Tameside Hospital serves a population of 250.000 across Tameside. Figures show that about 22% of the population are binge drinkers (37,000 people). Admissions almost tripled over the last 10 years. In April 2013 the HALS (Hospital Alcohol Liaison Service) was established. The team consists of a Team Leader Specialist nurse, 2 Alcohol Specialist nurses, Data Administrator and Consultant Hepatologist. The team run a 7 day 8am-8pm service, offering a duty response to all inpatient and outpatient departments within the hospital, in addition to the response work the service also runs a 7/7 Ambulatory Detoxification clinic, based at the hospital which is flexible to patient's needs. The team are predominantly based in A&E as a frontline service. Almost immediately it proved a positive impact on the support offered to patients admitted for alcohol misuse, the team have been pivotal in launching and applying the principles of the NICE Alcohol withdrawal pathway.
Aims and objectives
The service aims are to work with patients attending the Hospital for urgent and planned care, who are identified as harmful or dependent drinkers and those including working with those who attend as a direct result of alcohol related harm.
The overall aims of the service are to reduce the level of alcohol harm suffered by those patients through:
- Specialist Acute Alcohol Team assessment and intervention within the Accident and Emergency Department, inpatient wards and at preoperative assessment clinic.
- Specialist assessment of each patient and where indicated, to initiate a supportive treatment plan.
- Seamless referral into community based alcohol treatment services, for post discharge specialist support.
- Appropriate discussion to maximise the opportunity for planned Quick Start detoxification, for patients who require urgent clinical intervention. This is undertaken through a NICE endorsed Chlordiazepoxide prescribing pathway, in which patients on an appropriate prescribing regime following the assessment of the level of their alcohol dependency. This assessment also includes the screening of clinical appropriateness of management via an ambulatory Detoxification pathway, which involves daily clinic following discharge to the nurse led detoxification clinic for close clinical management and daily dispensing of Chlordiazepoxide medication. Parallel to HALS clinic intervention, patients managed through the Ambulatory Protocol are in receipt of psycho-social intervention from ACORN treatment services who reinforce coping strategies for future abstinence.
- Close management of patients who are identified as 'frequent flyers' to the Accident and Emergency Department, are done so through the Complex Care Identification group. In which all partner agencies meet on a monthly basis to discuss chaotic patients in respect to engagement in services. This is done to reinforce shared supportive pathways for each individual patient - who has been identified as attending A&E as a frequent attender for clinical, social and or psychological crisis. This reinforcement of partnership working has enabled significant improvements to be achieved in securing patient engagement and subsequently reducing attendances to hospital.
Reasons for implementing your project
In 2010/11, the alcohol-attributable admission episodes rate in Tameside was 25.63% higher than the North West at 3,266 per 100,000 populations, compared to 2,429 per 100,000 for the North West, and 1,898 per 100,000 for England (LAPE 2010). The number of alcohol-related Hospital attendances to Tameside Hospital A&E department in 2007/08 equated to 1,413 and during 2012/13 was reported at 2,149 demonstrating a 52.1% increase in activity over a 5 year period. This period preceded the appointment of the Hospital Alcohol Liaison Service (HALS), funded by the CCG to address the escalation of concern regarding the level of hospital attendance for alcohol related harm.
The team undertook a needs assessment within the first weeks of operational service, which identified a Trust wide inconsistent approach to Acute Alcohol management. Early process mapping highlighted the following concerns:
- Variable prescribing of Chlordiazepoxide
- Variable clinical outcomes
- Lengthened hospital stay for patients
- High re-presentations to A&E
- Lack of clarity on Therapeutic Chlordiazepoxide prescribing
- Staff lack of understanding of both the screening process and also diminished acknowledgement of the benefits of early identification of alcohol related harm
- Staff also reported some 'discomfort' in approaching the discussion of alcohol misuse with patients, many of which were presenting to hospital for other clinical reasons.
