Evaluation of the Effectiveness of the Alcohol Specialist Nurse Service. Final Report February Jane Ward WMC Limited

Transcription

1 Evaluation of the Effectiveness of the Alcohol Specialist Nurse Service Final Report February 2012 Jane Ward WMC Limited

2 Executive Summary In 2009 the Safer Portsmouth Partnership Alcohol Needs Assessment highlighted a significant increase (approx 18%) in the rate of hospital admissions for alcohol related harm in and a 6.8% increase in hospital admissions for the first three quarters of year compared to the previous year. The needs assessment concluded that reducing the rate of alcohol related hospital admissions required tackling these underlying causes of the hospital admissions. In Portsmouth residents accessed alcohol treatment in Portsmouth which is 8.6% of the estimated number of alcohol dependant people. Department of Health guidance recommends that treatment capacity should be approximately 15% of alcohol dependant people, this would equate to 1,050 per annum in Portsmouth. To meet this figure treatment capacity needed to be increased by 74%. In response to the Alcohol Needs Assessment (2009) and key national data and guidance the Portsmouth Alcohol Strategy ( ) stated to increase the capacity of our treatment services to see more people by developing an alcohol treatment team at Queen Alexandra Hospital(QAH), based on best practice from other areas. The expected outcomes would therefore be a reduction in repeat hospital admissions and to save resources. In 2010 Portsmouth City Primary Care Trust provided 200,000 in recurring funding for a dedicated nurse-led alcohol treatment team at QAH. The service started in April 2010 with a dedicated band 7 Sister in MAU. As of December 2011 the service has been delivered by a band 7 nurse, three band 6 nurses, an administrator and a health care assistant, and supported by several key services. Additional resources of 70,000 were allocated in April 2011 for two of these posts by Hampshire PCT for the pilot phase which runs to March The ASNS currently referred to as the Alcohol Team as the service has changed significantly since April As well as the nurse team there is additional input from the Alcohol Intervention Team (AIT), Cranstoun Frequent Flyers workers, a Kingsway House Frequent Flyer worker and assessment worker, a health trainer, a mental health nurse, twice weekly ACT classes and a planned weekly session from Job Centre Plus. The latter is a new addition based on information that 66% of Portsmouth patients were unemployed. This service model has evolved in response to patient need. Initially the aim was to support patients to engage with community services as part of their on-going care. Instead, patients have voted with their feet to where they want treatment and support, despite many being in poor physical health, preferring to travel to the hospital for their continued care. The current model of service offers a comprehensive package of care and appears to be unique in the UK. In November 2010 a staff audit questionnaire was conducted to assess the knowledge of units, weekly alcohol consumption by age and gender, screening methods, attitudes towards patient management and referral. 138 staff members completed the audit. In response the ASNS stepped up both formal and informal training across the hospital but prioritised Critical Care. A follow up was undertaken at the end of 2011 with 106 staff (76%) completing the questionnaire. The data highlighted an improvement in all areas of knowledge, screening and referral. The questionnaire was also administered at the TARGET meeting with primary care practitioners over the same time period. 82 practitioners completed the baseline questionnaire and 47 at follow up (57%). The data only showed a few improvements in knowledge and a slight increase in QAH referrals, but there i

3 was also a notable decrease in community referrals at follow up 31 responses to the question do you refer to any other service and where compared with109 at baseline. The ASNS accepts referrals from all departments/wards across the hospital. The top three referral sources for both Portsmouth and Hampshire come from MAU (611), Emergency Department (ED) (246) and C5 (161) where the ASNS has provided training and built up good working relationships in assessing patients in these settings, providing follow up, and group work on C5. In addition, the ASNS has made 832 referrals to community services for ongoing care and support of patients. To support the increase of referrals, Portsmouth City PCT also funded the development of Vital Pac to incorporate an electronic alcohol screening tool. Training using Vital Pac was delivered on 5 days in May 2011 and was rolled out on the 24th May. Screening data is scored and sent to the ASNS for allocation. Activity data on Vital Pac from June to December from MAU shows only around 4.0% of patients screened are referred. Approximately 1800 patients a month are being screened using Vital Pac. ED is currently only using the scratch cards to screen for alcohol consumption. Given the estimated numbers of alcohol related attendances (approx 14,270) there is need to find solutions for ED to improve screening and referral, perhaps using a tool such as Vital Pac, as ED is a critical point to prevent alcohol related hospital admissions. The total number of registered referrals to the Alcohol Specialist Nurse Service from April 2010 to December 2011 was 1482, (Portsmouth 753, Hampshire 729). The number of individual patients presenting was 472 for Portsmouth and 493 Hampshire (total 995), as there were a number of repeat presentations. Those attending more than four times were classed as frequent flyers, a total of 52 patients (28 Portsmouth, 24 Hampshire). Portsmouth PCT allocated additional resources for community workers to provide targeted support in the community to reduce admissions. Assessment data revealed that 1054 patient presentations had an Audit Score of 20+ (possible dependence), with 548 patients reporting the maximum score of 40. Of the 753 Portsmouth presentations 359 patients had no detox (48%) although 97 patients had CIWA -Ar score of started detox (50%) and 321 completed detox (86%). For Hampshire patients (n= 729) 379 had no detox although 78 patients had a CIWA-Ar score of patients started detox (43%) and 281 completed detox (90%). Therefore a total of 685 presentations started detoxification and 602 (88%) completed up to early December In addition the ASNS provided intervention and support for an additional 276 patients that did not receive detox ranging from 2 to 20 sessions, these patients would include binge drinkers or high risk drinkers who had significant health needs. The team selected the Alcohol Star to measure patient outcomes as it focuses on ten areas of a patient s life that alcohol can impact upon, and reflected the team s risk assessment. Completion of the Alcohol Star is undertaken at assessment, then at three month intervals. At the end of the evaluation only 40 records had been completed although there were 166 patients to be followed up with baseline scores already on the database. The follow up data from the Star is promising with 6 outcome areas showing positive change of 85%+. These were Alcohol, Use of Time, Social Networks, Physical Health, Emotional Health and Family and Relationships. There are plans to build the Alcohol Star into Vital Pac as part of the case management tools. The ASNS database has also been used to inform on cost savings. Estimated cost saving for admissions avoided is 1314 per patient based on information provided by Portsmouth PCT. For the three month period, October to December 2011, there were 18 admissions avoided in Portsmouth, giving a cost saving of 23,652. For a full year this would equate to 94,608. A similar calculation for ii

