Presented for discussion about meeting the needs of people with alcohol use disorders in North West London Hospitals Trust

1. Alcohol Pathways in the Acute Hospital
Dr Alex Thomson
Consultant Liaison Psychiatrist

2. 1
2
The Problem
The Evidence Base
3
4
Current work / services
Proposals/discussion

3. 1
The Problem

4. Alcohol affects every part of the body

5. Alcohol also affects every part of the hospital
Surgery
Complications, Higher mortality,
Longer stay, Readmissions
Obstetrics
Poor antenatal engagement,
complications, parenting issues
Wards
Complications, Higher mortality,
Longer stay, Readmissions
Ambulance
High callout rates, Frequent users
Outpatients
Emergency Dept
DNA rates, poor compliance, poor
response, higher morbidity
High rates of attendances, Frequent
users, Reattendances, “Mental
Health”, Violence & aggression

6. ...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

7. Alcohol problems are not coded in Hospital
Episode Statistics
All these different
conditions are recorded
– but not specified as
“caused by alcohol”

8. Here’s what we know about
acute & unscheduled care
1
Emergency Dept
Attendances
2
Non-dependent (high risk)
hospital admissions
3
Alcohol dependent
hospital admissions

9. 1
Emergency Dept
Attendances
We can look at the ED Hospital Episode
Statistics 2011-12 from the Health and
Social Care Information Centre

10. NPH and CMH combined have
210,525
4,050
?
Total ED attendances per year
Total ED attendances per week
Alcohol-attributable fraction not known

11. York ED did a casenote review and found:
9.8%
of attendances were alcohol-related
Between 21:00 and 09:00, this rose to
Alcohol was involved in
19.7%
45%
of “mental health” attendances
Kelly G et al. Emerg Med J 2013

12. “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

13. The Institute of Alcohol Studies did a National ED Survey
(2004) and estimated that:
40-70%
of ED attendances are alcohol-related

14. Applying these rates to our figures, we get:
210,525
4,050
9.8%=
397
Total ED attendances per year
Total ED attendances per week
Alcohol-attributable
attendances per week

15. 2
Non-dependent (high risk)
hospital admissions
3
Alcohol dependent
hospital admissions
Estimates come from the
Local Alcohol Profiles for
England 2010-11

16. Across our two boroughs there are:
7,095
25
110
35,628
97
Alcohol-specific and Alcoholattributable admissions per year
Alcohol-specific admissions
per week
Alcohol-attributable admissions
per week
Alcohol-attributable bed-days
per year
Acute hospital beds occupied by
people with alcohol-attributable
conditions every single day

17. 3
Alcohol dependent
hospital admissions
There are some data on clinical
outcomes / length of stay from a
small audit

18. Delirium Tremens / Seizures
DT
Treatment
not
reviewed
9
Developed
DT in
Hospital
8
DT on
Admission
5
DT
Treatment
reviewed
4
Did not
have DT
13
People who develop delirium tremens
during treatment for acute alcohol
withdrawal should have their
withdrawal drug regimen reviewed.
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
1 / 12
Phenytoin should not be offered to treat alcohol withdrawal seizures.

19. Length of Stay
6
Median 5.5 days
Mean 6.25 days
Range 1-28 days
4
2
0
1-2
3-4
5-6
Length of Stay
7-8
6
9 - 10
11+
Median 4.5 days
Mean 4.5 days
Range 1-7 days
4
2
0
1-2
3-4
5-6
7-8
Duration of Detox
9 - 10
11 +

20. Prolongation of admission by detox
8
12
10
6
8
4
6
4
2
2
0
0
0
1
2
3
4
5
6
7
>7
Days from Last Non-detox Treatment/Investigation to Discharge
0
>=1
Days from End of Detox to Discharge
So needing alcohol detox prolongs LOS

21. 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
?
Reattendance / readmission rates also
likely to be high

22. 2
The Evidence Base

23. 1
ED Attendances
2
Non-dependent (high risk)
hospital admissions
3
Alcohol dependent
hospital admissions

24. Mean units per drinking session
25
20
To avoid one ED attendance in
subsequent 12m:
-9 needed to be screened
-2 needed to be referred
15
10
5
0
0m
6m
12m
1
ED – Identification
and Brief Advice

25. Wards – Brief Interventions
2

26. Wards – Alcohol Dependence
3

27. 3
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

28. National guidance recommends on-site
provision of addiction services for alcohol
“All patients presenting to acute services with a
history of potentially harmful drinking, should be
referred to alcohol support services”
“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”
“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.”

29. 3
Current work / services

30. 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

31. 4
Proposals/discussion

32. Next Steps
1.
2.
3.
4.
5.
Formal Partnerships with community addiction services
Establish alcohol steering group / forum
7-day Alcohol Nurse Specialist Service in both hospitals
Alcohol Care Team with dedicated consultant sessions
Establish detox pathways – addictions unit /
ambulatory care
6. 7-day Identification and Brief Advice Team in ED
7. Psychosocial programme in hospital