Shared learning database

 
Organisation:
South London and Maudsley NHS Foundation Trust
Published date:
February 2018

In recognition of problem alcohol use often being a significant issue for people with mental health problems, South London and Maudsley NHS Foundation Trust (SLaM) has sought to deliver evidence-based practice in line with NICE guidance and quality standards (NICE PH24, CG115, CG120 and QS11).

NICE recommendations on alcohol screening and interventions have been integrated into Trust policies. Audits have demonstrated that some progress has been made but sustaining and improving practice is challenging, particularly in inpatient settings.  The ‘Preventing ill health’ commissioning for quality and innovation (CQUIN) has prompted a refocus on alcohol screening and interventions and a review of how best to support the delivery of evidence based practice.

Does the example relate to a general implementation of all NICE guidance?
No
Does the example relate to a specific implementation of a specific piece of NICE guidance?
Yes

Example

Aims and objectives

Aim:

  • Reduce the level of alcohol related harm experienced by people with mental health problems.

Objectives:

  • Increase the number of people admitted to inpatient wards that are screened for problem alcohol use using AUDIT (Alcohol Use Disorders Identification Test)
  • Increase the number of people receiving interventions appropriate to their alcohol risk category (‘increasing’ and ‘higher’ risk drinkers - brief advice; dependent drinkers – offer of referral to a specialist service).
  • Equip staff to conduct alcohol screening and deliver the appropriate interventions.

NICE (2010) (PH24) recommends that health and social care professionals that come into contact with people that may be at risk of harm from the amount of alcohol they drink should routinely carry out alcohol screening as an integral part of practice. A validated screening questionnaire, such as AUDIT, should be used to screen and decide whether to offer a brief intervention or make a referral.

The Alcohol Quality Standard (NICE 2011, QS11) re-iterates these requirements.

NICE (2011) (CG115) also recommends AUDIT for assessing the nature and severity of alcohol misuse. Further, it states that staff working in services that care for people who potentially misuse alcohol should be competent to identify harmful drinking and alcohol dependence.

NICE (2011) (CG120), Psychosis with Coexisting Substance Misuse, cross references the alcohol use disorder guidance. It states that staff should routinely ask people with suspected psychosis about their use of alcohol.  It also emphasises the importance of monitoring physical health and recommends paying particular attention to the impact of alcohol.

Alcohol is the substance most commonly used by people with mental health problems and evidence suggests that this group are more likely to drink problematically than the general population. Alcohol contributes to over 60 physical health conditions. People with mental health problems often have poor physical health and die up to 20 years younger than the general population.  Addressing problem alcohol use may prevent premature mortality. 

Alcohol is also associated with poor mental health, notably depression, anxiety and bipolar disorder, and with suicides and homicides by people with mental illness. Reducing alcohol use is likely to result in better mental health outcomes.


Reasons for implementing your project

The 'Preventing ill health by risky behaviours’ national CQUIN for 2017-2019 has set targets for alcohol screening and interventions in inpatient services in line with NICE guidance (PH24, QS11 and CG115).  It also requires that staff receive training to equip them to deliver brief advice.  The CQUIN has provided impetus for SLaM to re-focus its work in this area.

Alcohol is the substance most commonly used by people with mental health problems. Evidence suggests that the prevalence of alcohol use disorders in the psychiatric inpatient population may be as high as 50%. Alcohol contributes to over 60 physical health conditions and is likely to be a factor in the premature mortality of people with mental health problems.

Alcohol is also strongly associated with a range of mental disorders, including depression, anxiety and bipolar disorder, as well as a range of risks, including suicide and violence/homicide. Recent Public Health England guidance (2017) has emphasised that it is ‘everyone’s job’ to meet the needs of people with co-occuring mental health and alcohol problems.  


How did you implement the project

Key roles

A range of personnel have taken some responsibility for the CQUIN including: - consultant nurse (dual diagnosis): overall leadership - acute inpatient dual diagnosis practitioners: training delivery; practice development, support and supervision; liaison with team managers - strategic service leads: senior person taking responsibility in their services - team dual diagnosis leads: front line staff that champion dual diagnosis best practice in their teams,   including promoting alcohol screening and interventions - Digital service expertise: to develop and produce dashboards.

These personnel work together and communicate frequently.

Communication

Information about the CQUIN was produced and disseminated widely e.g. presentations made in various forums/meetings, written summary emailed to key personnel.

Electronic patient record

Electronic Patient Journey (EPJ) - the Trust’s patient record - was modified to facilitate automated data extraction. AUDIT was already incorporated.  It functions in a way to support staff to identify and deliver appropriate interventions.  It calculates the AUDIT score, identifies the drinking risk category and provides a prompt to the appropriate intervention.  Hyperlinks provide access to resources that can be printed out to support interventions.

