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 Gastroenterologist. 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 flexible to patient's needs - this is based at the Hospital. 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 guidance through a Chlordiazepoxide prescribing pathway alongside the establishment of an Ambulatory Detoxification Clinic.
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 Chlordiazepoxide prescribing pathway which is in line with NICE recommendations, in which patients are put 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 attendance following discharge to a 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 attenders' 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 were 25.63% higher than the North West. The number of alcohol-related Hospital attendances to the Emergency Department in 2012/13 was reported at 2,149 demonstrating a 52.1% increase in activity over 5 years. This period preceded the appointment of the Hospital Alcohol Liaison Service (HALS).
Within the first weeks of operational service the Team undertook a needs assessment, which identified Trust wide inconsistencies in Acute Alcohol management:
- 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 via a daily 12 hour bleep system. In addition to this, the team also ensured that early contact would be secured through a guaranteed assessment within 4 hours of the initial referral (for in hours referrals).
A large education and Trust awareness drive has ensured that all relevant staff were trained in the use of the AUDIT tool, approaching the discussion of harmful drinking and safe clinical management of the patient.
In addition to this, it was felt that it was imperative to share the HALS key performance indicators with the wider hospital workforce in order to publicise Trust expectations regarding service development and patient outcomes. The subsequent benefits have been significant in respect to reductions in length of stay, A&E presentations and improved clinical outcomes for patients.
Within the first 16 months of the service being operational, 1600 patients were screened and assessed by the HALS team, 879 (54.9%) of which were admitted as a direct result of their alcohol misuse.
How did you implement the project
Data was collated through a database created by the HALS Team administrator, and analysed on a quarterly basis for formal reporting to the Trust Executive Team. Quarterly reports were distributed throughout the Trust with recommendations for future service development.
Patient experience has remained a core component in all service developments in addition to the reinforcement of partnership working in order to ensure sustained improvements in patient pathways.
The strategy for change was as follows;
- 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.
- 70.2% of patients who engaged in Detoxification as an emergency response to acute clinical need have remained abstinent since Detoxification.
- 1280/1600 of patients were categorised as an escalating risk in respect to their alcohol intake = 80.0% (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.- 100% of patients screened as Harmful drinkers scored 16+ on the AUDIT, therefore were referred to the Team and as a result received inpatient or retrospective HALS Intervention.
- 100% of dependent drinkers who consented to onward referral, were referred to specialist services - 0.062% of patients re-attended the Emergency Department within 48hrs - this equates to 1/1600 of the overall sample - representing full compliance to the expected KPI.
- There have been significant sustained reductions in LOS for Alcohol related admission achieved over the last 18 months.
- A multi-agency Alcohol Case Management group and CCI (Complex Case Identification) Pathway has been established: early progress has enhanced collaborative management and discussion of complex cases and is proving to be a highly effective mechanism, in securing behavioural change which is improving outcomes for patients / clients.
- GP were notified of any detoxifications with inpatients in 100% of cases
- Patients referred to for Brief Interventions were seen within 48 hours of the referral in a 100% of cases
- Protocols and Procedures are now fully embedded.
- Integrated pathways and processes are now fully implemented
- A training pathway is now fully established
Patient experience feedback and collaborative working statements are demonstrating a positive position. The Team had the honour in presenting their successful Alcohol withdrawal pathway, at the British Medical Journal (BMJ) International Forum on Quality Safety in Health Care in Paris (April 2014 ). The Team have received an invitation to present their work in Orlando, America (December 2014) to the International Quality and Safety Forum on Clinical Excellence. We continue to strive for excellence.
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.