4 Hampshire patients based on data from April to November 2011 resulted in 49 admissions avoided, saving 64,386. Per annum this would equate to a 96,579 cost saving. Cost savings for bed days saved based on Gastro Non-Elective admissions is 273 per patient per day. For Portsmouth patients there were 830 bed days saved during a 9 month period (April to December 2011) saving 343,980. For Hampshire patients there was an average of 152 bed days saved per month. For the 8 month period April to November estimated savings were 373,464. Bed days saved may not have a financial saving to the commissioners, but will be of benefit to the hospital's efficiency. These savings are calculated for actual patients presenting at the hospital, they do not include future attendances and admissions that have been prevented as a result of the treatment. These savings are likely to be far higher, but are not easy to predict. The patient experience has also been an essential part of the evaluation. Data alone does not give the complete picture of what the ASNS has achieved and the impact it has had on patient care. Four case studies are included in the final report to give an overview of patient care provided by the ASNS and the outcomes that are not possible to record on a database. In August patients and 6 family members were interviewed (n = 51). 49 of which were face to face interviews, and 2 were telephone interviews. Patients were seen in ED, MAU, C5, and as an ASNS outpatient. The interviews focused on the patient s experience of; screening and interventions from Primary Care, QAH, Alcohol Interventions Team, the Alcohol Specialist Nurse Service and the ACT classes. Patients described a mixed response by GP s to their alcohol use, some positive but largely negative. In response to the question could GP s do more? There was a 100% yes reply. Patient feedback on the ASNS, AIT and ACT was of consistently high praise. Patients identified staff attitudes and their professionalism, the health feedback, quick access to treatment and meeting all their needs related to alcohol, as the key to their engagement and recovery. Hampshire patients were acutely aware of the different level of service given to Portsmouth patients and requested the same level of service e.g. ACT classes. Hampshire and Portsmouth patients reported considerable negative experiences of community services, current and past in helping them address their alcohol dependence. In summary, the effectiveness of the ASNS to date has been demonstrated as follows; The QAH hospital culture has changed and alcohol is now a lead issue for the Trust The role of the Alcohol Specialist Nurse Service and the establishment of an alcohol pathway is clear to practitioners both inside the hospital and in the community Treatment capacity has increased and patient outcomes are better now than before the start of the ASNS The ASNS has developed a model of patient care that has increased compliance with outpatient alcohol treatment, averted hospital admissions and reduced the number of bed days at QAH. A holistic package of patient care provided by the ASNS and key support services has provided a high level of patient satisfaction. iii

5 New referrals pathways to community-alcohol services are now established to provide ongoing support for patients The ASNS is a good return on investment and needs mainstreaming within the acute services contract Further development to increase efficiencies and effectiveness have been scoped and recommended. Recommendations These recommendations are based on the first 18 month period of the project. This evaluation indicates that the Alcohol Specialist Nurse Service (ASNS) has some development opportunities still to fulfil across the Trust. Many of these recommendations address the next steps in providing a comprehensive and integrated service around patients and the delivery of effective quality care for alcohol patients. Queen Alexandra Hospital (QAH) is committed to delivering alcohol patient care hospital-wide and working with commissioners to ensure the best value from the resources invested in alcohol prevention, intervention and treatment. Commissioners Commissioners should recognise from the data that the workload of the ASNS sees Portsmouth and Hampshire patients largely in equal measures. From this perspective it is essential that Portsmouth City and Hampshire Primary Care Trusts continue to collaborate on the joint-commissioning of the ASNS over the NHS transition period, as this will enable local authorities to take a view on a key aspect of alcohol harm reduction policy. Beyond the balance of funding will need to be addressed, or the level of service delivery for Hampshire patients will have to be reviewed. The joint-commissioning of the ASNS over will look to establish the service on a sustainable platform that will be resilient to NHS changes and able to respond to the increasing stresses placed by alcohol on the NHS. Commissioners should consider the balance of the team s work with dependant drinkers, which is and should remain their primary function, with the need to develop the skills of nurses and doctors across hospital departments to provide identification and brief advice (IBA). Additional resources may be needed to fully implement such IBA capacity building. The Portsmouth model of engagement with their substance misuse community-based service to provide in-reach hospital services which integrate and help the ASNS share the burden of supporting alcohol patients towards recovery is an invaluable development. This model should be investigated by Hampshire commissioners in terms of a likewise approach for Hampshire patients in respect of in-reach from the Hampshire HOMER service to support Hampshire patients. Safer Portsmouth Partnership and Queen Alexandra Hospital iv

6 To discuss and agree the future data requirements (monitoring and outcomes) for the ASNS before the end of the pilot phase in March Following the end of the evaluation phase in January the ASNS database could be redesigned with support from Business Intelligence to focus on capturing key clinical decisions such as avoiding admissions as well as keeping key activity data e.g. assessment, detox etc. In addition interventions for patients not having detox but who receive a package of care needs to be more explicitly recorded. To improve completion of Vital Pac within MAU, and revisit the implementation of routine screening, brief advice and referral with ED staff by providing additional training and support. To roll out Vital Pac alcohol screening across the hospital with referrals monitored closely to see if additional investment is required for meeting patient s needs. Vital Pac developers and commissioners to agree on the level of investment and a deadline for completing the case management tools for alcohol patients. QAH Senior Management To increase the profile of the QAH Alcohol Steering Group with support from the Chairperson to get representatives from wards and services other than ASNS to contribute to the alcohol agenda hospital-wide. To develop the remit of the QAH Alcohol Steering Group to ensure all wards and services across the hospital routinely feedback on activities, projects and research that contribute to the Alcohol Strategy. To provide consistency of management for the ASNS to enable further developments within QAH. To provide more formalised management support for the ASNS to resolve operational issues e.g. staffing levels, holiday cover, sickness etc and support the future development e.g. fortnightly meeting with the Sister, monthly meetings with the team To allocate new accommodation for the ASNS to ensure patients have confidential access such as a separate reception, and the team have sufficient office space to undertake their roles e.g. access to computers and hold team meetings. To review the job description and time allocation for administration in line with the expansion of the service to date and future monitoring and data requirements, plus the time needed for patient management issues e.g. reception duties, telephone calls, meetings etc To assess the training and development needs of staff to enable the nurses to access specialist training (e.g. mental health), attend key conferences and research development forums. As the service has developed into offering a diverse care package staff need to enhance their knowledge and skills to sustain the level of care offered. v

7 To improve access to the service for patients in poor physical health via consideration of different transport options, fare reimbursements, home visits or community based clinics. Alcohol Specialist Nurse Service To develop a system to monitor the Alcohol Star data is completed at assessment, three, six months and nine months for all patients. To develop a patient questionnaire to continuously monitor the quality of service delivery and gain feedback on areas for development or improvement. The team to collate information and report quarterly. To undertake targeted development work with ED to increase referrals via screening and focus on decreasing admissions. To update all back dated activity on to the National Alcohol Monitoring System database To continue a monthly programme of training and raise awareness by targeting wards/services linked to alcohol related admissions data from PAS. To develop targeted intervention and support for patients with high dependency scores To develop more formalised care pathways with Mental Services for patients especially following detoxification To continue to promote awareness of the ASNS and the AIT within primary care services. To provide a programme of training and information for primary care practitioners on alcohol consumption, screening and referral pathways. ASNS, AIT and community services to continue to raise the profile of their services within the community to aid appropriate referral and meet patient needs. vi

