COWS - clinical opiate withdrawal scale

COWS is an 11-item scale EMS personnel can apply to rate common signs and symptoms of opiate withdrawal, and to monitor these symptoms over time. They can use the summed score for the complete scale to determine the stage or severity of opiate withdrawal, and assess the level of physical dependence on opioids.

Score-able symptoms include:

  • Record beats per minute, after the patient is sitting or lying for one minute.

    • 0 - pulse rate 80 or below
    • 1 - pulse rate 81-100
    • 2 - pulse rate 101-120
    • 4 - pulse rate greater than 120

  • Sweating over the past half hour not accounted for by room temperature or patient activity.

    • 0 - no report of chills or flushing
    • 1 - subjective report of chills or flushing
    • 2 - flushed or observable moistness on face
    • 3 - beads of sweat on brow or face
    • 4 - sweat streaming off face

  • Observation during assessment.

    • 0 - able to sit still
    • 1 - reports difficulty sitting still, but is able to do so
    • 3 - frequent shifting or extraneous movements of legs/arms
    • 5 - unable to sit still for more than a few seconds
    • 0 - pupils pinned or normal size for room light
    • 1 - pupils possibly larger than normal for room light
    • 2 - pupils moderately dilated
    • 5 - pupils so dilated that only the rim of the iris is visible

  • If the patient was having pain previously, score only the additional component attributed to opiates withdrawal.

    • 0 - not present
    • 1 - mild diffuse discomfort
    • 2 - patient reports severe diffuse aching of joints/ muscles
    • 4 - patient is rubbing joints or muscles and is unable to sit still because of discomfort

  • Symptoms not accounted for by cold symptoms or allergies.

    • 0 - not present
    • 1 - nasal stuffiness or unusually moist eyes
    • 2 - nose running or tearing
    • 4 - nose constantly running or tears streaming down cheeks

  • Symptom over the last half hour.

    • 0 - no GI symptoms
    • 1 - stomach cramps
    • 2 - nausea or loose stool
    • 3 - vomiting or diarrhea
    • 5 - multiple episodes of diarrhea or vomiting

  • Observation of outstretched hands.

    • 0 - no tremor
    • 1 - tremor can be felt, but not observed
    • 2 - slight tremor observable
    • 4 - gross tremor or muscle twitching

  • Observation during assessment.

    • 0 - no yawning
    • 1 - yawning once or twice during assessment
    • 2 - yawning three or more times during assessment
    • 4 - yawning several times/minute
    • 0 - none
    • 1 - patient reports increasing irritability or anxiousness
    • 2 - patient obviously irritable anxious
    • 4 - patient so irritable or anxious that participation in the assessment is difficult
    • 0 - skin is smooth
    • 3 - pilo-errection of skin can be felt or hairs standing up on arms
    • 5 - prominent pilo-errection

A total score of 5–12 indicates mild withdrawal; 13–24 indicates moderate withdrawal; 25–36 indicates moderately severe withdrawal; more than 36 = severe withdrawal.

 

    1. Do one of the following.

      • (If you are already working in the ESO Suite) Click the Home icon in the upper left corner of the screen.

        1. In a web browser, go to https://www.esosuite.net/EsoSuite.

          The ESO Suite login screen appears.

        2. Enter your user name, password, and agency name, then click Let's Go.

          If MFA is enabled, the Multi-factor authentication dialog box appears, displaying one or more methods you can use to verify your login credentials. The number of methods that appear in the dialog box depends on what MFA methods your ESO Suite administrators enabled in the Admin module.

          Click graphics
          to open them.

          Information on enabling MFA and specific MFA methods is available in the Admin module online help, in Configure multiple-factor authentication.

          Note: If your ESO Suite administrators have disabled MFA ("opted-out"), this dialog does not appear.

        3. (If the Multi-factor authentication dialog box appears) Depending on which buttons appear in the dialog box, verify your login in one of the following ways.

          1. Click MFA verification via authenticator app.

            The dialog box updates with boxes for entering the numbers of the authentication code, and the ESO Suite sends an authentication code to the authenticator application installed on your device.

