Prescribing for substance misuse: alcohol detoxification

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1 Prescribing for substance misuse: alcohol detoxification POMH-UK Quality Improvement Programme. Topic 14a: baseline Prepared by the Prescribing Observatory for Mental Health-UK for Kent and Medway NHS and Social Care Partnership Trust Published date: 27/08/2014 Please use the following to cite this report: Prescribing Observatory for Mental Health (2014). Topic 14a: Prescribing in substance misuse: Alcohol detoxification. Prescribing 1 Observatory for Mental Health, CCQI181 (data on file) The Royal College of Psychiatrists. For further information please contact

2 Contents List of Figures... 3 List of Tables... 4 Executive Summary... 5 Introduction Method National Level Results Trust Level Results Clinical Team Level Results Appendix A: Patient demographic and clinical characteristics Appendix B: Data control Appendix C: Participating Trusts Appendix D: Audit data collection tool Appendix E: POMH-UK Topic 14a project team and expert advisors Appendix F: References

3 List of Figures Figure 1: Performance in the national sample and your Trust against audit standard 1 assessments and other assessments during admission for alcohol detoxification Figure 2: Performance in the national sample and your Trust against audit standard 2 assessments during admission for alcohol detoxification... 8 Figure 3: Performance in the national sample and your Trust against audit standard 5 during admission for alcohol detoxification Figure 4: Completion of prescribed alcohol detoxification regimen in the national sample and your Trust Figure 5: Distribution of daily alcohol consumption (units) of the total sample and whether alcohol detoxification regimen was completed Figure 6: Proportion of patients who had a documented assessment of drinking history at admission Figure 7: Proportion of patients who had a documented physical assessment at admission Figure 8: Proportion of patients who had documented assessments of the signs and symptoms of Wernicke s encephalopathy Figure 9: Proportion of patients who had a documented breath alcohol measurement Figure 10: Proportion of patients who had documented liver function tests during admission Figure 11: Proportion of patients who were prescribed medication recommended by NICE for managing symptoms of acute alcohol withdrawal Figure 12: Proportion of patients who had thiamine prescribed parenterally Figure 13: Proportion of patients whose alcohol detoxification was completed as planned Figure 14: Proportion of patients who had a documented assessment of drinking history at admission.. 54 Figure 15: Proportion of patients who had a documented physical assessment at admission Figure 16: Proportion of patients who had documented assessments of the signs and symptoms of Wernicke s encephalopathy Figure 17: Proportion of patients who had documented liver function tests during admission Figure 18: Proportion of patients who were prescribed medication recommended by NICE for managing symptoms of acute alcohol withdrawal Figure 19: Proportion of patients who had thiamine prescribed parenterally Figure 20: Gender distribution of patients in each Trust and the total national sample Figure 21: Patients' self assigned ethnicity in each Trust and the total national sample Figure 22: Distribution of age groups in each Trust and the total national sample Figure 23: Nature of admission for alcohol detoxification of patients in each Trust and the total national sample Figure 24: Proportion of patients under general (non-specialist) and specialist psychiatric care during treatment for alcohol detoxification in each Trust and the total national sample Figure 25: Mental Health Act status of patients in each Trust and the total national sample

4 List of Tables Table 1: Prescribing for substance misuse: alcohol detoxification: Quality Improvement Programme participation... 5 Table 2: Demographic characteristics of the total national sample Table 3: Clinical service providing care for alcohol detoxification Table 4: Mental Health Act status at point of admission Table 5: Documented psychiatric diagnoses Table 6: Smoking status recorded on admission Table 7: Documented past history of alcohol detoxification Table 8: Documented alcohol history for planned admissions (N=462) Table 9: Documented alcohol history for unplanned admissions (N=735) Table 10: Physical examination at admission Table 11: Documented assessments for the signs and symptoms of Wernicke s encephalopathy.. 27 Table 12: Documented assessments for the signs and symptoms of Wernicke s encephalopathy in non-specialist and specialist care Table 13: Standardised assessments/rating scales used during initial assessment Table 14: Documented measures within the first 24 hours of admission Table 15: Laboratory investigations documented at initial assessment Table 16: Type of benzodiazepine detoxification regimen prescribed Table 17: Starting daily dose for prescribed drugs to treat the symptoms of acute alcohol withdrawal Table 18: Other drugs initiated during alcohol detoxification Table 19: Documented brief intervention Table 20: Prescription of thiamine in non-specialist and specialist care Table 21: Specialist advice sought during admission under non-specialist and specialist care Table 22: Completion of alcohol detoxification regimen Table 23: Medication for relapse prevention prescribed at the point of discharge Table 24: Provisions for continuing management of alcohol use/alcohol-related problems at discharge in non-specialist and specialist care Table 25: Provisions for continuing management of alcohol use/alcohol-related problems at discharge in planned and unplanned care Table 26: Number of clinical teams and patient records audited from participating Trusts at baseline