Historically interventions were recorded as free text and it was not possible to extract data on the number provided. For digital data collection to be feasible the system was modified. Staff now record interventions using a ‘pull down’ menu.  Although data collection is more straight forward, staff have needed to become familiar with the new system.

Training

An Alcohol Screening and Interventions for Inpatient Staff course was developed.  Rather than focus solely on brief advice, as required by the CQUIN, a broader training package was developed to ensure that staff have the knowledge and skills to conduct alcohol screening, deliver brief advice, and know about, and can offer, referral to specialist substance misuse services.   The training is for half a day. It involves a mixture of learning styles: presentation, group discussion and role play.

The training evaluation (also a CQUIN requirement) is in two parts: - a pre and post training ‘Know your units’ quiz - participants’ views on whether the training met the learning objectives.

The content of the training was already integrated into the SLaM level 2 dual diagnosis course. This provides an alternative way of completing the training requirement.

There were no specific additional costs incurred as part of this project. The band 7 dual diagnosis posts, who are playing a key role in taking the work forward, were part of an initiative that was already being developed.  The initiation of their roles coincided with the project.


Key findings

 Alcohol Screening and Interventions

Data has been extracted from the electronic patient record and dashboards created. At baseline (Q1), screening was conducted on 31% of eligible service users.  By Q3 this had increased to 37%.  The target is 50% by the end of year 2.  There is considerable variability between teams. Those where performance is poor are being targeted for further support.  Initially reporting of interventions was very low.  This appears to have been because staff were unfamiliar with the new recording system.  At Q1 there were no records of brief advice having been delivered and just 10% of those eligible for referral to specialist services had been offered this.  By Q3 the figures had increased to 29% and 45% respectively.

Examination of the notes revealed that in some cases the interventions had been delivered but details are recorded in the free text, rather than the designated field. In others there is an explanation for the intervention not having been delivered, for example, the person is already in treatment with the substance misuse service.

Training

Our target is for 60% of qualified nurses and team dual diagnosis leads to complete the training. By Q3 32% of qualified nurses and 72% of team dual diagnosis leads had done this.

On the ‘Know your Units’ quiz the maximum score is 4. The average pre-training was 1.3, post-training it was 3.6.

Course participants’ ratings on the extent to which they agreed that the course met the learning objectives are below.

The training has helped me to:

Average Score (1 = strongly disagree - 5 = strongly agree)

Better understand units of alcohol

4.6

Increase my knowledge about the effects of alcohol on mental and physical health and social circumstances

4.5

Develop my skills for screening people for alcohol use disorders using AUDIT

4.5

Know what interventions to offer people that have different levels of drinking problems (eg increasing/higher risk, possible dependence)

4.5

Develop my skills in delivering brief advice

4.5

Know about the substance misuse service(s) I can refer people to in my borough and how to do this (or how to find out about local substance misuse services if working in a national service)

4.3

Know about the self-help/mutual aid groups that are available for people with alcohol problems

4.5

Know how and where to record alcohol screening and interventions on Patient Journey

4.6


Key learning points

What works well?

  • Having a range of personnel/roles with responsibility for different aspects of the CQUIN. These people communicating regularly.
  • Having a summary sheet outlining the CQUIN requirements and how to record interventions on EPJ that was circulated widely.
  • Modification of EPJ to support staff to screen using AUDIT and deliver the appropriate intervention (ie score automatically calculated, prompt to the appropriate intervention, hyperlinks to resources).
  • Development of a one page alcohol care pathway flow chart which staff are using to guide practice.
  • Band 7 dual diagnosis practitioner roles in the acute inpatient wards not only play a key role in delivering the Alcohol Screening and Interventions course, but are providing local training, role-modelling, supervision, and prompts.  They also discuss with ward managers strategies for improving practice.
  • Updates on progress are reported back to key personnel e.g. at ward managers’ meetings, at team dual diagnosis leads development days.
  • The Alcohol Screening and Interventions Course has been well evaluated.  It is being integrated into the training of new nurses as part of their preceptorship programme.

What could be better?

  • Refinements of the data collection method continued over several months. It would be wise to start testing systems in advance of needing to submit data.
  • Releasing staff to attend the training is a challenge. On occasions the course has been run with low numbers – pragmatism is needed.

Next steps

Although data from the digital reports indicate that progress is being made, quantitative data and artificial quarterly measurement points limit understanding of what is really happening in practice. At the end of Q4 a case note audit will be conducted in order to better understand some of the nuances of the data.  Auditors will be able to look in more depth at case records (including free text) and review care and treatment over more than one quarter.  The findings will inform future development plans.


Contact details

Name:
Cheryl Kipping
Job:
Consultant nurse – dual diagnosis
Organisation:
South London and Maudsley NHS Foundation Trust
Email:
Cheryl.Kipping@slam.nhs.uk

Sector:
Primary care
Is the example industry-sponsored in any way?
No