I Don’t CIWA We Can’t Use RASS Instead
July 25, 2024
Written by Nick Zelt
Spoon Feed
The first direct comparison of the Clinical Institute Withdrawal Assessment-Alcohol Revised (CIWA-Ar) scale to a slightly modified Richmond Agitation and Sedation Scale (mRASS-AW) in a pre-post quality assurance study found mRASS-AW to not compromise length of stay or safety for the evaluation of alcohol withdrawal syndrome (AWS), while we already know it to be faster and more intuitive.
CIWA always was a pain in the RASS
CIWA-Ar evaluations are long, making the scoring cumbersome. This represents a burden that falls mostly on already over-taxed nurses. The intuitive and rapid mRASS-AW*, already broadly familiar to all due to its use in intensive care, presents a tempting replacement that now has evidentiary support.
This was a pre-post quality assurance study from a single urban community hospital in western Canada. Patients were identified by ICD-10 codes for AWS, and data were collected retrospectively to compare the use of CIWA-Ar in the 21 months preceding their switch to mRASS-AW and then for the 5 following years until Dec 2020. This included 317 CIWA-Ar and 756 mRASS-AW assessed patients.
After the switch, there was no significant change in the primary outcome of mean quarterly length of stay (5.7 days pre vs. 5 days post), nor were there differences in delirium incidence, ICU admission, or mortality. The composite outcome of other post-admission complications (including sepsis, infection, GI bleed, cardiac arrest, myocardial infarction) was significantly lower in the mRASS-AW group (6.6% vs. 3.4%, p=0.02).
How will this change my practice?
I think every nurse I know would be hugely in favour of switching to mRASS-AW. Properly calculating a CIWA-Ar score takes approximately 5 minutes, compared to a mRASS-AW at only 30-60s. mRASS-AW also does away with several patient-reported measures, making assessment largely possible from the foot of the bed. While the further step of measuring nursing time and benzodiazepine use would have made this study even stronger, it has my full support. I already document mRASS scores on my AWS patients and may advocate for replacement of CIWA-Ar where I work.
*Essentially the RASS you know and love, with very minor adjustments to guide its use for AWS.
Source
Replacing the Clinical Institute Withdrawal Assessment-Alcohol revised with the modified Richmond Agitation and Sedation Scale for alcohol withdrawal to support management of alcohol withdrawal symptoms: potential impact on length of stay and complications. CJEM. 2024;26(6):431-435. doi:10.1007/s43678-024-00710-7