5 Executive Summary Background The Prescribing Observatory for Mental Health (POMH-UK) runs national auditbased quality improvement programmes open to all secondary mental health services in the UK. The aim is to help mental health services improve prescribing practice in discrete areas ( Topics ). This Topic 14a baseline report presents data on prescribing practice for alcohol detoxification conducted in acute psychiatric inpatient settings. In this report, data are presented at national, Trust and individual Trust team levels. Specifically, benchmarked performance against best practice standards is presented to inform reflective practice. Audit sample Trusts were asked to include patients who had been admitted to an acute adult or intensive care psychiatric ward in the past year (prior to March 2014) and who had undergone alcohol detoxification whilst an inpatient. Results For this baseline audit in 2014, data were submitted for 1,197 patients from 174 clinical teams across 43 Trusts. Of the 1,197 patients, 735 (61%) were admitted for an unplanned alcohol detoxification, while 462 (39%) were admitted for a planned alcohol detoxification. The majority of the total national sample (n=848, 71%) were admitted under the care of a general adult psychiatrist (nonspecialist), whilst 349 (29%) were admitted under the care of a psychiatrist with a specialist knowledge of alcohol/substance use. Demographic and clinical data for the total sample from all the participating Trusts are presented in Appendix A. The modest sample size for this baseline audit may partly reflect the national requirement not to code alcohol detoxification when it is not the primary reason for admission to a mental health unit. Thus the identification of all eligible patients for this audit proved challenging for many Trusts. Table 1: Prescribing in substance misuse: alcohol detoxification: Quality Improvement Programme participation Baseline 2014 Nature of admission Clinician overseeing care Number of Trusts that submitted data Number of clinical teams Total number of patients Sub-sample of patients whose admission for alcohol detoxification was unplanned Sub-sample of patients whose admission for alcohol detoxification was planned Sub-sample of patients who were admitted under nonspecialist care (acute or PICU) Sub-sample of patients who were admitted under specialist care (acute or PICU) , (61% of total) 462 (39% of total) 848 (71% of total) 349 (29% of total) 5

6 Audit standards and treatment targets The audit standards shown below were derived from the NICE clinical guidelines on alcohol-use disorders (NICE CG100, 2010 and CG115, 2011). Clinical practice standards for the audit 1. The decision to undertake acute alcohol detoxification of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake b. A physical examination, carried out on admission 2. Blood tests relevant to the identification of alcohol-related physical health problems (e.g. liver function tests including GGT, albumin, full blood count, glucose and renal function tests) should be carried out during the admission 3. Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine, carbamazepine or clomethiazole (derived from NICE CG 100, and NICE CG115, ) 4. Phenytoin should not be prescribed to prevent or treat alcohol withdrawal seizures (NICE CG 100, and BAP evidence-based guidelines for the pharmacological management of substance abuse, 2012) 5. Thiamine should be prescribed parenterally for inpatients in acute alcohol withdrawal These audit standards were agreed by expert advisors to POMH-UK, and have been primarily extrapolated from relevant recommendations in the NICE guidelines referenced above. In some cases, the evidence for practice recommendations falls short of supporting an audit standard, i.e. being applicable in 100% of cases. However, the evidence may be sufficient to support general guidance for good practice, allowing that deviation may be appropriate in a proportion of cases. For such treatment targets, clinicians may be particularly interested in how their practice benchmarks with their peers. Treatment targets 1. Breath alcohol should be measured as part of the initial assessment for alcohol detoxification (derived from NICE CG 115, recommendation ). 2. Following alcohol detoxification, initiation of relapse prevention medication should be considered (NICE CG 115, ). 3. After alcohol detoxification, referral to specialist alcohol services for continuing management and support should be considered (derived from NICE CG 115, and , and NICE Quality Standard for Alcohol Dependence and Harmful Alcohol Use, QS 11 statement 3). Benchmarked data on Trust performance are presented for treatment target 1 as this directly relates to prescribing practice for alcohol detoxification. Data for treatment targets 2 and 3 are only presented at national level. 6