          2. Open your authenticator application and note the authentication code currently displayed.

          3. Enter the authentication code displayed in the authenticator application.

          4. Click Log In.

          SMS

          1. Click MFA verification via SMS.

            The dialog box updates with boxes for entering the numbers of the authentication code, and the ESO Suite sends an authentication code to the phone number recorded in your PM records and identified with MFA codes.

          2. Enter the authentication code sent to your MFA-registered phone number.

          3. Click Log In.

          1. Click MFA verification via email.

            The dialog box updates with boxes for entering the numbers of the authentication code, and the ESO Suite sends an authentication code to your agency or department email address, recorded in your PM records.

          2. Enter the authentication code sent to your agency or department email address.

          3. Click Log In.

      The ESO Suite landing screen appears.

      Click graphics
      to open them.

      Note: If MFA is enabled, you can access and manage your MFA options through the PM module, on the Settings > Account page, as described in Manage a user account. If your agency or department has enabled MFA but has not purchased the full-featured version of the PM module, you can access your own MFA settings by clicking Change my Multi-Factor Authentication settings on the landing screen, then using the Settings > Account page that appears. If your agency has not enabled MFA, the Change my Multi-Factor Authentication settings link does not appear on the landing screen.

    2. On the top side of the home screen, click EHR.

      Tip: If your screen or browser window is too narrow to display all your agency's ESO Suite module icons, an options icon appears on the right side of the icon bar. If you click the options icon, a menu appears containing additional module icons.

      The EHR screen appears, displaying a list of patient records in the EHR module. The most-recent records appear at the top of the list.

      Different record status icons can appear in the list.

      Icon Status

      Unlocked/Draft

      The patient record exists in the ESO Suite database, and all crew members listed in the patient record may edit all fields in the record. ESO Suite administrators and personnel with security roles of either EHR Supervisor or EHR Manager can edit non-clinical fields.

      Mobile

      The patient record exists on the mobile device, and has not been synchronized with the ESO Suite database. ESO Suite administrators, personnel with security roles of either EHR Supervisor or EHR Manager, and all crew members listed in the patient record can only access a print view of the record.

      Once the Mobile record synchronizes with the ESO Suite database. the record reflects its current status.

      Locked

      The patient record exists in the ESO Suite database, and is locked. Only non-clinical fields can be edited by crew members listed in the patient record, ESO Suite administrators and personnel with security roles of either EHR Supervisor or EHR Manager.

  2. Information on adding or opening a patient record is available in Add a patient record and Search for a patient record.

    The patient record opens and displays the Incident tab, with the Response bookmark selected in the left pane. Fields appear in the right pane for specifying basic information about the incident

    If you manually created a new patient record, the Incident Number and State Tracking Number fields populate automatically with ESO Suite-assigned values. You must enter data in all other required fields.

    If you imported data from a CAD system, the Incident Number field populates with the data from that source. Other fields in the EHR module may also populate from these sources, depending on what data was recorded in them before the data was imported into the EHR module.

  3. At the top of the page, click the Forms tab.

    The contents of the Forms tab appear, listing all the forms your ESO Suite administrator has enabled in the Admin module.

  4. Click COWS - Clinical Opiate Withdrawal Scale.

    The COWS - Clinical Opiate Withdrawal Scale dialog box appears.

    1. Under Times, for Time Performed, click the number pad icon to the right of the field, then enter the appropriate numerical values from the number pad dialog box that appears for the time you evaluated the patient using COWS.

      The time you entered appears in the green box at the top of the page.

    2. For Date, click the calendar icon on the right end of the field and select the appropriate date from the calendar that appears for the date you evaluated the patient using COWS.

    3. Under Assessment, in COWS Score, click the number pad icon to the right of the field, then enter the appropriate numerical values from the number pad dialog box that appears to record the total score for the patient at that time, based on the 11 COWS criteria.

    4. (If you need another COWS assessment) At the top of the page, click Add.

      Another green box, with no time recorded in it, appears to the left of Add, and blank set of fields appears under Times and Assessment.

    5. Repeat the steps above to specify information for the new assessment.

  6. Repeat step 5 as many times as needed to record COWS assessments for the patient.

  7. Click OK.

    The dialog box closes, and a green triangle appears in the upper right corner of the form button, to indicate that data exists in this form.