Alcohol Pathways in the Acute Hospital

Dr Alex Thomson Consultant Liaison Psychiatrist

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The Problem The Evidence Base

Current work / services Proposals/discussion

1 The Problem

Alcohol affects every part of the body

Emergency Dept

High rates of attendances, Frequent users, Reattendances, “Mental Health”, Violence & aggression

Ambulance

High callout rates, Frequent users

Wards

Complications, Higher mortality, Longer stay, Readmissions

Surgery

Complications, Higher mortality, Longer stay, Readmissions

Outpatients

DNA rates, poor compliance, poor response, higher morbidity

Obstetrics

Poor antenatal engagement, complications, parenting issues

Alcohol also affects every part of the hospital

...but it’s hard to know the extent of the issue

Because alcohol problems are so pervasive and widespread, no specialty or dept takes an interest or responsibility

...except Addiction Psychiatry – but in traditional models of care this is usually located away from the hospital, possibly with an “inreach worker” or two

All these different conditions are recorded – but not specified as “caused by alcohol”

Alcohol problems are not coded in Hospital Episode Statistics

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Emergency Dept Attendances

Non-dependent (high risk) hospital admissions

Alcohol dependent hospital admissions

Here’s what we know about

acute & unscheduled care

We can look at the ED Hospital Episode Statistics 2011-12 from the Health and

Social Care Information Centre

1 Emergency Dept Attendances

210,525 Total ED attendances per year

4,050 Total ED attendances per week

Alcohol-attributable fraction not known ?

NPH and CMH combined have

9.8% of attendances were alcohol-related

Between 21:00 and 09:00, this rose to 19.7%

45% Alcohol was involved in

of “mental health” attendances

Kelly G et al. Emerg Med J 2013

York ED did a casenote review and found:

“Although 553 patients had evidence of alcohol in their attendance, it was only coded as such in 46 computer records”

These attendances get coded as “falls”, “chest pain”, “seizure”, “collapse” etc.

Unless you LOOK for alcohol problems you won’t find it in the statistics

40-70% of ED attendances are alcohol-related

The Institute of Alcohol Studies did a National ED Survey (2004) and estimated that:

397 Alcohol-attributable attendances per week 9.8%=

210,525 Total ED attendances per year

4,050 Total ED attendances per week

Applying these rates to our figures, we get:

Estimates come from the Local Alcohol Profiles for

England 2010-11

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Non-dependent (high risk) hospital admissions

Alcohol dependent hospital admissions

7,095 Alcohol-specific and Alcohol-attributable admissions per year

25 Alcohol-specific admissions per week

110 Alcohol-attributable admissions per week

97 Acute hospital beds occupied by people with alcohol-attributable conditions every single day

35,628 Alcohol-attributable bed-days per year

Across our two boroughs there are:

3 Alcohol dependent hospital admissions

There are some data on clinical outcomes / length of stay from a

small audit

Delirium Tremens / Seizures

People who develop delirium tremens should be offered oral lorazepam as first-line treatment. 5 / 13

People who develop withdrawal seizures during treatment for acute alcohol withdrawal should have their withdrawal drug regimen reviewed. 1 / 1

Phenytoin should not be offered to treat alcohol withdrawal seizures. 1 / 12

DT on Admission

5

Developed DT in

Hospital 8

Did not have DT

13

DT Treatment reviewed

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DT Treatment

not reviewed

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People who develop delirium tremens during treatment for acute alcohol withdrawal should have their withdrawal drug regimen reviewed.

Length of Stay

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1 - 2 3 - 4 5 - 6 7 - 8 9 - 10 11+ Length of Stay

Median 5.5 days Mean 6.25 days Range 1-28 days

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4

6

1 - 2 3 - 4 5 - 6 7 - 8 9 - 10 11 +

Duration of Detox

Median 4.5 days Mean 4.5 days Range 1-7 days

Prolongation of admission by detox

0

2

4

6

8

0 1 2 3 4 5 6 7 >7

Days from Last Non-detox Treatment/Investigation to Discharge

0

2

4

6

8

10

12

0 >=1

Days from End of Detox to Discharge

So needing alcohol detox prolongs LOS

Reattendance / readmission rates also likely to be high

In Summary...

400 135 25

?

ED attendances every week

Alcohol-related admissions / week

Admissions directly due to alcohol

•High complication rates •Longer stays •Poor engagement with community services

2 The Evidence Base

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ED Attendances

Non-dependent (high risk) hospital admissions

Alcohol dependent hospital admissions

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5

10

15

20

25

0m 6m 12m

To avoid one ED attendance in subsequent 12m: -9 needed to be screened -2 needed to be referred

Mean units per drinking session

ED – Identification and Brief Advice 1

Wards – Brief Interventions

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Wards – Alcohol Dependence

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Transfer pathways to specialist addiction unit

4w: 71% Engaged with community alcohol team; 43% with Mutual Aid 3m: 51% Engaged with community alcohol team; 28% with Mutual Aid

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“All patients presenting to acute services with a history of potentially harmful drinking, should be referred to alcohol support services”

“A multidisciplinary Alcohol Care Team, led by a consultant with dedicated sessions, should be established in each acute hospital and integrated across primary and secondary care.”

National guidance recommends on-site provision of addiction services for alcohol

“Each hospital should have a 7-day Alcohol Specialist Nurse Service... to provide comprehensive physical and mental assessments, Brief Interventions and access to services within 24 hours of admission”

3 Current work / services

Current Staff One liaison psychiatrist One alcohol specialist nurse (across both hospitals!) 0.4WTE alcohol liaison nurse (Compass – Harrow patients only)

Current Projects

Review of alcohol detoxification guidelines Transfer pathway to specialist addiction unit Psychiatric Assessment Lounge Frequent Attenders Project Training – junior doctors Audit – NICE Guidance

4 Proposals/discussion

Next Steps

1. Formal Partnerships with community addiction services 2. Establish alcohol steering group / forum 3. 7-day Alcohol Nurse Specialist Service in both hospitals 4. Alcohol Care Team with dedicated consultant sessions 5. Establish detox pathways – addictions unit /

ambulatory care 6. 7-day Identification and Brief Advice Team in ED 7. Psychosocial programme in hospital