Saturday Night in the A&E

Adrian BrownAlcohol Nurse SpecialistImperial College Healthcare & CNWL Substance Misuse Service

Alcohol health work and the role of Alcohol health work and the role of the alcohol nurse specialist atthe alcohol nurse specialist atSt Mary’s hospital, Central LondonSt Mary’s hospital, Central London

Saturday Night in the A&E

Misuse & MortalityMisuse & Mortality

• Adults reporting hazardous or harmful levels of consumption

• Harmful – males: 24.5%, females: 14.5%(General Household Survey, 2005)

• Total deaths in England• Alcohol specific – males: 1.39%, females: 0.59%

• Alcohol attributable – males: 5.8%, females: 3.9%(Association of Public Health Observatories, 2005)

Alcohol in HospitalsAlcohol in Hospitals• Number of hospital admissions per year with selected alcohol-related illnesses

as primary diagnosis (London: the highs and lows, 2007)

Primary diagnosis 00/01 03/04 change

Alcoholic psychosis, dependence or abuse 3,346 4,545 +36 %

Alcohol liver cirrhosis 1,380 1,670 +21 %

Alcohol poisoning 102 145 +38 %

Cirrhosis and fibrosis of the liver 294 364 +24 %

Chronic hepatitis (not elsewhere classified) 123 143 +16 %

Alcoholic gastritis 83 99 +19 %

Alcoholic cardiomyopathy 17 37

Alcoholic polyneuropathy 9 11

Total 5,354 7,014 +31 %

A&E attendances associated with alcoholA&E attendances associated with alcoholReason for presenting to St Mary’s A&E as identified at triage, and recorded on Symphony database.

AHW referrals 2006/7

n=1083 (N=72,607)(est. 25% PAT +ves)

AHW referrals 2005/6

n=973 (N=70,300)(est. 25% PAT +ves)

% of presentations referred for AHW

(2005 – 2007)

Alcohol problem* 75 (530) 46 (470) 12%

Fits [2] 58 (627) 39 (530) 8.4%

Psychiatric (inc DSH, OD) [9] 89 (1,372) 70 (1,360) 5.8%

Collapse [2] 56 (1,099) 39 (1,100) 4.3%

Head injury [3] 55 (1,863) 55 (1,650) 3.1%

Vomiting 25 (904) 20 (700) 2.8%

Assault [4] 24 (1,032) 21 (1,000) 2.2%

Fall (may include accident) [1] 42 (1,643) 26 (1,650) 2.1%

Unwell [6] 321 (17,136) 250 (18,000) 1.6%

Chest pain (inc cardiac) [8] 65 (3,665) 42 (3,500) 1.5%

Abdominal pain [7] 72 (5,252) 69 (5,000) 1.4%

Wounds 12 (3,409) 18 (3,100) 0.5%

Limb problem (may include accident) 48 (12,827) 40 (10,500) 0.4%

Other reason 141 (21,248) 238 (21,521) 0.9%

* Means alcohol with no other cause and includes “apparently drunk”There were around 1,000 referrals per year and estimated 4,000 potential referrals, cf previous slide: 7,000 “alcohol-related” for the whole of London in 2003/4.

Patients diagnosed as alcohol problem 2005-7 = 1329Complaint on arrival

Apparently Drunk 412

Unwell Adult 331

Collapsed adult 130

Mental Illness 62

Head Injury 52

Overdose & Poisoning 47

Falls 44

Fits 44

Abdominal Pain 34

Chest pain 34

Limb problems 24

Assault 20

Vomiting 19

Wounds 12

Deliberate self harm 11

Behaving strangely 6

other 47

PAT +ve category complaint Total

Fall   51

Collapse   187

Head Injury   34

Assault   16

Accident   8

Unwell   190

Non-Specific GI   33

Cardiac   3

Psychiatric Mental Illness 24

  Unwell Adult 19

  Overdose & Poisoning 8

  other 7

  Abdominal Pain 5

  Deliberate self harm 5

Apparently Drunk 5

  Wounds 3

Psychiatric Total   77

Other   259

Repeat Attender   45

Not Applicable   75

not recorded   351

Time of arrival at A&E - Patients subsequently diagnosed with alcohol-related problem

0

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00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23

2006/7 alcohol

2005/6 alcohol

Time of arrival at A&E - All patients

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2000

3000

4000

5000

6000

00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23

2006/7

2005/6

Time of arrival at A&E - Patients identified on admission with alcohol-related problem

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00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23

2006/7 apparentlydrunk

2005/6 apparentlydrunk

Monday and Friday are peak days for all attendances.Saturday is about average.

Alcohol-related attendances by weekday

0

20

40

60

80

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120

140

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

2005/6 "drunk"

2006/7 "drunk"

2005/6 alcohol

2006/7 alcohol

During admission to St Mary’s accident and emergency, medical and nursing staff consider the alcohol consumption of any patients presenting with one of the “top ten” reasons for admission (seen on earlier slide).

THE PADDINGTON ALCOHOL TESTTHE PADDINGTON ALCOHOL TEST

If PAT positive and the patient agrees, referral is made to A&E Alcohol Health Work session (AHW), which is operated by a clinical nurse specialist in substance misuse.

