
Once the process has been developed and approved for implementation, initial and ongoing education for the administrative team, physicians, and nursing staff would be a priority. Updated summaries of program progress during a pilot period should be made available to administration, physicians, and staff alike.
One or more outcome measures should be initiated to determine success of the process. Quality monitoring and data collection through retrospective audits should be completed to determine compliance with the program, as well as the success of the patient assessment and intervention processes as determined by LOS and subsequent health care costs. Further quality monitoring could be obtained through subjective data collection related to patient and staff satisfaction.
Implementation Plan
Theories of health behavior and promotion play a decisive role in helping to improve health by directing plans and processes that assist in the identification of risk issues, the management of disease processes, the development of implementation processes, and the measurement of process outcomes. When addressing alcohol withdrawal (AW), referred to as Alcohol Withdrawal Syndrome in some literature, theory helps to understand why AW is problematic and/or a significant health care issue; to identify what information is required in addressing the identified problem and how to use that information; to define and/or develop the necessary changes and processes; and to define what and how to monitor and evaluate the change for outcomes.
Incorporated Theory
There are two types of theory significant to the planning of health care, and to change in health care planning. Explanatory theory helps to identify why a problem exists and assists in the search for modifiable factors, while change theory guides the development of health promotion interventions (National Cancer Institute, 1998). Consideration of theory allows for review of research, in this case, related to AW and recognized interventions. Explanatory theory allows for focus on the problem of AW, its variables (i.e., co-morbidities, variations in clinical presentation, appropriate treatment); why it is a problem (i.e., increased severity of illness, increased health care costs); and what can be changed.
Change theory is directed at improvement processes and helps to identify the strategies for process change (i.e., early identification and assessment of patients at risk for AW, appropriate interventions based on assessments) and makes assumptions related to the success of those interventions. These theories incorporate concepts that can be translated or developed into strategies, plans, and evaluations. The use of theory allows for a complete review and appraisal of available information related to AW, with appropriate emphasis on solutions and interventions. Theory also provides the basis for judging the appropriateness of those solutions and intervention through an evaluation process.
Alcohol withdrawal is most often defined as a group of symptoms that occur with the cessation, usually abrupt, of alcohol intake. It affects people who are accustomed to regular alcohol intake, and is the most common withdrawal syndrome next to nicotine withdrawal. Alcohol addicted patients admitted to an inpatient setting may not be recognized as at risk for AW, which can produce negative outcomes and increase health care costs (Patch, Phelps, & Cowan, 1997). Ten million Americans consume alcohol excessively on a regular basis. Fifteen to forty percent of hospitalized patients are addicted to alcohol, putting them at risk for prolonged and/or complicated hospital stays; 25% of them may experience seizures within the first 24 hours of hospitalization.
Alcohol withdrawal has a 1-10% mortality rate with the majority of those deaths occurring from cardiovascular or metabolic complications as a result of severe withdrawal, particularly delirium tremens (DT). Delirium tremens occurs in approximately 5% of patients undergoing withdrawal, appearing 2-4 days after the patient stops drinking (Myrick & Anton, 1998). Twenty percent of the total national expenditure for hospital care is related to alcohol dependence (Phillips et al., 2006). In the year 2008, a total of 90 patients were hospitalized at Casa Grande Regional Medical Center (CGRMC) with a diagnosis of AW: 10 of them with an admission diagnosis of AW, 27 with a principal diagnosis of AW, and 53 with a secondary diagnosis of AW. Despite a significant patient population with documented or verbalized histories of AW, CGRMC currently has no program in place for assessment and intervention related to AW. If changes are not implemented within the Casa Grande Regional Medical Center organization, the impact will remain significant as it relates to patient care, patient safety, and health care costs.
Therefore, the development of an assessment process and interventional protocol, the initiation of education for the physicians and staff on the new process and protocol, and evaluation of the effectiveness of the process and protocol should be given high priority. If process changes are not considered, developed, and implemented, a health care system already compromised, will continue to be impacted by issues such as AW.
Manifestations of mild AW may begin as soon as 5-12 hours after the patient’s last drink, while major withdrawal syndromes tend to occur 48-72 hours after the last drink, manifesting themselves as hallucinations, seizures and/or delirium tremens (Hartsell, Drost, Wilkens, & Budavari, 2007). Though there are many tools and processes for evaluating the patient with a history of alcohol abuse and/or at risk for AW, a screening process using the CAGE questionnaire (Ewing, 1984)(Appendix A) readily determines whether the patient may be at risk. The CAGE, designed to be a screening tool, was developed by Dr. John Ewing and introduced for international use in Australia in 1970; its simplistic question format has made it the instrument of choice in most clinical settings (O’Brien, 2008). This questionnaire would serve as an initial screening tool for patients having been identified with a past or current alcohol dependency.
