Alcohol Withdrawal Delirium Room Assignment

Q&A: Query for ’tremors’ related to alcoholism for additional specificity

CDI Strategies, December 5, 2013

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Q: An intoxicated patient comes into the emergency department with a history of alcoholism and the physician prescribes precautions for withdrawal and documents “tremors.” Can we assume that the physician means “delerium tremors” or “DTs”?

A: No, tremors in an alcoholic cannot be assumed as DTs. If the provider documents “tremor” without additional specification it defaults to code 781.0, abnormal involuntary movements (tremors, NOS – not otherwise specified). The provider would need to specifically refer to the condition as DTs or they could document “alcohol withdrawal delirium” or “alcoholic delirium,” both of which map to code 291.0, which is a CC. The key word is “delirium” not tremors. The code set can also differentiate between acute and chronic alcoholic delirium (alcohol induced persisting dementia a.k.a. alcoholic dementia), but both are CCs.

Additionally, the documentation would need to be clear that the patient was experiencing DTs rather than preventing DTs. A condition that is being prevented does not qualify as a secondary diagnosis so it would not be appropriate to assign a code based on this documentation. Documentation of alcohol withdrawal (291.81) is also a CC as a secondary diagnosis.

The key here is for the provider to document the patient has alcohol “dependence” rather than alcohol abuse. The code set only recognizes withdrawal as a condition that occurs with dependence of any substance, which is a physiological response to cessation of use of the substance. Therefore, alcohol dependence with withdrawal symptoms also supports use of code 291.81.

Something else you can consider when reviewing an alcoholic case is that these patients usually receive a “banana bag” in the emergency room, which is IV fluids with multi-vitamins including thiamine. If the provider documents “evidence of thiamine deficiency” as a diagnosis associated with the treatment of a “banana bag” (it is appropriate to query when treatment is documented without documentation of the condition being treated), then this maps to a 265.* code.

However, if the “banana bag” is a prophylactic treatment then it would not be appropriate to assign a code. A multiple choice query with prophylactic treatment as an option may be a compliant way to approach such a query. For example:

Dear Dr. Z:

Please provide a diagnosis associated with the administration of an IV “banana bag” in the emergency department on (date/time) for Mr. X who has a history of “alcoholism” in the next 24 hours or next progress note by documenting your response below:

  • Evidence of thiamine deficiency due to chronic alcohol use/alcoholism
  • Prophylactic treatment of potential thiamine deficiency associated with chronic alcohol use/alcoholism
  • Unable to determine
  • Other: ______________

And be sure to have the physician provide his/her authentication per your organizational guidelines if documentation occurs on query form.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview. This article originally published on the ACDIS Blog. 



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Healthcare providers may encounter signs and symptoms of alcohol withdrawal when patients with alcohol abuse or dependency are admitted to the hospital. About 20% of patients admitted to general hospitals exhibit signs or symptoms of alcohol abuse or dependence. During 2010, approximately 17.9 million Americans ages 12 and older were abusing or dependent on alcohol. (See the box below.)

Defining alcoholism

The National Institute on Alcohol Abuse and Alcoholism describes alcoholism as a disease whose signs and symptoms include:

  • craving for alcohol
  • loss of control, with difficulty or inability to stop drinking once alcohol consumption begins
  • physical dependence, causing alcohol withdrawal symptoms (such as nausea, anxiety, tremors, and diaphoresis) after alcohol intake ceases
  • alcohol tolerance—the desire or need to consume greater amounts of alcohol to obtain the same effect.

Manifestations of alcohol withdrawal syndrome (AWS) occur at the onset of detoxification. They may arise within 6 to 8 hours after the last drink and peak at 24 to 48 hours. Untreated or undertreated patients may experience anxiety, irritability, headache, nausea and vomiting, diaphoresis, and decreased appetite. Some have visual or auditory hallucinations in the first 2 days after withdrawal. Symptom severity may depend on length and severity of alcohol abuse.

