Chamberlain College of Nursing

Abstract (NR 709)

Please use the following headings for the abstract. The abstract should be brief, 150-200 words.

Background:

Problem:

Methods:

Intervention:

Results:

Conclusions:

 Keywords: [Click here to add keywords.]

Dedication (NR 709)

[Directions – In NR709- a dedication provides the author with the opportunity to thank people who may have special meaning in the author’s life. For example – you may want to thank your spouse or a specific family member for their support during your doctoral education. The dedication should be concise and convey your appreciation for these individuals while you were a Doctor of Nursing Practice student.]

Acknowledgment (NR 709)

[Directions –In NR709– the acknowledgment page is reserved for the author to acknowledge the important role specific professionals have made toward the successful completion of the project, for example, your course faculty, your preceptor, stakeholders, and members of your DNP practicum course faculty.

Table of Contents

Abstract……………………………………………………………………………………….2

Dedication…………………………………………………………………………………….3

Acknowledgment……………………………………………………………………………..4

Introduction…………………………………………………………………………………..6

Problem……………………………………………………………………………………….6

Project Aim and Supporting Objectives………………………………………………………7

Practice Question………………………………………………………………………………7

Evidence-Based Intervention with Research Synthesis………………………………………7

Methodology………………………………………………………………………………….8

Organizational Setting……………………………………………………………………..8

Population Description…………………………………………………………………….8

Theoretical Model and Project Management……………………………………………..9

Plans for Sustainability……………………………………………………………………9

Barriers, Facilitators, Ethical Considerations (NR 705)…………………………………….11

Data Collection and Analysis  Plan (NR 705)………………………………………………11

Required Resources and Proposed Budget (NR 705)……………………………………….12

Results (NR 709……………………………………………………………………………..12

Conclusions (709)……………………………………………………………………………13

Clinical Relevance (709)…………………………………………………………………….13

References……………………………………………………………………………………15

Appendices, Tables, and Figures…………………………………………………………….16

Appendix A Johns Hopkins Individual Evidence Summary Table………………………….16

Appendix B………………………………………………………………………………….21

Appendix C………………………………………………………………………………….22

Appendix D………………………………………………………………………………….23

Appendix E………………………………………………………………………………….24

Tables………………………………………………………………………………………..25

Figures……………………………………………………………………………………….27

 

 

 The Modified Minnesota Detoxification Scale for the Assessment of Alcohol Withdrawal Severity in Adults Admitted to a Rural Minnesota Hospital

Alcohol use disorder (AUD) has increased over the past three years during the COVID-19 pandemic. Alcohol use disorder is the third leading preventable cause of mortality and morbidity in the US (Centers for Disease Control and Prevention [CDC],2022; Lawsi et al., 2021). Minnesota is fifth among the fifty-one states and territories with adults who report excessive drinking and 17th for overall alcohol consumption (Minnesota Department of Health, 2022). Alcohol Withdrawal Syndrome (AWS) occurs with the abrupt cessation of alcohol, which causes severe illness and death (Goodberlet et al.,2021). Implementing an effective assessment tool that can recognize the progression of AWS in hospitalized patients can reduce hospital costs, decrease the utilization of resources, and save lives (Nguyen & Lam,2020).

The DNP manuscript introduces an evidence-based intervention to improve the care of patients admitted with alcohol withdrawal syndrome. The proposed aim of this project is to use the modified Minnesota Detoxification Alcohol Severity Scale (mMINDS), an assessment tool for documenting alcohol withdrawal severity and directing symptom-scheduled therapy. The process requires initiating mMINDS and educating hospital staff on AUD and the treatment of AWS. mMINDS success is the result of the rapid identification and management of AWS.

The practice problem is an inaccurate assessment of AWS patients, leading to disease progression in hospitalized patients. The current assessment tool CIWA-AR has limitations, including the need for patient response, which can create a misleading low score.  Implementing the mMINDS scale as a compelling evidence-based practice (EBP) assessment tool that can recognize the progression of AWS in hospitalized patients can reduce hospital costs and decrease resource utilization. The gap in practice occurred with the current health system change in treatment philosophy from symptom trigger medications to scheduled AWS treatment medications. Further, the observed gap in practice is the lack of clinical assessment precision and accuracy with CIWA-Ar, which mMINDS alleviates when treating AWS. The DNP manuscript will cover the practice problem, the project’s aims and objectives, practice questions, research synthesis and evidence-based interventions, methodology, project results, and conclusions.

Problem

The impact of AUD on the multiplicity of co-morbid complications, including alcohol withdrawal syndrome, has significant prevalence in the United States and the world. The Centers for Disease Control and Prevention (CDC) states that alcohol misuse is one of the leading preventable causes of death in the United States. AUD claims 95,000 deaths every year, making it the third leading cause of premature deaths in the country (CDC, 2022). The proportion of Americans battling with alcohol use disorder has expanded exponentially with COVID-19. According to an estimation, AUD affects 14.5 million adults in the US aged eighteen and older, making up a substantial part of the adult population (Koob, 2022).

The mortality rate from AWS is astonishing. It is as high as 15% of untreated cases of delirium tremens (Elliott, 2019). Progression of AWS is the most dangerous, encompassing neurologic disruptions, including vision, consciousness, cognition, perception, memory orientation, and language, in addition to autonomic hyperactivity that can lead to lower cardiac output (Elliott, 2019). Minnesota has seen a surge in AUD and hospital admissions for AWS (Gloppen et al., 2023). Traditionally, the prevalence of alcohol use disorder is highest among white males. However, in Minnesota, Native American males have the highest rate of binge drinking at 32% compared to white males at 23.8%. Binge drinking increases the risk of AUD. Alcohol-attributable deaths (motor vehicle collisions, falls, and worsening comorbid diseases) in Minnesota have increased over the past 4-5 years (Gloppen, 2021). The rural practicum site is neighboring three Native American reservations, whose members represent a sizable portion of the patient population. Native American people’s mortality from alcohol has increased by 43.6% from 2000- 2018 (Braun et al., 2021). AWS awareness prompts interventions and treatment that stymies AWS progression and prevents end-of-life.

mMINDS is a compelling assessment tool that is accurate, adaptable, and applicable to patients hospitalized with AWS. The gap in practice occurred with the change in treatment philosophy from medication trigger treatment to scheduled medication dosage. The gold standard alcohol severity assessment tool is the Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA-Ar) (Steel et al.,2021). The CIWA scale is a 10-item scale that requires input from the patient. CIWA-Ar has been challenging for patients who cannot answer questions, such as intubated patients (Littlefield et al.,2018). Also, there are subjective assessments that an inexperienced nurse would not accurately score. An inaccurate CIWA score would hinder appropriate medication administration that causes oversedation or progression of AWS to delirium tremens. My practicum site has adopted phenobarbital as their maintenance treatment of AWS. They are attempting to “move away” from CIWA-Ar because of the increase in sedation and prolongation of hospital stays.

 

Project Aim and Supporting Objectives

My project aims to implement the modified Minnesota Detoxification Scale (mMINDS) as the assessment tool to determine alcohol withdrawal severity and reduce the length of hospital stay. mMINDS assessment comprises nine items to assess alcohol withdrawal severity. This project aims to replace CIWA-AR, the current alcohol severity assessment tool, with mMINDS. mMINDS. The following objectives are:

1. The mMINDS assessment of alcohol severity tool will provide more accuracy of alcohol withdrawal severity and disease progression.
2.  The patients admitted with AWS will have a shorter length of stay.
3. The nursing staff will adopt mMINDS as the replacement AWS assessment tool.
4. The nursing knowledge and assessment skills of AWS will be  enhanced

 

Practice Question

The following practice question will serve as the basis for the DNP project.

In adult patients admitted to a rural Minnesota hospital with alcohol withdrawal, what is the impact of the modified Minnesota Detoxification Scale alcohol withdrawal severity assessment tool on the length of hospital admission within ten weeks?

