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BRIEF REPORT ON THE DEVELOPMENT
OF ALCOHOL SCREENING AND BRIEF
INTERVENTIONS AT CHARING CROSS
HOSPITAL A&E DEPARTMENT
Neal Richardson
Alcohol Nurse Specialist
27th May 2008
Introduction
The Alcohol Nurse Specialist(ANS) post at Charing Cross Hospital A&E was
commenced on 19th November 2007. The first four weeks in post were used to
meet key individuals in the hospital and visit other local statutory and nonstatutory services, as well as publicise the new system for screening and brief
intervention (SBI) in the A&E department. ANS clinics were commenced on
17th December 2007.
In addition to basic data, this report will describe the system for SBI
implemented at the hospital. The role of the ANS will be outlined and areas for
future development discussed.
Basic Data
17th December 2007 to 15th August 2008:
436 patients screened.
346 assessments and brief interventions.
43 individuals seen on more than one occasion.
90 directed towards specialist alcohol services (Attendance rate data is still
being compiled).
335 males; 101 females
Borough (primarily by GP address):
Hammersmith and Fulham: 227
Kensington & Chelsea: 42
Hounslow: 40
Ealing: 25
Wandsworth 17
Westminster: 10
Other: 75
10% of those referred are registered as NFA
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Screening for alcohol use
The screening tool used in the A&E department is the Paddington Alcohol Test
(PAT). It is designed for use in a busy A&E setting, with prompts to consider
screening for patients attending hospital with complaints which may arise as a
result of excessive drinking (fall, collapse, head injury, assault, accident,
“unwell”, non-specific gastro-intestinal, psychiatric, cardiac and repeat
attendance). While doctors at Charing Cross have taken the lead in the
screening process, all clinical staff are encouraged to screen and refer
patients. It has recently been agreed that PAT forms will be included in all
A&E patient notes, as a prompt for doctors and nurses to consider screening.
The PAT involves 5 questions:
1
Do you drink alcohol?
2
What is the most you will drink in one day?
A scale is included to assist calculation of standard alcohol units.
3
How often do you drink more than twice the recommended amount?
Guidance is given to the patient about the recommended limits.
4
Do you feel your attendance here is related to alcohol?
If “yes”, patients are given feedback: “We advise you that this drinking is harming
your health". If they are drinking daily, but not excessively, they are advised
about drink-free days. Patients are also given the Dept. of Health booklet: “How
Much Is Too Much?”
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We would like to offer you advice about your alcohol consumption;
would you be willing to see our alcohol nurse specialist?
ANS Clinics
Patients accepting the offer of an appointment will then be booked into the
next available ANS appointment. Clinics are held each weekday morning
from 10am to 12pm. An appointment card is given to the patient, with the ANS’
contact number if they are unable to attend and would like to arrange another
date.
Patients Admitted To Hospital
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Any patients referred and then admitted to hospital will be followed up on the
ward by the ANS. The ANS also visits the Emergency Assessment Unit (A&E
admissions ward) each morning to see any patients who may benefit from a
brief intervention but may not have been referred while in the A&E
department. If appropriate, patients will be seen by the ANS while in the A&E
department
Brief Interventions
The brief intervention consists of assessment of the patient’s drinking pattern
and history, as well as questions related to physical and mental health and
social circumstances. This information is used to provide personalised
feedback about the risks associated with excessive drinking. The aim of the
brief intervention is to elicit change in harmful drinking behaviour. The
patient is given advice and information on reducing or stopping drinking and,
if appropriate, directed towards specialist services for ongoing
support/treatment. In certain cases the patient may be offered follow-up
appointments with the ANS eg the harmful drinker who wishes to reduce
his/her alcohol intake and would benefit from an extended brief intervention
to support this goal.
Feedback for staff
All staff who have referred a patient to the ANS are given written or verbal
feedback about the outcome of the intervention.
Training and Support
The provision of training for hospital around SBI and alcohol is an important
part of the ANS’ role. Since commencing the post 14 formal training and
educational sessions have been provided to clinical staff. The topics covered
have been:
The Use of SBI in the A&E Department
Alcohol Awareness
Alcohol Dependence and Managing Withdrawal Symptoms
Detecting and Treating Wernicke’s Encephalopathy
The hospital emergency nurse practitioners have been given training on
providing brief advice to hazardous/harmful drinkers. All new A&E staff have
a session with the ANS as part of their induction. Education is also provided on
a less formal basis during day to day discussions with staff.
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The provision of specialist advice around managing alcohol withdrawal and
working with patients with alcohol problems is an important and well utilised
aspect of the ANS’ role. As well as assessing withdrawal symptoms and
reviewing chlordiazepoxide dose for patients admitted to a ward, individuals
will also be assessed while in the A&E department, if requested.
Partnerships
The development of working relationships with staff from other disciplines
within the hospital and external agencies has been vital in offering effective
interventions to problem drinkers. This has involved liaison with mental
health services, children’s services, homeless agencies, GPs and social
services; in addition to statutory and non-statutory alcohol services.
Developing The Service

While hospital staff are generally supportive of the new SBI system and
early data is encouraging, the screening and referral of excessive
drinkers is not yet standard practice. Not all patients who may benefit
are being screened and referred. Staff are also more likely to refer
alcohol dependent individuals than hazardous and harmful drinkers.
The low proportion of females referred may be indicative of staff
perceptions of individuals appropriate for screening and referral.
Ongoing training, education and promotion of the benefits of SBI will be
important in raising awareness among staff.

As a means to promote screening and the provision of advice around
safer drinking, self-screening information will soon be available for
patients in the A&E, Emergency Assessment Unit and Urgent Care
Centre waiting areas. This will be a short booklet with the AUDIT
screening tool for self-completion; information about risks associated
with excessive drinking and brief advice on reducing intake. The
booklet – put together with the support of the DAAT - will also include
the ANS contact details, to encourage self-referral. It is hoped to
introduce more detailed self-help material into waiting areas in the
near future.

With recent changes to medical training, Senior House Officers work in
A&E department for four months (previously six months). As the SHOs
are the main referrers to the ANS, numbers of individual referrals are
monitored and feedback will be given to the group at the 2 month stage
of their rotation as a means to encourage screening. As an added
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incentive it may be beneficial to consider a prize for the individual
making the most ANS referrals over the four month period.

The establishment of an alcohol specific, open access service in
Hammersmith & Fulham would be beneficial not only for alcohol
dependent hospital patients requiring treatment but also for harmful
drinkers who would benefit from an extended brief intervention.

The main focus to date has been on the development of SBI in the A&E
department. It is apparent from visits to other hospital wards that a
significant number of patients with alcohol related admissions are not
receiving interventions around their alcohol use. These patients may
have been too unwell to be screened and referred by staff while in the
A&E department, or admitted directly to other wards. It is planned to
expand the promotion of screening and referral to the ANS to other
wards, although this work may be limited due to the large number of
patients involved. As well as hospital wards, other hospital based
services eg sexual health clinic, fracture clinic and maxillofacial clinic
are settings which may benefit from the use of SBI. To adequately
implement SBI throughout the hospital is likely require additional
resources.

Future reports will include more detailed breakdown of data. This will
include information about numbers of hazardous, harmful and
dependent drinkers seen and whether patients directed towards
specialist services attended appointments.
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