Evaluation of a Web-based Educational Program to Teach the Identification and Management of Alcohol Withdrawal in the Emergency Department.

Abstract

Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom-driven approach, where patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised [CIWA-Ar]) and treated according to severity. Accurate administration of the CIWA-Ar requires experience, yet there is no training program to teach this competency. The objective of this study was to develop and evaluate a curriculum to teach clinicians how to accurately assess and treat AWS. This was a three-phase education program consisting of a series of e-learning modules containing core competency material, an in-person seminar to orient learners to high-fidelity simulation, and a summative evaluation in an objective structured clinical examination setting using a standardized patient. To determine the impact of the AWS curriculum, we recorded how often the CIWA-Ar was appropriately applied in the emergency department (ED) before and after training. A CIWA-Ar protocol breach was defined as inappropriate administration of benzodiazepines (CIWA-Ar<10) and failure to administer benzodiazepines when required (CIWA-Ar ≥ 10). ED length of stay, amount of benzodiazepines administered in the ED, discharge prescriptions, and unit doses (take-away bottle of four tablets) of benzodiazepine given were recorded. Seventy-four ED nurses completed the curriculum over an 8-week period. In the 5 months prior to the educational program delivery, we identified 144 of 565 (25.5%) CIWA-Ar protocol breaches, compared to 64 of 547 (11.7%) in the 5 months after training (∆13.8%, 95% confidence interval [CI]= 9.3%-18.3%). Program completion resulted in a reduction in the median total dose of diazepam administered in the ED (40mg vs. 30mg, ∆10mg, 95% CI= 0-20mg) and no change was detected in ED length of stay and benzodiazepines prescribed. Completion of this curriculum resulted in better compliance with the CIWA-Ar protocol by those who administer the CIWA-Ar; however, changes in inappropriate benzodiazepine prescribing practice will require future interdisciplinary initiatives.