AWS may cause potentially life-threatening effects in those who abruptly stop heavy, prolonged drinking, because sudden withdrawal causes hyperactivity of the central nervous system (CNS). Delirium tremens (DT, also called alcohol withdrawal delirium) is a severe complication. Left untreated, it can be fatal in up to 20% of patients. Signs and symptoms, such as hypertension, agitation, disorientation, tachycardia, diaphoresis, and low-grade fever, may arise within 2 to 4 days after the last drink and persist for 3 to 5 days. Without treatment, up to 25% of alcohol-dependent patients may experience grand mal seizures during the first day of alcohol cessation. In acutely ill medical patients, alcohol withdrawal symptoms may be misdiagnosed as another serious condition, such as hypoxia, pneumonia, uremia, sepsis, stroke, hypoglycemia, postoperative delirium, or adverse drug reactions.

Many healthcare facilities don’t provide the education clinicians need to recognize AWS, and too few patient screenings are done. Healthcare providers are in a unique position to screen patients for alcohol use during the history and physical examination. On admission, every patient should be screened for alcohol abuse or dependency using a questionnaire that asks about daily and weekly alcohol intake, extent of intake, type of alcohol consumed, and time of last alcohol consumption. (The National Institute on Alcohol Abuse and Alcoholism [NIAAA] provides patient-screening guidelines at www.niaaa.nih.gov/publications/clinical-guides-and-manuals.) If findings suggest alcohol abuse or dependency, notify the physician for further assessment and diagnosis. After discharge, the patient should receive appropriate referrals to continue treatment.

Stages of AWS

Clinicians must be able to recognize AWS early. Not all patients experience all symptoms or all stages of AWS.


  • Stage 1 usually begins 5 to 8 hours after the last drink. Signs and symptoms may include anxiety, restlessness, mild nausea, anorexia, insomnia, diaphoresis, mild tremors, fluctuating tachycardia and hypertension, and mild cognitive impairment.
  • Stage 2 occurs about 24 to 72 hours after the last drink, manifesting as increased restlessness and agitation, increased tremors, hallucinations, disorientation, diaphoresis, nausea and vomiting, 0diarrhea, tachycardia (heart rate faster than 120 beats/minute), systolic pressure above 160 mm Hg, and seizures (usually grand mal). Untreated patients have a 25% chance of experiencing grand mal seizures 1 to 5 days after alcohol cessation.
  • Stage 3 (DT) typically arises 72 to 96 hours after the last drink. Patients may experience fever, severe hypertension, tachycardia, delirium, drenching sweats, and severe tremors. Death may ensue from arrhythmias, fluid and electrolyte imbalances, aspiration pneumonia, or infection.

Physiology of alcohol withdrawal

Learning about the physiologic effects of alcohol can enhance your understanding of AWS. Alcohol enters the body through the mouth. Some enters the bloodstream in the stomach, but most goes on to the small intestine. Alcohol enters the bloodstream through the walls of the small intestine. The heart pumps alcohol throughout the body, and alcohol reaches the brain. The liver oxidizes alcohol at a rate of about 0.5 oz/hour. Finally, alcohol is converted into water, carbon dioxide, and energy.

Specific effects of alcohol consumption vary with the amount of alcohol consumed and the blood alcohol level. (See the box below.)

How blood alcohol levels affect the body

This chart shows the physiologic effects of alcohol consumption by blood alcohol concentration (BAC). In the United States, 0.08% is the illegal BAC for adult drivers. Most deaths from alcohol poisoning occur at BACs of 0.35 to 0.50.