 

Research Synthesis and Evidence-Based Intervention

Evidence-Based Intervention

The specific evidence-based intervention implemented in this project is the Modified Minnesota Detoxification Scale for the assessment of alcohol withdrawal severity in adults admitted to a rural Minnesota Hospital to reduce hospital length of stay. The mMINDS is an assessment tool used to assess the severity of alcohol withdrawal symptoms and guide treatment. It involves assessing symptoms, including tremors, sweating, anxiety, agitation, diastolic blood pressure, heart rate, and hallucinations. The total score identifies the level of withdrawal severity that the patient is experiencing, which determines treatment. The mMINDS assessment ensures accurate, consistent evaluation and that the logarithmic treatment is specific to each patient, thus improving patient safety and the quality of care during alcohol withdrawal (Nguyen & Lam, 2020). The United States organizations that recognize mMINDS include the Substance Abuse and Mental Health Services Administration (SAMHSA), the American Society of Addiction Medicine (ASAM), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). These organizations offer best-practice guidelines and resources for managing alcohol withdrawal and support the use of recommended standardized assessment tools such as mMINDS.

Evidence Synthesis

            This literature synthesis aims to determine the impact of implementing mMINDS in evaluating the severity of alcohol withdrawal. The authors use a variety of study designs in the ten current peer-reviewed studies. This synthesis comprehensively reviews the empirical evidence for implementing mMINDS in rural and tertiary healthcare systems.

A grading system synthesizes the evidence for a more comprehensive understanding of the literature (Dang et al., 2022). The Johns Hopkins Levels of evidence were used to determine the level and quality of the research (Dang et al., 2022). The studies level categories were found to be: two of the selected articles are Level II, seven articles are Level III, and one study is Level V. This distribution gives a clear and diverse picture of the quality of evidence for the feasibility and efficacy of mMINDS as an effective alcohol withdrawal assessment tool.

The Level II evidence, Harris et al. (2019) quantitative retrospective study targeted the surgical and trauma ICU environment. The results revealed the efficacy of the mMINDS score-based symptom-triggered protocol, which yielded less benzodiazepine consumption and a trend to reduced treatment length and intubation frequency.

The Level III evidence involving the articles by Lewis-Wolfson et al. (2024), Bradley et al. (2023), Huang& Bhalla (2021), Khan et al. (2023), Krcmarik et al. (2021); Miller et al. 2023 Patel et al. (2022) illustrates the usability of mMINDS. These studies, performed in various healthcare facilities, included correlational research, retrospective chart review, and cohort-based research, stressing the clinical outcomes of mMINDS, which reduced benzodiazepine utilization, fewer hospital days, and reduced patient mortality during alcohol withdrawal.

Furthermore, supplementing the synthesis with Level V evidence from Smith et al. (2020) enriches the synthesis with a valuable point of view as this was a quality improvement project; it provides practical insight into the possibilities of using mMINDS in a medical ICU environment. The findings of their study indicate a significant reduction in the mean cumulative benzodiazepine dose after implementing mMINDS-based protocols, thus offering real-world evidence of mMINDS’ efficacy.

Altogether, the evidence synthesis gives a general insight into the effectiveness of mMINDS as an assessment tool for identifying the severity of alcohol withdrawal. Regarding the heterogeneity of the studied methodologies and healthcare contexts, mMINDS is a valuable tool in enhancing patients’ care and safety during alcohol withdrawal. Therefore, implementing the findings in clinical practice is a possibility to improve the outcome of the treatments as well as the patient’s condition during alcohol withdrawal.

Main Themes in the Research

The main themes that emerged during the literature review are a) the Nurse preference and usability of the mMINDS assessment tool, b) enhanced patient safety and positive clinical outcomes, reduced benzodiazepine use, and hospital stay reduced resource utilization, specifically patient hospital days.

Nurse Preference and Usability of Assessment Tools. The research studies indicate that nurses prefer mMINDS over other assessment tools like CIWA-Ar because the assessment points are easy to understand and correlate with clinical assessments (Bradley et al., 2023; Harris et al.,2019; Smith et al.,2020). The significance of nursing preference is the enhanced likeliness of using the less cumbersome mMINDS compared to CIWA-Ar, as indicated by the frequency of reassessment and reduced need for medications (Bradley et al., 2023; Smith et al., 2020). Frequent nursing assessments correspond to reduced benzodiazepine administration and over-sedation, resulting in shorter ICU days (Harris et al., 2019; Smith et al., 2020).

Clinical Outcomes and Patient Safety. mMINDS, with its focus on frequent nursing assessment, earlier intervention, and reduced nosocomial injury, has been proven to enhance clinical outcomes and patient care significantly (Khan et al.,2023; Krcmarik et al., 2023; Miller et al., 2023). This reassures healthcare professionals, researchers, and policymakers about the effectiveness of mMINDS in improving patient outcomes.
The literature review of charts of patients with alcohol withdrawal compared the mMINDS tool against the CIWA protocol and found that mMINDS was associated with lower mortality and fewer days in the ICU, which assists that also directly affects nursing performance and job satisfaction (Bradley et al., 2023; Goodberlet et al., 2019; Smith et al., 2020). Also, implementing a protocol that used mMINDS assessments demonstrated improvements in patients’ clinical status and safety in a rural hospital. Furthermore, the mMINDS assessment observed decreased proportion and duration of uninterrupted benzodiazepine use, mechanical ventilation proportion, and ICU-acquired pneumonia rates in adult ICU patients (Miller et al., 2021). This theme indicates the potential for success and sustainability of the intervention linked to clinical benefits and enhanced quality of care.

Reduction in Benzodiazepine Use and Hospital Stay. As highlighted above, mMINDS implies lower mortality levels, less time spent in the ICU, and improved patient results, leading to clinical enhancements and safety (Miller et al., 2021). The results of the studies confirmed that mMINDS assessment enables a decrease in the consumption of benzodiazepines and a decrease in the days spent in the hospital (Huang & Bhalla, 2021; Lewis-Wolfson et al., 2024; Nelson et al., 2019l; Patel et al. 2022; Smith et al.,2020;). Moreover, Smith et al. (2020) noted a statistically significant reduction in the mean cumulative dose of benzodiazepines and the length of stay in the ICU after adopting the mMINDS protocol, as did other reviewed researchers in this review (Lewis-Wolfson et al., 2020; Patel et al., 2020). Hence, the theme is reducing medication utilization by effective patient symptom management during an AWS event. This theme is related to the success of the intervention since the protocols employed in mMINDS effectively reduce benzodiazepine doses, hospital days, and ICU-LOS, which benefit patient care.

Smith et al. (2020) established that the clinical efficacy of mMINDS is superior to CIWA because it lowers mortality rates and the length of stay in the ICU. Krcmarik et al. (2023) found out that there was a marked clinical improvement, and safety was also improved when MINDS-based protocol was implemented in a rural hospital.  Lewis-Wolfson et al. (2024) have shown that the mMINDS protocol contributes to reducing the length of ICU stay and mortality compared to CIWA. Miller et al. (2021) noted reduced benzodiazepine prescribing, mechanical ventilation, and ICU-acquired pneumonia rates following mMINDS implementation. Nelson et al. (2019) offered comparative data about the differences in outcomes of benzodiazepine and barbiturate protocols, as well as the need to understand the specificities of the correct symptom-triggered regime. Patel et al. (2022) further proved that patients who received high-dose diazepam following the mMINDS protocol had shorter hospitalization and needed fewer physical restraints.

 

Contrasting Elements in the Research

The studies varied in study design as there were dissimilar settings, patient criteria, treatment medications, and study duration. The studies varied on AWS severity, including ICU (either surgery-trauma or medical), emergency department, or medical-surgical (floor) settings in local, rural, and tertiary hospitals (Harris et al.,2019; Hyang &Bhalla, 2021; Krcmarik et al., 2023). The diffuse patient population gives mMINDS higher credibility in effectively and accurately assessing all levels of AWS patients. The studies that included patients’ characteristics (gender, age, race, comorbidities, etc.) as a factor in using mMINDS consistently correlated with CIWA-Ar and had improved patient outcomes, which is a further demonstration of the versatility of mMINDS (Butterfield et al., 2020; Huang & Bhalla, 2021).

There was a variation in the treatment practices with researchers using traditional benzodiazepines associated with CIWA-AR scoring or high-dose benzodiazepines versus alternative agents such as phenobarbital, dexmedetomidine, or gabapentin to treat the pharmacokinetics of AWS while implementing mMINDS as the assessment tool (Nelson et al., 2019; Petal et al.,2022).

