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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 1 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?” 5 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 2 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. 3 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 4 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. 5