8 Contents 1.0 Introduction Background Implementation of the Alcohol Specialist Nurse Service at Queen Alexandra Hospital (QAH) ASNS Project Broad Staff recruitment ASNS Accommodation Vital Pac development Management of alcohol misuse at QAH Management structure Data reporting Quarterly Progress Reporting National Alcohol Monitoring System (NATMS) QAH Staff Audit Primary Care Audit Patient data Referrals Patient numbers Gender Ethnicity Age profile Employment status Age first used alcohol Age regular use of alcohol Age when alcohol became a problem Number of presentations by patients Admission presentation/diagnosis Referral sources AUDIT Scores

9 6.14 Unit Consumption Clinical Institute Withdrawal of Alcohol Scale(CIWA-Ar) Detoxification Alcohol Star outcomes Alcohol Intervention Team support for alcohol dependent patients Referrals to others services The Patient Journey Case Studies Qualitative Interviews Patient profile Primary Care QAH Admission Experience of ASNS Experience of Alcohol Intervention Team Experience of ACT classes Cost effectiveness Recommendations References Appendix A QAH Staff Audit Appendix B Primary Care Audit... 50

10 1.0 Introduction This document is the final report on the evaluation of the Alcohol Specialist Nurse Service at Queen Alexandra Hospital. The evaluation was commissioned by Safer Portsmouth Partnership in July The aim of the evaluation is to consider the effectiveness of the ASNS in the following areas: The level of implementation across the hospital; o Assessing the buy in and support from managers and clinicians o Implementation and use of Vital Pac (software) o Recruitment of staff and suitability of the team, including Grade of nursing staff o Level of integration within the hospital and the alcohol treatment system Analysis of data (quantitative and qualitative); o o o o Vital Pac screening data Interviews with patients to show the effectiveness of the service in terms of patient outcomes Outcomes for the patients in terms of sustained reduced drinking or abstinence, sustained reduction in AUDIT score, reduced readmissions / attendances at hospital Profile of patients and identify any gaps The patient journey; o o Attendance/admission at hospital to discharge and then access to ongoing support either through outpatient appointments or community services Quality of the treatment and support provided including the perspective of patients and stakeholders Cost effectiveness; o Provide recommendations to inform the future of the service. An interim report was produced in September 2011 focusing on the progress of the Alcohol Specialist Nurse Service. This report will update those findings and provide additional information on the effectiveness of the service. Page 1 of 59

11 2.0 Background In 2009 the Portsmouth Alcohol Needs Assessment highlighted; a significant increase (approx 18%) in the rate of hospital admissions rate for alcohol related harm in from the previous year data (July 2009) pertaining to the first three quarters of indicated a 6.8% increase in hospital admission rate for the year compared to the previous year In chronic effects of alcohol consumption contributed to about 60% of hospital admissions related to alcohol; acute mental and behavioural consequences of alcohol consumption contributed about 23% of admissions; o acute effects of alcohol consumption (acute intoxication) contributed to about 16% of admissions and diseases o modest alcohol effect contributed just over 1% of hospital admission The needs assessment concluded that reducing the rate of alcohol related hospital admissions required tackling these underlying causes of the hospital admissions. In Portsmouth residents accessed alcohol treatment in Portsmouth. This is 8.6% of the estimated number of alcohol dependant persons. The Department of Health Guidance recommends that treatment capacity should be approximately 15% of alcohol dependant people, this would equate to 1,050 per annum in Portsmouth. To meet this figure treatment capacity would need to be increased by 74%. In response to the Alcohol Needs Assessment (2009) and key national data and guidance, the Portsmouth Alcohol Strategy ( ) stated under Objective 5 to increase the capacity of our treatment services to see more people by developing an alcohol treatment team at Queen Alexandra Hospital, based on best practice from other areas. The aim of which would provide a quick and timely service to those admitted to hospital, or as an emergency for alcohol related cases. The expected outcomes would therefore, be a reduction in repeat hospital admissions and save resources. Prior to the Alcohol Strategy, patients at QAH who were admitted with an alcohol dependency received an ad hoc service with inconsistent levels of prescribing and inconsistent care. Patients were being discharged half way through a detox, and in cases where the GP would not prescribe they were being advised to drink for their own safety. Patients were also being hospitalised longer than they needed to be as they were not able to receive treatment in the community. In response Portsmouth City Primary Care Trust provided 200,000 in funding for a dedicated nurse-led alcohol treatment team with 3 nurses (1 Band 7 and 2 Band 6) and an administrator. The Alcohol Specialist Nurse Service (ASNS) was established informally in April 2010 to provide a range of alcohol interventions from the provision of brief advice to overseeing the detoxification of patients who were admitted (planned or unplanned). The aim was to target patients that had been admitted and had withdrawal symptoms; and then discharge patients as soon as it was clinically Page 2 of 59

12 safe to do so. Patients were then to be seen on a daily out-patient basis to provide them with their daily prescription and complete a health check until their detox is complete. The nurses would then provide ongoing support to the patient. In addition, Portsmouth City PCT has supported the development of Vital Pac, an electronic alcohol screening tool, across the hospital enabling staff to identify increasing and high risk drinkers, provide advice and where appropriate referral to the Alcohol Interventions Team (AIT) based at QAH for brief interventions and the Alcohol Specialist Nurse Service. An initial 30,000 was allocated at the start of the development, with 70,000 allocated by the end of the financial year A Frequent Flyers project worker was also funded by Portsmouth City PCT to work with the top 20 patients with the highest alcohol related admissions from Portsmouth. The remit of this post is to engage the patients via the hospital and work with them proactively in the community to prevent re-admissions. The ASNS and other supporting projects were all initially funded by Portsmouth City PCT. As QAH covers South East Hampshire as well as Portsmouth, the ASNS provided the same service to all patients with no additional funding, until Hampshire PCT allocated 70,000 for an additional Band 6 nurse post and a Band 2 Support Worker, which was signed off by PHT in March Page 3 of 59

