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W Sussex, July 2008

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(General Household Survey, 2005) Total deaths in England ... to St Mary's A&E as identified at triage, and recorded on Symphony database. ... – PowerPoint PPT presentation

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Title: W Sussex, July 2008


1
(W Sussex, July 2008)
Alcohol health work atSt Marys Hospital,
Paddington
Adrian Brown Alcohol Nurse Specialist Imperial
College Healthcare CNWL Substance Misuse
Service
2
WHYSCREENFOR ALCOHOL USE ?
3
Misuse 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)

4
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5
Alcohol in Hospitals
  • Number of hospital admissions per year with
    selected alcohol-related illnesses as primary
    diagnosis (London the highs and lows, 2007)

6
AE attendances associated with alcohol
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.
7
AE attendances associated with alcohol
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.
8
ST. MARYS HOSPITALIMPACT OF ALCOHOL HEALTH WORK
2004/5 (three sessions per week only) 540
patients accepted referral, and 119 attended
their AHW appointment (22 of referrals). 2005/6
(five sessions per week, full time ANS)973
patients accepted referral, and 453 attended
their AHW appointment (46 of referrals).
2006/7 (as above, plus two research projects
recruiting) 1083 patients accepted referral, and
593 attended their AHW appointment (55 of
referrals). 2007/8 (research projects ended
mid-year)848 patients accepted referral, and
533 attended their AHW appointment (63 of
referrals).
9
MEANWHILE, ELSEWHERE
  • A London DAAT recently commissioned a study into
    the prevalence of alcohol related presentations
    to the local Hospitals Emergency Department.
  • The results of the study indicated that between
    30-40 of presentations to AE are alcohol
    related which is similar to other studies carried
    out nationally.
  • The research showed that
  • 20 of clients had been drinking on the day of
    presentation to AE
  • 33 drank hazardously (i.e. above safe government
    limits)
  • 43 drank more than the recommended limits on a
    monthly basis or more.
  • 20 had in the last year been told of concerns
    about their drinking from a health worker,
    medical doctor or relative.
  • 12 of cases were for alcohol abuse

10
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11
Social Impact of Alcohol
  • FAMILY and RELATIONSHIPS
  • Children affected by parental alcohol problems
    780,000-1.3m
  • Number of street drinkers 5,000-20,000
  • WORKPLACE
  • Working days lost due to alcohol-related
    sickness 11-17m
  • Working days lost due to reduced employment
    15-20m
  • CRIMINAL ACTIVITY
  • Arrests for drunkenness and disorder 80,000
  • Victims of alcohol-related domestic violence
    360,000
  • Alcohol-related sexual assaults 19,000
  • Drink-driving deaths 530
  • HEALTH
  • Alcohol-related deaths due to acute incidents
    4,000-4,100
  • Alcohol-related deaths due to chronic disease
    11,300-17,900

12
Social Impact of Alcohol
  • EMPLOYMENT
  • Alcohol involved in 25 of accidents at work
  • estimated 2 billion p.a. cost to industry in
    absenteeism poor performance (Alcohol Concern
    2002)
  • CRIMINAL ACTIVITY
  • 40 of violent crimes inc. domestic violence
    (Kershaw et al, 2000)
  • One in five violent crimes takes place in or
    around pubs and clubs 70 of these incidents
    take place on weekend evenings (Cabinet Office
    Strategy Unit Alcohol Project, 2003).

13
WHY SCREEN WITH THE PAT?
14
SCREENING TOOLS
  • AUDIT 10 questions or 5 questions
  • includes
  • How often during the last year have you failed to
    do what was normally expected from you because of
    your drinking?
  • How often during the last year have you had a
    feeling of guilt or remorse after drinking?
  • Has a relative or friend, doctor or other health
    worker been concerned about your drinking or
    suggested you cut down?

15
SCREENING TOOLS
  • FAST 4 questions (variation on AUDIT)
  • includes
  • How often during the last year have you failed to
    do what was normally expected from you because of
    your drinking?
  • How often during the last year have you been
    unable to remember what happened the night before
    because you had been drinking?
  • Has a relative or friend, doctor or other health
    worker been concerned about your drinking or
    suggested you cut down?
  • These tools can be judgemental, but do measure
    the extent of dependence.

16
SCREENING TOOLS
  • MAST 10 questions
  • includes
  • Questions about the impact of alcohol on
    relationships, work and other social situations.
  • Questions about the persons attempts to stop or
    engage in treatment services.
  • Again somewhat judgmental, and distances the
    conversation from current hazardous drinking, due
    to focus on long term problems and help-seeking.