Studies differed in the duration of data collection and analysis. For instance, some studies gathered data for 23 months versus 224 hours utilizing cross-sectional, case-controlled, cohort designs and pre/post-intervention retrospective designs (Miller et al., 2021; Nelson et al., 2019)

Finally, the studies focused on several variables, such as symptom-trigger therapy, scheduled dosing, complications (intubation, hypotension, transfers, etc.), and correlation to CIWA-Ar (Bradley et al., 2021.; Harris et al., 2019; Miller et al., 2021). Notably, the reviewed studies found statistical differences in the length of hospitalization, ICU duration, lower total dosing of benzodiazepines, and a significant reduction in morbidity and mortality of hospitalized AWS patients (Butterfield et al., 2020; Krcmarik et al., 2023; Miller et al.,2021; Patel et al., 2021). The different study variables highlight the complexity of AWS patients, the disease process, and the treatment that prevents mortality. Also highlighted is the success of the mMINDS tool in ascertaining disease progression and directing treatment in various patient populations and clinical settings.

Research Support for the Evidence-Based Intervention

The findings of these ten studies support the utility of mMINDS as an assessment tool for severe AWS across various settings. Bradley et al. (2023) demonstrated that mMINDS was the preferred tool concerning usability, and its correlation with CIWA-Ar was high. Also, nurses had higher clinical satisfaction and user confidence with mMINDS than with CIWA-Ar. Another study by Harris et al. (2019) showed that mMINDS-based, symptom-triggered protocol in surgical and trauma ICUs reduced the number of benzodiazepines administered and the intubation rate. Huang & Bhalla (2021) demonstrated the benefits of the mMINDS-directed symptom-triggered protocol, which lowered benzodiazepine dosages, hospital days, the incidence of disease progression, and intubation.

The presented research of these studies shows that the mMINDS protocol is effective and safe for managing AWS. This evidence, including the satisfaction of the nurses and the clinical outcomes, including the reduction in benzodiazepine use, length of hospitalization, and mortality, make the mMINDS protocol worthy of clinical practice implementation.

 

 

Methodology

Organizational Setting

The project will occur in a 10-bed ICU in a rural Minnesota hospital. The typical patient population supported by this facility contains patients from three Native American reservations, and it is diverse. A typical patient who will be admitted to the ICU with AWS most often presents with comorbid conditions such as liver disease and cardiovascular and mental health disorders. On average, 10-15 patients will be admitted in a month with AWS. Lengths of stay are variable and may be several days to greater than one week based on symptom severity and relative response to treatment. Interdisciplinary team members caring for these patients include nurses, hospitalists, pharmacists, and social workers, with comprehensive management provided by the team (Bradley et al., 2023).

Population

The study participants will be adult patients between 18 and 99 years old, admitted to the rural hospital with AWS/AUD DSM/ICD 10 criteria without an allergy to phenobarbital or benzodiazepines. About 8–10 participants are projected for the sample size. Patients will be identified as part of their regular admissions to the hospital. Informed consent is unnecessary as the intervention is standard of care. The population for this quality improvement project includes nursing staff, hospitalist staff, and adult patients admitted to the rural hospital with alcohol withdrawal syndrome (AWS). Inclusion criteria for nursing staff are all nurses who care for patients with AWS in a rural 10-bed ICU. Hospitalist providers manage all hospitalized patients in rural settings and are responsible for prescribing the mMINDS tool and medications. Inclusion for all provider participants is voluntary. The inclusion criteria include adult patients diagnosed with AWS, and the exclusion criteria include patients who do not have AWS and have not been intubated or required transfer to tertiary care referral centers (Souphis & Weitz, 2022).

Anticipated population size: 8-10

Inclusion criteria: Adults 18-99, admitted with AWS or symptomatic alcohol use disorder.

Exclusion criteria:  allergies to phenobarbital or benzodiazepines

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Formative Evaluation Plan

The project’s formative evaluation design plan ensures high intervention fidelity and promptly identifies issues during implementation. The project will utilize a combination of observation, 1:1 discussion, huddles, leadership meetings, and other processes for a comprehensive week-to-week assessment to integrate mMINDS into the treatment of patients admitted with alcohol withdrawal.

Steps and Tools for the Week-to-Week: Formative Evaluation Process

1. Educate Staff: Modified Minnesota Detoxification Scale to assess alcohol withdrawal severity. The patient populations are adults admitted to the ICU with alcohol withdrawal. mMINDS will be a standard of care to replace CIWA-Ar.

I will conduct training sessions for ICU staff, including nurses, physicians, and other healthcare providers, on the mMINDS tool, its scoring criteria, alcohol use disorder, alcohol withdrawal syndrome, and the importance of early detection and management of alcohol withdrawal.

• Scoring Criteria: I will ensure all staff are familiar with the specific criteria and scoring components of the mMINDS tool, including:
  • Blood Pressure: Monitor and score based on systolic and diastolic readings.
  • Heart Rate: Record and score based on beats per minute.
  • Other Symptoms: Assess and score other symptoms such as tremors, sweating, agitation, and orientation.
• Documentation: I will encourage staff to maintain accurate and timely documentation of all assessments and scores in the patient’s medical record and on the provided paper assessment tool located at the patient’s bedside
•  I will conduct direct observations of staff using the mMINDS tool. I will note any deviations from the protocol and gather initial feedback.
• If deviations from the protocol or identified areas of improvement, I will address them in real time.

2. 1:1 Discussions
   I will schedule weekly 1:1s with team members to receive qualitative feedback on the tool’s implementation and any difficulties they may be experiencing.
3. Huddles
   I will hold brief stand-up huddles 1-2 times weekly to discuss immediate concerns and remind staff to use the mMINDS assessment tool effectively.
4. Leadership Meetings (Preceptor and Project leader)
   I will schedule weekly leadership meetings with my preceptor and me to review the implementation plan’s progress and the information compiled, make appropriate revisions, and collect bedside mMINDS assessment sheets.
5. Questionnaires and Feedback Forms
   I will perform a weekly quantitative assessment of the confidence and competence of all staff through surveys, feedback forms, 1:1 discussions, and secure chats with me.

If formative evaluation results show low intervention fidelity,

1. Identify issues
   I will conduct an initial analysis to pinpoint a break in fidelity, collect feedback from staff, and review mMINDS assessment records.
2. Targeted Training
   I will organize focused training sessions addressing the specific concerns identified in Week 1 and emphasize the importance of accurate scoring and documentation.
3. Increased monitoring
   I will Implement more frequent and detailed monitoring of the intervention and schedule additional check-ins and audits to ensure adherence to the protocol.
4. Mentorship and Support
   My preceptor and I will mentor and support staff members struggling with the implementation, providing one-on-one guidance and practical tips.

 

5. Tweak Implementation Plan

I will modify the implementation plan based on feedback and observed challenges. I will adjust protocols to meet staff needs better and improve fidelity.

The following table outlines the week-to-week formative evaluation plan, detailing specific activities and the intervention week in which they will occur:

 

Week	Activity	Description
1	Initial Training and Baseline Assessment	The project leader conducts comprehensive training sessions, and baseline assessments were conducted to gauge initial staff understanding of Alcohol Use Disorder, an introduction to the mMINDS paper scale, and the treatment dot phrase.
2	Observation and Initial Feedback	Regular observations will begin, and initial feedback from staff will be collected through 1:1 discussions and surveys.
3	First Huddle and Leadership Meeting	The first huddle will address early challenges, followed by a review of progress in the leadership meeting.
4	Targeted Observation and Follow-Up Training	The preceptor and project leader will conduct targeted observations to identify specific issues, and follow-up training will be provided as needed.
5	Mid-Implementation Survey	Staff will complete a mid-to-implementation survey that assesses overall staff confidence and identifies any persistent issues.
6	Intensive Monitoring and Support	Monitoring will be increased, and additional support will be provided to ensure high intervention fidelity.
7	Data Review and Adjustments	Collected data will be reviewed with leadership, and necessary adjustments to the implementation plan will be made.
8	Final Huddle and Leadership Review	A final huddle and leadership review will be conducted to consolidate progress and address any last-minute issues.
9	Post-Implementation Feedback Collection	Comprehensive post-implementation feedback from nursing staff is gathered to evaluate the success and areas for improvement. The mMINDS assessment sheets are tallied weekly to assess the number of admission days and medications administered.
10	Final Evaluation and Reporting	A final evaluation will be conducted, and a detailed report on the intervention’s outcomes and fidelity will be prepared. This week will also include data retrieval from the EMR of patients admitted to the hospital with AWS/AUD codes for admission days and medication administration to be used for t-test analysis. Thank-you pizza party

