Correlation Between mMINDS and CIWA-Ar Scoring Tools in Patients With Alcohol Withdrawal Syndrome

Design

Prospective, single-center, nonrandomized, single-blinded, observational, correlation, crossover study

N=30

Objective

To determine the strength of correlation between the revised Clinical Institute Withdrawal Assessment (CIWA-Ar) and modified Minnesota Detoxification Scale (mMINDS) scoring tools in patients with alcohol withdrawal syndrome

Study Groups

CIWA-At (n=30)

mMINDS (n=30)

Inclusion Criteria

Aged ≥18 years; admitted to the medical intensive care unit (ICU) or medical step-down unit; actively treated for alcohol withdrawal syndrome (AWS) using the Yale Alcohol Withdrawal Protocol (YAWP)

Exclusion Criteria

Patients not cared for by the trained study nurses

Methods

This was an observational study from a tertiary-car academic medical center in Connecticut. Nurses at the institution were trained to use the mMINDS tool as part of their standard competency in the ICU. These nurses were also trained in the use of the CIWA-Ar tool and required to pass a written CIWA-Ar competency test. The nurses were blinded to the study objectives.

Nurses administered both the CIWA-Ar and the mMINDS a maximum of once per hour. The mMINDS results were documented in the electronic medical record and served as the basis for medication administration, while the CIWA-Ar scores were manually recorded for study purposes. 

Duration

November 2015 and March 2016

Outcome Measures

Primary: the correlation between the CIWA-Ar and mMINDS scoring tools in AWS patients

Secondary: length of hospital stay, duration of YAWP therapy, adjuvant medication use, median dose of benzodiazepines

Baseline Characteristics

AWS patients (N=30)

Age, years (range)

Male

Race

White

Black

Hispanic

73%

20%

7%

Alcohol-related history

Daily alcohol use

History of alcohol withdrawal

History of delirium tremens

History of withdrawal seizures

Previous admission for AWS

90%

77%

33%

43%

43%

Charlson Comorbidity Index (range)

2.9 (0-8)

Results

AWS patients (N=30)

Alcohol withdrawal scores

mMINDS score (interquartile range)

CIWA-Ar score (interquartile range)

6 (3-9)

7 (3-10)

Length of hospital stay, days (interquartile range)

Length of ICU or step-down unit stay, days (interquartile range)

7 (5-13)

2.8 (1.5-4.2)

Duration of alcohol withdrawal therapy, hours (interquartile range)

Benzodiazepine dose, mg of lorazepam equivalents (interquartile range)

Pearson correlation coefficients*

CIWA-Ar score ≤10

CIWA-Ar score >10

Tremors

Agitation

Orientation

Tactile disturbance

Auditory disturbance

Visual disturbance

0.87  (strong correlation)

0.52

0.98 (strong correlation)

0.84 (strong correlation)

0.87 (strong correlation)

0.07

-0.07

0.04

*A total of 185 CIWA-Ar and mMINDS scores were included in the correlation study. Across all 185 scores, the overall correlation coefficient was 0.82 (strong correlation). 

Adverse Events

Not studied

Study Author Conclusions

This study revealed a strong correlation between the CIWA-Ar and mMINDS scoring tools in patients with AWS, particularly at scores ≤10. The CIWA-Ar tool has been validated only in patients with uncomplicated AWS and has never been studied in patients requiring ICU-level care. 

The MINDS scoring tool has been evaluated only in patients with symptoms severe enough to require ICU admission. As a result, it is difficult to determine at what point AWS patients being assessed with the mMINDS are stable enough for transfer from the ICU to the general unit.

InpharmD Researcher Critique

Patients with more severe AWS will be less able to communicate verbally, which could lead to a difference between scoring tools at higher values, as the CIWA-Ar assessment questions are largely dependent on the patient’s ability to respond.

A limitation of this study is the ability of nurses to use CIWA, as they were trained to use mMINDS; however, each study nurse passed a written exam on the use of CIWA-Ar. Another limitation is the amount of scores of 10 or less exceeded scores greater than 10. This suggests there may not have been enough patients to assess the correlation adequately at scores greater than 10.

Should the CIWA-Ar be the standard monitoring strategy for alcohol withdrawal syndrome in the intensive care unit?

Design

Retrospective, observational, single-center, cohort study

N=97

Objective

To evaluate the frequency of Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) monitoring among intensive care unit (ICU) patients with alcohol withdrawal syndrome (AWS) and variation in CIWA-Ar monitoring across patient demographic and clinical characteristics

Study Groups

No CIWA-Ar assessment (n=43)

CIWA-Ar assessment (n=54)

Inclusion Criteria

Exclusion Criteria

Methods

This was a single-center study at an academic institution in Washington. Emergency department providers started treatment for AWS on a case-by-case basis without the use of a screening tool. Once admitted to the ICU, CIWA-Ar and Richmond Agitation-Sedation Scale (RASS) protocols could be triggered by physician order; however, nurses could decline the order for CIWA-Ar monitoring in patients who cannot respond to CIWA-Ar questions.

Treatment for AWS was defined by continuous infusion or multiple administrations of benzodiazepines, antiepileptics, antipsychotics, antisympathomimetics, propofol, and/or ethanol intended to treat AWS.

Duration

January 1, 2017 to December 31, 2017

Outcome Measures

Primary: presence or absence of CIWA-Ar assessment within 24 h of ICU admission

Secondary: AWS severity, level of agitation/sedation

Baseline Characteristics

AWS patients (N=97)

Age, years

Male

Race

White

Black

Native American

Other

72.2%

11.3%

11.3%

5.2%

Intubated upon admission

Prior-year hospitalization for AWS

Positive serum/urine alcohol level

Severity of illness upon admission

Extreme

Major

Moderate

Minor

35.1%

38.1%

24.7%

2.1%

Results

CIWA-Ar assessment (n=54)

P-value

Severity of illness upon admission

Extreme

Major

Moderate

Minor

24 (55.8%)

11 (25.6%)

8 (18.6%)

0

10 (18.5%)

26 (48.1%)

16 (29.6%)

2 (3.7%)

0.001

Race

White

Native American

Black

Other

31 (72.1%)

1 (2.3%)

7 (16.3%)

4 (9.3%)

39 (72.2%)

10 (18.5%)

4 (7.4%)

1 (1.9%)

0.014

Intubated

Prior-year hospitalization for AWS

Positive serum/urine alcohol level

Of the 54 patients with CIWA-Ar assessments, the majority (52%) had scores indicating mild AWS (CIWA-Ar ≤ 8) requiring no additional pharmacotherapy.

Adverse Events

Not studied

Study Author Conclusions

CIWA-Ar monitoring was used inconsistently in ICU patients with AWS and completed less often in those who were intubated or identified as Black. These hypothesis-generating findings raise questions about the utility of the CIWA-Ar in ICU settings. Future studies should assess alternative measures for titrating AWS medications in the ICU that do not require verbal responses from patients and further explore the association of race with AWS monitoring.

InpharmD Researcher Critique

This was a single-center study that focused on the correlation of baseline characteristics to the use of the CIWA-Ar tool within 24 hours of admission. The retrospective design allows for confounding variables and relies on accurate documentation. Any results from this study can only be hypothesis-generating, especially due to the small sample size.