Evaluation of the appropriate use of a CIWA-Ar alcohol withdrawal protocol in the general hospital setting

Am J Drug Alcohol Abuse. 2018;44(4):418-425. doi: 10.1080/00952990.2017.1362418. Epub 2017 Oct 5.


Background: The Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) is an assessment tool used to quantify alcohol withdrawal syndrome (AWS) severity and inform benzodiazepine treatment for alcohol withdrawal.

Objectives: To evaluate the prescribing patterns and appropriate use of the CIWA-Ar protocol in a general hospital setting, as determined by the presence or absence of documented AWS risk factors, patients' ability to communicate, and provider awareness of the CIWA-Ar order.

Methods: This retrospective chart review included 118 encounters of hospitalized patients placed on a CIWA-Ar protocol during one year. The following data were collected for each encounter: patient demographics, admitting diagnosis, ability to communicate, and admission blood alcohol level; and medical specialty of the clinician ordering CIWA-Ar, documentation of the presence or absence of established AWS risk factors, specific parameters of the protocol ordered, service admitted to, provider documentation of awareness of the active protocol within 48 h of initial order, total benzodiazepine dose equivalents administered and associated adverse events.

Results: 57% of patients who started on a CIWA-Ar protocol had either zero or one documented risk factor for AWS (19% and 38% respectively). 20% had no documentation of recent alcohol use. 14% were unable to communicate. 19% of medical records lacked documentation of provider awareness of the ordered protocol. Benzodiazepine associated adverse events were documented in 15% of encounters.

Conclusions: The judicious use of CIWA-Ar protocols in general hospitals requires mechanisms to ensure assessment of validated alcohol withdrawal risk factors, exclusion of patients who cannot communicate, and continuity of care during transitions.

Keywords: Alcohol withdrawal syndrome; CIWA-Ar; PAWSS; alcohol withdrawal; benzodiazepine.

MeSH terms

  • Adult
  • Aged
  • Alcohol Withdrawal Delirium / drug therapy*
  • Alcoholism / drug therapy*
  • Benzodiazepines / therapeutic use
  • Blood Alcohol Content
  • Clinical Protocols
  • Ethanol / adverse effects*
  • Female
  • Hospitals, General
  • Humans
  • Male
  • Middle Aged
  • Retrospective Studies
  • Substance Withdrawal Syndrome / drug therapy*


  • Blood Alcohol Content
  • Benzodiazepines
  • Ethanol