 

 

 

 

 

 

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Theoretical Frameworks and Project Management

Theoretical Framework

The integrated Promoting Action on Research Implementation in Health Services (iPARiHS) framework guides the project, emphasizing the interplay between evidence, context, facilitation, and recipients in successful project implementation (Harvey & Kitson, 2015)

• Innovation: This component concerns the quality, applicability, and relevance of the research evidence (Olmos-Ochoa et al., 2021). In this project, the evidence was taken from research studies that support the superiority of the mMINDS tool over CIWA-Ar in confirming AWS. This evidence bolsters the need for an accurate and reliable assessment tool as a premise for improved patient outcomes in the management of AWS.
• Recipients: Recipients are the persons or groups who would have the implementation affected by them (Steffens et al., 2020). This project identifies the recipients as adult patients admitted to a rural Minnesota hospital with AWS and nurses who care for these patients. They benefit from a precision assessment tool that improves the management of AWS and enhances nursing knowledge.
• Context: Context refers to the environment or setting where the evidence is being implemented (Roberts et al.,2021). This includes the hospital’s cultural, organizational, and leadership aspects. The rural Minnesota hospital’s diverse patient population, including many from Native American reservations, presents unique challenges and opportunities. The hospital’s support, readiness for change, and engagement of the healthcare staff are crucial elements of the context that can influence the success of the implementation.
• Facilitation: Facilitation involves the processes and strategies to help people change their behaviors, attitudes, and work practices (Steffens et al., 2020). The DNP student, the project manager, will be the facilitator, providing the nursing staff with hands-on training, support, and feedback. Regular meetings and continuous education sessions will help address issues and ensure adherence to the new assessment protocol. Facilitation is a continuous process involving interaction and evaluation to ensure success. Facilitators are essential, as they can identify barriers and enablers and help overcome them. They must avoid burnout to sustain the implementation process, from engagement to empowering the recipients.

Facilitation Activities:

1. Education and training: The nursing staff shall receive in-service training via laptop PowerPoint presentation on the characteristics of the mMINDS tool, AWS, and other treatment protocols relevant to this training; practice will be combined with theory.
2. Regular Monitoring and Feedback: Monitor the use of the mMINDS tool regularly and provide feedback to staff about its usage. This will entail daily check-ins and weekly review meetings to discuss progress and challenges expected in the implementation process.
3. Supportive Leadership: Engage hospital nursing leadership in support of the implementation process, with increased efforts to make the needed resources and administrative backing available.
4. Ongoing Assessment and Adaptation: Continue to assess the implementation process, gather weekly data on mMINDS scores and patient outcomes, and adapt as appropriate based on feedback and findings.

Project Implementation Plan

The project will be implemented over 8- 10 weeks and divided into three phases:

Implementation Phase (Weeks 1)

• Staff Training and Pre-Implementation Testing

• • Conduct pre-implementation testing for two weeks before project implementation from hospital staff, including a quiz on AUD and AWS (National Institute of Alcohol Abuse and Alcoholism, 2022).
  • Give pre- and post-tests with questions like “Score CIWA for a patient with a slight tremor, alert, with BP 170/110, and HR 110, vs. score mMINDS for the same symptoms” (National Institute of Alcohol Abuse and Alcoholism, 2022).

 

• • Conduct training and education on the mMINDS tool through interactive sessions, exercises, hands-on experience, and case studies.
  • Distribute educational materials and resources for staff to study and reference.

• Present data from electronic medical record retrospective review for patients admitted for the eight-week pre-implementation/AUD.

 

Implementation Phase (Weeks 2–9)

• • Daily/hourly mMINDS assessments
  • Implement routine use of the mMINDS for all patients admitted with AWS. The frequency is to be determined by alcohol severity.
  • Monitor compliance with the new protocol, supporting and providing continuous feedback to staff.
  • Hold weekly meetings with the care team for progress, challenges, and training to be provided if necessary.

·        Week	Activity	Description
1	Initial Training and Baseline Assessment	Comprehensive training sessions and baseline assessments on the mMINDS tool will be conducted to gauge initial staff understanding.
2	Observation and Initial Feedback	Regular observations will begin, and initial feedback from staff will be collected through 1:1 discussions and surveys.
3	First Huddle and Project Meeting	The first huddle will address early challenges, followed by a review of progress in the project meeting.
4	Targeted Observation and Follow-Up Training	Targeted observations will be conducted to identify specific issues, and follow-up training will be provided as needed.
5	Mid-Implementation Survey	A mid-implementation survey will be distributed to assess overall staff confidence with alcohol withdrawal severity assessment and identify any persistent issues.
6	Intensive Monitoring and Support	Monitoring will be increased, and additional support will be provided to ensure high intervention fidelity.
7	Data Review and Adjustments	Collected data will be reviewed with leadership, and necessary adjustments to the implementation plan will be made.
8	Final Huddle and Leadership Review	A final huddle and leadership review will be conducted to consolidate progress and address any last-minute issues.
9	Post-Implementation Feedback Collection	Comprehensive post-implementation feedback will be gathered from staff to evaluate the success and areas of improvement.
10	Final Evaluation and Reporting	A final evaluation will be conducted, and a detailed report on the intervention’s outcomes and fidelity will be prepared.

 

Evaluation Phase (Weeks 10)

• Post-Implementation Testing
  •  The post-implementation, like the pre-test for the improvement evaluation of staff’s ability to use the mMINDS tool.
  • Analyze the test results and determine where the gap may have occurred in knowledge or applying the mMINDS tool
  • Collect data on hospital length of stay for the eight weeks of implementation
  • Compare pre- and post-implementation data to evaluate the effectiveness of the mMINDS tool in reducing hospital stays and improving patient outcomes.

All the participants will use the mMINDS tool continuously from admission to discharge, ensuring a comprehensive understanding of its effectiveness. Treatment is administered by registered nurses, who ensure that the therapy given is understood and concise (Rutledge et al., 2021). The study will collect data on details of medications administered, the results produced by mMINDS, and the length of hospitalization for each patient.

Plans for Sustainability

Sustainability plans include ongoing training and monitoring using the mMINDS alcohol severity assessment tool. This continuous effort is crucial for the tool’s sustainability and the audience’s confidence in its long-term success. Stakeholders will be dedicated to shifting from traditional CIWA-Ar assessments to the mMINDS assessment. Continuous education and audit feedback mechanisms will be set to maintain high intervention fidelity in long-term success (Joseph et al., 2023). Regular review meetings will be set up to establish the tool’s impact and make necessary changes based on feedback and data analysis. Nursing educational staff will continue to review mMINDS implementation and effectiveness.

Barriers, Facilitators, Ethical Considerations

Barriers

Staff Resistance: Nursing staff may initially resist introducing the mMINDS tool because it is unfamiliar. However, extensive training and continued support can overcome this, and it is associated with an increased nursing preference for mMINDS assessment (Bradley et al., 2023).

• Resource Constraints: Few resources may be available for holding training sessions and providing educational material (Barrio & Gual, 2023). This may be challenged by obtaining additional educational sources, such as using the health system’s educational programs (SABA).

Facilitators

• Strong Leadership Support: Engagement and

 

Ethical Considerations

Ethical considerations for this work will involve maintaining confidentiality, protecting patients’ rights, and obtaining IRB approval from Chamberlain University (Wood et al., 2018). The hospital does not require IRB approval.  The project will be undertaken according to ethical standards concerning patient involvement in care and data handling.

Plan for Data Collection and Analysis

Data collection

Data to be collected include recording mMINDS scores, symptom-triggered medication administration, and patient outcomes pre-and post-intervention. Data will also be collected from electronic health records and supplemented by reviewing the completed mMINDS assessment tool. Pre-intervention data collection aims to give a baseline length of stay using CIWA-Ar to compare the hospital length of stay after the implemented intervention. The hospital’s project leaders and preceptor can collect the scores while implementing the mMINDS tool. This hands-on approach ensures accurate data recording and prompt issue resolution. Daily scores and interventions are extracted from a paper scale and entered via a password-protected computer database for review. The following flow sheet will document and compare the mMINDS and CIWA-AR scores and the treatments administered for each scale.

