Using the CIWA Scale: FAQ and Best Practices for Facilities

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale has become the gold standard for evaluating the severity of withdrawal symptoms and facilitating care for individuals with alcohol withdrawal syndrome (AWS). The most recent version, CIWA-Ar, is a 10-item assessment tool that relies on a mix of subjective and objective information to determine the patient’s condition. Care providers can collect this data in as little as two minutes, making it a practical and useful strategy in many different clinical settings.

Despite the scale’s validity and proven usefulness, it isn’t appropriate for all patients experiencing alcohol withdrawal. Nursing staff using this tool should be trained regarding how and when to use it, and what to infer from results. Furthermore, providers engaging with the tool rely on facility-specific protocols and procedures to guide treatments based on their assessment results.

This guide covers what the CIWA assessment tool is, how it can be applied, and best practices for utilizing scores to improve patient care. Learn the importance of implementing a standardized CIWA protocol at your facility, along with best-practice tips to ensure your protocol is effective.

Why Is Alcohol Withdrawal Assessment Scoring Important?

Roughly 2 million people in the U.S. suffer from AWS each year. Many people with AWS seek both inpatient and outpatient care, warranting the use of effective assessment tools that can help inform their treatment plan. Identifying and monitoring withdrawal symptoms is also important when patients are in healthcare settings due to other chief complaints. If left untreated, withdrawal from chronic alcohol consumption can be fatal.

What Is a CIWA Scale?

CIWA is a 10-item instrument that helps providers assess symptoms of alcohol withdrawal in patients. Using this tool, providers can determine the severity of a patient’s withdrawal and their level of dependency on alcohol. This tool provides a structured approach to monitoring a patient’s symptoms and informing appropriate treatment.

What’s the Difference Between the CIWA-A and CIWA-Ar Scale?

The CIWA-A scale was the first version of the instrument created, originally containing 30 items. The CIWA-Ar scale is the revised version of this scale that is now widely used in practice. The CIWA-Ar is essentially a shortened version of the CIWA-A, containing 10 items instead of 30. The CIWA-Ar has been shown to be valid and reliable and is now the most widely used AWS measurement tool. However, there are still some mixed opinions on its utility.

What’s On the CIWA Scale?

There are 10 total items on the CIWA-Ar scale, and each item measures a different symptom of alcohol withdrawal. These symptoms include:

1. Nausea/vomiting
2. Tremor
3. Paroxysmal sweats
4. Anxiety
5. Agitation
6. Tactile disturbances
7. Auditory disturbances
8. Visual disturbances
9. Headache/fullness in head
10. Orientation/clouding of sensorium

Staff using the tool are then asked to rate the severity of the symptom described in each item on a scale of 1 to 7 (except for item 10, which is rated on a scale of 1 to 4). You can find a complete description of each item and its rating scale, along with a helpful CIWA calculator, on the full CIWA assessment tool.

How Is the CIWA Scale Administered?

CIWA is designed to be administered by licensed healthcare providers, such as nurses and doctors. In order to assess each symptom, providers will both observe the patient and ask them questions listed on the tool. They will then select the number rating that most closely describes each symptom.

How Is CIWA Scoring Calculated? Example

To calculate a total score, providers should add up the numbers selected for each respective item. To give you a better idea of how this works in practice, we’ll walk through a scenario and scoring process below.

Example Scenario: You walk into a patient’s room to conduct a CIWA assessment. Upon entering the patient’s room, you notice sweat dripping from their forehead and tremors when they extend their arms. You ask the patient to recite their name, the date, and location, and they answer all three questions correctly. Throughout the assessment, you notice the patient frequently fidgeting their arms while seated. As you go through the remainder of the questions on the assessment, the patient also reports:

• Mild nausea.
• Feelings of nervousness.
• Slight numbness in their arms and legs.
• No abnormal sound disturbances.
• That the room light is too bright.
• Mild heaviness in their head.

Example CIWA Scoring:

Based on the example above and the assigned point systems outlined on the full CIWA tool, we’ll provide ratings for each item in the table below. The total score is calculated by adding up the points assigned to each item.

CIWA Score Interpretation: Example

Now, let’s take a look at how a score is interpreted. In addition to learning more about the patient’s condition, providers can also use scores to guide clinical decisions.

To use the results of a CIWA assessment to guide treatments, like administering a medication, providers must adhere to facility protocols and procedures.

Example CIWA Score Interpretation:

In our example scenario above, you assessed your patient and documented a score of 22. Your next step is to decide what CIWA score range this falls within using the recommended guidelines below:

• <8: Mild withdrawal that can generally be treated with supportive care measures
• 8-15: Moderate withdrawal that may require initiation of scheduled medication
• 15 or more: Severe withdrawal that may require scheduled medication in addition to other intensive treatment measures

Based on these ranges, we can conclude that the patient in this example is experiencing severe withdrawal that requires intensive intervention, since their score (22) is greater than 15.

Using the CIWA Scale: 3 Best Practices for Facilities

CIWA should be implemented as part of a more comprehensive protocol for treating patients with AWS. Below are three best practices that will help your staff utilize this tool more effectively.

1. Provide Staff Training and Education

While this tool is designed to be used by most licensed health professionals, research has shown that implementation is more successful if staff receive thorough training prior to conducting assessments. At baseline, your training should include:

• Education on when and why the tool is used.
• Examples that allow staff to practice assessment and scoring.
• Guidance for how CIWA can be used to inform treatment based on your facility’s protocols.

2. Determine Whether CIWA Is Right for Your Patient Population

Evidence-based care recommendations for CIWA can vary by setting. It’s important to utilize reputable resources and journals to help you determine whether CIWA is appropriate for your patient population and how to shape your care protocols.

For example, in outpatient settings, CIWA is used as more of a general monitoring tool to assess how patients with mild withdrawal are responding to supportive measures. However, in the Emergency Department, patients may need hourly assessments to inform more intensive care planning.

This tool also generally only applies to patients who are at risk of AWS and responsive enough to answer questions about their subjective experience. For patients with limited communication (intubated patients, for example) or altered mental status, an objective alcohol withdrawal assessment scoring method may be a better choice.

3. Create a Standardized Order Set for AWS Treatment

An order set is a standardized template that healthcare providers use to generate care instructions and orders. By creating an order set for the treatment of AWS, you can more clearly outline how the CIWA score chart should inform care decisions. Below are a few specific examples of what CIWA protocols and AWS order sets can look like:

• Alberta Health Services Order Set for the ED
• META PHI Order Set for Alcohol Withdrawal
• Houston Methodist Alcohol Withdrawal Standing Order

Discover More Ways to Elevate Your Care

Implementing new tools like the CIWA scale takes time and effort. Looking for ways to engage your staff and set these initiatives up for success? Our team of experts offers dozens of other facility management tips and insights that can help you deliver the best care possible.