7 Summary of key audit findings for the Total National Sample (TNS) and Trust 079 Audit Standard 1: The decision to undertake acute alcohol detoxification of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake b. A physical examination, carried out on admission Figure 1: Performance in the national sample and your Trust against audit standard 1 assessments* and other assessments during admission for alcohol detoxification. For the TNS, the sample size was n=1,197 and for your Trust it was n=7. 100% 90% Not documented Proportion of patients 80% 70% 60% 50% 40% 30% 20% Patient declined assessment Documented assessment or measure 10% 0% Smoking status Alcohol history* Assessment Breath alcohol Physical examination* Orientation/ confusion Ataxia Wernicke's encephalopathy Opthalmoplegia and/or nystagmus Pulse rate Blood pressure Health check Trust 079 Documented assessment or measure N.B.: if your Trust s performance, as indicated by the diamond, is in the red area of the bar, this means that practice in your Trust is nearer to the standard than in the total national sample (TNS). 7

8 Audit standard 2: Blood tests relevant to the identification of alcohol-related physical health problems (e.g. liver function tests including GGT, albumin, full blood count, glucose and renal function tests) should be carried out during the admission None of the recommended blood tests were documented in 15% of the TNS. The respective figure for your Trust was 29%. Figure 2: Performance in the national sample and your Trust against audit standard 2 assessments during admission for alcohol detoxification. For the TNS, the sample size was n=1,197 and for your Trust it was n=7 100% 90% Not documented Proportion of patients 80% 70% 60% 50% 40% 30% 20% 10% 0% Documented assessment or measure Trust 079 Documented assessment or measure Liver function tests GGT Clotting (PT, PTT or INR)* Albumin FBC MCV Renal function tests (U&Es) Glucose *Whilst documentation of clotting levels was recorded in this baseline audit, it is recognised that this may not be clinically indicated in all patients. N.B.: if your Trust s performance, as indicated by the diamond, is in the red area of the bar, this means that practice in your Trust is nearer to the standard than in the total national sample (TNS). 8

9 Audit standards 3 & 4: Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine, carbamazepine or clomethiazole (derived from NICE CG 100, and NICE CG115, ). Phenytoin should not be prescribed to prevent or treat alcohol withdrawal seizures (NICE CG 100, and BAP evidence-based guidelines for the pharmacological management of substance abuse, 2012). Audit standards 3 and 4 were met in almost all cases. See Tables 17 and 18 for analysis relating to these standards. 9

10 Audit standard 5: Thiamine should be prescribed parenterally for inpatients in acute alcohol withdrawal Figure 3: Performance in the national sample and your Trust against audit standard 5 during admission for alcohol detoxification. For the TNS, the sample size was n=1,197 and for your Trust it was n=7. Figure 4: Completion of prescribed alcohol detoxification regimen in the national sample and your Trust. For the TNS, the sample size was n=1,197 and for your Trust it was n=7. 100% 90% 80% Proportion of patients 70% 60% 50% 40% 30% Not prescribed Prescribed orally Prescribed parenterally Proportion of patients 100% 90% 80% 70% 60% 50% 40% 30% Not documented/ unknown Patient declined detoxification and/or self-discharged Detoxification was terminated by medical staff Completed alcohol detoxification regimen as planned 20% 10% Trust 079 Prescribed parenterally 20% 10% Trust 079 Completed alcohol detoxification regimen as planned 0% Prescription of thiamine 0% Completion of alcohol detoxification regimen 10