Patient ID MRN

mMINDS Score

CIWA-AR Score

mMINDS Treatment

CIWA-AR Treatment

Hospital Day

Data Collection Plan

Description of Data Collection:

Pre-Intervention Phase: Use retrospective chart audits for the same time in 2023 to collect baseline data on alcohol withdrawal symptoms and management practices in the ICU.

Intervention Phase: Implement the mMINDS assessment tool in the ICU for 8-10 weeks

Post-Intervention Phase: Collect data on alcohol withdrawal symptoms and management practices using the mMINDS tool for two weeks following the intervention.

Data Collection Timeline:

Week 1: Retrospective chart audit for pre-intervention data and education to nursing staff on the mMINDS assessment tool.

Week 2-10-: Implement the mMINDS tool and data collection during the intervention phase.

Week 8-10: Post-intervention data collection using the mMINDS tool.

Retrospective Chart Audit

Pre-Intervention Data: Collect data on patient hospital length of stay, alcohol withdrawal symptoms, and management practices, including CIWA scores from electronic health records (EHR) during a similar time in 2023.

Post-Intervention Data: Collect nursing views on using the mMINDS tool for two weeks following the intervention.

Data Collection Instrument

Instrument: Minnesota Detoxification Scale (mMINDS) for assessment of alcohol withdrawal severity

Validity and Reliability: The mMINDS tool has been validated and has high inter-rater reliability and internal consistency (Bradley et al., 2023; Smith et al., 2020).

Permission: The mMINDS tool is in the public domain and does not require permission.

 

Data Analysis

The research will use descriptive statistics to compare patient demographics and clinical features. The duration of hospitalization and the number of medications between the pre-intervention and post-intervention phases will be compared through paired sample t-tests (Jaworowski et al., 2019). The significance level will be p < 0.05 (Nguyen & Lam, 2020).

Statistical Analysis

Descriptive Statistics: Summarize patients’ alcohol withdrawal symptoms and management practices.

Inferential Statistics: Use paired t-tests or Wilcoxon signed-rank tests to compare pre-and post-intervention data.

Comparison of Pre- and Post-Intervention Data

Outcome Measurement: Compare the severity of alcohol withdrawal symptoms, length of ICU stays, and patient outcomes before and after the implementation of the mMINDS tool.

Practice Change Outcome: Determine if implementing the mMINDS tool decreases patient length of hospitalization patient outcomes.

 

Required Resources and Proposed Budget

Required Resources

Training Materials: All learning resources, including printed guides, reels, digital demonstrations, and practical support materials.

Staff Training Hours: Time allotted for nursing staff to participate in initial and ongoing training sessions.

Data Collection Tools: Software is required for data collection, such as Excel for inputting data and statistical analysis.

Meeting Space: The nurse’s break room can be used for training and weekly evaluation meetings.

Administrative Support: The project leader and my preceptor will schedule educational times, recruit providers, enter data, and coordinate project activities.

Proposed Budget

The Budget includes training materials, staff training hours, and data analysis software expenses. Funding sources included hospital Budget allocations and external grants. The Budget table (Table 1 ) provides a detailed breakdown of expenses and funding sources, ensuring a balanced Budget (Krcmarik et al., 2023).

Expenses

1. Salary and Benefits: The calculated average hourly rate for training hours will be paid to nursing staff as per scheduled hours.
2. Training materials, such as printed guides and digital resources, will be developed to educate staff about the mMINDS tool.
3. Software licenses for data collection and statistical tools will be required to document and interpret all mMINDS scores and outcomes.
4. A professional statistician will be contracted to analyze the collected data, interpret the findings exhaustively, and report on them.
5. Meeting Space: A conference room will be hired for the initial training sessions and weekly review meetings to enable all staff to participate fully.
6. Administrative support addressed the coordination of project activities, including scheduling training sessions and assigning nurses willing to participate in the quality improvement project.

Sources of Revenue

1. External donations will be explicitly secured for the statistical analysis portion of the project so that the data presentation and interpretation will be meaningful and professional.
2. Institutional Budget Support: The hospital will invest its budgetary allocation toward most project expenses, as it should recognize the intervention’s value in improving patient outcomes and resource utilization.

Results (NR 709)

Refer to the assignment guidelines and rubric for the exact content required in this section. Present the results of your project. Represent the data from statistical results in tables or figures. Explain the results and what the results mean in the context of the purpose of the project and your stated outcome in your practice question.

Conclusions (NR 709)

Refer to the assignment guidelines and rubric for the exact content required in this section. Conclusions indicate what is known regarding nursing practice when your results and results from prior literature are considered together. Conclusions should relate directly to your purpose and practice question. You can discuss your thoughts on what may have affected the results. If your results are similar to those found in previous studies, you may state that. However, if your results are completely different and/or contradict previous studies, you should let the reader know that these results cannot be used beyond the project population and setting.

Clinical Relevance (NR 709)

Refer to the assignment guidelines and rubric for the exact content required to be in this section. Conclusions should relate directly to your purpose and project question. They are generalizations that look back to the existing literature on your topic. For each conclusion you make, cite the sources that support or contradict your findings. The conclusion should represent the contribution your practice project has made to the body of scientific knowledge on this topic and relate this to the significance of the project, which is always, in some way, to improve nursing practice. Conclusions indicate what is now known regarding nursing practice when your results and results from prior literature are considered together.

Implications for nursing or clinical relevance should answer: What do the findings mean to nurse leaders, and would society care about the results? Recommendations based on the findings should be for the nursing profession and to specific nursing leaders. Be sure to make specific recommendations for leaders in the nursing field and/or policy makers.

 

References

Bradley, M., Kiser, T. H., Mueller, S. W., Reynolds, P. M., & MacLaren, R. (2022). Correlation between and nursing satisfaction with CIWA-Ar, mMINDS, and SEWS scoring tools for the assessment of severe alcohol withdrawal syndrome in ICU patients. Annals of Pharmacotherapy, 57(2), 175–183. https://doi.org/10.1177/10600280221102562

Braun, N. J., Gloppen, K. M., & Roesler, J. (2021). Trends in deaths fully attributable to alcohol in Minnesota, 2000-2018. Public Health Reports, 137(6), 1091–1099. https://doi.org/10.1177/00333549211044019

Butterfield, M., Thorne‐Humphrey, L., Suzuki, J., & Herschenhous, N. (2020). Evaluation of A novel protocol for assessment and treatment of alcohol withdrawal syndrome in psychiatric inpatients. The American Journal on Addictions, 29(6), 500–507. https://doi.org/10.1111/ajad.13058

Centers for Disease Control and Prevention. (2022, July 11). Excessive alcohol use. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/alcohol.htm

Centers for Disease Control and Prevention (2023 November 13) Data on Excessive Drinking | https://www.cdc.gov/alcohol/datastats.htm#:~:text=According%20to%20the%20ARDI%20application

Dang D, Dearholt S.L., Bissett K, Ascenzi J, & Whalen M(Eds.), (2022 Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals Model and Guidelines, 4e. Sigma Theta Tau International Honor Society of Nursing. https://apn.mhmedical.com/content.aspx?bookid=3144&sectionid=264684927

Minnesota Department of Health (2021) Estimates of alcohol poisoning deaths. https://www.health.state.mn.us/communities/alcohol/documents/alcoholpoison2021.pdf

Goodberlet, M., Dube, K., Kovacevic, M., Szumita, P., & DeGrado, J. (2021). Evaluation of a phenobarbital-based protocol for severe alcohol withdrawal in critically ill patients. Hospital Pharmacy, 56(5), 550–559. https://doi.org/10.117/0018578720931464

Elliott, D. Y. (2019). Caring for hospitalized patients with alcohol withdrawal syndrome. Nursing Critical Care, 14(5), 18–30. https://doi.org/10.1097/01.ccn.0000578828.37034.c2

Harris, K., Mohrien, K., Bhimani, P., Beard, J., Dauer, E., Goldberg, A., & Pathak, A. (2019). 1739: Outcomes of a symptom-triggered protocol for alcohol with withdrawal in the Surgical and Trauma ICU. Critical Care Medicine, 47(1), 843. doi: 10.1097/01.ccm.0000552477. 50063.b5

Harvey, G., & Kitson, A. (2015). PARIHS revisited: From heuristic to integrated framework for the successful implementation of knowledge into practice:  Implementation Science, 11(1).

https://doi.org/10.1186/s13012-016-0398-2

Holaday, K., Hanovich, S., Beddow, D., & Patel, L. (2019, September 18). Minnesota Detoxification Scale (MINDS) Assessment Protocol for Treatment of Alcohol Withdrawal, Pre, and Post Implementation Comparison. Minneapolis; Abbott Northwestern Hospital. www.anwhospitalist.com/wp-content/uploads/2019/01/MINDS

Huang, P. W., & Bhalla, R. (2021). Implementation of a symptom–triggered protocol for severe alcohol withdrawal treatment in a medical step-down unit. Journal of Science Communication,28(3). https://cdn.mdedge.com/files/s3fs-public/JCOM02803134.PDF

Joseph, I., Renz, S., & Polomano, R. (2023). Evaluating Interventions and Outcomes in Patients Withdrawing from Alcohol. MEDSURG Nursing, 32(3), 190–196.

