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Enfermería Global

versión On-line ISSN 1695-6141

Enferm. glob. vol.15 no.41 Murcia ene. 2016




Alcohol dependence syndrome in emergency services: assessment protocol for the professional nursing practice

Síndrome de dependência alcoólica em serviços de emergência: protocolo de avaliação para a prática profissional de enfermagem

Síndrome de dependencia alcohólica en servicios de urgencia: protocolo de evaluación para la práctica profesional de enfermería



Villar Luis, Margarita Antonia*; Barbosa, Sara Pinto*; Luchesi, Luciana Barizon* and Santos, Jair Lício Ferreira**

*Department of Psychiatric Nursing and Human Sciences, School of Nursing of Ribeirao Preto, University of São Paulo/USP. E-mail:
**Professor at the Department of Social Medicine, Faculty of Medicine of Ribeirao Preto, USP, Ribeirão Preto, São Paulo. Brazil.




This is a quantitative study carried out in emergency services of Ribeirao Preto, a city located in the countryside of Sao Paulo state.
The aim of this study was to assess signs and symptoms of the Alcohol Withdrawal Syndrome (AWS) by the nursing team with the use of a protocol.
Data collection took place over 642 on duty hours. Of the 463 participants, 297 had AUDIT >7, and of these, 59 (12.7%) had AUDIT >20, which indicates the occurrence of SAA and, due to this, were included in this investigation. Concerning the signs, of the 59 users, 8 were unable to tell the time of hospitalization, 7 could not say what year or month it was, and 13 seemed uneasy. In relation to the physical signs of the dependence, 17 had signs of tremor, 8 mentioned to have had seizures.
The emergency services may be privileged places to identify symptoms of alcohol abuse and dependence and the use of the nursing assessment protocol may be a useful strategy in the monitoring and intervention.

Key words: Alcohol; Alcohol Withdrawal Syndrome; Emergency Services; Professional Nursing Practice.


Estudo quantitativo exploratório realizado em serviços de emergências do município de Ribeirão Preto, interior do Estado de São Paulo, Brasil.
O objetivo do estudo foi avaliar sinais e sintomas da Síndrome de Abstinência Alcoólica (SAA) pela equipe de enfermagem, utilizando para isso um protocolo.
A coleta de dados foi realizada durante 642 horas de plantões. Dos 463 participantes, 297 apresentaram AUDIT (Alcohol Use Disorders Identification Test) >7, destes, 59 (12,7%) apresentavam AUDIT >20, ou seja, sugestivo de SAA sendo, por isso, incluídos nesta investigação. Quanto aos sinais, dos 59 usuários, 8 não sabiam mencionar o tempo de hospitalização, 7 não souberam afirmar em que ano ou mês estavam, e 13 apresentavam inquietação. Em relação aos sinais físicos da dependência, 17 apresentaram sinais de tremores, 8 referiram convulsões.
Os serviços de emergências podem ser locais privilegiados para identificar sintomas de uso abusivo e de dependência de álcool e a utilização do protocolo de avaliação de enfermagem pode ser uma estratégia útil no rastreamento e intervenção.

Palavras chave: Álcool; Síndrome de Abstinência Alcoólica; Emergências; Enfermagem.


Estudio cuantitativo exploratorio realizado en los servicios de urgencias del municipio de Ribeirão Preto, interior del Estado de São Paulo, Brasil.
El objetivo del estudio fue evaluar señales y síntomas del Síndrome de Abstinencia Alcohólica (SAA) por el equipo de enfermería, utilizando para esto un protocolo.
La colecta de datos se realizó durante 642 horas de turnos. De los 463 participantes, 297 presentaron AUDIT (Alcohol Use Disorders Identification Test) >7, de estos, 59 (12,7%) presentaban AUDIT >20, o sea, sugerente de SAA siendo, por esto, incluidos en esta investigación. En cuanto a las señales, de los 59 usuarios, 8 no sabían decir el tiempo de hospitalización, 7 no sabían en qué año o mes estaban, y 13 presentaban inquietud. En relación a los signos físicos de la dependencia, 17 presentaron signos de temblores, 8 refirieron convulsiones.
Los servicios de urgencias pueden ser lugares privilegiados para identificar síntomas de consumo abusivo y de dependencia del alcohol y la utilización del protocolo de evaluación de enfermería puede ser una estrategia útil en el seguimiento e intervención.

Palabras clave: Alcohol; Síndrome de abstinencia alcohólica; Urgencias Enfermería.