11 Conclusions The quality of prescribing practice and care for inpatients in an acute psychiatric setting who underwent alcohol detoxification was considered in terms of whether the admission has been planned (39% of the total national sample) or unplanned (61%) and whether care was provided by a specialist in alcohol detoxification (30%) or by a general adult psychiatrist (non-specialist) (70%). Of the 43 participating Trusts, only 16 submitted data on any patients whose alcohol detoxification was under the care of a specialist. Those patients whose admissions were unplanned were more likely to have comorbid mental illness or personality disorder and to have been detained under the Mental Health Act. For those patients in whom information on previous detoxification was collected, only a quarter were undergoing alcohol detoxification for the first time. During the admission, advice from a physician was sought for just under 20% of the total sample, three-quarters of whom were under the care of a general adult psychiatrist. Of the total sample, 7% were transferred to a medical bed during admission. This suggests that some alcohol detoxifications undertaken in general adult mental health settings are medically complex. Assessment on admission Alcohol history During the initial assessment, there was no documented information regarding alcohol history for more than 1 in 5 (22%) of the total national sample. Documentation of alcohol history was considerably closer to the audit standard when the admission was planned compared with unplanned admission. Where the admission was unplanned, there was no documentation of whether or not this was the first detoxification in more than a third of cases, compared with less than a fifth where the admission was planned. Such information is central to generating an effective clinical management plan. Physical examination and investigations on admission While the vast majority (88%) of the total national sample had a documented physical examination, results for the range of blood investigations related to the detection of the potential complications of alcohol use were less consistently documented in those patients under non-specialist care. The recommended monitoring of breath alcohol concentration was not routinely carried out, a breath alcohol measure being documented in only 22% of the total national sample. 11

12 Screening for Wernicke s encephalopathy Wernicke s encephalopathy, a recognised complication of alcohol withdrawal, can lead to permanent brain damage (Korsakoff syndrome) if untreated. Documented screening for at least one sign or symptom of Wernicke s encephalopathy was recorded for almost two-thirds (63%) of patients in the total sample, and of these, 15% had at least one sign or symptom of the condition. Thus, clinically-significant signs and symptoms of Wernicke s encephalopathy are likely to have been missed in a proportion of cases who were not screened. Management of alcohol detoxification Medication regimen In the total national sample, the NICE-recommended medication for detoxification (i.e. a benzodiazepine) was prescribed in 94% of patients. A fixed-dose reducing regimen was used in around three-quarters (77%) of cases. Symptom-triggered medication regimens were less commonly used (15%), mostly in non-specialist care settings where they perhaps reflected unstructured prn prescribing. NICE guidelines recommend that in a fixed-dose detoxification regimen, the dose should be reduced over a maximum of 10 days. The median duration of the alcohol detoxification regimen in the total national sample was 7 days; in 11% the duration of the regimen was over 10 days. Patients who were under the care of specialist services were more likely to complete their alcohol detoxification regimen. During detoxification, patients under the care of a specialist were more likely to start medication for the maintenance of abstinence and less likely to have an antipsychotic or antidepressant initiated. Thus, prescribing practice in specialist care adhered more closely to NICE recommendations. Use of thiamine Parenteral thiamine protects against the development of Wernicke s encephalopathy. Those patients under the care of specialist services were more likely to be prescribed parenteral thiamine than those patients under the care of a general adult psychiatrist (approximately three-quarters and half of the respective sub-samples). In the total national sample, 5 patients had a diagnosis of Wernicke s encephalopathy, 11 Korsakoff syndrome and 9 delirium tremens. The small number of parenteral doses of thiamine administered to these patients was inadequate for those with Wernicke s encephalopathy and represented low dosage for the other two conditions. 12

13 Brief intervention aimed at moderating future alcohol consumption There is evidence that a brief intervention, when a healthcare professional discusses with a patient the harms that alcohol has or can potentially cause (for example, directly sharing the results of liver function tests), can reduce alcohol consumption. Such a brief intervention was documented in less than half of the total sample. This may reflect a simple failure to document activity, although it could reflect that the value of discussing with patients the health consequences associated with excessive alcohol use and advising them to cut down their intake has not been recognised by clinical teams. Discharge planning Specialist continuing care for alcohol-related problems following discharge was most commonly arranged for patients whose admission for detoxification had been planned and/or they had been under the care of a specialist in alcohol detoxification. For patients whose admission had been unplanned, there were no arrangements for specialist follow-up care in around half of cases, thus falling well short of the NICE quality standard related to this (see treatment target 3). Medication for relapse prevention At discharge, a quarter of the total national sample was prescribed medication recommended by NICE for relapse prevention. Relapse prevention medication was more likely to be prescribed for patients who were under specialist care. 13