Khan, S., Anwar, J., Rojas, E., Badami, V., Kovacic, N., Troyer, B., & Hadique, S. (2023). Modified Minnesota Detoxification Scale (mMINDS) protocol assessment for treatment of patients with severe alcohol withdrawal. In C46. Studies In Cardiac Arrest, ICU Pharmacy, And Alcohol Withdrawal. American Journal of Respiratory and Critical Care Medicine: A5154 https://doi.org/10.1164/ajrccm-conference.2023.207.1_MeetingAbstracts.A5154

Krcmarik, K. M., Hulley, B. J., Huang, J., Juang, D., Cadman, P., Urbiztondo, C., Vo, C., Vargas, J., Motarjemi, R., Moinizandi, T., & Kwan, B. (2023). Assessment of a modified minds‐based protocol for management of alcohol withdrawal syndrome on an inpatient medical service. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. https://doi.org/10.1002/phar.2855

Miller, M., Limouze, K., Mohrien, K., & Pathak, A. (2020). 881: Impact of symptom-triggered protocol for the management of alcohol withdrawal in the ICU. Critical Care Medicine, 49(1), 437–437. https://doi.org/10.1097/01.ccm.0000729412.71792.4e

 

National Institutes of Health(2023, July). Risky alcohol use: An epidemic inside the COVID-19 pandemichttps://covid19.nih.gov/news-and-stories/risky-drinking-alcohol-use-epidemic-inside-covid-19-pandemic

Nelson, A. C., Kehoe, J., Sankoff, J., Mintzer, D., Taub, J., & Kaucher, K. A. (2019). Benzodiazepines vs barbiturates for alcohol withdrawal: Analysis of 3 different treatment protocols. The American Journal of Emergency Medicine, 37(4), 733–736. https://doi.org/10.1016/j.ajem.2019.01.002

Laswi, H., Attar, B., Kwei, R., Ojemolon, P., Ebhohon, E., & Shaka, H. (2022). Trends of alcohol withdrawal delirium in the last decade: Analysis of the nationwide inpatient sample. Gastroenterology Research, 15(4), 207–216. https://doi.org/10.14740/gr1550

Lewis-Wolfson, T., Switzer, M., Williamson, L., Joyner, K., & Morgan, K. (2024). 120: CIWA versus MINDS in alcohol withdrawal syndrome: A retrospective cohort analysis. Critical Care Medicine, 52(1), S35. Doi: 10.1097/01.ccm.0000998672.04475.6a

Nguyen, T. A., & Lam, S. W. (2020). Phenobarbital and symptom-triggered lorazepam versus Lorazepam alone for severe alcohol withdrawal in the Intensive Care Unit. Alcohol, 23–27. https://doi.org/10.1016/j.alcohol.2019.07.004

Olmos-Ochoa, T. T., Ganz, D. A., Barnard, J. M., Penney, L., Finley, E. P., Hamilton, A. B., &

Chawla, N. (2021). Sustaining implementation facilitation: A model for facilitator resilience.

Implementation Science Communications, 2(1). https://doi.org/10.1186/s43058-021-00171-4

Patel, L., Beddow, D., Kirven, J., Smith, C. S., Hanovich, S., Holaday, K., Agboto, V., & St. Hill, C. A. (2022). Outcomes of Minnesota detoxification scale (MINDS) assessment with high dose front-loading diazepam treatment for alcohol withdrawal in hospitalized patients. The American Journal of the Medical Sciences, 363(1), 42–47. https://doi.org/10.1016/j.amjms.2021.10.003

Roberts, N., Janda, M., Stover, A., Alexander., Wyld, D., & Mudge, A. (2021). The utility of the implementation science framework “Integrated Promoting Action on Research Implementation in Health Services” (i-PARIHS) and the facilitator role for introducing patient-reported outcome measures (PROMs) in a medical oncology outpatient department. Quality of Life Research, 30(11), 3063–3071. https://doi.org/10.1007/s11136-020-02669-1

Rutledge, S. M., Schiano, T. D., Florman, S., & Im, G. Y. (2021). COVID-19 aftershocks on Alcohol‐associated liver disease: An early cross‐sectional report from the U.S. epicenter. Hepatology Communications, 5(7), 1151–1155. https://doi.org/10.1002/hep4.1706

Smith, R. M., Benzio, B., Hendrickson, A. L., Telford, E. D., & Franck, A. J. (2020). Implementation of the modified Minnesota detoxification scale (MMINDS) for alcohol withdrawal syndrome in critically ill patients. The Joint Commission Journal on Quality and Patient Safety, 46(11), 656–658. https://doi.org/10.1016/j.jcjq.2020.08.006

Souphis, O., & Weitz, E. (2022). Which assessment tools are most useful for identifying hospitalized patients at risk of developing severe alcohol withdrawal syndrome? Evidence-Based Practice, 26(3), 18–19. https://doi.org/10.1097/ebp.0000000000001814

Steel, T. L., Giovanni, S. P., Katsandres, S. C., Cohen, S. M., Stephenson, K. B., Murray, B., Sobeck, H., Hough, C. L., Bradley, K. A., & Williams, E. C. (2021). Should the CIWA-Ar be the standard monitoring strategy for alcohol withdrawal syndrome in the Intensive Care Unit? Addiction Science & Clinical Practice, 16(1). https://doi.org/10.1186/s13722-021-00226-w

Steffen, K. M., Holdsworth, L. M., Ford, M., Lee, G. M., Asch, S. M., & Proctor, E. K. (2020). Implementation of clinical practice changes in the PICU: A qualitative study using and refining the IPARIHS framework. Research Squarer, (1) 1–23. https://doi.org/10.21203/rs.3.rs-76124/

 

U.S. Department of Health and Human Services. (n.d.). Alcohol use disorder: From risk to diagnosis to recovery. National Institute on Alcohol Abuse and Alcoholism. https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/alcohol-use-disorder-risk-diagnosis-recovery

 

 

Appendices, Tables, and Figures

Appendix A

 

Johns Hopkins Nursing Evidence-Based Practice

Individual Evidence Summary Tool

Ó The Johns Hopkins Hospital/The Johns Hopkins University

Practice Question: In adult patients admitted to a rural Minnesota hospital with alcohol withdrawal, what is the impact of the modified Minnesota Detoxification Scale alcohol withdrawal severity assessment tool on the length of hospital admission within ten weeks?

