Hospital Alcohol Liaison Seven Day Service – A pilot to reduce quality of care and Alcohol related admissions Lancashire Teaching Hospitals NHS Foundation Trust Poster from the 'Delivering NHS services, seven days a week' event held in Birmingham on 16 November 2013 More information about this event can be found at http://www.nhsiq.nhs.uk/news-events/events/nhs-services-seven-days-a-week.aspx

1. Hospital Alcohol Liaison Seven Day Service – A Pilot to Improve
Quality of Care And Reduce Alcohol Related Hospital Admissions
Hospital Alcohol Liaison Service (HALS)
Lancashire Teaching Hospitals NHS Foundation Trust
Aims and Objectives
In 2010/11 alcohol related harm cost the NHS in Lancashire £141.92 million.
Reducing alcohol related hospital admissions is a priority nationally and locally. The public
health outcomes framework 2013-16 identifies reducing alcohol related hospital admissions
as a health improvement indicator.
In central Lancashire alcohol related hospital admissions have increased annually from
2005/06 up to 2010/11.
In 2010/11 Preston had the highest rate of hospital admissions for alcohol related liver
disease in the North West.
Prior to April 2013 there was no Hospital Alcohol Liaison Service (HALS) for Lancashire
Teaching Hospitals NHS Trust.
The aim of the service is to reduce alcohol related hospital admissions by
•
Reducing the rate of increase in alcohol related hospital emergency attendances
•
Reducing the rate of increase in alcohol specific hospital admissions
•
Reducing the length of hospital stay for alcohol specific hospital admissions
•
Facilitating improved clinical pathways and co-ordinated discharges, and in doing
so increasing patient access and engagement with primary care and community
specialist substance misuse services.
The objectives include:
•
Development of appropriate pathways and protocols to support delivery of HALS
•
Training to support ‘front line’ clinical and nursing staff implement alcohol use
screening using Alcohol Use Disorders Identification Toolkit (AUDIT) and deliver
opportunistic brief interventions and brief advice for all patients
•
Implementation of Hospital Alcohol Liaison Service across all Lancashire Teaching
Hospitals adult wards and departments.
From April 2013 HALS have carried out the comprehensive assessment of patients who have
attended the Emergency Dept (ED) or have been admitted to the wards of the Royal Preston
Hospital and Chorley District Hospital and who score 8 or above on the AUDIT, seven days
per week. Referrals can be made 24 hours per day by means of bleep, voicemail or diaries
kept in ED departments.
Types of Alcohol Misuse
150
28
0
31
10
0
27
16
0
7
15
18
11
50
68
66
26
22
25
14
Apr-13
May-13
Jun-13
Jul-13
Aug-13
1
23
100
50
0
Low Risk
Dependent
Harmful
Hazardous
0
27
15
70
unknown
Data collection started from 8th April. Work commenced with IT and data analysis to
develop a data base.
It was evident on the commencement of the team that there was a culture in the hospital
of delayed discharge due to patients being on a reducing regime of Chlordiazepoxide, if
medically fit the majority of patients were being kept in to complete this regime, regardless
of whether the patients wanted to stop drinking and often were not being offered follow
up in the community, leading to relapse and re attendance at hospital seeking further
detoxification. HALS were able to identify these patients and using assessment tools
advise on whether patients could be discharged safely with follow up from community
services. Numbers of bed nights saved have been calculated using the severity of alcohol
dependency questionnaire (SADQ) and the Clinical Institute Withdrawal Assessment
(CIWA) to determine whether the patient would have needed a mild to moderate reducing
regime (5 days) or a severe regime (7days), using the existing clinical guideline for assisted
withdrawal for LTHTR.
Number of Bed Nights Saved by Month
134
77
19
87
123
The Team
Apr-13
HALS started on the 8th April 2013
with two team members, Emma
Dermody, Clinical Lead Specialist
Nurse, previously employed by Greater
Manchester West mental health NHS
Foundation Trust (GMW) as the Alcohol
Liaison Nurse for the Royal Bolton
Hospital, and Keighley Allan, Clinical
Nurse Specialist, previously employed
by GMW as a Substance Misuse
Practitioner working for community
substance misuse service in Preston.
They were joined by Kerry Anderson,
previously a sister in the Emergency
Department on the 22nd April and then by Angela Platt on the 20th May, previously Senior
Substance Misuse Nurse at Preston Prison, employed by GMW.
The team cover two sites, Royal Preston Hospital and Chorley District Hospital and work
seven days per week. Weekends were covered from the 4th May.
Progress
Referrals were taken from 8th April;
pathways were developed quickly to
cope with demand for the service.
Total referrals to 31.10.13 are 813.
Number of Referrals by Gender
140
120
100
80
60
40
20
0
83
34
17
Apr-13
95
97
89
45
36
35
37
May-13
Jun-13
Jul-13
Aug-13
Female
Male
Referral criteria - patients who score 8
or above on the Alcohol Use Disorders
Identification Tool (AUDIT). This tool
was already in use in the Integrated
Care Pathway documentation (ICP) on
the wards. The AUDIT – C was in use in
the Emergency Department (ED)
Across both sites the team visit ED daily and throughout the day to check for referrals, key
wards, including the Medical Assessment Units and the Gastroenterology wards are visited
daily in the morning to check for referrals.
An assessment tool has been developed for use by the team to help identify type of alcohol
misuse, level of dependency, severity of withdrawal, other needs and risks. This allows
appropriate interventions, evidence based good practice and assessment of motivation.
Appropriate community services and solutions can then be offered for any unmet need
which may have contributed to attendance at hospital.
May-13
Jun-13
Jul-13
Aug-13
Improved referral pathways with community services have been developed. HALS are
currently able to refer patients, based on need, risk and motivation to the right part of the
treatment service. In appropriate cases community services have continued detoxification
at home on discharge. A Process Mapping Event was held in July with community and
hospital nursing, managers and medical staff, to identify where pathways can be improved.
Joint working has been developed with the senior outreach worker from Discover
community services, who was offering a clinic to ED prior to HALS, making better use of
his time at the hospital.
Pathways developed with the Mental Health Liaison Service, joint assessments taking
place when possible.
Work has taken place to standardise assessment and referral criteria with HALS from
Southport and Ormskirk hospital.
Programmes for teaching rolled out to key areas, topics including introduction to HALS,
AUDIT screening, brief interventions and alcohol detoxification. Teaching delivered to FY1
and FY2 doctors as part of the rolling programme for induction. Teaching also delivered
to nurses as part of the preceptorship programme.
Work has been commenced on the NCEPOD recommendations for Alcohol related liver
disease with Dr Sharma, Consultant Physician and Gastroenterologist, including the
development of a daily multi- disciplinary care team meeting.
Work has been commenced with data analysis identifying high impact users. For those
high impact users already identified by the team, case management meetings set up with
community services to flag up the issue of repeat attendances and to devise alternative
plans. For those not already known, appropriate referrals on to relevant services.
What is the feature of your work that you feel best demonstrates
energy, imagination and innovation?
April – October 2013 a total of 813 patients were referred, the majority receiving
comprehensive assessment of need, on the same day or following day of referral, and
an appropriate intervention, including referral to substance misuse services, brief
interventions, referral to other community services and close monitoring of detoxification
if admitted for other medical reasons. HALS will work with patients whatever their level
of motivation. A hospital admission is seen as a window of opportunity. HALS provide
a menu of options designed to help people improve any social problems and health
outcomes for the future.
Effective and supportive clinical leadership has enabled HALS to start a service from scratch,
with clear aims and objectives and ensuring there were no barriers to the introduction of
the service and backing all changes to existing pathways