1. PAT 2009 with clinical signs and blood alcohol concentrations
PAT 2009 with clinical signs and blood alcohol concentrations. ‘Make the Connection’
Prof. Robin Touquet & Adrian Brown RMN
St Mary’s Hospital, Imperial College HCT,
Paddington, London, England.

2. Early Identification of Alcohol Misuse
History – Paddington Alcohol Test (PAT)
Examination – “SAFE Moves, ABCD”
Special Investigation – Blood Alcohol Concentration (BAC)
Leads to
- Brief Advice (B.A.) (by all staff) + offer of referral
- Brief Intervention (B.I.) (by Alcohol Nurse Specialist)

3. PAT is a clinical tool for early identification: 1 to 3 Brief focused history.
4 Introduces relationship between drinking and A&E attendance.
5 Offering appointment for Brief Intervention (B.I.)

4. SAFE Moves
Back of PAT 2009

5. All new A&E SHOs 1 hour Education Alcohol Misuse DAY 2!
Early detection in natural history of misuse
- noting clinical signs of alcohol
- use of PAT & Alcohol Health Work
- ? BAC if not ‘PAT-able’
Every SHO gives RT 5 PATs 1st 2/52
- once you ‘give me 5’, symphony will suffice for patients who do not accept referral
Each month feedback presented as a league table of referrals

6. 1 year Resuscitation Room positive BACs - Prevalence by Y90 coding20 40 60 80
100
120
No. of
patients
Collapse
GI Bleed
NCCP
DSH
Trauma
Other
mg/100ml
Y Y Y Y Y Y Y Y90.8
Note. DSH denotes deliberate self harm, and NCCP denotes Non Cardiac Chest Pain
110/291 (38%)
> 240 mg/100ml
Note that at Y90.6 BAC >120 mg /100ml, incidence of “BAC Top 5 increases
From “Resuscitation Room blood alcohol concentrations: one year cohort study” Touquet et al, Emergency Medicine Journal 2008: 25: 752-6

7. Symbiosis to counter ‘clinical inertia’
Alcohol Nurse Specialist – ‘stress reducer’ for staff:
seeing patients perceived as ‘difficult’ - B.I. (20 mins +)
Consultant Alcohol Support
ensuring referrals, supporting education/audit/feed-back for giving simple B.A. (1/2 -2 min)

8. Role of the Alcohol Nurse Specialist
Brief intervention following referral – both by appointment and in real time if on observation/admission ward; liaison with local services.
Education,e.g. for brief advice (by all staff) with resulting referral rate increase, withdrawal, detox. regimes, etc.
Audit – improving practice.
Feedback – patient outcomes. CHANGING ATTITUDES.
ANS attends every weekday 8am including CDU & DAAU

9. 30 months in A&E (initial research done in resusc only)
174,764 adult attendances at A&E
52% 84,024 had PAT possible condition
1% (1,714) “apparently drunk”
2.0% (1,812*) diagnosed “alcohol problem”
2.6% (2,191) referred to ANS
5,384 had BAC carried out on
2,315 BAC < 10 mg/100ml) ie NEGATIVE
2,554 BAC > 120 mg/100ml
31% (804) referred to ANS
9011 admitted via resuscitation room
64% (5788) PAT possible condition
33% (2967) BAC top 5
1% (72) “apparently drunk”
1.5% of these (126) diagnosed “alcohol problem”

10. Reminder: PAT possible conditions as recorded on A&E database
Apparently Drunk
Falls
Collapsed adult
Fits
Head Injury
Assault
Abdominal Pain
Chest pain
Mental Illness
Deliberate self harm
Overdose & Poisoning
Behaving strangely
Unwell Adult
Limb problems
Wounds

11. Outcome of ANS referrals (PAT possible conditions)
31% of referrals to ANS have positive BAC (679 out of 2179)
12% have BAC <10 (259 out of 2179)

12. Outcome of ANS referrals (where BAC done)
NB among BACs <10, 54 previous contact, 168 referred to ANS

13. Patient TG, 30 y.o. male Feb 2009 to July 2009: 23 attendances
16 times “apparently drunk”
15 occasions, BAC tested
all > 250 mg/100ml (only two below 400)
mean 474 mg/100ml
highest 652 mg/100ml
Admitted to hospital three times
Observed in Clinical Decisions Unit twice
Referred to ANS ten times, seen eight*
*always when in hospital!

14. Patient EF, 51 y.o. male Never previously attended A&E
Head injury after bicycle accident
Initially reluctant to admit he’d been drinking
BAC tested
Did not want to stay in hospital, discharging doctor advised him of BAC score and he then accepted referral to ANS.
Attended ANS appointment 2 days later
Admitted his drinking had been a problem, and agreed to referral to community services.

15. BAC level vs PAT test Maximum units per day, reported on PAT mg/ 100ml
Where PAT completed, self report <15 units per day but BAC score suggests more !
mg/ 100ml
Maximum units per day, reported on PAT

16. There will be one less reattendance within the next 12 months.
PAY OFF For every two patients referred to the Alcohol Nurse Specialist
There will be one less reattendance within the next 12 months.
Screening and referral for B.I.
Lancet 2004;364:1334-9

18. When to order a BAC? - always with a sugar (grey bottle)
1. If in Resuscitation Room.
- Collapse
- Trauma
- Self-harm & overdose
- G.I. & Abdominal
- Chest pain
2. If giving IV B vitamins (pabrinex) for chronic alcohol misuse with poor diet
- ? Signs of Wernicke’s
3. If clinical signs of withdrawal
- patient in majors (on trolley needing bloods being taken)

19. BAC score vs PAT test No reason for PAT ?
Q At what level should PAT be deemed +ve ? 240 is evidence of drinking > twice UK recommended limits!

20. BAC score vs Referral to ANS
Unfortunately the majority in the “hazardous” range are not referred, but there is evidence that these patients leave (intoxicated) before result is known.
Increasing likelihood that referral will be made.

21. BAC score vs Age group
Younger adults (20-40) tend toward higher consumption,

22. BAC score vs gender