SEWS Protocol — Severity of Ethanol Withdrawal Scale
Overview
SEWS (Severity of Ethanol Withdrawal Scale) replaced CIWA-Ar as the standard alcohol withdrawal assessment at SPH. Go-live date: January 2, 2024.
- SEWS flowsheet in EPIC replaces both the CIWA assessment and the phenobarbital flowsheet
- All patients admitted for management of alcohol withdrawal are assessed using the SEWS flowsheet (SJH LM & SPH locations)
- SEWS initially Q4, then per algorithm
- Lorazepam dosing is guided by the SEWS algorithm
- Phenobarbital continues to be dosed by Pharmacy; PRN phenobarbital administered per order instructions
Why SEWS Over CIWA?
From the literature review (Beresford et al.):
| Measure | Outcome |
|---|---|
| Time on medication protocol | Reduced (p < 0.0001) |
| Medication use within first 24h | Patients received half as much (p < 0.05) |
| Nursing satisfaction | Rated easier to use and more accurate |
Monitoring Schedule
- Vital signs: Q2h during initial 24–48 hours of use; upon dose de-escalation, consider Q4h
- SEWS assessment: Initially Q4h, then per algorithm
- RASS (Sedation) assessment: Q2h (with vitals), goal RASS 0–2
SEWS vs CIWA Scoring Comparison
| Domain | CIWA (0–7) | SEWS (weighted) |
|---|---|---|
| Anxiety | 0–7 | 0 or 3 |
| Nausea/Vomiting | 0–7 | Nausea AND Vomiting — 0 or 3 |
| Sweats | 0–7 | 0 or 2 |
| Tremor | 0–7 | 0 or 2 |
| Agitation | 0–7 | 0 or 3 |
| Orientation | 0–4 | 1 or 3 |
| Hallucinations | Tactile 0–7, Auditory 0–7, Visual 0–7 | ANY hallucination — 1 or 3 |
| Headache/Fullness | 0–7 | — (removed) |
| Vital Signs | — | 0 or 3 |
Pharmacologic Therapies
Lorazepam (Ativan)
- Guided by SEWS monitoring
- Reassess with SEWS 1 hour after each dose
- Dosing per SEWS algorithm in EPIC
Phenobarbital
- As per previous protocol (dosed by Pharmacy)
- PRN phenobarbital given per order instructions, not per SEWS algorithm
SEWS Algorithm (Lorazepam Dosing)
| Current SEWS | Action |
|---|---|
| ≥ 16 (Severe) | Administer 4mg IV lorazepam. Reassess in 1h |
| 9–15 (Moderate) | Administer 2mg IV/PO lorazepam. Reassess in 1h |
| 1–8 (Mild) | Administer 2mg PO lorazepam. Reassess in 1h |
| 0 | Hold dose. Reassess in 1h |
After two held doses at SEWS 0: Continue to hold and reassess in 1h. When SEWS remains 0, can consider spacing assessments.
EPIC Workflow
- SEWS flowsheet found under: Flowsheets → “SEWS Assessments SJH & LM Only”
- Summary report found under: Summary → “Alcohol Withdrawal Report”
SEWS Scores
Summary tab -> Alcohol Withdrawal Report
Link to original - Nursing manually adds reminders for SEWS/RASS/VS documentation to the brain
Key Points
- SEWS is simpler — fewer domains, binary/weighted scoring instead of 0–7 ranges
- RASS goal 0–2 — assessed Q2h alongside vitals
- Always reassess in 1 hour after a lorazepam dose
- Withhold dose if SEWS = 0, even if scheduled
- If SEWS ≥ 16, go straight to 4mg IV lorazepam
References
- Beresford TP, et al. Working toward a gold standard: The Severity of Ethanol Withdrawal Scale (SEWS) versus the CIWA-Ar. Alcohol and Alcoholism. 2023;58(3):324-328.
- Beresford T, et al. The severity of ethanol withdrawal scale in scale-driven alcohol withdrawal treatment: A quality assurance study. Alcoholism Treatment Quarterly. 2017;35(3):232-242.
Source: SEWS Education materials sent to Hospitalist team, June 2026. Attachments: SEWS Handout.docx, SEWS Education.pptx, Practice Alert SEWS.docx (saved in ~/Downloads).