Alcohol consumption is harmful to health, and it is estimated that 3.8% of all deaths around the world and 4.6% of disability-adjusted life year are could be attributed to alcohol and the cost associated to its use affects more than 1% of the gross domestic product of countries with medium and high yields1. Therefore, the dependence to this substance is dealt with as a multifactorial health problem that can be recurrent or chronic. About 2% to 9% of the patients seen in family doctor clinics have alcohol related complications2, as well as social and individual damages caused by its abuse3. The fact that alcohol is a legal substance almost everywhere in the world can be an underlying factor to these conditions4. There are many explanations for the high rates of use, but the fact that the dependence results from the interactions of biological5 and cultural factors6 is a consensus, since the symbolic meaning of the alcohol will determine how people relate to this substance, in a process of individual and social learning that indicates the situations and rules related to alcohol consumption7.

For many people with a significant degree of dependence, a set of organic and psychological symptoms may appear that characterize the so called Alcohol Withdrawal Syndrome (AWS). This is caused by ceasing or reducing alcohol consumption or even in circumstances where someone has reached such a significant level of tolerance that their body do not bear to consume the doses that would be sufficient to avoid withdrawal symptoms8.

Depending on the degree of physical dependence, the symptoms related to the withdrawal syndrome can range from discomfort, with headaches, nausea, visual sensitivity and fine tremor of the extremities, to a more severe state of delirium, which requires prompt intervention and greater medical2 and nursing care9.

The range of withdrawal symptoms and the average time for the onset of these symptoms after alcohol consumption is stopped ranges from 6 to 72 hours. Generally, this happens around 24 to 36 hours after the last alcohol consumption8. It is estimated that only 10% to 20% of the patients with alcohol withdrawal syndrome are hospitalized to receive treatment. In the United States, where the largest study groups of psychoactive substances are concentrated, alcohol withdrawal syndrome is not given the importance it deserves despite the severity of this condition, which can be prevented even in its most severe cases10.

In Brazil, there are broader studies about the use of alcohol and other psychoactive substances within the general11 and specific populations, and patients hospitalized due to alcohol dependence12. Despite the severity of this condition, Brazilian studies about the frequency of the AWS and the care provided to alcohol dependents with this condition were not found, although this is common in the emergency services practice and presented as a single condition of signs and symptoms of increasing severity when the management of the problem is not properly done.

The Professional Nursing Practice has the responsibility to monitor patients in relation to their needs, thus avoiding the occurrence of fatal outcomes. Based on this, this study is aimed at applying a standardized protocol created for the nursing team to identify signs and symptoms, as well as assessing the withdrawal syndrome in patients treated at five medical emergency services located in a countryside city of Sao Paulo state, Brazil.



This is an exploratory quantitative study to verify the ability to assess signs and symptoms of the Alcohol Withdrawal Syndrome (AWS) using an instrument (Withdrawal Syndrome assessment protocol) developed for application in alcohol users treated at emergency services.

The instrument is composed of five parts: 1- Physical appearance and living conditions; 2- Clinical conditions of the patient; 3- Symptoms reported by the patient; 4- Self and hetero-aggression outbursts; 5- Registration of nursing care. For the development of the second and third parts, information requiring observation and basic nursing procedures (checking of pulse, temperature and blood pressure) were included and also items present in the Clinical Withdrawal Assessment Revised (CIWA-R); however, only the presence or absence of signs and symptoms were marked and their severity was not evaluated. The first part was designed based on the observation of researchers while treating this population and the fourth part considered the evidences of the literature13,14,15. The fifth part was developed with the purpose of encouraging the reflection of nursing professionals in relation to the care provided, which will be detailed in another article.

The use of the items of the CIWA-R is justified because this is a validated scale in Brazil16 with 10 items, used to quantify the severity of the AWS and to monitor and medicate patients with this condition. The translation of the CIWA-R is widely used in Brazil and suggested by the Department of Chemical Dependency of the Brazilian Psychiatry Association17. The application of this scale, according to an American study18, requires up to 5 minutes with a trained person.

The developed instrument includes observation, interview and registration of the intervention in a more streamlined manner, suitable to the time and nursing staff, who are the first ones to approach the patients. The development of the protocol presented in this article was successfully tested19 through a pilot study, and involved nursing professionals who evaluated the potential of the questionnaire as a source of knowledge, a manual guiding the nursing care, and the sematic appropriateness of the terms.

