‘high impact team’ ealing hospital/ealing primary care’ sue murphy & adrian jugdoyal
TRANSCRIPT
‘High Impact Team’Ealing Hospital/Ealing Primary Care’
Sue Murphy & Adrian Jugdoyal
Population breakdown
Overall population of 248,000 16 years and above 41% BME majority Sikh Indian 4% Irish largest population of Polish in England (over 1% born in
Poland) and 10,000 registered High levels of alcohol consumption within these groups
above White British population Younger than average population More males than females
Hospital admissions ‘alcohol related harm’
Ealing has the highest level of alcohol related hospital admissions in London NI39 (Hospital Admissions for alcohol related harm): per 100,000 population
[2007/08] = 1906 [2008/09] = 2146 increase of 13%. This is above the national average increase of 7.5%.
Cont’d
Local Alcohol Profiles for England comparative data indicate that Ealing do significantly worse than the national average on other indicators
The rank of the local indicator among PCT organisations in England. 1 being the best and 152 the worst.
Alcohol attributable hospital admissions male – national rank 131 Alcohol attributable hospital admissions- female – national rank 51 Alcohol specific hospital admissions –male - national rank 113 Alcohol related recorded crimes National rank 130 Alcohol related violent crimes National rank 128
Local response September 2008 commissioned – Alcohol Drug Liaison Nurse
Specialist (ADLNS) based on ST Mary’s model – SBI/IBA – progressive service
2010 – funding from DoH to lead on the West London Sub Regional Hub and to implement a programme promoting high impact changes. This enabled Ealing to appoint:
an ADLNS in Ealing Hospital Acute Wards an ADNLS in Ealing Primary Care GP practice’s an A+E joint data clerk covering alcohol and knife crime data
The 3 ADNLS and data clerk formed the ‘High Impact Team’
High Impact Team NI 39 Alcohol Intervention In Ealing Hospital Emergency Department
The Story So Far!
It has been well documented that barriers to screening and implementing brief interventions in an A&E setting appear to be negative attitudes, lack of time, training and support, and lack of confidence and skills (Kanner et al 1999).
Opportunities
Provision of a screening and referral process of alcohol/drug problems for A&E patients using the Paddington Alcohol Test.
Delivery of a model of evidenced based brief interventions to hazardous/harmful drinking/substance misuse, assessment for dependent drinkers.
Improved engagement of this client group by offering an immediate appointment on the day or next working day in A&E following presentation and sign post to appropriate services in the community for longer term interventions
The provision of provide training and specialist consultation for A&E staff including the use of the screening tool and withdrawal management. Further develop protocols and procedures in line with both Trusts policies and clinical governance structures
Opportunities
Reduce health inequalities for patients who would not normally access treatment for alcohol problems, through provision of an evidenced based intervention in A&E.
To reduce re-attendance rates of patients with alcohol problems attending A&E.
To reduce alcohol consumption and alcohol related harm in patients who present to A&E, defined as physical, psychological and social negative consequences of drinking alcohol.
Achievements in first year of pilot
2144 patients were screened and had a completed Paddington Alcohol test. 854 patients were PAT +.Of those PAT + patients 686 (80%) requested to be seen by ADNS for BI.
A total of 601 patients were seen by the ADNS for BI Increased skills, awareness , attitudes, confidence of workforce.
Improved Relationships/communication Training packages/education Ealing Hospital Alcohol Withdrawal Guidelines;
Review of current guidelines/update CNWL/St Mary’s Set up steering group Audit of prescribing
Total number of patients screened 6688 in the last year and total patents seen through the year was 990. This is approximately 82 patients per month, and on average 19 per week. Of the patients that screened 2530 were identified as PAT positive, these accounts for 37% of all patients screened.