13 3.0 Implementation of the Alcohol Specialist Nurse Service at Queen Alexandra Hospital (QAH) The development and implementation of the Alcohol Specialist Nurse Service (ASNS) has been monitored against ten key objectives. Progress against each of the following objectives was reviewed initially in the interim report and has been updated to inform the final report. 3.1 ASNS Project Broad Objective 1 Establishment of appropriate Project Board (meeting monthly initially, less once the project is more established) and steering group (meeting fortnightly initially, less often once the project is more established) Achieved The first ASNS Project Board consisted of a small number of stakeholders within the hospital (ED, MAU, Hepatology) and Safer Portsmouth Partnership. Members established the terms of reference for the Board and monitored the developments monthly. Following an inspection report from the Department of Health Alcohol Harm Reduction National Support Team in September 2010, Queen Alexandra Hospital (QAH) was recommended to take the following steps to maximise their contribution to reducing alcohol related admissions: Identify a senior champion for alcohol Ensure senior representation at the Alcohol Steering Group Develop a delivery plan for their contribution to the Alcohol Strategy Utilise the new hospital alcohol service steering group to coordinate the various elements of the hospital alcohol delivery plan Following this report the remit of the Board changed and extended its membership. The Board was renamed as the QAH Alcohol Strategy Steering Group and is chaired by Dr Richard Aspinall, Consultant Hepatologist. The Committee originally consisted of the following members: Trust Alcohol Champion (Chair) Head of Nursing/ General Manager Emergency CSC Sister Alcohol Specialist Nurse Service Sister Alcohol Advisory School Nurse Service Sister C5 Ward Matron Medicine CSC ED Consultant MAU Consultant Critical Care Consultant Consultant Psychiatrist Substance Misuse Coordinator Nutrition lead Pharmacy lead Mental Health Liaison Team Lead Trust Paediatric Rep Trust Maternity Rep Occupation Health Rep Page 4 of 59

14 It was agreed that other members may be co-opted onto the group as required, either for additional work or for the purpose of communication or presentation. This has enabled key individuals from within the hospital and community services to be included such as; ITU Consultant, Consultant Psychiatrist Specialist Substance Services, Commissioner for Young People s Services, Hampshire PCT Commissioner, Primary Care Nurse, School Nurse etc. The whole hospital approach has also raised the profile of the Alcohol Specialist Nurse Service, (ASNS), helped support training events for staff and initiated referral protocols and significantly increased the buy-in from the hospital. This is evidenced later in this report in the referral data section which shows referrals from different departments even though Vital Pac is currently only being used in MAU. Although the Project Board objective was achieved the current situation is that the membership of this forum has been reduced with fewer people attending quarterly meetings, and the broader alcohol agenda across the hospital not addressed as members are not routinely reporting back other than the ASNS. The meetings continue to be chaired by the Trust Alcohol Champion, but other key practitioners and senior management representatives are no longer attending regularly as evidenced in the minutes. 3.2 Staff recruitment Objective 2 To ensure appropriate staff are recruited an in place by 1 st September 2010 Partially met by target date Sister Sue Atkins started seeing patients in April 2010 in MAU Outpatients. In June 2010 she was joined by Trudi Barrett (Band 6). The remainder of the team started in December 2010, Donna Bowman (Band 6), and Kat Rackham (Administrator). The three month delay in recruitment had an impact on data input and reduced capacity to meet target numbers. Recruitment continued to be a problem even when funding was allocated by Hampshire PCT for an additional nurse and support worker, but only signed off by PHT in March The support worker started in April 2011 and an additional band 6 nurse in September 2011, with only 6 months of the pilot phase remaining. Recruitment procedures, annual leave, and a seven day service for a small team have resulted in the nurses being restricted in developing their role throughout the hospital. The ASNS prioritise seeing patients referred each day, running outpatient clinics for detoxifications and follow up reviews, plus visiting patients on key Wards e.g. C5. All staff had an induction, but also hit the ground running. As the service has developed there has been no opportunity for staff and the Steering Group to reflect on the training and development needs of staff. Sister Atkins has been supported in becoming a nurse prescriber but the roles, responsibilities and development of the team needs addressing as the service develops across the hospital. For example, there are two new hepatology nurses who started in September 2011, and they will link up with the ASNS to do joint working. There are also joint assessments with the Mental Health Team in Emergency Department (ED). Therefore, developing assessment and management skills related to liver transplants and psychosis, for example, warrants more specialist training and development for nursing staff. Page 5 of 59

15 Staffing levels were based initially on similar services in the UK. In response to increased referrals Hampshire PCT did provide an extra nurse post and health care assistant following consultation with Portsmouth City PCT to support the pilot, but as yet no further commitment has been made. As there is a 50:50 split in referrals from Hampshire and Portsmouth, future staffing levels and costs need revisiting. It has been difficult to benchmark this service against others operating in the country in order to inform future staffing and operational issues. Dr Lynn Owens from the Liverpool PCT service on which the ASNS was based has similar staffing levels, covering 7 days a week from 8am 8pm, but nurses are seeing fewer patients per day, 10 on average, compared with the ASNS who see per day based on two nurses on duty 8am 4.30pm. The Liverpool model also does not provide the wrap-around services in the hospital as developed by the ASNS e.g. ACT groups, one to one followup. The Alcohol Nurse Service is developing referral and care pathways around the 10 areas based on the Alcohol Star outcome monitoring tool. These key wrap around services for patients provide a comprehensive package of care that incur costs beyond the ASNS costs. In June 2010 there was one band 7 nurse, in December 2011 the service is as follows; RMN Mill House The Safer Portsmouth Partnership (SPP) has also funded Frequent Flyers workers and two members of the Alcohol Intervention Team to work with patients following detox by providing one to one support and group facilitation. More recently SPP has funded an RMN post to work between Mill House Hostel and to support patients at QAH regarding their mental health needs. In considering future commissioning of the developing service, the additional posts and on-costs will need to be looked at collectively. Page 6 of 59

16 3.3 ASNS Accommodation Objective 3 To ensure appropriate office space is allocated for the ASNS (including the administrator), as well as hot desk space for the visiting alcohol workers (with IT access to PCC system arranged by PCC) Partially met The team started with a clinic room in MAU Outpatients but were only given a dedicated office space in March The team outgrew this office as soon as they arrived in it because of the addition of support workers to the team e.g. AIT team, Health Trainer, Kingsway House Staff, and Frequent Flyers workers. The office space is very restricted and access to the three computers is limited. Protecting patient confidentiality continues to be of concern as patients come to see the administrator for appointments and staff are often in discussion about their work. The ASNS office can no longer accommodate everyone at team meetings held on Thursday mornings due to lack of space. A room has been allocated on the MAU for the ACT classes, which are offered as part of the on-going support package for patients. Attendance has been very good since it was established and the current room allocated can accommodate 16 people comfortably. At present only Portsmouth patients can access the classes. Should the service be extended to Hampshire patients then either extra space or extra rooms will be needed. All patients who attend the ASNS come via MAU reception. Concern has been expressed by staff and patients about patient confidentiality in such a public area. A separate reception with easy access to making appointments or enquiries to the team has been raised by staff and patients. Members of the AIT team who see dependent patients continue to input their data on the Portsmouth City Council system which cannot be accessed at QAH. This takes the team away from the hospital setting when their support could be needed. The AIT data activity is currently not being recorded as part of the overall activity of the ASNS. This is important to give an overall account of the time and support allocated to dependent patients and is important for costing the service. SPP are looking into a web-based database to resolve this problem and hope to have this resolved by early AIT intervention data has been included in this report as part of patient activity data in section Vital Pac development Objective 4 To ensure implementation of the Vital Pac developments (screening October 2010 and data capture November 2010) Partially met The development of the alcohol screening content for Vital Pac was undertaken over a whole day away from QAH in November 2010 by Dr Paul Schmidt MAU Consultant and Sister Sue Atkins. This is highlighted because the nature of both their jobs makes project development such as Vital Pac very difficult to do in the clinical environment. The development of content alone took a whole day before Dr Schmidt took this to IT development and piloting. In addition the planning day also explored other possibilities where other data could be gained from using Vital Pac e.g. outcomes in the future, case management etc. Page 7 of 59

