Hospital Alcohol Project James Crosbie, Gastroenterologist Alcohol Delivery Group 1 st July 2011

Hospital Alcohol ProjectJames Crosbie, Gastroenterologist

Alcohol Delivery Group 1st July 2011

Hospital Alcohol ProjectJames Crosbie, Gastroenterologist

Alcohol Delivery Group 1st July 2011

Hospital Alcohol Project

• Background• Objectives• Personnel

• Activity & outcomes– 1. Emergency Dept– 2. Gastroenterology– 3. Turning Point

• The way forward (& barriers)

RPIWSarah Fox & Ben Seale

Background

National Indicator 39 (NI 39)

• Measures rate of alcohol related admissions using Hospital Episodes Statistics (HES)

• “Alcohol Attributable Fractions” for medical conditions applied to HES

• 47 conditions : – 13 wholly attributable conditions– 22 partially attributable chronic conditions– 2 partially attributable acute consequences. – eg ALD =1, hypertension <1 (depending on age & sex)...

• 60-70% NI39 admissions in NE “partially attributable”

National Indicator 39 (NI 39)

• Measures rate of alcohol related admissions using Hospital Episodes Statistics (HES)

• “Alcohol Attributable Fractions” for medical conditions applied to HES

• 47 conditions : – 13 wholly attributable conditions– 22 partially attributable chronic conditions– 2 partially attributable acute consequences. – eg ALD =1, hypertension <1 (depending on age & sex)...

• 60-70% NI39 admissions in NE “partially attributable”

Objective

• Reduce Alcohol Related Hospital admissions (NI39?)

• Increase hospital based resources for patients with alcohol related illness

• Alcohol Steering group

CHS Personnel• Emergency Dept

– Kate Lambert ED Consultant– Cain Thomason Data manager

• Gastroenterology– James Crosbie Clinical Lead– Deb Smith Alcohol Specialist Nurse

• Turning Point– Geoff Anderson Senior Alcohol Worker– Laura Thubrun Alcohol Worker– Tracey Stewart Alcohol Worker

1. Emergency Department

1. Emergency DepartmentThe Scale of the Problem:

• April 2009 – March 2011

– 9150 Alcohol related ED attendances

– 1337 Alcohol related admissions via ED– 269 of these readmissions by 136 individuals

• June 2010 – May 2011

– Top 50 attendees accounted for 598 attendances– Top 10 attendees accounted for 328 attendances

1. Emergency DepartmentThe Scale of the Problem:

• April 2009 – March 2011

– 9150 Alcohol related ED attendances

– 1337 Alcohol related admissions via ED– 269 of these readmissions by 136 individuals

• June 2010 – May 2011

– Top 50 attendees accounted for 598 attendances– Top 10 attendees accounted for 328 attendances

Year 1 of the Hospital Alcohol Project 2009/10 – 2010/11:

– Total ED attendances increased by 1%

– Alcohol related attendances fell by 8%(10% men 5% women)

– Alcohol % total attendances fell by 0.66%

Heavy Service Users Group• Initial activity stopped due to info sharing barriers• Restarting following RPIW

– Info sharing protocol v5.1– Care Navigator post

• Top 20 frequent attenders & others from ED dashboard (or if complex needs identified)

– Kate Lambert -Probation– Data manager -Mental Health– ASN -Housing– DAT -C4

Heavy Service Users Group• Initial activity stopped due to info sharing barriers• Restarting following RPIW

– Info sharing protocol v5.1– Care Navigator post

• Top 20 frequent attenders & others from ED dashboard (or if complex needs identified)

– Kate Lambert -Probation– Data manager -Mental Health– ASN -Housing– DAT -C4– James Crosbie -GP

Youth Drug and Alcohol Project

• Service reinstated with permanent Hospital Link Worker March 2011• 36 alcohol related ED attendances < 18 since then (2.25 /week)• Age range 10 – 17 years (median 15 mean 14)

• 19 referred to YDAP– 10 attended Brief Intervention– 3 sent information packs– 2 already known to YDAP, – 2 open referrals to YDAP– 2 declined any input.