If the patient reports alcohol issues, presents with other conditions they can also be referred. This is particularly the case with repeat attendees.

DETECTIONDETECTIONby by DrNurseDrNurse

REFERRALREFERRALby by DrNurseDrNurse

Advice & Advice & InformationInformation

DesiresDesires HelpHelp

ST MARY’S MODEL for ALCOHOL INTERVENTIONSST MARY’S MODEL for ALCOHOL INTERVENTIONS

ANSANS gives gives feedback to feedback to

referrerreferrer

BRIEF BRIEF INTERVENTIONINTERVENTION

from from ANSANS

ChangesChanges LifestyleLifestyle

PATIENTPATIENT

PATIENTPATIENTPATIENTPATIENT

PATIENTPATIENT

using PATusing PATConsidersConsiders

ConsequencesConsequences

AttendsAttendsA&EA&E

AcceptsAcceptsProblemProblem

F.R.A.M.E.S.

FEEDBACK about impact on health etc

RESPONSIBILITY for own lifestyle change

ADVICE regarding abstinence (or moderation)

MENU of alternatives for treatment etc

EMPATHY & non-judgmental interview style

SELF-EFFICACY promotes likelihood of change

Motivation & not MoralityMotivation & not Morality

• A&E liaison via PAT• Includes CDU, Douglas & Joseph Toynbee ward

• Ward referrals can be made directly

• Alcohol withdrawal management• St Mary’s alcohol guidelines being reviewed

• Advice & support for ward staff

• Psychiatric liaison• Where dual diagnosis is an issue

• Brief assessment of substance misuse

• Referral to community alcohol services

ALCOHOL HEALTH WORKALCOHOL HEALTH WORK

WHO IS REFERRED FORWHO IS REFERRED FORAHW INTERVENTION?AHW INTERVENTION?

Referral & ReductionReferral & Reduction

For every two (hazardous/harmful drinking) patients referred for AHW

there will be one less re-attendancewithin the next 12 months.Crawford MJ et al, Lancet,

2004;364:1334-39

ST. MARY’S HOSPITAL:ST. MARY’S HOSPITAL:Impact of “full time” alcohol nurse specialistImpact of “full time” alcohol nurse specialist

2004/5540 patients accepted referral, and 119 attended their AHW appointment (22% of referrals).

2005/6973 patients accepted referral, and 453 attended their AHW appointment (46% of referrals).

2005/61083 patients accepted referral, and 593 attended their AHW appointment (55% of referrals).

(from 2004-7 figures, approx 300 people /year recorded)

36% of referrals (where data was reported) said that the most they will drink in a day is 11 to 20 units of alcohol.

4% (est. 30 cases) said that they drank over two bottle of spirits or equivalent per day.

18% said they did not drink every day.

Type and amount of alcoholType and amount of alcohol

Many patients do not consider the amount they are drinking to be a problem. (NB Younger people are less likely to take this seriously, less likely to attend appointments.)

If we know it is implicated in their admission to hospital, we can offer brief advice regarding reducing their drinking or attempting controlled drinking.

Team AHW

Mr Robin Touquet Adrian Brown

Robin.Touquet@St-Marys.nhs.uk ade.brown@nhs.net020 7886 7663

END OF PRESENTATION

The History of AHW at St Mary’s A&EThe History of AHW at St Mary’s A&E• Began in 1988 - 46% of patients detected as misusing

alcohol - using a combination of the CAGE and modified MAST questionnaires (Green et al, 1993).

• CAGE and MAST time-consuming for A&E routine, and detect dependent as opposed to hazardous drinkers.

• This led to the "1-minute Paddington Alcohol Test” (PAT) (Smith et al, 1996)

• Using PAT, pilot cohort study showed 65% of patients detected and subsequently counselled by an alcohol health worker (AHW) reduced their alcohol intake at 6-month follow-up (Wright et al, 1998).

• PAT refined to screen top 10 clinical conditions associated with alcohol misuse. A four-fold increase in detection rate compared with the previous PAT (Huntley et al, 2001).

• Brief feedback for hazardous drinkers re health consequences of alcohol consumption resulted in a significant increase in numbers accepting AHW referral (Patton et al, 2003).

• Assessed SHOs attitudes towards PAT (Huntley & Touquet, 2004).

• PAT is an evolving pragmatic clinical tool (Patton et al, 2004) – several short papers

• Randomised controlled trial (2001-2003) and economic evaluation’ (REDUCE) funded by the AERC (Crawford, Patton, Touquet et al, 2005)

• The half-life of the 'teachable moment' for alcohol misusing patients in the emergency department (Williams et al 2005)

• This work carried out with 3 AHW sessions per week

The History of AHW at St Mary’s A&EThe History of AHW at St Mary’s A&E

• Post REDUCE & Teachable moment:

• Evidence to employ full time Alcohol Nurse Specialist to carry out Alcohol Health Work– Patients who wait less likely to attend– PAT results in reduction of drinking– AHW session results in greater reduction

• Full time post extends role to the rest of the hospital, referrals double, patients receiving brief intervention trebles.

• Further development of alcohol guidance & models of care network for Westminster.

The History of AHW at St Mary’s A&EThe History of AHW at St Mary’s A&E

PAT pathway