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

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. 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. To improve health and
wellbeing of patients
presenting to hospital
with alcohol related liver
disease (ARLD)
AIM

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. 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. 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. 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. 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. 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. 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. 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. 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. 35 WITH
ALCOHOL
CODES
71 NON
ALCOHOL
13 MISSING /
NOT FOUND
NOTES SEEN / NOT SEEN

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. 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. 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. ARLD – 33 PATIENTS
(39 Admissions)
3 ITU
34 Asked
2 Not asked

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. 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. 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. 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. 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. 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. 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. 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