• Of the 17 not referred, 13 have been sent letters from YDAP offering follow up and information packs.

BREAK

2. Gastroenterology

2. Gastroenterology

• Alcohol Specialist Nurse (ASN)

• Introduction of symptom triggered detox

• Alcohol IBA training– Targeted clinical areas & staff– Embedded in junior doctor teaching programme– SASQ embedded in medical admission proforma

Alcohol Specialist Nurse– Inpatient referrals: harmful drinkers

– Liaison with :• Gastroenterology• Community team (Counted 4)• Turning Point• DAT• Other agencies

– Facilitate discharge of gastro patients through early follow up

– Phoneline, voicemail & bleep for direct patient access

– Clinic for review of discharged patients, direct access and scheduled follow up

– Day case paracentesis service with view to nurse led service

– Nurse prescribing

– Alcohol Link Nurse Network (all wards)

A&E

Turning Point

Counted 4

Primary careGastroenterology

Hospital wards

Drug & Alcohol Team

Deb SmithA L N

NeRAF

NECA

Alcohol Specialist Nurse

Activity Jan 2011 – (mid) June 2011

• 392 referrals (70 / month)• Onward Referrals:

– TP: 122 C4: 7 DAT: 17– Housing: 17 Other:29 Huntercoombe: 8

• 285 clinic follow up• 165 BI• 161 liver disease blood tests + 38 liver USS• 128 telephone referrals (56 onward referral / discussion• Direct access paracentesis 26

Alcohol Specialist Nurse

Profile

Staff Education & Training

• Alcohol Link Nurse network

• Nursing Clinical skills

• Medical students

• Hospital meetings

Inpatient detox

• Previous model: Fixed dose detox– 5-7 day admission with controlled reduction– Standard dosing to all “increasing risk” drinkers

• Symptom triggered detox (NICE recommended)– Identify dependence (withdrawal)– Reduce LOS for those not requiring treatment– Increased monitoring & treatment for withdrawal– Reduction in overall drug dispensing & cost– Increased effectiveness of treatment when needed

CIWA-Ar for the management of Alcohol Withdrawal SyndromePatient name______________________ X number_________________________Date started______________________ Time (24hour)_____________________

Pre CIWA (baseline) audit

June – August 2010

• 239 admissions for 194 unique patients• 26 (13%) had been admitted >1 occassion (group A)

Group A Group BAverage total amount per patient (mg) 258.99 213.76Average Daily Amount (mg) 47.93 31.020-24 hours (mg) 89.82 78.5824-48 hours(mg) 87.38 77.7648 hours +(mg) 198.25 213.49

Average amount of chlordiazepoxide used during admission from both single admission (group B) and repeat admission (group A) patients

Pre CIWA (baseline) audit

June – August 2010

• 239 admissions for 194 unique patients• 26 (13%) had been admitted >1 occassion

Repeat Patients

Single Admission patients

Total Admissions 70 168Number of Patients 26 168Average length of stay (days) 4.27 6.83Range (days) 0-20 0-78

number of admissions and average length of stay of both repeat and single admission patients.

Turning Point

Turning Point• All inpatients & A&E attendances identified as problem drinkers

• Monday to Saturday service (diary appointment if intoxicated or out of hours)

• Delivery of alcohol interventions

• Initial assessment with onward referral to community services:– NeRAF– NECCA– Drug & Alcohol Team– Counted 4

Turning Point

February 2011           

No of Referrals     80    Assessed     10    Brief Interventions     69    Declined Service     1    Previously Assessed     18    

January 2011           

No of Referrals     80    Assessed     12    Brief Interventions     65    

Declined Service     3    Previously Assessed     29    

March 2011

         No of Referrals 58 Assessed 18Brief Interventions 40 Previously Assessed  

April 2011           

No of Referrals 64

Assessed and Referred On 8

Assessed and Taken Onto Caseload 6

Extended Brief Intervention Only 42

Out of Area Referrals 8

Follow Up Appointments 24

December 2010

           No of Referrals 66 Assessed 54Brief Interventions 12 Previously Assessed 25

Turning Point

February 2011           

No of Referrals     80    Assessed     10    Brief Interventions     69    Declined Service     1    Previously Assessed     18    