17 Alcohol Assessment Training using Vital Pac was delivered on 5 days in May 2011 and was rolled out on the 24th May. Referrals from MAU are printed off by the administrator daily and are allocated for follow-up by the appropriate team based on the score. The team have reported that the scores are not always reflective of need. For example patients scoring between 4 and 6 (high risk drinking) have been more suitable for the ASNS rather than brief intervention provided by the AIT and sometimes vice versa. The ASNS keep a list of Vital Pac trouble shooting points on and are in constant discussion about resolving these. Activity on Vital Pac from June to December via MAU shows; Total no of screenings Referrals to ASNS Referrals to AIT June (4.7%) 66 July (3.8%) 62 August (3.6%) 74 September (4.0%) 77 October (4.76%) 63 November (3.45%) 46 December (4.0%) 72 From the data above it can be seen that the percentage of referral are low compared to the number of screenings. Problems highlighted in early January 2012 were; problems with the server, completion errors, staff are still not asking the questions about alcohol (skip the question by putting in 0), some staff still refer verbally and that there remains a problem with scoring sensitivity - too high or too low. The implication of increased referrals is currently of concern as the ASNS is running at capacity with assessments, detoxifications, and follow up reviews. ED trialled Vital Pac but have not continued to use it for alcohol screening as it was indicated to the team that the environment is too busy. The Department of Health reported that up to 35% of ED attendances are alcohol related. Data from , highlighted Portsmouth residents accounted for 40,772 ED attendances, at an average cost of per attendance. If 35% were alcohol related this would be 14,270 attendances. Not all would be dependent drinkers but up until mid December 2011 there have only been referrals from 131 Portsmouth (115 from Hampshire). This highlights an urgent need to find solutions for ED to improve screening and referral, perhaps using a tool such as Vital Pac. The ED department is also a critical point to prevent alcohol related hospital admissions. 3.5 Management of alcohol misuse at QAH Objective 5 To improve the management of alcohol misuse by PHT patients across the hospital (with a particular focus on ED in relation to identification and brief advice) by improving protocols, referrals systems, providing staff training and guidance commencing September 2010 Partially met Page 8 of 59

18 This objective has had mixed fortunes during the development of the service. In February 2011 the baseline Staff Audit completed in December 2010 was presented to the Steering Group in February. A total of 138 staff completed questionnaires. The baseline questionnaire was re-administered between October and December 2011 following a mail out to the wards and teaching sessions on; units, effects of alcohol, withdrawal, prescribing regimes, the role of the alcohol specialist nurse service, other support services and the patient experience. 106 (76%) staff members completed the follow-up questionnaire. The purpose of the questionnaire was to assess current knowledge of alcohol, screening approaches, attitudes on how alcohol patients should be treated, and referral for hospital or community treatment. A similar questionnaire was administered with primary care staff via the TARGET meetings. 82 primary health care practitioners completed the baseline questionnaire, and 47 (57%) completed the follow-up questionnaire. Findings from the QAH staff and primary care audits are detailed in Section 4.0 and in appendices A and B. Informal and formal training has been provided since the early stages of the ASNS, although not all of this activity has been recorded. A regular programme of training is now offered each month, although delivery and take up of training is affected by annual leave (hospital wide) and staff capacity. Members of the AIT have been supporting the nurses in delivering training to increase capacity. Training has been delivered to 368 members of staff across the hospital. The training was targeted at key departments with highest attendance from ED (106), MAU (90) and ITU (53). All training events were evaluated and eight evaluation reports from the full day training programme were forwarded to the external evaluator. All evaluations demonstrated positive learning and review of attitudes. Joint working arrangements with key wards and departments have increased referrals and uptake of training which in turn have improved the management of alcohol misuse for patients across the hospital. However, further work and development needs to be undertaken with ED as they are not using Vital Pac to screen for alcohol and referrals are low based on presenting conditions despite good attendance at the training. In addition, there are other key wards where the ASNS want to start screening via Vital Pac to increase access to the ASNS. 3.6 Management structure Objective 6 To provide clear line management structure within PHT for the ASNS, providing appropriate management and clinical supervision Partially met There has been support from different managers throughout the development and implementation of the project. However due to the nature of management within a large general hospital, restructuring and turnover of staff, this has resulted in an inconsistent approach e.g. membership of the Steering Group meetings or no representation at key meetings with commissioners. The ASNS moved from Emergency Medicine to Medicine on 1 st November 2011 which involves reporting to new managers. Page 9 of 59

19 Clinical supervision is provided by Sister Atkins to the ASNS team. Additionally the ASNS and the key support services e.g. AIT, have been holding team meetings to share information and concerns, identify joint working opportunities, problem solve e.g. Vital Pac and discuss future developments. However, the day to day management and development of the service has been affected as Sister Atkins continues to see a large numbers of patients whilst on duty, due to her clinical expertise and relationship with other departments, and the need to cover shift patterns over seven days. This has impacted substantially on the Sister s management role to cover duties such as e.g. correspondence, writing quarterly reports to commissioners, attending meetings to schedule, performance appraisals, and external liaison with key services. As a result much of this work is undertaken on days off, in holidays, or following a shift. The ASNS also needs more support from senior managers on day to day operational issues that are key to the continued success of the service, these include; support with improving accommodation and access for patients, recruitment of more administration, and data monitoring and reporting. 3.7 Data reporting Objective 7 To provide monthly data on KPIs to Portsmouth City Council by the 10 th of each month, commencing September 2010 Met Providing monthly data has been a difficult process and a steep learning curve for all involved. Setting up a comprehensive monitoring system whilst providing a rapidly expanding clinical service with limited technical and administration support resulted in this being slow to start and involved a misunderstanding of what was actually required i.e. counting the number of interventions rather than the number of detoxifications. This highlights the need for commissioners, hospital management and staff to agree targets, data collection systems, administration and a cost for this at the outset. Following the initial teething problems, the ASNS now provides Safer Portsmouth Partnership with the required data monthly. However the database needs to be consistent and kept up to date in all required fields e.g. AUDIT scores and unit consumption, admissions avoided etc. As the team continues to be busy there are occasions when information gets missed. The administration allocation for the team is 1.2WTE and 0.2 of the allocation has not been filled. Despite considerable discussion about filling the extra hours this post has not been filled. The pressures on the Administrator are considerable. Administration is a crucial role for this team; processing Vital Pac information, completing the database, running the day to day office activities, attending meetings, answering the telephone and liaising with patients on a variety of matters e.g. completing forms, people presenting to request appointments for family members. Although monthly KPI s have been provided the ASNS could provide more key information especially on admissions avoided. In addition not all ASNS activity is being captured on the patient database e.g. crisis interventions, work with non-detox patients. The ASNS bleep alone is reported by Switchboard as one of the busiest in the hospital (e.g. 387 in August) and is also an indication of the profile they have within the hospital. Page 10 of 59

