1. Saturday Night in the A&E

2. Adrian Brown Alcohol Nurse Specialist Imperial College Healthcare & CNWL Substance Misuse Service Alcohol health work and the role of the alcohol nurse specialist at St Mary’s hospital, Central London Saturday Night in the A&E

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. Alcohol in Hospitals Number of hospital admissions per year with selected alcohol-related illnesses as primary diagnosis (London: the highs and lows, 2007) Primary diagnosis 00/0103/04 change Alcoholic psychosis, dependence or abuse3,3464,545+36 % Alcohol liver cirrhosis1,3801,670+21 % Alcohol poisoning102145+38 % Cirrhosis and fibrosis of the liver294364+24 % Chronic hepatitis (not elsewhere classified)123143+16 % Alcoholic gastritis8399+19 % Alcoholic cardiomyopathy1737 Alcoholic polyneuropathy911 Total5,3547,014 +31 %

5. A&E attendances associated with alcohol Reason 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% Vomiting25 (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% Wounds12 (3,409)18 (3,100)0.5% Limb problem (may include accident)48 (12,827)40 (10,500)0.4% Other reason141 (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.

6. Patients diagnosed as alcohol problem 2005-7 = 1329 Complaint on arrival Apparently Drunk412 Unwell Adult331 Collapsed adult130 Mental Illness62 Head Injury52 Overdose & Poisoning47 Falls44 Fits44 Abdominal Pain34 Chest pain34 Limb problems24 Assault20 Vomiting19 Wounds12 Deliberate self harm11 Behaving strangely6 other47 PAT +ve categorycomplaintTotal Fall 51 Collapse 187 Head Injury 34 Assault 16 Accident 8 Unwell 190 Non-Specific GI 33 Cardiac 3 PsychiatricMental Illness24 Unwell Adult19 Overdose & Poisoning8 other7 Abdominal Pain5 Deliberate self harm5 Apparently Drunk5 Wounds3 Psychiatric Total 77 Other 259 Repeat Attender 45 Not Applicable 75 not recorded 351

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

9. 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 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.

10. DETECTION by DrNurse REFERRAL Advice & Information Desires Help ST MARY’S MODEL for ALCOHOL INTERVENTIONS ANS gives feedback to referrer BRIEF INTERVENTION from ANS Changes Lifestyle PATIENT PATIENT PATIENT PATIENT using PAT ConsidersConsequences AttendsA&E AcceptsProblem

12. F.R.A.M.E.S. FEEDBACK about impact on health etc RESPONSIBILITYfor own lifestyle change ADVICEregarding abstinence (or moderation) MENU of alternatives for treatment etc EMPATHY& non-judgmental interview style SELF-EFFICACYpromotes likelihood of change Motivation & not Morality

13. 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 WORK

14. WHO IS REFERRED FOR AHW INTERVENTION?

15. 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, 2004;364:1334-39

16. ST. MARY’S HOSPITAL: Impact of “full time” alcohol nurse specialist 2004/5 540 patients accepted referral, and 119 attended their AHW appointment (22% of referrals). 2005/6 973 patients accepted referral, and 453 attended their AHW appointment (46% of referrals). 2005/6 1083 patients accepted referral, and 593 attended their AHW appointment (55% of referrals).

17. (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 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.

18. Team AHW Mr Robin TouquetAdrian Brown Robin.Touquet@St-Marys.nhs.ukade.brown@nhs.net 020 7886 7663

19. END OF PRESENTATION

20. The 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).

21. 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&E

22. 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&E

23. PAT pathway