The CAGE questionnaire can be administered in as little as five minutes; a positive CAGE (a score of 2 or greater) would prompt further assessments of the patient, based on developed protocol, using the Revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) (Sullivan, Sykora, Schneiderman, Naranjo, & Sellers, 1989) (Appendix B) which has a documented utility for measuring withdrawal symptoms. Pharmacological therapy using the symptom-triggered approach would be initiated according to an approved and established physician order set/protocol, based on the patient’s CIWA-Ar scores.
Nurses can help to improve patient outcomes by developing a plan of care that includes assessment for AW, providing interventions accordingly, and evaluating the outcomes of those interventions. Implementation of a process change, related to a plan of care for those patients identified as at risk for AW, would begin with a patient history and assessment. Early physical indicators of AW can be identified during routine assessments; these indicators occurring as early as 5-12 hours after the patient’s last drink and manifested as mild tremors, diaphoresis, agitation, insomnia, and increased heart rate and blood pressure (Phillips et al., 2006).
When implementing the CAGE questionnaire, those patients receiving a score of 2 or greater would then be assessed initially, and at established intervals, using the CIWA-Ar to determine the existence and severity of withdrawal symptoms. A score of less than 10 would prompt supportive care to include maintaining a quiet and safe patient environment and providing psychosocial support. A score equal to or greater than 10 would prompt the initiation of an approved physician treatment order set/protocol (Appendix C) for pharmacological therapies, including symptom triggered dosing of Lorazepam. Thiamine and electrolyte replacement and ongoing assessment guidelines would be also addressed.
Patients should be reassessed using the CIWA-Ar every 4 hours while their score remains under 10; when their score equals or exceeds 10, assessment should be completed every hour following the initiation of pharmacotherapy times three doses of medication (Crumpler & Ross, 2005). If a score of less than 10 is not achieved at that time the physician should be notified and further direction obtained. Studies demonstrate that symptom triggered pharmacotherapy/treatment achieves symptom control and has demonstrated a decreased amount of drugs used, decreased duration of treatment, a decrease in the occurrence of oversedation or undersedation, a decrease in the number of adverse events, and a decrease in the use of restraints and sitters (Stanley et al., 2003). All documentation would initially be in paper form using an approved assessment and treatment flow sheet (Appendix D).
Pertinent information required by the flow sheet includes hourly assessments, medication administration, any additional nursing interventions applied. Following a 6 month trial period, the suitability of converting the documentation of all process components to an electronic format would be discussed and determined. It is anticipated that electronic documentation would promote consistency, expediency, and efficiency. In addition, there would be an opportunity to write a report within the documentation software to expedite data collection and analysis. Policy and procedure would be developed to support the process change (Appendix E).
The process plan in its entirety would initially be presented to the Senior Administration members at a specifically scheduled meeting, using a PowerPoint presentation and handouts. In addition to the planned process change itself, the group would be given information on the impact of AW on patient morbidity and mortality as well as health care costs. Following presentation to, and approval by this group, a presentation in the same manner would be given to the members of the Medical Executive Board. A third presentation of the same information and in the same format would be given to the Nursing Directors. Following approval by the Medical staff and review by the Nursing Directors, the plan for the process change would be rolled out to the staff. An abbreviated PowerPoint presentation and handouts, with specific focus on process and intervention would be given to the nursing unit Patient Care Coordinators at their monthly meeting.
Written information and education would be presented to general nursing staff by means of the hospital’s “Topic of the Week” education process; additional information by means of oral presentation and handouts would be provided at individual nursing department meetings as needed. Ongoing education would be provided using the Care Learning computerized process during annual competency reviews. Education of the nursing staff would include a pre- and post-test (Appendix F); information/direction on conducting a risk assessment, including patient observation, recognition of early signs and symptoms, and use of the CAGE questionnaire; information on withdrawal management, including use of the CIWA-Ar tool and review of the protocol and/or order set; and discharge planning to include social service referrals and patient education on AW (McKay, Koranda, & Axen, 2004).
Education would include orientation focused on the appropriate use of the CAGE questionnaire and the CIWA-Ar assessment tool, using the actual forms as a reference point. In addition, an assessment and treatment algorithm (Appendix G) would be provided to nursing staff to assist in decision making. A review of that form would be included in their process focused education. As well, the treatment protocol/order set would be reviewed/discussed at length during the education process.
