Shared learning database

Newcastle University: Institute Health and Society
Published date:
January 2013

This multi-disciplinary service evaluation is built on the results of recent national research (Kaner et al 2013), reviewing the effectiveness of screening and brief alcohol intervention in primary care. It is a pragmatic service evaluation which has been designed to assess the feasibility of implementing alcohol screening and brief advice into a routine hospital outpatient department (as recommended in NICE PH Guidance 24). The endoscopy department at Newcastle Hospitals Trust has been the chosen clinical setting, including the national bowel screening element, due to the association between alcohol and gastrointestinal diseases. Drawing upon the theory of implementation science and reviewing professional behaviour change, the aim is to understand how to best roll out alcohol screening and brief advice across the hospital trust, as part of making every contact a health improving opportunity.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The aim of this service evaluation is to assess the extent to which it is feasible to implement alcohol screening (10 question AUDIT) and brief intervention into a busy endoscopy outpatient department as a part of routine hospital clinical practice.
1. To undertake a rapid review of the literature regarding how to implement evidence based practice into routine hospital care.
2. To provide a brief epidemiological summary of the relationship between alcohol consumption and gastrointestinal disease (including colorectal cancer).
3. To ensure regular communication is maintained throughout the period of the project through the development of a time limited stakeholder steering group.
4. To undertake a brief ethnographic study of a patient's journey for both bowel screening and symptomatic referral to assess where in the patient's pathway alcohol screening and brief advice should take place.
5. To plan, develop and roll out training for staff teams through the development of a standardised toolkit.
6. To develop, pragmatically pilot and utilise a data collection template.
7. To develop, facilitate the delivery of and analyse a pre and post training and post three month pilot staff questionnaire and focus groups to ascertain attitudes, values and beliefs for implementing alcohol screening and brief advice in a routine hospital outpatient setting.
8. To provide regular feedback and engagement from clinical champions to maintain motivation for project.
9. To administer a three month pilot of whole nursing team delivering alcohol screening and brief intervention (ASBI) to all patients with regular feedback to nurses on initial data outcomes built in.
10. To undertake data analysis to complete process evaluation.
11. To develop recommendations to enable NUTH?s Senior Management Team to make informed decisions regarding how to implement alcohol screening and brief advice as part of routine care

Reasons for implementing your project

Recent national research and NICE guidance (Kaner et al 2013, NICE 2010, Newbury-Birch et al, 2009; Coulton et al, 2009) has highlighted the beneficial impact of screening the adult population for risky alcohol consumption and providing feedback/brief advice, resulting in the subsequent reduction of alcohol consumption in one in seven people. Whilst the evidence demonstrates impact within the primary care setting as well as accident and emergency departments and probation, little work has been undertaken within the context of hospital outpatient departments. When considering which outpatient department to focus on, the published literature on the epidemiology of alcohol and associated diseases was reviewed. In partnership with key stakeholders at Newcastle Upon Tyne Hospitals (NUTH), endoscopy was deemed to be an appropriate department due to the association between moderate to heavy alcohol use and gastrointestinal disease, including various types of cancer. Within an endoscopy pre assessment appointment there is a health improvement opportunity to discuss alcohol consumption and prevent/reduce on going damage caused by risky drinking.

Local context:
NUTH hosts a multi-disciplinary Public Health Trust Group (PHTG). The remit of this group is to ensure health improvement targets are systematically integrated into the structure and function of the hospital setting through a coordinated action plan. As alcohol is one of the PHTG?s priority areas they are committed to the service evaluation and are keen to consider recommendations emerging from the work.