20 3.8 Quarterly Progress Reporting Objective 8 To provide quarterly progress reports to Portsmouth City Council by the end of the first month following each quarter (i.e. by end of October 2010 for period July-Sept.) Not met The Alcohol Project Manager for Safer Portsmouth Partnership has reported that quarterly reports have not been submitted. The problems in producing such a report are the same as those described for Objective 7. The team needs more support from Senior Management to produce these reports. 3.9 National Alcohol Monitoring System (NATMS) Objective 9 To ensure alcohol treatment data is captured and returned to the National Alcohol Treatment Monitoring System (NATMS) or if this does not exist in the future return to Portsmouth City Council. This should lead to an increase in the number of Portsmouth residents accessing alcohol treatment. Met The data for NATMS has been collected by the Administrator on the ASNS database since December However the NATMS team only came to visit the Administrator to discuss the method of reporting to them on 19 th August So this objective was held up by NATMS. The team are still in the process of back dating all the information for NATMS so current figures are under-reported Support for the evaluation Objective 10 Provide support for the management consultant who has been commissioned to undertake the independent evaluation of the service, July 2010 December Met The ASNS team has given 100% support to the evaluation process. The external evaluator has worked alongside the team since July 2010 and has seen the development of Vital Pac, the assessment and referrals pathways, and the staff audit. In addition the evaluator has been given access to patients on the Wards in ED and MAU, observed an ACT class and attended team meetings. Throughout the evaluation there were some key objectives and specific areas to focus on. However there have been other key events that are worth noting. The ASNS has been acknowledged by the Chief Executive in hospital briefings twice, and also the service won 'The News - hospital team of the year' award. The work of the team has also sparked significant interest around the South East and beyond with many different professionals coming to QAH to observe the nurses at work with a view to replicating the service elsewhere. The service has created a success factor that other professionals and services want to be part of, and evidenced by letters of support for their work. Page 11 of 59

21 4.0 QAH Staff Audit A staff questionnaire was developed and piloted in QAH in September The purpose of the questionnaire was to assess knowledge of alcohol units, screening approaches, attitudes on how alcohol patients should be treated, and referral for hospital or community treatment. The ASNS distributed questionnaires at meetings, in training sessions and on the wards. A total of 138 staff completed the questionnaires. Following the analysis of results presented to the Steering Group in February 2011 both informal and formal training continued to be rolled out across the hospital. The baseline questionnaire was re-administered between October and December 2011 following a mail out to the wards and via teaching sessions on; units, effects of alcohol, withdrawal, prescribing regimes, the role of the alcohol specialist nurse service, other support services and the patient experience. 106 (76%) staff members completed the follow-up questionnaire. Staff were asked to answer questions on the following; Knowledge based questions; Knowledge of units in a 4% pint of beer, a 750ml of 14% wine, a litre of 5.5% cider and a 75cl bottle of 40% whisky/vodka Knowledge of unit consumption by age and gender; under 15, years, women 18+, men 18+ Paddington alcohol test (PAT) and its functions Defining hazardous (increasing risk, harmful (high risk) and dependent alcohol consumption Practice based questions on; When alcohol is discussed with patients Screening methods Actions/interventions following screening Referral sources at QAH and the community The full analysis of the QAH audit can be found in appendix A of this report. The key findings from the QAH staff audit are as follows; Response by job role Doctor Nurse HCA Pharmacist Total Baseline 8 (5.8%) 99 (71.7%) 31 (22.5%) Follow-up 12 (11.3%) 72 (67.9%) 15 (14.2%) 7 (6.6%) % of those who responded at follow up were from Critical Care staff a target group for the ASNS. Page 12 of 59

22 Unit Calculation In the baseline audit (46.4%) and at follow-up (64.2%) the majority of staff were close to the accurate figure of 2.2 units in a pint of 4% beer. Staff tended to give round numbers in the responses. There was an improvement between baseline (7.2%) and follow up (33%) in staff accurately reporting the numbers of units in a 750 ml bottle of 14% wine. However around 22 % of staff did not give an answer. Education on units was addressed via the training and is important for screening. At baseline only one staff member (0.7%) correctly knew that there are 5.5 units in a litre of 5% cider. This rose to 55.7% at follow up. The unit calculations for beer, wine and cider were chosen specifically to see if staff could accurately calculate units. The estimated units for a 75cl bottle of whisky or vodka at baseline had an enormous range from 1 unit to 70+, with 10 staff (7.2%) identifying this correctly at 30 units. At follow up there was marked improvement in accuracy, up to 49%. However 29 (27.4%) staff members did not give an answer to this question. DoH recommended unit consumption by age and gender Although there have been few children presenting to the ASNS it is important that staff have knowledge of unit consumption by age. There was a high rating for no units at baseline (77.5%) and follow up (91.5%) For young people years there was a varied response (0-21 units). At follow up the staff had taken on the information in the training, as well as putting 1 unit, staff added the guidance about under parental supervision on their questionnaire. At baseline and follow up there around 32.6% and 33 % of staff accurately stated 14 units per week for women 18+. There were 35 (33%) responses to women drinking 3 units at follow up. This is probably in response to daily consumption as some staff marked this as such on their questionnaire. Messages around daily consumption are more important than weekly consumption for future training based on Department of Health guidance. There was similar reporting for the correct answer of 21 units for men at baseline 26.1% and follow up 32.1%. In similarity to rating female units, 36 (34%) staff members gave the answer as daily units 4 rather than weekly. Future training should clarify daily and weekly consumption as the emphasis is now on daily consumption to prevent binge drinking. Patient alcohol consumption In response to the question When do you discuss the patient s alcohol consumption? the most notable change between baseline audit and follow up is staff reporting they are not involved in screening. This has decreased from 45 staff to 19. This seems to be supported by an increase in the number of staff reporting they screen routinely -61 (57%). At baseline the Page 13 of 59