14 What happens next? We hope that the data presented in this report, and any evident change in prescribing practice in your Trust over the successive audits, will generate local review and discussion of monitoring practice in patients who are admitted for alcohol detoxification. In order to facilitate this, Trusts should consider local practice with respect to aspects of care which fall short of the standards, or where the Trust, or teams within the Trust, appear to be outliers in terms of their practice Customised PowerPoint slide sets will be generated for each participating Trust, summarising the benchmarked findings of this audit. This is to help ensure that all participating clinical teams have access to the audit findings. Clinicians who reflect on their performance data and generate and implement action plans as appropriate should be encouraged to submit evidence of this process as part of their CPD, to inform their appraisal and to support revalidation. On the basis of the audit findings, POMH-UK will consider appropriate change interventions for provision to participating Trusts to support their local action plans. 14

15 Introduction POMH-UK The Prescribing Observatory for Mental Health (POMH-UK) runs national auditbased quality improvement programmes (QIPs) open to all specialist mental health services in the UK. The aim is to help mental health services to improve prescribing practice in discrete areas ( Topics ). This Topic 14a baseline report presents prescribing data that have been collected about patients who were admitted to acute adult psychiatric wards for alcohol detoxification. The results presented in this report will allow comparison of your team s/trust s practice against: a. Treatment recommendations in nationally recognised guidelines, including the NICE guidelines for alcohol-use disorders; b. The practice of other participating Trusts; c. The practice of other participating teams in your Trust (unless only one team participated) Clinical background Alcohol use disorders span a wide spectrum of severity from hazardous and harmful drinking through to severe and complex alcohol dependence and place a considerable cost burden on the NHS. Alcohol is now the third leading cause of disability in Europe and is the leading preventable cause of morbidity and mortality in working age adults. Alcohol related hospital admissions in England have doubled to 1.2 million in the last 9 years. Alcohol dependence affects 4% of the adult population in England (6% of men and 2% of women), which represents approximately 1.6 million adults. Alcohol dependence leads on average to 25 years of life lost. Patients with alcohol dependence are often admitted to acute and mental health hospitals with alcohol related disorders as a primary or, more commonly, a secondary reason for admission. One study in South London found that 50% of mental health inpatients had an alcohol use disorder, and 24% were alcohol dependent, primarily those with depressive or personality disorders and this was accompanied by a considerably increased risk of suicidality. Such admissions present opportunities for intervention and treatment for alcohol dependence, and this means that all mental health staff need to be competent in diagnosis and management of alcohol withdrawal and alcohol related complications. Recent NICE guidelines set out a series of recommendation for best practice in diagnosis, assessment and management of harmful drinking and alcohol dependence and related complications (NICE, 2010; 2011a). Subsequently NICE quality standards set out a series of benchmarks against which current practice can be compared (NICE, 2011b). However, in spite of this guidance alcohol use disorders remain under-diagnosed in acute and mental health care leading to suboptimal clinical management. 15