Date: 5/25/2024

 

Article Number	Author and Date	Evidence Type	Sample, Sample Size, Setting	Findings That Help Answer the EBP Question	Observable Measures	Limitations	Evidence Level, Quality
	Bradley, M., Kiser, T. H., Mueller, S. W., Reynolds, P. M., & MacLaren, R. (2023). Correlation between and nursing satisfaction with CIWA-Ar, mMINDS, and SEWS scoring tools for the assessment of severe alcohol withdrawal syndrome in ICU Patients. Annals of Pharmacotherapy, 57(2), 175–183. https://doi.org/10.1177/10600280221102562	Quantitative correlational study.	Patients with AWS in ICU, 21 patients, 49 nurses, single-center study.	The mMINDS tool was deemed the most user-friendly by nurses and emerged as their preferred choice. While the CIWA-Ar and SEWS tools demonstrated strong correlations with mMINDS, they were not favored as highly.	CIWA-Ar: 14 ± 8.3, mMINDS: 13.9 ± 6.5, SEWS: 10.1 ± 4.5; Pearson correlation coefficients: CIWA-Ar and mMINDS: 0.814, CIWA-Ar and SEWS: 0.722, SEWS and mMINDS: 0.658.	Small sample size, single-center study, potential bias in nurse self-reporting on ease of use.	Level III (Non-randomized study), Quality B (Good).
	Butterfield, M., Thorne‐Humphrey, L., Suzuki, J., & Herschenhous, N. (2020). Evaluation of A novel protocol for assessment and treatment of alcohol withdrawal syndrome in psychiatric inpatients. The American Journal on Addictions, 29(6), 500–507. https://doi.org/10.1111/ajad.13058	A quantitative retrospective cohort study	Single center 138 psychiatric patients admitted for nonalcohol-related psychiatric illness but developed or were at risk of developing AWS. TAU (CIWA-Ar) 83 Novel treatment (not named) 55	CIWA-Ar was not an effective tool to assess psychiatric patient because of their inability to accurately participate in CIWA-Ar assessment.	The average benzodiazepine dose in the TAU group is 5 mg versus 30 mg in the Novel Group. The average duration of treatment in the Novel Group was 19 hours, compared to 0 hours in the TAU group. Adverse hospital events in the Novel group were 0 compared to 4.8% adverse events in the TAU.	The retrospective cohort study did not control AWS severity. Staff training was varied, and physician prescribing was not controlled. The data were collected nonrandomized.	Level III Quality B Good
	Harris, K., Mohrien, K., Bhimani, P., Beard, J., Dauer, E., Goldberg, A., … & Pathak, A. (2019). 1739: Outcomes of a Symptom-Triggered Protocol for Alcohol Withdrawal in the Surgical and Trauma ICU. Critical Care Medicine, 47(1), 843. DOI: 10.1097/01.ccm.0000552477. 50063.b5	Quantitative, retrospective, pre- and post-protocol implementation study	Single-center, 48 patients (24 PRE and 24 POST), Surgical and Trauma ICU	The study concluded that using a symptom-triggered protocol based on the MINDS score in a Surgical and Trauma ICU decreases overall benzodiazepine use. Additionally, there is a tendency towards shorter treatment durations and lower intubation rates.	Age, gender, SAPS II score, trauma admission rates, benzodiazepine dose, use of benzodiazepine infusions, duration of treatment, ICU LOS, need for intubation	This study was conducted retrospectively at a single center and involved a small sample size. There is also a possibility of bias due to provider discretion in the POST group.	Level II (Quasi-experimental Study), Good.
	Huang, P. W., & Bhalla, R. (2021). Implementation of a symptom–triggered protocol for severe alcohol withdrawal treatment in a medical step-down unit. JCOM, 28(3). https://cdn.mdedge.com/files/s3fs-public/JCOM02803134.PDF	Quantitative, pre-and-post intervention study.	A study involving 141 episodes of alcohol withdrawal in adults was carried out in a medical step-down unit.	Implementing a symptom-triggered protocol (STT) significantly reduced the average dosage of benzodiazepines, shorter hospital stays, and decreased incidences of delirium tremens and the need for intubation.	Total benzodiazepine use, duration of hospital admission, occurrence of delirium tremens, intubation necessity.	Single-center scope, potential selection bias, and applicability to other environments might be limited.	Level II (Quasi-experimental), High Quality.
	Khan, S., Anwar, J., Rojas, E., Badami, V., Kovacic, N., Troyer, B., … & Hadique, S. (2023). Modified Minnesota Detoxification Scale (mMINDS) protocol assessment for treatment of patients with severe alcohol withdrawal. In C46. Studies In Cardiac Arrest, ICU Pharmacy, And Alcohol Withdrawal A5154-. American Thoracic Society. https://doi.org/10.1164/ajrccm-conference.2023.207.1_MeetingAbstracts.A5154	Retrospective Chart Review.	There were 94 adult patients admitted to the ICU with AWS (49 in the CIWA group, 45 in the mMINDS group).	The mMINDS protocol resulted in significantly lower mortality rates than the CIWA protocol (p < 0.01). Patients on the mMINDS protocol also had a shorter ICU stay (p = 0.04). The CIWA group had higher Apache scores (p = 0.03). Although not statistically significant, there was a trend towards fewer intubations and fewer days of intubation with the mMINDS protocol (p = 0.14).	Mortality rates, ICU length of stay, Apache scores, intubation rates, and days of intubation.	The retrospective design is limited to one hospital setting.	Level III, Non-experimental Study, Good Quality.
	Krcmarik, K. M., Hulley, B. J., Huang, J., Juang, D., Cadman, P., Urbiztondo, C., … & Kwan, B. (2023). Assessment of a modified MINDS‐based protocol for management of alcohol withdrawal syndrome on an inpatient medical service. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 43(12), 1297–1306. https://doi.org/10.1002/phar.2855	Retrospective cohort study.	Adult patients were admitted to a rural Minnesota hospital.	Implementing a revised protocol for alcohol withdrawal syndrome (AWS) based on the Minnesota Detoxification Scale (MINDS) resulted in notable enhancements in patient outcomes and safety.	Median total benzodiazepine exposure, length of hospitalization, duration of benzodiazepine administration, incidence of complications.	Limited to a single-site retrospective study; lack of randomization; potential confounding variables not fully addressed.	Level III, Non-experimental Study, Good Quality.
	Lewis-Wolfson, T., Switzer, M., Williamson, L., Joyner, K., & Morgan, K. (2024). 120: CIWA versus MINDS in alcohol withdrawal syndrome: A retrospective cohort analysis. Critical Care Medicine, 52(1), S35. DOI: 10.1097/01.ccm.0000998672.04475.6a	Retrospective cohort analysis.	Adult patients admitted to ICU with alcohol withdrawal syndrome (AWS).	Implementing the MINDS protocol led to notable outcomes: a considerable reduction in ICU length of stay (LOS) and milder withdrawal symptoms. It decreased in-hospital mortality when contrasted with the outcomes under the CIWA protocol.	ICU LOS, the severity of AWS, in-hospital mortality.	Limited to a single-center retrospective analysis, potential confounding variables are not fully controlled.	Level III, Non-experimental Study, Good Quality.
	Miller, M., Limouze, K., Mohrien, K., & Pathak, A. (2021). 881: Impact of symptom-triggered protocol for the management of alcohol withdrawal in the ICU. Critical Care Medicine, 49(1), 437. DOI: 10.1097/01.ccm.0000729412.71792.4e	Retrospective Observational Study.	Patients in the ICU who used benzodiazepines for alcohol withdrawal syndrome showed notable improvements when treated with the modified Minnesota Detoxification Scale (mMINDS) protocol.	This approach resulted in reduced duration of benzodiazepine therapy, lower rates of mechanical ventilation, and fewer cases of ICU-acquired pneumonia.	Cumulative BZD dose, continuous BZD infusion duration, ICU and hospital stay length, incidence of mechanical ventilation, and ICU-acquired pneumonia.	Exclusion criteria limited sample representativeness. Retrospective nature may introduce bias.	Level III, Non-experimental Study, Good Quality.
	Nelson, A. C., Kehoe, J., Sankoff, J., Mintzer, D., Taub, J., & Kaucher, K. A. (2019). Benzodiazepines vs barbiturates for alcohol withdrawal: analysis of 3 different treatment protocols. The American journal of emergency medicine, 37(4), 733-736. https://doi.org/10.1016/j.ajem.2019.01.002	Retrospective Cohort Study.	Adult patients in ED for acute alcohol withdrawal from April 1st, 2016, to January 31st, 2018.	Benzodiazepine and barbiturate use for alcohol withdrawal treatment in ED.	Rate of ICU admission, rate of mechanical ventilation.	Limited to ED presentations and treatment protocols, retrospective design.	Level III, Non-experimental study. Good Quality.
	Patel, L., Beddow, D., Kirven, J., Smith, C. S., Hanovich, S., Holaday, K., … & Hill, C. A. S. (2022). Outcomes of Minnesota Detoxification Scale (MINDS) assessment with high dose front-loading diazepam treatment for alcohol withdrawal in hospitalized patients. The American Journal of the Medical Sciences, 363(1), 42–47. https://doi.org/10.1016/j.amjms.2021.10.003	Retrospective cohort study.	Patients undergoing alcohol withdrawal while hospitalized were included in the study, which took place at a rural hospital in Minnesota. However, specific details regarding the sample size were not provided.	Patients who underwent treatment following the MINDS-based high-dose diazepam protocol experienced a decrease in physical restraints compared to those who did not (Adjusted Odds Ratio [AOR] = 0.8, 95% Confidence Interval [CI]: 0.70-0.92). Additionally, they had shorter hospital stays and a reduced duration of benzodiazepine use (p < 0.001). Conversely, the MINDS-based diazepam treatment group showed a higher probability of readmission within 30 days (AOR = 1.13, CI: 1.03-1.26). The total dosage equivalent of diazepam administered was similar in both groups. However, mortality rates and the utilization of intensive care units did not show significant differences between the two groups.	– Use of physical restraints – Length of hospital stay – Days on benzodiazepines – Readmission rates within 30 days – Total diazepam equivalent dosing – Mortality rates – ICU use rates.	– The exact sample size was not provided, limiting the generalizability of the findings. – Lack of detailed information on patient characteristics and comorbidities could influence outcomes. – Retrospective design may introduce biases and confounding variables. – Limited to a single rural hospital setting, potentially affecting the applicability to other settings.	Level III, Non-experimental study. Good Quality.
	Smith, R. M., Benzio, B., Hendrickson, A. L., Telford, E. D., & Franck, A. J. (2020). Implementation of the Modified Minnesota Detoxification Scale (mMINDS) for alcohol withdrawal syndrome in critically ill patients. Joint Commission Journal on Quality and Patient Safety, 46(11), 656-658. https://doi.org/10.1016/j.jcjq.2020.08.006	Quantitative Quality Improvement Project.	Single-center, 12-bed medical ICU; 58 patients analyzed.	Changing from the CIWA-Ar-driven AWS protocol to the mMINDS-based AWS protocol led to a notable decrease in the average cumulative dose of benzodiazepines (p < 0.01).	Impact of transitioning from CIWA-Ar–based AWS protocol to mMINDS–based AWS protocol on benzodiazepine dose, ICU length of stay, requirement for invasive mechanical ventilation, and duration of mechanical ventilation.	Observational study design may introduce biases; single-center evaluation limits generalizability; small sample size may limit detection of differences in outcomes	Level V, Quality Improvement, Good Quality.