Graph to show patients screened and patients PAT positive
300333
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663735 761
657 673
863
172 182 184 172 194 218 213 205 186242
276 286
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Patients screened PAT Positive Patients
6% of all patient’s screened in the ED seen by the alcohol nurse specialist, there appeals to be no seasonal trends at present. Alcohol awareness training is conducted every 2 months to the medical team,
Graph to shop the number of patients screened and seen by month
47 64 81 70 75 77 101 87 80 82 106 120
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Patients seen Patients Screened
The age range of PAT positive patient are is between 30-60, the average age being 42. the youngest person was on there 16th birthday and the eldest was 92
Due to Ealing's profile of having a high proportion of people from South Asia, the proportion of people screened is similar to that of White British 16% of white British patients were seen and 18% of Indians
Graph to show the ethnicity of patients
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Ethnicity
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Patients Seen Patients PAT positive Patients screened
Patients Seen 354 382 93 36 13 33 52 17 10
Patients PAT positive 810 659 164 88 52 94 49 82 31
Patients screened 2279 2087 382 195 231 193 631 313 46
W British
Indian PolishSri
LankanB
BritishIrish
Pakistani
W Other
B Other
3 months data showing the time of arrival of PAT positive patients, this shows that most patients attend during the day as opposed to traditional knowledge that it is mainly at night. 58% of patients PAT positive attend within the ‘High Impact Team’ hours 7.30-18.00. This also covers the patients that are in CDU from the night before (not medically fit for discharge)
High Impact Service
An Ealing Hospital and Ealing GP Primary Care service that will deliver high quality alcohol services to people who are admitted to hospital for alcohol related harm and ensuring there are clear pathways to continued treatment into primary care and alcohol specialist services.
Aim: To reduce hospital admissions alcohol related
harm National Indicator 39 (NI39)
Acute Ward Based Alcohol Liaison Nurse Specialist Role To Provide specialist information and
advice for patients. To assess compliance to trust approved
alcohol withdrawal guidelines. To promote/refer to community aftercare
programmes. To provide training to MDT at all levels
Ealing Primary Care Alcohol Liaison Nurse Specialist To continue detoxes initiated in the acute
hospital in the community. To screen patients in primary care for
appropriateness of community detox. To provide uncomplicated detoxes in
primary care.
Ealing Primary Care Alcohol Liaison Nurse Specialist To promote adjunctive medication to aid
prevent relapse. To promote community based aftercare
programmes.
Patients seen
No. of patients referred to GP Alcohol Clinics = 42
No. of patients who attended GP Alcohol Clinics = 33
Referrals made
Number of detoxes initiated at in primary care = 9
Number of patients referred for inpatient Detox programme = 9
Patients referred for community aftercare programmes = 18
Referred for adjunctive medication = 11
Ward nurse Started in post end of July 10. Patients seen 287 Male 92% Average age 52 Ethnicity >50% Indian origin, White British 30%
How patients are screened.
Emergency department. Medical and surgical clerking MDT referrals Ward round referrals
Most common presentation
Abdominal painDecompensating liver diseaseGI bleeding.
Chest pains/failureAlcohol related gastritisLeft ventricular failure/DCM
Most common presentation
Seizures Moderate electrolyte imbalance Trauma Endocrine issues Mental health (self harm/overdoses).
Not admitted to acute wards
Primary alcohol withdrawal unless actively fitting, hallucinations evidence of Wernicke-Korsakoff syndrome
Patients presenting with a primary alcohol withdrawal are seen by the ED alcohol nurse specialist and referred to the appropriate agency.
Link between ward based nurse and GP liaison nurse 3 patients have been referred in 3 months
period, this is due to only 8 GP surgeries have been identified at present.
Many of the patients seen within the acute hospital are from other surgeries or of NFA.
3 months activities
145 patients seen 287 contacts made 90 detoxes supervised 150 referrals made to aftercare
programmes. All 145 patients were given brief
intervention work
Typical daily tasks for ward based nurse
Review past 24 hour/weekend attendances through emergency department data.
Review medical/surgical inpatient log Assess and review patient on acute
assessment wards. Review patients previously seen before.