January 2011           

No of Referrals     80    Assessed     12    Brief Interventions     65    

Declined Service     3    Previously Assessed     29    

March 2011

         No of Referrals 58 Assessed 18Brief Interventions 40 Previously Assessed  

April 2011           

No of Referrals 64

Assessed and Referred On 8

Assessed and Taken Onto Caseload 6

Extended Brief Intervention Only 42

Out of Area Referrals 8

Follow Up Appointments 24

December 2010

           No of Referrals 66 Assessed 54Brief Interventions 12 Previously Assessed 25

Turning Point April 2011Gender

Male 40 62.5%Female 24 37.5%

Age

18-24 1 1.6%55-64 8 12.5%

25-34 16 25.0%65-74 3 4.7%

35-44 20 31.3%75+ 3 4.7%

45-54 13 20.3%    0.0%

Ethnicity

White British 63 98.4%Other White 1 1.6%

Accommodation

Hostel 4 6.3%Owned 9 14.1%

Parental 6 9.4%Rented - Gentoo 20 31.3%

Rented - Private 15 23.4%Rented - RSL 7 10.9%

Sheltered Accommodation 1 1.6%Supported Housing 2 3.1%

Postcode

SR1 5 7.8%DH3 1 1.6%

SR2 8 12.5%DH4 3 4.7%

SR3 6 9.4%DH5 7 10.9%

SR4 6 9.4%NE37 1 1.6%

SR5 11 17.2%NE38 3 4.7%

SR6 4 6.3%TS8 1 1.6%

SR7 7 10.9%    0.0%

SR8 1 1.6%    0.0%

Level of Alcohol Use

Abstinent 3 4.7%Harmful 13 20.3%

Binge 13 20.3%Hazardous 2 3.1%

Dependent 29 45.3%Sensible 4 6.3%

Complex Needs

None 6 9.4%Medium 12 18.8%

Low 34 53.1%High 12 18.8%

Children

Parent/Childcare Responsibilities 24 37.5%Children Living in Property 7 10.9%

Armed Forces

Yes 0 0.0%Forces Attributable? 0 0.0%

No 63 98.4%

Referral Source

A&E 2 3.1%Alcohol Nurse 7 10.9%

AMU 3 4.7%ASN 1 1.6%

B28 2 3.1%C33 1 1.6%

C36 37 57.8%ESAU 1 1.6%

D57 1 1.6%F51 1 1.6%

Self 6 9.4%Self Harm Team 2 3.1%

Referrals Made

AA 1 1.6%Counted 4 1 1.6%

Cruise 1 1.6%Dual Diagnosis Nurse 2 3.1%

Durham CAS 5 7.8%NECA 5 7.8%

NERAF 1 1.6%Self Harm Team 1 1.6%

Presenting Complaints

Abdominal Pain 3 4.7%Alcohol Excess 1 1.6%

Alcohol Withdrawal 5 7.8%Assaulted 1 1.6%

Cellulitis 2 3.1%Chest Pain 2 3.1%

Collapsed 2 3.1%Depression 1 1.6%

Fall 8 12.5%Generally Unwell 1 1.6%

Overdose 12 18.8%Self Harm 5 7.8%

Stomach Cancer 1 1.6%Stroke 1 1.6%

Suicidal Ideation 9 14.1%Vomiting 2 3.1%

N/A 8 12.5%    0.0%

The way forward• Implement RPIW outcomes

– Care Navigator– Enhanced data set & data management– 7 day alcohol liaison service

• Roll out CIWA across all (non medical) wards– Complete audit (post CIWA)

• Enhanced ASN role including– Increased outpatient capacity– Prescribing role– Further bid for additional post (readmission funds)

Barriers

Barriers

• NI39– Unresponsive (majority partially attributable)– Newcastle model: wholly attributable analysis