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Wessex AHSN - Alcohol Related Liver Disease, Audit and Pathway

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Getting to Grips with Alcohol 2016
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Wessex AHSN - Alcohol Related Liver Disease, audit and pathway
Helen Phillips & Beki Osborne

Published in: Healthcare
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Wessex AHSN - Alcohol Related Liver Disease, Audit and Pathway

  1. 1. Background • Admissions and deaths due to alcohol are increasing • Liver deaths continue to rise while Mortality from other conditions has been declining. • Greatest increase in Liver deaths have been in Alcohol Related Liver Disease • Alcohol accounts for 77% of Liver Mortality • 2010 BSG / BASL / Alcohol Health Alliance UK joint position statement
  2. 2. NCEPOD 2013 National Confidential Enquiry into Patient Outcome and Death Alcohol Liver Related Deaths • Care `less than good `in more than half of cases reviewed • Frequent Attenders – longer admissions – complex needs • Missed opportunities during previous admissions • RECOMMENDATIONS • Screening of hospital patients for alcohol misuse/alcohol history • Provide comprehensive physical and mental assessments, Brief Interventions and access to specialist services within 24 hours of admission • The referral and outcomes should be documented in the notes and communicated to the patient’s general practitioner
  3. 3. To improve health and wellbeing of patients presenting to hospital with alcohol related liver disease (ARLD) AIM
  4. 4. OUTCOMES • Reduce Emergency Admissions • Reduce Bed days- length of stay • Reduce Mortality • Improve Patient journey • Improve staff Knowledge *Increased Rates of early detection of Harmful Alcohol use and associated risk*
  5. 5. Audit sample 1. Patients 18 yrs who had a Liver diagnosis and who had a stay in Hospital of over 24hrs FROM 01/01/15 – 31/03/15 2. K codes (liver disease)
  6. 6. Patient Journey Admissions • 67 % Admissions to MAU and AAU Discharges • 13% from MAU and AAU • 36% from Gastro wards • 7% from Coronary Care • 12% from Surgery • 12% other beds • 20% Mortality
  7. 7. All Patients Admitted 1st Jan – 31st Mar 2015 Basingstoke and Winchester > 24 hrs 2 17 43 32 12 13 1 7 27 18 9 9 1 10 16 14 3 4 0 5 10 15 20 25 30 35 40 45 50 18-25 26-45 46-65 66-75 76-85 85+ All Patients Male Female
  8. 8. Length of Stay- All Admissions 36 41 29 12 8 4 0 5 10 15 20 25 30 35 40 45 1-2 days 3-7 days 8-14 days 2-4wks 1-2 mths 2 mth+
  9. 9. Length of Stay – ARLD Patients 10 15 13 6 3 1 0 2 4 6 8 10 12 14 16 1-2 days 3-7 days 8-14 days 2-4 wks 1-2 mths 2 mths+
  10. 10. ED attendances <24 HRS STAY • 220 ED attendances for Patient Group in previous year • 78 people attended on average 3 times each during the period • 10 most frequent attenders accounted for 44% of all of the A&E attendances. • The most frequent attender visited ED 25 times in the period accounting for 11% of all of the attendances Continued
  11. 11. ED continued • 12% (26) had a primary diagnosis of Alcoholic liver disease • Unspecified liver disease 5% (12) • 55% (120 ) presentations resulted in Hospital Admission
  12. 12. PATIENTS SCREENED JANUARY – MARCH 2015 PATIENTS ADMITTED TO MAU – BASINGSTOKE AND WINCHESTER JANUARY 5% out of 1,234 patients FEBRUARY 3% out of 1,148 patients MARCH 3% out of 1,291 patients Source - Business Intelligence and from Pastplus Data -Alcohol Intervention Team
  13. 13. 35 WITH ALCOHOL CODES 71 NON ALCOHOL 13 MISSING / NOT FOUND NOTES SEEN / NOT SEEN
  14. 14. ARLD Admissions (39) NON ARLD Admissions (71) 87% Were asked about their alcohol use 85.9% Were asked about their alcohol use (61) 38.4% Had units documented (15) 11.4% Had units documented 1/3 Units incorrectly calculated Units correctly / incorrectly calculated – unknown / not documented
  15. 15. NON ARLD 61 PATIENTS ASKED ABOUT THEIR ALCOHOL INTAKE – Documented:- 31 13 1 3 4 9 No alcohol intake =50.8% Occasional =21% Denied excess use = 1.6% Audit C score – 1 positive (not referred)=4.9% Rarely / minimal = 6.5% Alcohol Qty = 14.75%
