Background: The standard of care for the treatment of alcohol withdrawal is symptom triggered treatment using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. However, this 10-item scale is cumbersome to use.  

Purpose: To develop and implement a symptom-triggered alcohol withdrawal treatment protocol utilizing a simplified withdrawal scale.  

Description: We piloted a 6-item withdrawal scale developed at another institution.  Based on a comparison with the CIWA-Ar, we adapted this into a 5-item scale that we called the Brief Alcohol Withdrawal Scale (BAWS).  We compared the BAWS to the CIWA-Ar and developed a withdrawal protocol utilizing the BAWS.  This protocol was implemented on an inpatient unit dedicated to treating substance withdrawal in adults.  We evaluated patient demographics, administered dose of benzodiazepines, length of stay, occurrence of seizure or delirium, and transfers to higher level of care.  We compared data from the first 3 months after implementation to the preceding 3 months.  There were 641 non-pregnant adult patients admitted for alcohol withdrawal and treated with diazepam comprising 664 admissions during the study period: 348 during the pre-implementation window and 316 during the post-implementation window.  The demographics of patients in the two time periods were similar:  the mean age for the study group was 45.9 years, 70.6% were male, and 30.9% received concurrent treatment for opioid withdrawal.  A BAWS score of 3 or more predicted CIWA-Ar ≥ 8 with sensitivity of 85.3% and specificity of 65.8%.  During the BAWS phase, patients received significantly less diazepam (mean dose 81.4 vs 60.3, p-value < 0.001).  There was no significant difference in length of stay (2.76 vs 2.74 days, p-value 0.76). None of the patients in either phase experienced seizure or delirium. One patient in the pre-implementation period was transferred to a different unit.  

Conclusions: The optimal treatment of alcohol withdrawal should incorporate regular assessments using an objective, symptom-driven scale to guide the dosing and frequency of medication administration.  This simple protocol utilizing a 5-item withdrawal scale performed well in a unit dedicated to substance withdrawal. However it’s effectiveness in patients with concurrent medical illnesses or more severe withdrawal is not known.  Further study of the protocol in acutely ill hospitalized adults is needed.