The experience of the contact with alcohol users who attend the emergency services and with the nursing staff working in these services, in addition to the results of the pilot investigation, influenced the option of developing a specific questionnaire, mainly descriptive, to the Professional Nursing Practice. Demographic data of patients were added.

The expectation is that the protocol can provide nursing professionals with: the presence or absence of symptoms, a general assessment of the patient, an identification of the risks and needs of those who should be given priority. However, it is believed that the time and motivation of the nursing team can be a major obstacle.


Place Of Study

The Project was developed in a countryside city located in the state of Sao Paulo, which has about 649,556 inhabitants20, which has a healthcare network divided into areas. There are five medical emergency services in the city, and these are community services that provide assistance to patients in emergency situations in general for 24 hours a day. These services are maintained by the local council. The Local Health Bureau, at that time, did not authorize the participation of nursing workers, claiming that this could affect the workflow of the healthcare service, since the staff would be using the AWS assessment protocol with the patients during the appointments, which would "delay the general assistance to users".

Due to this refusal on the part of the city's Bureau, the team that performed the application of data was composed of a professor nurse with Ph.D., five nurses linked to the University of Sao Paulo, one postgraduate student nurse and six undergraduate nursing students with experience in performing researches in the area of mental health.

The Alcohol Use Disorders Identification Test (AUDIT) was also applied to all patients who were present in the five services during the time the researchers were in those facilities.

During June and July 2010, the team gathered to undergo training about the application of the AUDIT, of the AWS assessment protocol, ethical conduct and brief approaches for reducing alcohol consumption, since the team's objective was to help users/families in case the risky use and alcohol abuse was detected, seeking to help with changing behaviors and/or to agree with the local healthcare team about the referral of users to a specialized service.

All the users of public healthcare services (free) who were admitted at the emergency services, accepted, and were in physical and psychological conditions to participate in the study were approached. The collection was aimed at applying the AWS assessment protocol and the AUDIT at the facilities. This occurred twice a week in alternate days in order to check the demand of patients per week. At all the facilities, at least one shift from 7am to 1pm, from 1pm to 7pm and from 7pm to 10pm was carried out and these took place at least seven times in different days of the week. The collection lasted four months (August to November 2010). The staff worked a total of 136 shifts (42 in the afternoons and 40 in the evenings), at the five medical emergency services, totaling 642 shift hours in the facilities. In total, the instruments were applied to 463 patients. Of these, 297 had score in the AUDIT < 7 (64.1%); 86 (18.7%) with AUDIT from 8 to 15; 21 (4.6%) had AUDIT from 16 to 19 and 59 (12.7%) had AUDIT >20, that is, indicative of alcohol dependence and, therefore, were included in this investigation.

The research was submitted and approved by the Research Ethics Committee (CEP) of the EERP-USP and Informed Consent Forms were signed by the patients who accepted to answer the questions or by a responsible family member who accompanied them to the service.



96% of the people approached in the research lived in the city, 40.7% had not completed elementary education and 61.1% were male. In relation to the 59 patients with AUDIT >20, 53 (18.73%) were male and six (3.35%) were female. It was also found that 26 (16.25%) patients with possible dependence were aged in the range between 30 and 49.

Among the sample (59 patients) with likely alcohol dependence, 13 patients showed to have poor hygiene and three had pronounced weight loss. As for the living conditions, there was no significant relationship between the variables living with family and likely alcohol dependence. Among the patients with indicative alcohol dependence, the relationship between living or not with family had basically the same incidence (Pr= 1.725).

Concerning possible mental disorders, it was observed in relation to the notion of time and place that eight could not inform how long they had been in the care facility for and seven were unable to say what year of month it was. In relation to motor skills, 12 showed signs of uneasiness. As for mood, nine patients showed signs of irritability or had verbally aggressive attitudes. For all these variables, Pr was <0.05.

With respect to specific signs of the AWS, 17 showed signs of tremor, and the relationship between tremor and dependence was significant (Pr= 0.001). Nine patients had excessive sweating and the relationship between this variable and the dependence was significant (Pr= 0.0046). Only seven users showed changes in blood pressure (BP). Such data must have been underestimated because the checking of vital signs was the responsibility of the nursing team of the emergency service and this information was not always recorded in the medical records of the patient due to the approach for application of the instruments.

As symptoms observed or reported by the set of users with likely dependence, 38.98% reported nausea (Pr= 0.005), eight of them stated to have had seizures and four had body temperature higher than 38oC, with no statistically significant relationship for these two variables. The most common symptoms that were noted or informed by the patients and can indicate AWS are shown in Table 1.