Very early within the process, a decision was made to ensure that the referral process was as easy as possible - reducing the need for paper referral and ensuring that staff had 'open and easy access' to referring patients via a daily 12 hour bleep system. In addition to this, the team also ensured that once a patient was referred, early contact would be secured through a guaranteed assessment within 4 hours of the initial referral - to ensure the patient was placed on a safe clinical pathway. In order to ensure staff competence with the referral process, a large education and Trust-wide awareness drive was undertaken. All relevant staff were trained in the use of the audit tool.
How did you implement the project
- Baseline assessment was undertaken - identification of variable practice
- Assessment of best practice - acknowledgement of NICE Clinical Guidelines
- Presentation to Clinical Governance on proposed changes
- Forum discussion through clinical Governance
- Development of Treatment sheet - reflecting NICE instruction
- Development of a prescribing protocol reflecting NICE guidelines
- Formal sign off through Clinical Governance
- Information cascade to all Line Managers, clinical staff
- 1:1 Teaching support for all staff through formal and information presentation
- Large education campaign throughout the Trust in conjunction with Alcohol Awareness Week aimed at all staff, patients and Public
- Open access to the HALS Team for ongoing guidance and support - available 8am-8pm 7/7 days
- Consultant Hepatologist support
- Executive board support
Barriers to proposing the changes required were noted as follows:
- Staff engagement due to a lack of initial understanding
- Community partner engagement
- Time in respect to training staff away from the clinical areas
- Acceptance of new processes - however these have now been fully integrated into practice
- Communication from Community partners regarding data sharing on patients
- Securing clinic accommodation
Costs: The costs of the team have been picked up by the Clinical Commissioning Group as part of the initial service costs for the Team. The Ambulatory clinic did not form part of the initial business case - but has been delivered within the current financial budget.
01/04/13 - 31/12/13 a total of 907 patients have been seen by the HALS Team 354/907 of the referred patients were admitted as a direct result of their Alcohol misuse = 39.03% 720/907 of patients were categorised as an escalating risk in respect to their alcohol intake = 79.38% (scoring 16+) therefore a large proportion of HALS Team work has focused on early intervention and treatment initiation for patients presenting with other clinical reasons - however identified as drinking at elevated risk levels.
Data reflects that:
- To date (03/03/2014) HALS have 157 repeat attender patients on our database of the 157 patients 12 are deceased and 88 patients (56%) have not reattended A&E for over three months. - We have calculated the number of A&E attendances in respect of Repeat Attenders for 2012 and prior to the patient being picked up by HALS, the outcome is that in 2012 there were 724 presentations compared to 346 prior to HALS commencing in April 2013 equates to a 48.8% reduction. - 1/907 of patients re-attended the Emergency Department within 48hrs - this equates to 1/907 of the overall sample = 0.11% - HALS has achieved a reduction of 1 day in respect of LOS (reported in September 2013) based on information provided by Trust Information Department. - Case Study = Patient A presented to A&E on 83 occasions during 2012 and on 8 occasions in 2013 prior to the HALS service being launched, this equates to a reduction of presentations to A&E of 81.93%. Since 04/13 the patient has attended A&E on 7 occasions during which the HALS Team escalated interventions and reinforced the supportive clinical pathway for detoxification. With effect from 04/08/2013 the patient has been abstinent and no longer classified as a repeat attender. The cost analysis of the A&E attendances is = £42,918.
For further results and evaluation, please see the supporting material at the link below.
Key learning points
The changes should be reflective of the following key recommendations:
-Ensure a comprehensive timetabled approach to securing change
-Support all staff throughout the process
-Training and education should be a core principle
-There should be continuous re-enforcement of the required process, offering the work force adequate rationale for change
-There should be open and transparent reporting mechanisms in order to identify service improvement
-Patient involvement and experience should be a core principle
-There should be open access for securing ongoing support for staff
-Training should be undertaken within a flexible approach
-Secure early Trust Executive Board Level and Lead Clinician support
-Ensure partnership working with allied professionals
-Ensure that all changes are underpinned by evidence and thus formally delivered through Clinical Governance Committee
-Avoid conflict in respect to community pathways - this can only be achieved through ensuring open and frequent communication channels with external providers.