  16. 16. Harm / Reduction Advice 1 person  Other • 6 x Admitted HX excess alcohol use • 5 x Conflicting accounts from Nursing / Medics • Documented not significant – elsewhere documented >20 / 30 a week • 1 x Elective admission, not on Endoscopy admission • 10 Patients not asked about their alcohol use
  17. 17. ARLD – 33 PATIENTS (39 Admissions) 3 ITU 34 Asked 2 Not asked
  18. 18. ARLD PATIENTS – 34 ASKED ALCOHOL HISTORY DOCUMENTED:- 6 6 7 15 Stopped drinking / Not current 17.6% Quantities documented 17.6% Vague History 20.5% Unit History 44.1%
  19. 19. 34 Asked (above) 6 x Stopped drinking / Not current 6 x Quantities documented eg • Bottle of vodka a day • 2 Glasses wine a day • Bottle gin a day • 2-3 bottles wine or ½ bottle vodka • 300mls a day • 3.5 litres cider 7 x Vague History eg • Couple whiskies a day • Drinks one box • High intake prior to fall • Known to drink • Multiple bottles of alcohol 15 x Unit History • 5 Incorrect • 2 Conflicted • 5 Correct • 3 Not known
  20. 20. ISSUES IDENTIFIED • Frequent attendances. • Poor Alcohol History- vague • Not Using Screening tool • Risk of Withdrawal – longer admissions • Lack of knowledge around units- reduced confidence • Limited referral to Specialist nurses • More collaboration • Specialist Liver nurse input
  21. 21. ALCOHOL RELATED LIVER DISEASE INPATIENT PATHWAY Questions Scoring system Your score0 1 2 3 4 How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? How often have you had 6 or more units if female or 8 or more if male, on a single occasion in the last year? AVERAGE WEEKLY UNIT INTAKE – TOTAL... ARLD DIAGNOSIS + POSITIVE ‘AUDIT C’ AT INITIAL ASSESSMENT - SCORE 8+ ALCOHOL TEAMLIVER CONSULTANT (A) CARE BUNDLE IF DECOMPENSATED LIVER CIRROHIS TRANSFER TO GASTRO WARD (A) DISCHARGE PLAN – INTERAGENCY CARE PLAN - SUMMARY TO GP MAU 1ST 24 HOURS MANAGE AS PER POLICY IF THE RISK WITHDRAWAL CIWA – PABRINEX – CONSIDER ADJUNCTIVE PHARMALOGICAL THERAPY ALCOHOL R/UHEPATOLOGY R/U (A) WARD / MDT (A) HEPATOLOGY OPA (A) ALCOHOL FOLLOW UP (A) =Auditable PT LABEL
  22. 22. CHALLENGES • Screening tool removed from Nursing Assessment • Liver nurse not commissioned for ARLD • Time lost – Non effective • Screening for PH – Different procedure • Limited In-Reach From Specialist services • Not a 7 day week service • Referrals • Across two sites
  23. 23. NEXT STEP • Training- Units awareness – staff MAU /AAU • Screening • B.I • Referral ! • MDT attendance and Integrated Discharge Planning • Working Party • Promote In –Reach • OPA – With Gastro - Joint ARLD clinic • Medical Training Re Documentation
  24. 24. Coding Clinicians to be clear and detailed. Harmful Use Code F101 – Not defined in ICD 10 ? Changes to Local Hospital Policy for clear definition Need a clear diagnosis documented - No ‘impressions’, no ‘queries’ and no ‘likely’. Semantics – Possible can not be coded – Probable is acceptable Alcohol codes not documented unless: Clearly written alcohol excess • Secondary to alcohol • Diagnosis is clear • Units • Advice given needs to be documented
  25. 25. On-going Service Development • Co-ordination and Collaboration between interface of services • Working party across both sites – to include Housing Social services ,Mental Health ,Older Persons, Specialist services • Pilot involvement with High Impact User Group – involving Police , Probation Mental Health , Ambulance • Joint Assessment with Patients presenting with Mental Health issues and Psychiatric Liaison • Integrated pathways between hospital and community services- • Identification of patients who can finish treatment with community services • Professionals Meeting prior to discharge to devise care plan at D/C so can be on clinical tag if were to be readmitted either site • Attendance at Gasto Ward MDT – enable early discharge planning • Development of joint ARLD – Consultant / Alcohol Follow up

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