Blood alcohol concentration (%)Physiologic effects
0.02Mild alteration of feelings

Slight intensification of mood

0.05Feelings of relaxation, giddiness, lowered inhibitions

Slight impairment of judgment and motor skills

0.08Impaired muscle coordination and reaction time

Tingling and numbness of face, hands, arms, and legs

0.10Flushed appearance

Ataxia (imbalance and difficulty walking)

Impaired fine muscle coordination

Impaired mental abilities, judgment, attention span, and memory

More improvement in mood

Increased sociability and self-confidence

0.15Irresponsible behavior

Euphoria

Delayed reactions

0.20Slurred speech

Staggering

Measurable effects on motor and emotional control centers

Loss of balance

Blurred or double vision

Urinary incontinence

Sedation

Amnesia

0.40Lapses in and out of consciousness

Amnesia

Vomiting (with the risk of pulmonary aspiration)

Reduced heart rate

Decreased circulation to extremities, causing cold or numb extremities

Respiratory depression

Depressed eye reflexes

0.45Life-threatening respiratory depression and possible cessation

Markedly decreased heart rate

Coma

0.50Death

Role of neurotransmitters

Neurotransmitters (chemicals released by neurons) promote transmission and stimulation of nerve impulses throughout the nervous system. Excessive alcohol consumption depresses neuronal excitability and impulse conduction and enhances the effects of the neurotransmitter gamma-aminobutyric acid (GABA) in the brain. Over time, chronic alcohol use suppresses GABA, and the person needs increasing amounts of alcohol to obtain the desired effects. Chronic alcohol use also inhibits activity of the excitatory neurotransmitter glutamate; as a result, glutamate functions at a far higher level in alcoholics. When a heavy drinker suddenly cuts back sharply or stops drinking entirely, neurotransmitters that had been suppressed by chronic alcohol use rebound, causing brain hyperexcitability and mild to severe AWS.

Early evaluation

Patients with alcohol dependency who are admitted to the hospital for surgery, accidents, or medical conditions with such complications as fever, hemorrhage, arrhythmias, malnutrition, infection, acid-base imbalance, and fluid/electrolyte disturbances are at increased risk for major AWS manifestations. This underscores the need for nurses to perform a physical examination and obtain a history of the patient’s past and present medical condition and alcohol use. If initial assessment suggests alcohol abuse or dependency, proceed to an appropriate questionnaire. Assessment guidelines for clinicians are available from various sources. For instance, the National Institute on Alcohol Abuse offers “Helping Patients Who Drink Too Much: A Clinician’s Guide,” (see http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm). Topics covered include managing AWS, definition of a standard drink, alcohol’s effects on the body, alcohol use disorders, and fetal alcohol syndrome. An instructional PowerPoint presentation also is available on this page for clinician education.

If the patient has abruptly stopped drinking in the past few days after continuous, heavy alcohol use, clinicians should use the Clinical Institute of Withdrawal Assessment for Alcohol Scale, revised (CIWA-Ar), available at http://www.chce.research.va.gov/apps/PAWS/content/quiz.htm. The Alcohol Use Disorders Identification Test (AUDIT) is a 10-question screening tool that helps healthcare providers identify alcohol problems experienced by the patient within the last year. (See http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide11.htm.)

Assess, stabilize, and intervene

The healthcare team should work promptly to stabilize the patient by obtaining vital signs, blood samples for laboratory testing, and radiologic tests. (See the box below.) As appropriate, they should administer medications and fluids.

How alcohol abuse and dependency affect laboratory values

TestResult
AlbuminDecreased
Aspartate aminotransferase (ALT)Increased

Ratio of ALT to alanine aminotransferase may
exceed 1.0 with alcoholic cirrhosis.

Gamma glutamyl transferaseIncreased
Mean corpuscular volumeElevated in liver disease and alcoholism
Total bilirubinIncreased
Uric acidIncreased

Intervention

Signs and symptoms of AWS may cause fear and anxiety in both patients and family members. During the acute detoxification phase, the main goal of nursing care is to manage symptoms by keeping the patient safe and comfortable, giving drugs as ordered, and minimizing complications. Provide nonjudgmental supportive care, perform a general assessment, evaluate nutrition and hydration status, and implement the management protocol. Be sure to assess the patient’s risk for falls and seizures, and use precautions as indicated. If the patient must be restrained, assess skin around the restraints hourly for breakdown and provide treatment, if needed. However, avoid restraints whenever possible.