Benefits of implementing NICE guidance:
Currently the endoscopy department do not systematically screen patients for alcohol using a validated tool. As part of a general lifestyle conversation alcohol may be discussed informally with patients or their weekly consumption may be asked. It is therefore not possible to quantify the baseline activity. By implementing NICE guidance a more systematic and standardised approach to alcohol screening can be embedded into everyday clinical practice, addressing risky alcohol consumption with an element of the general population

How did you implement the project

This service evaluation builds upon the foundations of professional behaviour change theory and implementation science. A public health intervention such as alcohol screening and brief advice can be defined as a complex intervention. The Medical Research Council's framework for developing and evaluating complex interventions describes four components: 1) Development 2) Feasibility 3) Evaluation 4) Implementation

This service level evaluation covers stages 1, 2 and 3. Whilst the project is classified as a service level 'evaluation' the scope is insufficient in size to demonstrate true 'effectiveness'. However, the pilot is designed to explore the change process for professionals to embed alcohol screening and brief advice into every day clinical practice. Assessing the feasibility of implementing alcohol screening and brief advice within a busy hospital outpatient department will enable the development of recommendations to NUTH regarding roll out and wider implementation. Steps in implementation:
-Senior management champions, such as senior nurses and consultants, are essential when implementing a new programme of work. -The process of implementation has been driven by a Public Health Specialty Registrar who has been able to utilise strong partnership links and forge new relationships with key stakeholders throughout the hospital trust. A time limited steering group has been established to support the programme management. -Working within the academic rigour of a university setting has enabled a robust service evaluation protocol to be developed, following appropriate research governance procedures.

Potential problems have been discussed within the protocol as possible barriers to implementation. These barriers have been identified through the published literature on professional behaviour change and incorporated into the planning of the programme. By completing pre-training questionnaires and focus groups, underpinned by behaviour change theory, nursing staff have an opportunity to raise concerns. These concerns can then be factored into staff training and enable the process to evolve and adapt to suit the needs of the staff, whilst retaining authenticity to service evaluation methodology. A three month pilot will assess the implementation, followed by post implementation questionnaires and focus groups to gain feedback from staff. The only financial cost to the project is the printing of questionnaires and training resources

Key findings

The intended improvements are to be able to identify risky alcohol consumption and provide a brief intervention as an opportunity to improve the health of the patients seen within endoscopy outpatient assessment unit. This service evaluation is an on-going project but the intended outcomes measured against the 11 objectives include:

1. Outcome: An in-depth overview of implementation theory will aid understanding in how to develop the most practical way to embed alcohol screening and brief advice into endoscopy outpatient dept.
2. Outcome: Sharing knowledge on the association between alcohol and gastrointestinal disease will ensure intervention can be tailored to nurse specialist interest.
3. Outcome: Stakeholder steering group will ensure ownership of project.
4. Outcome: To identify the best opportunity to include alcohol screening and brief advice into mainstream assessment paperwork
5. Outcome: Feedback on training will provide a mechanism to develop an 'off the shelf' template to other outpatient departments
6. Outcome: A pragmatic data collection process that is user friendly with a minimum dataset is more likely to be completed.
7. Outcome: Pre and post questionnaires can demonstrate a change in knowledge, attitudes, values and beliefs for staff group engaged. Focus group will draw out the more in-depth feelings on barriers and facilitators to implementation.
8. Outcome: Review the 'added value' of audit and feedback loop as part of the three month pilot to assess if this should be part of implementation intervention.
9. Outcome: Pilot will highlight some barriers and facilitators to implementing alcohol screening and brief advice in a hospital outpatient department
10. Outcome: Data analysis will measure outputs and outcomes.
11. Outcome: Final report presented to NUTH PH Trust Group

Key learning points

Success Criteria:
-Engage relevant senior stakeholders early in process.
-Share a strategic vision to engage stakeholders in the added value of implementing public health NICE guidance into the secondary care environment.
-Coordinate a time limited multi-disciplinary steering group to galvanise interest and ownership.
-Develop a robust protocol that is approved by hospital trust R&D.
-Ensure implementation project plan has a professional behaviour change theoretical underpinning.
-Embed evaluation from the start of the process to demonstrate proposed outcomes.
-Ensure time management of project is realistic to account for staff sickness and holiday.
-Confirm dissemination channels for both internal and external communication during the implementation process.
-Apply a pragmatic approach to process and retain strong and positive relationships so barriers can be discussed and overcome in partnership.

Contact details

Gill O'Neill
Public health Specialty Registrar
Newcastle University: Institute Health and Society

Is the example industry-sponsored in any way?