23 main reason for discussion or screening was initiated by the patient s behaviour, this has been overtaken by routinely screening all patients. Staff were asked to report what method or tool they use to address alcohol consumption. When the baseline audit was completed Vital Pac was not operational. In the follow up group 26 (24%) reported to be using Vital Pac. However informal discussion still remains the highest rated method of ascertaining a patient s level of consumption (51%). Screening for alcohol consumption The question what should be done with the information from screening? was designed to look at staff attitudes towards interventions for alcohol patients. Referring to a specialist team was the preferred option at baseline and at follow up, although this had increased from 30 (21%) to 41 (38%) respondents rating it as first preference. In addition the lowest preference ranked 6 th pointless to intevene has increased from 21% to 35% with more staff rating this as the least preference. The Paddington Alcohol Test was updated in 2009 as a tool to be used for screening in A and E and determines daily unit consumption and pattern of consumption. Daily consumption the primary purpose of using PAT was only identified by 25 people at baseline, but increased to 38 at follow-up. Pattern of consumption e.g. weekly was rated the highest at baseline and at follow-up. Staff were asked Would you know when to define alcohol consumption as hazardous (increasing risk) harmful (high risk) or dependent? This was a Yes/No answer and staff did have to qualify this answer. There was a marked increase in the number of staff reporting how to distinguish between different consumption patterns of drinking. In the baseline audit only 51 (37%) compared with 81 (76%) at follow up. The ASNS training and the role out of Vital Pac training will have had an impact on increasing staff knowledge of consumption patterns. Referral sources Knowledge of where to refer to in QAH for increasing risk and dependent alcohol consumption patients rose from 36% in the baseline audit to 91% at follow up. In the baseline audit only 39 staff members referred to the ASNS service, at follow up this has increased to 76, 71% of those completing the questionnaire. Referrals to AIT remain low but this may be because staff are not distinguishing between increasing risk patients and dependent patients. This needs to be addressed in future training and via Vital Pac screening. Referral to other services remains low; 9% at baseline and only 21% at follow up. Further work needs to be done on promoting the roles of community services within QAH. Page 14 of 59

24 5.0 Primary Care Audit The QAH staff questionnaire was adapted and distributed to primary care practitioners at the primary care TARGET meeting in September The questionnaire was updated with a couple of specific questions about the Alcohol Intervention Team and re-administered at another TARGET event a year later. The questionnaire contained all the same questions as the QAH questionnaire other than the question about the Paddington Alcohol Test. The full analysis of the audit data can be found in appendix B of this report. The key findings from the primary care staff audit are as follows; Response by job role No. of Responses baseline GP Nurse HCA Total % 30.5% 8.5% 100.0% No. of Responses at follow up GP Nurse HCA Total % 17.0% 8.5% 100.0% There was a 57% follow up rate from the initial baseline line questionnaire. Unit calculation The correct number of units for a 4% pint of beer is 2.2 and responses decreased from 55 (67%) baseline audit to 26 (55%) at follow up. The reporting of units in a 750 ml bottle of 14% wine was; 11 (13%) individuals reported the closest amount at 10 units, and 3 (0.3%) accurately reported 10.5 units at baseline, whereas 12 (25%) reported it as 10 units at follow up and 5 (10%) staff reported the correct at amount at 10.5 units. Reports for a 5.5% litre of cider did not show much difference in the units at both audits. At baseline 6 (7%) staff reported 5 units, 10 (12%) stated 6 units, and 8 (9.7%) responses accurately reported 5.5 units. At follow up the 8 (17%) people stated 5 units, 7 (14%) stated 6 units and only 4(8.5%) people accurately stated 5.5 units. 20 (24%) practitioners at baseline accurately reported 30 units in a 75cl bottle of 40% whisky or vodka, and 12 (25%) at follow up, a similar reponse rate. There was also a range of answers at follow up with 9 practioners reporting 20 units and below. There is clearly a need to do more education with primary care practitioners to improve accurate unit calculation, which in turn will assist practioners to calculate patients levels of consumption and make the appropriate intervention and/or referral. Page 15 of 59

25 DoH recommended unit consumption by age and gender With two exceptions all practitioners recorded that for the under 16 s no alcohol consumption was the recommended guidance. However at baseline audit and at follow up there were a number of practitioners who were unaware of the Department of Health guidance for year olds. 15 people reported 2.6 or more units for this age group. The overall reporting on women s weekly consumption was accurate at baseline and follow up. 7 practitioners were reporting the old DoH unit recommendation of 21 units, but this did decrease at follow up to 6 reports compared with 15 at baseline. The overall reporting on men s weekly consumption was accurate at baseline and follow up. However there were still 7 practitioners reporting the old DoH unit recommendation of 28 units. Patient alcohol consumption Primary health care staff were asked to report on when they discussed alcohol consumption from a range of options. A patient s behaviour or presentation suggests excess alcohol was the main reason for discussing alcohol with patients at baseline and follow up; however the number of practitioners screening all patients routinely had decreased from 30% to 23%. This is an area for future development as patients surveyed at the hospital when asked could GP s do more there was a 100% yes response. Practitioners were asked to report what method or tool they used to assess alcohol consumption. Informal discussion and weekly alcohol calculation remained the preferred methods of discussing alcohol consumption rather than a specific tool such as AUDIT. Screening for alcohol consumption The question what should be done with the information from screening/discussing consumption? was designed to look at attitudes towards interventions for alcohol patients. Pointless intervening as patients rarely changed their habits remained the lowest preference at both baseline and follow up. Being referred to a specialist team was the highest preference. However the second preference was for the screening information to be recorded in the notes, but not to be made know to anyone other than the primary health care team. 77% of respondents at follow up stated they would know when to define the different drinking patterns (hazardous, harmful, dependent) compared with 60% at baseline. It would be useful to explore this further as only 8 practitioners reported using AUDIT for screening which enables the different patterns of drinking to be scored. However in the question What method or tool do you use for screening? 31 practitioners reported that weekly calculation of alcohol consumption was the preferred method of discussing alcohol with a patient. If practitioners know the unit guidance from the DoH they would be able to distinguish between hazardous (increasing risk), harmful (high risk) and possible dependency, but this still needs clarifying. Page 16 of 59

26 Referral sources At the baseline audit only 13% of repondents knew who to refer to at QAH for increasing or dependent alcohol consumption. This had risen to 49% with the largets increase in reporting by GPs. Despite the reported increase in who to refer to, only 9 responses stated the ASNS and 7 the AIT. There were significantly fewer responses at follow up (31) to the question do you refer to any other service and where than at baseline (109). This may be as a result of referring to AIT and QAH more, although the numbers of referrals to QAH were reported to be low. Referrals need further exploration via the Alcohol Intervention Team working in primary care practices. The final three questions were only asked at follow up audit about the Alcohol Intervention team. 46 (97.8%) practitioners reported they were aware of the AIT, with 28 (59%) referring in the last year. Practitioners experience of the Alcohol Intervention Team (AIT) compared to other outside organisations that may access the surgery was rated; Average - 6 (12%), Good - 23 (48%), and Excellent -15 (31%) The primary care follow up audit has highlighted a number of areas that need further clarification, and more awareness raising and training on unit consumption, screening, and referrals sources. Page 17 of 59