Patient monitoring

Patients with AWS should be admitted to a telemetry unit with pulse oximetry used to measure oxygen saturation (SaO2); administer oxygen if SaO2 falls below 92%. A patient with moderate to severe AWS may be admitted to the intensive care unit or critical care unit for close monitoring and care. Provide safety precautions according to facility policy.

Closely monitor the patient’s vital signs, heart rhythm and rate, respirations, fluid and electrolyte balance, blood glucose level, skin, elimination, mental and neurologic status, and nutritional status. Bleeding tendencies from liver damage may necessitate vascular volume substitution or blood transfusions if the patient’s iron and blood volumes are diminished. Beta blockers may be used to control hypertension and tachyarrhythmias.

Give ordered medications in a timely manner to decrease symptom severity and ease the patient safely through the detoxification period. Assess the patient for unstable mood, such as delirium, psychosis, depression, and suicidal or homicidal ideation.

Every hour the patient experiences AWS signs or symptoms, complete the CIWA-Ar scale and obtain vital signs. Used to evaluate the patient’s progress during alcohol withdrawal, the CIWA-Ar takes 5 to 10 minutes to complete. It helps reduce the risk of under- or overmedicating and evaluates the patient’s response to treatment. The clinician assigns a score of 0 to 7 in each of 10 categories. The maximum score is 67 points; the higher the score, the more severe the AWS symptoms. A score of 10 or lower indicates mild symptoms that usually don’t warrant medication. A score of 15 or higher suggests increased risk of seizures and DT. Patients who score 10 or higher should receive medications (such as benzodiazepines or anticonvulsants) according to the management protocol to decrease withdrawal symptoms, seizure risk, and DT.

Continue to administer the CIWA-Ar hourly and give medications as ordered until the CIWA-Ar score is below 10 for 3 consecutive hours. At that point, assess the patient and administer the CIWA-Ar every 4 hours; if the score rises above 10, resume hourly CIWA-Ar assessment. If needed, titrate medications as ordered and expect to withhold sedatives for lethargy, abnormal vital signs, or neurologic abnormalities.

Using an AWS protocol

Every healthcare facility should have a management protocol or standing orders for acute alcohol withdrawal so nurses can intervene appropriately without constantly consulting the physician. A hospital-approved protocol is a physician order sheet filled out and signed by the physician that allows nurses to use certain medications, treatments, and guidelines to treat patients. (See the box below).

Medications

Most alcoholics have a high alcohol tolerance and may require larger dosages or more frequent dosing of medications such as psychoactives (for instance, benzodiazepines), anticonvulsants, antiemetics, antiarrhythmics, antihypertensives, analgesics, and skeletal muscle relaxants, to suppress alcohol withdrawal effects. Otherwise, the patient may experience unwanted side effects from alcohol cessation and undertreatment. Be aware that failure to manage pain could make detoxification more difficult—or even fatal.

Benzodiazepines (such as diazepam, chlordiazepoxide, oxazepam, and lorazepam) are the drugs of choice for AWS if the patient is experiencing anxiety, agitation, restlessness, hallucinations, and seizure activity. However, benzodiazepines are addictive and must be used carefully to avoid cross-addiction.

Nurses who haven’t been educated in chemical dependencies may be uncomfortable giving medications according to the AWS protocol. An up-to-date in-service program and yearly hospital competencies for nursing staff can give them a better understanding of the protocol. Increased ongoing education can help them recognize AWS signs and symptoms, understand appropriate treatments, and ease their anxiety.

Increasing patient comfort

Implement measures as needed to make the patient more comfortable. To the extent possible, provide a quiet, dark environment by dimming lights, and limiting environmental stimulation. To keep body temperature comfortable, apply or remove blankets as needed and adjust room temperature. Offer fluids every hour while the patient is awake and record fluid intake.

