ACTS – new opportunities? (Alcohol Care and Treatment Service) Nick Sharer May 2015 Hogarth’s Gin Lane and Beer Street 1751 – total chaos

Addressing liver disease in the UK Ten key recommendations …….. 1.Strengthen detection of early liver disease and its treatment by improving the level of expertise and facilities in primary care

Time period between referral to a liver clinic and first admission with cirrhosis or liver failure

The Big Three Alcoholism Obesity Viral hepatitis (hepatitis B & C)

NCEPOD: measuring the units a review of patients who died from alcoholic liver disease Jan – June 2011 deaths from alcohol-related liver disease 2454 patients from 218 hospitals 1752 patients (71%) had a previous admission in last 2 years to that hospital 62% of these (1082/1752) were with ARLD 18% had presented to other hospitals Advisors felt that for many patients opportunities had been missed in previous admissions that had the potential to influence outcome. The majority of these would have been referral to alcohol support agencies

Cohort: Patients over 65 years admitted with wholly attributable alcohol ICD-10 diagnosis e.g. alcohol intoxication, alcoholic liver disease / myopathy / pancreatitis etc. June June 2014 (253 patients) 18 died as in-patients (14M : 4F) Retrospective study: Review of admissions in ~30 years preceding death PGH study: Data collection

Results (18 patients) Age range (average 69) 155 admissions over 30 years: 6 admitted 6-15 times 2 admitted >15 times One attended A&E 98 times in 20 years (database goes back to 1993) Remaining 17 patients totalled 145 A&E attendances PGH study

DepartmentExamplePercentage SurgicalFracture, epistaxis, abdominal pain, pancreatitis, 35% MedicalConfusion, LOC, SOB, chest pain, AF, 65% PGH study: Reasons for admission Difficulties in categorising: Paper notes Multiple co-morbidities

Alcohol History: Only 4 patients had history taken every admission Examples of inadequate history (‘occasionally / a couple‘) Correlation between specialty and full alcohol history – a need to target surgical specialties! PGH study: Results continued

None of the patients were found on the drug and addictions services database. Any referrals, appointments offered or contacts should be recorded (since 2007) 14/18 (77%) patients had correspondence with GP (Clinic letter, IDS) who was asked to review alcohol intake of detox regime on discharge

77 yr old female 12 admissions (one elective) 11 A&E attendances 5/11 alcohol history was taken Case history 1995 Epistaxis No history or f/u 1999 Epistaxis No history or f/u 2002 Epistaxis No history or f/u 2004 Epistaxis No history or f/u 2006 Haematemesis - PUD History taken No f/u 2010 NOF # No history or f/u 2010 Haemetemesis- varices History taken No f/u 2011 Elective femoral Nail No history or f/u 2012 Gen unwell No history or f/u 2012 Sepsis History taken No F/U 2013 Confusion History taken No f/u 2014 Pneumonia Alcohol history taken Died Cause of death: I a Bronchopneumonia b Decompensated alcoholic liver disease II Type 2 diabetes

Hb MCV Plts INR Creat ALT ALP Bil Alb  GT Variceal bleed USS: Cirrhosis and ascites Epistaxis Decomp ALD USS: Cirrhosis, splenomegaly, ascites 2002/ Missed opportunity early on for intervention despite high MCV and GGT 2006 – no mention of alcohol on IDS despite  GT and MCV results Haematemesis: PUD

NCEPOD recommendations: Acute hospital model for an alcohol care team  A consultant-led, multidisciplinary, patient-centred alcohol care team to be integrated across primary and secondary care  7 day alcohol specialist nurse service  Coordinated policies for the emergency department and acute medical units  Rapid assessment, interface, and discharge liaison psychiatry service  An alcohol assertive outreach team for frequent attender to hospital  Formal links with local authority, clinical commissioning groups, public health, and other stakeholders

Hughes NR, Houghton N et al. Salford alcohol assertive outreach team: a new model for reducing alcohol-related admissions. Frontline Gastroenterol. 2013: 4;  Multi-disciplinary team: medical, psychiatric, drug misuse worker, nurse, social worker  54 patients for 6 months  Comparing 3 months pre and post intervention  Admissions 151 -> 50  A&E attendances 360 -> 146

Poole AAOT: pilot started Sept 14 2 workers appointed Local, generic and specific training Risk management issues (lone workers) 31 patients taken onto case load as of April months Pre AO6 months Post AO Mode of conveyance to ED Ambulance9147 Other6214 Total153 (£11,894)61 (£4,612) Inpatient admissions97 (£104,454)27 (£34,264) GP / Practice contacts Alcohol related problems / All conditions 96/22547/93

Take home messages: 1.Liver disease is rising exponentially 2.Consider alcohol excess in multitude of presentations 3.Use screening (AUDIT C tool) and ACT on it 4.Utilise resources available