16 Acute alcohol withdrawal, if untreated or sub-optimally managed, can be a life threatening condition with a risk of grand mal seizures, delirium tremens, and in extreme cases, preventable deaths. Also in the absence of adequate prophylaxis with thiamine, there is a risk of a rare but serious complication of Wernicke s encephalopathy, which can lead to permanent brain damage in the form of Korsakoff syndrome. Adequate management of alcohol withdrawal requires clinicians to be competent in diagnosis of alcohol dependence and the alcohol withdrawal syndrome, prescribing of medications, and monitoring of response to treatment. Once alcohol withdrawal has been completed, there is an opportunity to prevent relapse through advice and counselling, medication prescribing and referral to specialist alcohol services. The NICE guidelines set out evidence-based methods for clinical management during alcohol withdrawal and beyond. This national audit of the management of alcohol withdrawal for mental health inpatients examines all aspects of clinical assessment and management against NICE guidelines and quality standards. It is intended that this first national audit of alcohol withdrawal will provide a benchmark against which a national quality improvement programme can be developed. Further reading NICE (2010) Alcohol-Use Disorders: Diagnosis and Clinical Management of Alcohol- Related Physical Complications. Clinical Guideline 100. London: NICE. NICE (2011a) Alcohol-Use Disorders: Diagnosis, assessment and Management of Harmful Drinking and Alcohol Dependence. Clinical Guideline 115. London: NICE. NICE (2011b) Alcohol Dependence and Harmful Alcohol Use Quality Standard. Quality Standard 11. London NICE. Schuckit, MA (2009) Alcohol-use disorders. Lancet, 373(9662),

17 Clinical practice standards 1 for the audit The decision to undertake acute alcohol detoxification of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake b. A physical examination, carried out on admission 2. Blood tests relevant to the identification of alcohol-related physical health problems (e.g. liver function tests including GGT, albumin, full blood count, glucose and renal function tests) should be carried out during the admission 3. Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine, carbamazepine or clomethiazole (derived from NICE CG 100, and NICE CG115, ). 4. Phenytoin should not be prescribed to prevent or treat alcohol withdrawal seizures (NICE CG 100, and BAP evidence-based guidelines for the pharmacological management of substance abuse, 2012). 5. Thiamine should be prescribed parenterally for inpatients in acute alcohol withdrawal These audit standards were primarily extrapolated from relevant recommendations in the NICE guidelines referenced above and have been agreed by expert advisors to POMH-UK. In some cases, the evidence for practice recommendations falls short of supporting an audit standard, i.e. being applicable in 100% of cases. However, the evidence may be sufficient to support general guidance for good practice, allowing that deviation may be appropriate in a proportion of cases. For such treatment targets, clinicians may be particularly interested in how their practice benchmarks with their peers. Treatment targets 2 For this QIP, there are three such treatment targets: 1. Breath alcohol should be measured as part of the initial assessment for alcohol detoxification (derived from NICE CG 115, recommendation ). 2. Following alcohol detoxification, initiation of relapse prevention medication should be considered (NICE CG 115, ). 3. After alcohol detoxification, referral to specialist alcohol services for continuing management and support should be considered (derived from NICE CG 115, and , and NICE Quality Standard for Alcohol Dependence and Harmful Alcohol Use, QS 11 statement 3). Benchmarked data on Trust performance is presented for treatment target 1 as this directly relates to prescribing practice for alcohol detoxification. Data for treatment targets 2 and 3 are only presented at national level. 1 The standards have been derived from the following references: 1. National Institute for Health and Clinical Excellence. Diagnosis and clinical management of alcohol-related physical complications. NICE clinical guideline 100, National Institute for Health and Clinical Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE clinical guideline 115, Lingford-Hughes, Anne R., et al. BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. Journal of Psychopharmacology 26.7 (2012): The treatment targets have also been derived from NICE CG 115, and in addition: 1. National Institute for Health and Clinical Excellence. Alcohol dependence and harmful alcohol use quality standard. NICE quality standards QS11, Quality statement 3: Referral to specialist alcohol services. 17

18 The audit results are divided into three sections: Section 1 (National data page 20) describes the demographic and clinical characteristics of patients in the total national sample (TNS) i.e. combined data from all participating Trusts. The data were analysed in a variety of ways to facilitate understanding of the national picture and stimulate discussion in participating clinical teams Section 2 (Trust level data page 42 and Appendix A) presents each Trust s results benchmarked against other Trusts and the TNS. The analyses conducted on the national data were repeated for each Trust. This allows Trusts to compare the demographic and clinical characteristics of their patients, and their practice in relation to the prescribing of medication during alcohol detoxification with the anonymised data from each of the other participating Trusts and the national data set as a whole Section 3 (Service level data page 53) presents team level data for your Trust benchmarked against other teams, your total Trust sample and the TNS. This allows Trusts and individual clinical teams to compare their practice with each other and against the national data. Data from each clinical team or Trust are presented by code only. The POMH-UK Project Team does not know the identity of individual teams. Only the Local POMH-UK lead for your Trust has the key to team codes for your Trust. You should contact this person if you need to identify data for your own particular team. Further analysis of your Trust s data Control of data submitted to POMH-UK is retained by the Trust that provided it (see Appendix B for further information on data control). An Excel file containing the data submitted by your Trust has been made available to your Local Project Team lead. Please contact this person if you wish to conduct further analyses of your data. 18