The most common indicators of AWS in the population of this study were discomfort, headache and insomnia, but it can be highlighted that visual and hearing hallucination in alcohol users, although less frequent, are indicators of a stronger AWS. Other symptoms showed by patients in relation to the clinical presentation of AWS, to which the Professional Nursing Practice should be aware of, are the sensitivity to sound and light, perception disorder, such as the feeling that insects are crawling over their bodies and forgetfulness. It is also important to consider the possibility of this clinical condition to generate or encourage suicidal tendencies, as seen in Table 2.



The actions developed by the nursing team responsible for data collection were registered for analysis, together with the identification of the signs and symptoms, since the study intended to verify the possibility and applicability of the AWS assessment protocol and interventions due to this demand in emergency services. It could be noted (Table 3) that 11.4% of the nurses focused on the basic instructions (alcohol consumption and risk to the health, diet and hydration, driving motor vehicles) in relation to the actions directed at the patients approached and 3.7% were referred to specialized services in mental health and/or chemical dependence (SM/DQ).



It is important to mention that, although these actions had been carried out by trained nurses or nursing students involved in the mental health field, they were free to carry out those actions they considered appropriate during the development of nursing interventions. It can be noted that, sometimes, they carried out more than one advice or intervention in relation to the same alcohol user and also the non-standardization of nursing actions, because while some nurses only provided basic instructions to patients, others expanded the range of interventions such as sharing the case with the local team (discussion) or, further to it, referring patients to specialized or other healthcare services. This helped identify the possible difficulties in developing standardized proposals of nursing interventions focused on the needs of patients, when the development of an intervention protocol is being considered.

The team executing the project during the application of the protocol also found out that the healthcare service where data were collected did not provide a suitable place for the care of this kind of patient, although alcohol abuse seemed to be significant within these services, based on the fact that the rate of likely dependence (12.7%) shown in the study was of concern.



Alcohol abuse causes considerable morbidity and mortality21, and the AWS is likely to be the most serious complication resulting from alcohol abuse. The identification of the indicative symptoms, even if performed in a non-specialized mental health service, is essential for the clinical and nursing interventions to be successful, given that the symptoms are insidious and often not very specific22.

Unfortunately, the studies are still rare in the nursing field concerning the implication of the AWS and the care practice in this profession within the context of emergency services, although these professionals have the potential to provide facilitating and continuous conditions to rebuild the harmful lifestyle of heavy drinking users23. In a qualitative study involving nurses of the Psychosocial Care Center in Sao Paulo, it was found that 68.8% of these nursing professionals are not qualified in the area related to alcohol and drugs and 93.8% did not have any training during the graduation in nursing24. Such fact confirms the need for instruments that guide and enable the detection of signs of complications resulting from alcohol use, since these may not be recognized in the daily clinical practice of the nurses, especially if they do not have specific knowledge about it. The use of the nursing assessment protocol has the potential to overcome the difficulties in identifying the signs and symptoms of AWS and the approach of patients in the healthcare services, particularly those treated in the emergency services.

A study conducted with nurses in New Zealand confirmed the positive potential of using instruments, such the AUDIT, or protocols in conjunction with the clinical appointment in emergency services. The authors mentioned the capacity to reduce the costs spent on health, including social costs, in the treatment of people with alcohol related problems25.

It is believed that the selection of the sample of users who attend the service (463), as well as the shift hours spent by the nurses/researchers contributed to advising this group and, therefore, showed to be possible to offer a quality care. However, it should be considered that the group providing this care was external and, therefore, there was a number of additional nursing staff to the team, which leads to the reflection about whether the local nursing team would be able to develop their daily work, added with the activity performed by the research team.

The symptoms of AWS addressed in this study, and listed for this nursing protocol, followed the specialized literature and were also object of investigation for being easily observed by the nurses who are not specialized in mental health, although it is understood that other aspects such as the observation of the delirium process, patient safety, hydration, other vital functions, physiological eliminations, mobilization and stabilization of chronic diseases, such as hepatitis or anemia should be considered during the clinical observation of heavy drinking users4.

However, it is noteworthy that, after the detection of the signs and symptoms of the AWS by the researchers, and the verification of the AUDIT scores, feedback was provided to patients with the purpose of encouraging them to consider that the clinical data presented in the emergency appointment could be correlated with alcohol abuse26.