17
SCREENING TOOLS
  • CAGE 4 questions
  • Have you ever felt you should Cut down on your
    drinking?
  • Have people Annoyed you by criticising your
    drinking?
  • Have you ever felt bad or Guilty about your
    drinking?
  • Eye opener Have you ever had a drink first thing
    in the morning to steady your nerves or to get
    rid of a hangover?
  • Two positive responses are considered a positive
    result indicating further assessment needed.
    (Nilssen Cone, 1994 taken from Mayfield et
    al 1974)

18
WHY THE PADDINGTON ALCOHOL TEST ?
During admission to St Marys Emergency Dept,
medical and nursing staff consider alcohol
consumption of any patients presenting with one
of the top ten reasons for admission that might
be related to alcohol. It was felt that less
judgmental questions would be easier for doctors
in a busy AE to ask their patients. Three
simple questions, plus (if needed) two
motivational questions, followed by feedback and
advice giving.
19
THE PADDINGTON ALCOHOL TEST
  • Do you drink alcohol?
  • What is the most you will drink in any one day?
  • How often do you drink?(NB daily drinking with
    some episodes more than twice the recommended
    amount )
  • Do you feel your attendance here is related to
    alcohol?
  • We would like to offer advice about your alcohol
    consumption, would you be willing to see our
    alcohol nurse specialist?

20
ST MARYS MODEL for ALCOHOL INTERVENTIONS
Attends AE
PATIENT
PATIENT
DETECTION by DrNurse
Considers Consequences
using PAT
REFERRAL by DrNurse Advice Information
ANS gives feedback to referrer
Accepts Problem
BRIEF INTERVENTION from ANS
PATIENT
PATIENT
Changes Lifestyle
Desires Help
21
ALCOHOL HEALTH WORK
  • AE liaison via PAT
  • Includes Clinical Decisions unit, admission and
    assessment wards (and out-patients?)
  • Other ward referrals can be made directly
  • Alcohol withdrawal management
  • St Marys alcohol guidelines were reviewed
    comprehensively
  • Advice support for ward staff
  • Psychiatric liaison
  • Where dual diagnosis is an issue
  • Brief assessment of substance misuse
  • Referral to community alcohol services

22
WHAT EXACTLY IS ALCOHOL HEALTH WORK ?
23
Interventions
  • Type of intervention depends on goal
  • Brief intervention
  • Motivational enhancement therapy (MET)
  • Psychological therapy
  • Eg. Cognitive therapy, Behavioural treatments,
  • Marital therapy, Social skills training, Relapse
    prevention
  • 12 step approach / Alcoholics Anonymous
  • Pharmacological interventions

24
Harm reduction
  • Address basic needs, food hygiene
  • Reduction in the number of cans/ bottles
  • Replacement of stronger drinks by weaker ones(eg
    replace 9 by 5)
  • Reduction of number of drinking days per week
  • Access to GP/ health assessment
  • Encourage medical screening eg blood tests for
    engagement.

25
A BRIEF INTERVENTION
  • Reason for admission to hospital, attendance at
    GP surgery ... etc
  • Current alcohol use and extent of problem, or
    patients understanding of problem.
  • Alcohol history, esp. previous periods of
    abstinence, withdrawals, treatment.
  • Current social, health and psychiatric status.
  • Significant family, employment and legal history.
  • Risk assessment.
  • Feedback

26
Brief Intervention
FEEDBACK about impact on health
etc RESPONSIBILITY for own lifestyle
change ADVICE regarding abstinence MENU OF
ALTERNATIVES for treatment etc EMPATHY during
interview non-judgmental SELF-EFFICACY promotes
likelihood of change
27
Why Brief Interventions ?
  • In primary care 47 have reduced intake at 1
    year compared to 25 among controls (Wallace et
    al, 1988)
  • In ED 23 units less at 6 months, 14 units less
    at a year. Fewer re-attendances in the department
  • 1 attendance saved for every 2 referred
  • Decreased mortality by 50 (Cuijpers et al, 2004)
  • Longer sessions (gt30 minutes) no additional
    benefit
  • Cost of providing them less than savings
    resulting from improved health (5 back for every
    1 spent)

28
Stages of change
  • Prochaska DiClemente (1982)
  • Pre-contemplation Not considering any change
  • Contemplation Thinking about change
  • Action Changes are being made
  • Maintenance New behaviours preserved

29
Motivational Enhancement Therapy
  • Many who misuse are unsure about the need to
    change
  • Confrontation is generally unhelpful
  • MET aims to promote contemplation action
  • Express empathy, avoid arguing, increase
    awareness of problem (agree factual information
    about harm)
  • Highlight differences between aims and behaviour
  • avoid arguing e.g. when asking about the effects
    of excessive alcohol consumption a person
    launches into a detailed description of the good
    times they have when drunk.

30
Roll with resistance
Let them describe this there will be an end to
their sense that drinking is worthwhile
Selective active listening and paraphrasing
By the end of the day at work, Im like so
stressed out, and then 5.00pm, hit the
pubtheres always a crowd, its usually a real
laugh. Sometimes I have too much and it can end
up in a row or something embarrassing, but
generally theres a good feel about the place and
its a great way to catch up with friends
31
Referral Reduction
  • For every two (hazardous/harmful drinking)
    patients referred for AHW
  • there will be one less re-attendance
  • within the next 12 months.
  • Crawford MJ et al, Lancet,
  • 20043641334-39

32
Team AHW
33
The History of AHW at St Marys AE
  • 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 AE 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).

34
The History of AHW at St Marys AE
  • 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

35
The History of AHW at St Marys AE
  • 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.
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