Evaluation Plan
Outcomes of nursing care must be shown to relate to the specific care aspects of the process change (Frisch & Kelley, 2002). The general purpose of an evaluation is to measure the impact of the process change and to determine if compliance with all aspects of the process has been met. A 6-month pilot will be completed to test the efficacy and feasibility of a process change related to the early recognition and effective management of AW. The AW Protocol Quality Management/Performance Improvement Data Collection Tool (Appendix H) will be used when doing a retrospective audit of charts for all patients admitted with a principal, primary, or secondary diagnosis of AW during the 6-month trial period. Questions to be answered during that audit will include:
* Were the assessment tools (CAGE and CIWA-Ar) appropriately and successfully completed?
* Was the treatment protocol appropriately initiated?
* Was documentation adequately and appropriately completed based on the protocol and policy?
* Was additional supportive care in the form of restraints and/or sitters required?
Data collection for this evaluation process will be limited to a retrospective chart audit that may be labor intensive. However, the actual number of patients diagnosed with AW at Casa Grande Regional Medical Center (90 patients in 2008) may impact the time/work necessitated by this audit. Patient identification for the intent of the audit will be based on information obtained from Health Information Management (HIM), related to and restricted by admission diagnosis type as defined earlier.
Data for this pilot time frame will be collected by the author and prepared for oral presentation to identified groups. Handouts recalling the general outline of the process change/protocol and the results of the chart audit, in graph format, will be made available to all groups. The initial presentation will be made to the senior administrative group and will allow them to review and determine how the data may impact patient care and safety, as well as possible financial impact. The Medical Executive Board will receive the information to review for the appropriate use of the CAGE and CIWA-Ar tools in successfully and accurately identifying patients at risk and in need of treatment. As well, this group will examine the appropriateness of the protocol orders, specifically pharmacotherapy. They would further review data for the accuracy and efficacy of the documentation flowsheet as it relates to assessment and intervention.
The nursing department directors will review the data and address the efficiency and efficacy of the assessment tools (CAGE and CIWA-Ar) and the treatment protocol as it relates to nursing assessment and documentation and for any impact on nursing care delivery as it relates the use of restraints and/or sitters. The Patient Care Coordinators and nursing staff groups will review the data and discuss any impact related to the assessment tools, the treatment protocol, and the documentation flowsheet, and they will discuss the use of restraints and/or sitters as it impacts their care delivery. All recommendations will be forwarded to a committee, yet to be formed, at the completion of the pilot.
Following the initial data review by the indicated groups, a quality management/performance improvement team composed of four to six nursing department staff and a medical advisor will be formed. Data will be collected monthly using the same process previously outlined; data will be collated and reported quarterly to all groups. Team meetings will be held monthly to address any newly identified limitations to the protocol and/or the evaluation process, discussing any necessary process changes related to the protocol, and to discuss continued validity of the data collection tool. These activities will help to establish and validate an evidence-based and standardized process for the early identification of AW and any required interventions. In addition, collected data may provide the basis for additional changes including expansion of electronic documentation for AW, development of nursing care plans specific to AW, and development of AW clinical pathways.
Dissemination Plan
The ultimate impact of a process change rests in the effectiveness of the dissemination strategy and presentation (RUSH, 2001). To promote and expedite the proposed protocol/process change, the intent is to complete the dissemination plan in a 2-month time frame. This would allow for sufficient time to schedule presentations with all groups comprising the audience. The intended audience for the introduction of the protocol/process change at CGRMC is the senior administration team, the medical staff, the nursing department directors, the PCCs, and the professional nursing staff. The variation in audience needs, which is based on position within the CGRMC organization, can be met on all levels by the information provided.
The goal of the dissemination plan is for all members of the audience, as previously noted, to have access to information related to the significance and impact of AW, and to the design and implementation of the AW protocol/process change. By way of an objective, that same group will acknowledge an understanding of the significance of the development and implementation of the AW protocol/process change. Content of the presentation will include research data related to the significance and impact of AW on the patient and the health care delivery system, and an outline of the proposed protocol/process change. Secondary to time constraints, all groups will be addressed through oral presentations. Handouts which include data related to the significance/impact of AW and copies of the policy, the assessment tools, the treatment protocol, the documentation flowsheet, and the process evaluation tool will be made available to all members of the audience. A review of all handout information will be included in the presentation.
Ultimately the intent of the presentation is for the audience to improve practice. All members of the identified audience have the skills and awareness levels to effectively promote and implement the protocol/process change. Continued monitoring following implementation will help to keep the group engaged as they become aware of the successes and failures, and what needs to be done to achieve success with the new protocol/process change.
Evaluation of the proposed process change would be based on retrospective chart audits using a specifically developed paper data collection tool. Elements to be examined would include compliance in the use of the Cage and CIWA-Ar screening/assessment tools, compliance in initiating and following the physician order set/protocol, review of the need/use of restraints and/or sitters, and review of the level of care required by the patient. Results of those audits would be reviewed, collated, and made available to Senior Administration,...