Provide an appropriate diet as tolerated. During times of nausea or vomiting, restrict oral intake. If the patient has epigastric distress, encourage deep breathing and relaxation. Administer antiemetics as needed and offer ice chips, cool cloths, and a fan for comfort if the patient desires.

Change the patient’s position as needed and use pillows for support. Adjust the head of the bed often. Make sure the call light is working and the bed is in a low position. If the patient is restrained, check skin around the restraints hourly.

Check the patient’s temperature frequently. Allow rest or sleep between assessments. Avoid disturbing the patient, especially during the acute withdrawal phase. Help the patient to the bathroom and record output. Keep the patient oriented to time, place, and person. Place family photos and familiar items from home, as well as a clock and calendar, where the patient can see them. Provide reassurance, and reinforce the patient’s progress and positive elements of treatment. Allow only family visitors, but limit them if needed.

Provide education about alcohol abuse, dependency, and withdrawal to the patient and family to give them a better understanding of AWS and help them cope with the situation. Education can be verbal or provided by pamphlets, handouts, videos, and Internet sources. Additional education topics may include the risk that alcohol abuse could worsen associated diseases (such as infectious diseases, cancer, diabetes, neuropsychiatric disorders, cardiovascular conditions, and liver and pancreatic disease).

For optimal patient outcomes, use appropriate screening forms and the hospital-approved AWS protocol. Consult the dietitian and chaplain (if desired). Make appropriate referrals (such as to social services) so the patient can be treated appropriately for alcohol abuse or dependency.

Rita K. Driver is an adult clinical nurse specialist at Jackson Purchase Medical Center in Mayfield, Kentucky.

Selected references

Elliott DY, Geyer C, Lionetti T, Doty L. Managing alcohol withdrawal in hospitalized patients. Nursing. 2012;42(4):22-30.

Lee Memorial Health System. Adult ICU Alcohol Withdrawal Protocol Orders. http://www.leememorial.org/FormsManagement/PDF/PhysicianOrders/CriticalCare/3354AlcoholWithdrawal.pdf. Accessed May 8, 2013.

National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much. Updated 2005. http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm. Accessed May 8, 2013.

National Quality Forum. National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices. Robert Wood Johnson Foundation; 2007. www.policyarchive.org/handle/10207/21566. Accessed May 15, 2013.

Ng K, Dahri K, Chow I, Legal M. Evaluation of an alcohol withdrawal protocol and a preprinted order set at a tertiary care hospital. Can J Hosp Pharm. 2011;64(6):436-45.

Phillips S, Haycock C, Boyle D. Development of an alcohol withdrawal protocol: CNS collaborative exemplar. Clin Nurse Spec. 2006;20(4):190-8.

Pittman B, Gueorguieva R, Krupitsky E, Rudenko AA, Flannery BA, Krystal JH. Multidimensionality of the Alcohol Withdrawal Symptom Checklist: a factor analysis of the Alcohol Withdrawal Symptom Checklist and CIWA-Ar. Alcohol Clin Exp Res. 2007;31(4):612-8.

Rehm J. The risks associated with alcohol use and alcoholism. Alcohol Res Health. 2011;34(2):135-43.

Reiners G. Alcohol withdrawal assessment training protocol: a case study. J Nurs Care. 2012;1:5. omicsgroup.org/journals/2167-1168/2167-1168-1-118.pdf. Accessed May 8, 2013.

Riddle E, Bush J, Tittle M, Dilkhush D. Alcohol withdrawal: development of a standing order set. Crit Care Nurse. 2010;30(3):38-47.

Sirohi S, Bakalkin G, Walker BM. Alcohol-induced plasticity in the dynorphin/kappa-opioid receptor system. Front Mol Neurosci. 2012;5:95.

U.S. Department of Health and Human Services. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2011. www.samhsa.gov/data/nsduh/2k10nsduh/2k10results.htm. Accessed May 8, 2013.

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