Concerning the profile of users, there is similarity with the data presented by an observational and cross sectional study undertaken in the South of Brazil, which also found the most prevalent consumption among male (p <0.001) and people under 39 years of age27. The prevalence of 7.55% for men and 1.21% for women with scores equal to or higher than 20 in the AUDIT was observed in a study conducted in 2011 in the same city28. Therefore, in this study, the rates were higher in relation to this risk range AUDIT.

The suicide attempts informed by patients can be highlighted, with a rate of 20.3% of reports in the past, and currently with 13.5% of patients with indicative dependence. Studies are unanimous concerning this association, and while some of them confirm15 and indicate that heavy drinking users have 60 to 120 times more probability to commit suicide than the population that do not use alcohol, another study does not find significant relationship between regular alcohol consumption in the last month and depression27. This information draws attention to the need to develop researches and practical actions focused on the alcohol user population and it is a warning, not only to the nurses specialized in mental health, but to the clinical nursing professionals in relation to the care and observation of intrinsic aspects of this population.

In the United States, the American College of Surgeons included in 2006 the screening for alcohol use in emergency services29. The Professional Nursing Practice, in these services, spend a considerable amount of time with patients, and the health education and the involvement with the patients treated due to alcohol use is an important part of their professional practices, although there are reports of nurses expressing to feel uncomfortable while approaching these patients30.

A research has shown that nurses and other professionals are aware that alcohol use is a health issue, yet many patients are not questioned about their alcohol consumptions habits31. The reasons for this are the lack of time and trust in their professional abilities to help patients to change their habits32. Further to it, alcohol abuse is seen as one of the most difficult habits to discuss with patients, and that is why the approach is considered more complex33. The authors finalize their work by proposing that further studies are conducted to assist with this approach and it was based on this perspective that the present study was developed.

The difficulty found in the articulation with the organization (Local Health Bureau) responsible for the healthcare services contacted can be highlighted which, having the possibility to experience advancements resulting from studies for the improvement of nursing care in the emergency services, seemed not to understand and not to support the initiative of the present study. This is a different position from that presented during the pilot study, by another manager. This confirms the organizational support as one of the care obstacles, and this is also claimed in a study about the users of emergency services32. The AWS assessment protocol for the use by the nursing team in a previous research was shown to be adequate, since it allows the monitoring of signs and symptoms of patients in emergency units and was also identified by these workers as a guide to nursing care, since they have to be aware of the importance of this profession to the health-related education about the risks associated with alcohol consumption19.

It is recommended that an assessment of alcohol use in all healthcare facilities where nurses are present is made, and there should be consideration about the fact that there is little focus on the development of protocols and support to nurses in order to perform this activity in the emergency services34. However, there is criticism concerning this position based on the consideration that the practice of providing the nursing teams with standardized protocols and organizational support for all kinds of health care they have to provide in the service is not realistic in the short term. The suggestion is for the nurses to be responsible for their own training, specifically in relation to alcohol, acquire adequate knowledge to evaluate the consumption by patients and incorporate this knowledge into their practice35.

Within the Brazilian context, the acquisition of specific knowledge by the nurses already occurs, but there are difficulties such as low wages, lack of incentive on the part of the services (they do not provide time for continuous education) and staff restriction, taking into account that nurses supervise the team (composed of nursing technicians and assistants) and the service and this takes a lot of their time. Under these conditions, the protocol developed in the research may contribute with the self-education of nurses and their assistant staff.


Role of nurses and Conclusions

The study showed that the application of the AUDIT in the monitoring of alcohol use and the AWS assessment protocol are instruments that benefited the patients treated by nurses at the emergency services, because all of those who were approached had the opportunity to be advised about their level of consumption, the health problems associated and the places for treatment. Therefore, the project allowed the approach of the thematic with patients in general and those seeking specialized services, due to an excessive level of consumption. The application of the protocol emphasized to patients the need for and the importance of continuous treatment in mental healthcare services or additional services.

The development of the study pointed out the emergency services as a likely and effective space to provide advice to users and families, which is an opportunity for them to associate the symptoms presented with excessive alcohol consumption. Therefore, the nurses allocated to these services can be trained to handle patients with alcohol abuse problem and perform more appropriate interventions to the needs of these users. The application of the AWS assessment protocol can be an additional resource in the training and guidance in the area of nursing care.

One limitation of this study is the fact that the group who applied the instrument was external to the services and, therefore, did not have the responsibility to work in other areas that needed actions being performed or specific nursing procedures. Therefore, the authors confirm the need for the professionals applying this protocol to be part of the local team.




Received: January 19, 2015
Accepted: 12 June 2015



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