19 Method The Prescribing Observatory for Mental Health (POMH-UK) invited all National Health Service (NHS) Trusts and other healthcare organisations (hereafter referred as Trusts) in the United Kingdom providing specialist mental health services to participate in a baseline audit as part of a QIP on prescribing for alcohol detoxification. All Trusts and clinical teams were self-selected in that they chose to participate. All participating Trusts are listed in alphabetical order in Appendix C: Participating Trusts. Subjects and settings Each Trust was invited to include as many clinical teams as they wished. Each participating team was asked to collect data from the clinical records of patients on their case load who had been admitted to an adult psychiatric ward for alcohol detoxification in the past year from the time of data collection (March 2014). Data collection A copy of the data collection form can be found in Appendix D: Audit data collection Submission of data Each Trust was allocated an identifying (code) number that was known only to the Trust and POMH-UK. Trusts were asked to allocate codes to participating services and eligible patients and, if they wished, individual consultants. The key to these codes is held by the Trust and is not known to POMH-UK. Data coded in this way were entered onto an internet-based form and submitted to POMH-UK via a secure website. Data cleaning Data were cleaned to correct instances of obvious data entry error. Details of corrections are held on file by POMH-UK; please contact if you wish to examine these. Data analysis The data were analysed and results presented at three levels, as described on the previous page. Data were collected, stored and analysed using SNAP (electronic survey software) and IBM SPSS statistics. All figures presented are rounded to zero decimal places for clarity of presentation. Therefore, the total percentages for some charts or graphs may not add up to 100%. The abbreviation TNS on some charts refers to the combined data set of the total national sample. The local POMH-UK lead for each participating Trust has been sent an Excel dataset containing their Trust s data. This allows Trusts to conduct further analyses on their own data should they wish. 19

20 National Level Results Patient demographic and clinical characteristics The table below provides demographic information on the total national sample of patients who were admitted for alcohol detoxification. The table also shows the characteristics of the sub-samples of those patients whose admission for alcohol detoxification was either planned or unplanned. Of those under the care of a general adult psychiatrist (non-specialist), 16% of admissions for alcohol detoxification were planned. The respective figure for those under the care of a specialist in alcohol detoxification was 93%. Table 2: Demographic characteristics of the total national sample Key demographic characteristics Gender Ethnicity Age Sub-sample of patients whose admission for alcohol detoxification was planned Baseline N=1,197 Sub-sample of patients whose admission for alcohol detoxification was unplanned Total sample All patients who were admitted for alcohol detoxification N = 462 (39%) N = 735 (61%) N = 1,197 n (% of subsamplesample) n (% of sub- n (% of total sample) Female 162 (35%) 205 (28%) 367 (31%) Male 300 (65%) 530 (72%) 830 (69%) White British/Irish or White Other 408 (88%) 624 (85%) 1,032 (86%) Black/Black British 4 (1%) 25 (3%) 29 (2%) Asian/Asian British 9 (2%) 13 (2%) 22 (2%) Mixed 6 (1%) 5 (1%) 11 (1%) Other ethnic group 3 (1%) 15 (2%) 18 (2%) Not stated/refused 14 (3%) 23 (3%) 37 (3%) Not collected 18 (4%) 30 (4%) 48 (4%) Median age in years Range (min max): years Age bands years 40 (9%) 87 (12%) 127 (11%) years 145 (31%) 199 (27%) 344 (29%) years 159 (34%) 263 (36%) 422 (35%) years 100 (22%) 143 (19%) 243 (20%) 61+ years 18 (4%) 43 (6%) 61 (5%) The demographic characteristics of the two sub-samples are similar. 20

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