 

 

Attach a reference list with full citations of articles reviewed for this Practice question.       Ó The Johns Hopkins Hospital/ The Johns Hopkins University

 

 

.       Ó The Johns Hopkins Hospital/ The Johns Hopkins University

 

 

 

 

Appendix B

Plan for Educational Offering

 

 

 

 

Appendix C

 

 

 

 

 

 

 

 

 

 

 

 

CIWA vs mMINDS

CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol revised)

• Mild Withdrawal: 0-8
• Moderate Withdrawal: 9-15
• Severe Withdrawal: 16 and higher¹²

mMINDS (Modified Minnesota Detoxification Scale)

• Mild Withdrawal: 0-15
• Moderate Withdrawal: 15-19
• Severe Withdrawal: 20 and higher

The Modified Minnesota Detoxification Scale (mMINDS) assesses the severity of alcohol withdrawal symptoms using the following components, and each scored to reflect the intensity of symptoms:

 SCORE

 

1. Pulse (beats per min)

• 0: <90
• 1: 90-110
• 2: >110 _____

1. Diastolic Blood Pressure (mmhg)

• 0: <90
• 1: 90-110
• 2: >90-110 ______

1. Tremors

• 0: None
• 1: Not visible, but can be felt
• 2: Moderate, visible with arms extended
• 3: Severe, even with arms not extended ______

1. Sweating  

• 0: No sweating
• 1: Barely perceptible, palms moist
• 2: Beads of sweat visible on forehead _____
• 3: Drenching sweats

1. Agitation

• 0: Normal activity
• 1: Somewhat more than normal activity
• 2: Moderately fidgety and restless
• 3: Paces back and forth or constantly thrashes about _______

1. Hallucinations

• 0: Not present
• 1: Mild, aware they are not real
• 2: Moderate, unsure if real or not
• 3: Severe, convinced they are real _____

1. Orientation

• 0: Oriented X 3 (person, place, time)
• 2: Oriented x 2 (person, place)
• 4: Oriented x1 (person or place)
• 6: Total disoriented
• 0: Intubated or sedated                                       _____

1. Delusions

• 0: Absent Seizures
• 6: Present Seizures _____

1. Seizures

• 0: Absent Seizures
• 6: Present Seizures _____

 

Each component is scored from 0 to 6, with a total possible score ranging from 0 to 46.

Higher scores indicate higher withdrawal severity.

SCORE_________

 

TREATMENT (dot phrase mMINDS adjunct treatment): The phenobarbital protocol should have already been started.

     mMINDS score:

• 0-15 no medication- continue hourly monitoring until stable
• 16-19: Diazepam (Valium) 2 mg IV/PO; reevaluate in 1 hour and repeat dose according to score
• 20-29: Diazepam (Valium) 4 mg IV/PO; reevaluate in 1 hour and repeat dose according to score
• 30-39: Diazepam (Valium) 8 mg IV/PO; reevaluate in 1 hour and repeat dose according to score (notify the provider of high score)
• 40-46: Diazepam (Valium) 12 mg IV/PO; reevaluate in 1 hour and repeat dose according to score (notify the provider of high score)
• (Dr. Hanna Altman, Essentia Pharmacist,2024)

 

                                                                                                 TREATMENT________

 

 

 

 

 

 

 

 

Appendix D

Compliance Checklist                             

                                                             Yes                                                     Needs Review

 

Review education on alcohol use disorder
Review signs and symptoms of Alcohol withdrawal syndrome.
Review the CIWA-Ar score.
Become familiar with the Minnesota Detoxification Alcohol Severity Assessment.
Calculate patients’ mMINDS scores for accuracy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix E

 

 

May 22, 2024

Chamberlain University

DNP Program

To Whom It May Concern:

On behalf of Essentia Health, I am pleased to offer a letter of support for Ms. Stephanie Alexander to conduct a DNP project at an Essentia Health facility.

 

Ms. Alexander is in the early stages of developing her DNP project. She is aware that Essentia Health is able to support DNP students in quality improvement, quality assurance, and program evaluation projects; but not in federally defined human subjects research. This aligns with the requirements of her program to implement an evidence-based intervention at the practicum site. Essentia also requires identification of an Essentia Health project sponsor. Ms. Alexander has proactively secured a DNP to sponsor this project, and will design the project with support from departmental leaders.

 

Ms. Alexander is required to submit a one-page executive summary of the study to me for human subjects research determination. This is generally done about two to three months prior to project implementation. She will receive a letter of HSR determination and, if it is determined not to be HSR, approval to proceed.

 

Please note that prior to the implementation of the project, Ms. Alexander must be onboarded into the Essentia Health student management system. This process is initiated by the school and generally occurs upon receipt of the HSR determination letter (about 6-8 weeks before project implementation). During this process the school will work with the Essentia Student Experience team (studentplacement@essentiahealth.org) to assign Ms. Alexander to the DNP project experience. Ms. Alexander is aware she will need to upload vaccination and background study records during this process. Upon completion, Ms. Alexander will be issued a student account which will provide her with access to the electronic medical record and permissions to be onsite and access this data through the duration of her project.

 

We look forward to supporting our employee, Ms. Alexander, on her DNP journey. Please contact me if you have any questions regarding conducting DNP projects at Essentia Health.

 

 

Sincerely,

 

Kate Dean, Executive Director, Essentia Institute of Rural Health

Kate.Dean@essentiahealth.org

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tables

Table 1

Budget

EXPENSES		REVENUE
Direct		Billing
Salary and benefits (providers)	$105//hr	Institutional budget support	$17,640
Supplies (medications, hospital bed)	$21,500	Institutional budget support	$21,500
Services (preceptor)	$3,360	Professional acumen	$3,360
Statistician	$175/hr	4 hours-pro-Bono	$700
Indirect
Overhead		Breakroom/AV equipment	Hospital budget
Total Expenses	$43,200	Total Revenue	$43,200
Net Balance			0

 

 

 

 

 

 

 

Table 2

[Table Title]

Column Head	Column Head	Column Head	Column Head	Column Head
Row Head	123	123	123	123
Row Head	456	456	456	456
Row Head	789	789	789	789
Row Head	123	123	123	123
Row Head	456	456	456	456
Row Head	789	789	789	789

Note:

 

 

 

 

 

 

 

 

 

 

 

 

Figures

Figures Title

Figure 1.

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