27 6.0 Patient data 6.1 Referrals The total number of registered referrals to the Alcohol Specialist Nurse Service from April 2010 to mid December 2011 = Patient numbers Portsmouth= 753 Hampshire = 729 A number of patients presented to the service on more than one occasion. The following demographic data is based on the number of individual patients, not the total number of referrals. Portsmouth = 472 Hampshire = 493 A total of 995 patients seen by ASNS from April 2010 Mid December Gender Portsmouth Male 329 (69%) Female 144 (31%) Hampshire Male 345 (69%) Female 148 (31%) 6.4 Ethnicity Ethnic Ethnic Description Portsmouth Hampshire Code A British C Any other White 9 5 background E White and Black African - 1 G Any other Mixed 2 1 background H Indian 1 - L Any other Asian 3 2 background N African 2 - R Chinese 1 - S Any other Ethnic background 1 1 Page 18 of 59

28 6.5 Age profile Portsmouth Hampshire 6.6 Employment status Employment Description Portsmouth n = 472 Hampshire n = 493 Employed 63 (13.3%) 74 (15%) Medically Retired 12 (2.5%) 15 (3.4%) Retired 53(11.2%) 79 (16%) Student 1(0.2%) 1 (0.2%) Unemployed 315 (66.7%) 294 (59.4%) Volunteer 2 (0.4%) 1 (0.2%) No data 26 (5.5%) 29 (5.8%) Data was collected on employment as this was an area the team were interested in reviewing and was discussed in the patient interviews. As a result of the high number of unemployed the ASNS have set up a weekly session with Job Centre Plus to visit patients at the hospital. Page 19 of 59

29 6.7 Age first used alcohol Under 5 Age Ports n=324 Hants n= Age regular use of alcohol 5 and under Ports N=324 Hants N= Age when alcohol became a problem 5 and under Ports n=324 Hants n= The data on children and young people should be of interest to Children s services and commissioners. 39% of the Portsmouth patients and 34% of Hampshire patients under 18 regularly used alcohol, and 9% (both areas) stated it was a problem under Number of presentations by patients n= Ports N =753 Hants N = presentations (Frequent Flyers) = Portsmouth 24 Hampshire The Portsmouth patients are followed up by the Frequent Flyer Project workers. As the ASNS has developed the Portsmouth City PCT has provided additional financial support for the frequent flyers from both Kingsway House (KWH) and Cranstoun. There is no similar provision for the Hampshire patients resulting in extra work for the team to engage them with local services and meet their needs. The Hampshire patients are aware of the different level of service they get compared to Portsmouth residents. Page 20 of 59

30 6.11 Admission presentation/diagnosis The following list shows the top 10 admission diagnoses from PAS (nb. some patients had more than one diagnosis); Portsmouth Hampshire Alcohol Dependence 94 Overdose 84 Overdose 80 Alcohol Dependence 61 Alcohol withdrawal 72 Alcohol withdrawal 39 Collapse 36 Seizures 38 Chest Pain 36 Chest pain 37 Unwell 36 Collapse 35 Seizures 34 Falls 33 Falls 34 Unwell 31 Abdominal pain 23 Haematemesis 22 Haematemesis 14 Fitting 21 Presentation diagnosis is important to help plan and target wards and departments where alcohol is a contributing factor. Patients and staff have asked whether the ASNS team need to have dedicated beds for detox. A case example was a referral from a Psychiatrist from Catch 22 in Hampshire to detox a 16 year old in hospital for patient safety. On this and on other occasions the nurses needed to admit patients briefly for medical safety. Support from MAU has been given for this, however this may not always be the case and especially as referrals increase with the roll out of Vital Pac Referral sources Portsmouth Other referral sources C7 = 2 D7 = 5 D8 = 4 E2 = 1 E4 = 2 E5 = 4 E7 = 6 Obs = 1 F1 = 1 F3 = 1 F4 = 2 G1 = 1 G3 = 2 G9 = 1 Page 21 of 59

31 Hampshire Other referral sources Avalon = 1 Maternity = 1 C7 = 3 CDU = 1 D2 = 1 D3 = 1 D4 = 4 D6 = 3 D7 = 3 D8 = 2 E2 = 2 E5 = 5 E6 = 1 F1 =1 F2 = 2 F3 = 2 F4 = 3 F7 = 1 G1 = 1 G3 = 1 G9 = 2 HNU = 1 SAU = 3 Relative = 1 (C5 Gastroenterology C6 - Cardiology/General Med, C7 Cardiology, D1 D4 Orthopaedics, D8 Gynaecology, E1 - Surgical Assessment Unit E2 E4 Surgical E5 - Critical Care, E6 - Respiratory High Care, E7 Respiratory, E8 - Respiratory / Diabetes / Urology, F1 - Under 65 Neurology, F2, F3 - Stroke Ward, F4 Elderly care, F5 F7 Oncology / Haematology, G1- G3 - Elderly Acute, G4 - Head and Neck Unit G6 G9 Renal) The top three sources of referrals for both Portsmouth and Hampshire come from MAU, ED and C5 where the ASNS has provided training, built up good working relationships in assessing patients in these settings, providing follow up, and group work on C AUDIT Scores 20+ (for possible dependence) The ASNS service and the Alcohol Intervention Team use AUDIT to screen for alcohol use and to plan intervention. All patients scoring 20+ are referred to the ASNS to assess alcohol dependence. SCORE 0-7 Low Risk 8-15 Increasing risk High risk 20+ Possible dependence 40 maximum score Portsmouth Hampshire Not known 6.14 Unit Consumption Portsmouth 0 21 units Not known Page 22 of 59

32 Hampshire 0 21 units Not known Information on unit consumption is useful for targeted intervention as well as managing withdrawal. Collecting this information should be used to identify and work with high levels of dependency which will have significant impact on other aspects of health Clinical Institute Withdrawal of Alcohol Scale(CIWA-Ar) 2008 Score Not known Portsmouth Hampshire Patients scoring less than 10 do not usually need additional medication for withdrawal Detoxification A total of 685 presentations started detox and 602 (88%) completed up to early December Portsmouth n= 753 presentations 359 No detox (48%) although 97 patients had CIWA -Ar score of started detox (50%) ( 20 missing entries) 321 completed detox (86%) Of the 379 presentations that did not receive detox 137 received intervention ranging from 2 to 19 sessions. (511) Hampshire n= No detox (51%) - missing data on an additional 39 presentations) although 78 patients had a CIWA-Ar score of started detox (43%) 281 completed detox (90%) Of the 379 presentations that did not receive detox 149 received intervention ranging from 2 to 20 sessions (460). Page 23 of 59

33 6.17 Alcohol Star outcomes n=40 In addition to collecting activity data the ASNS has explored options for measuring patient outcomes. Although the AUDIT score and unit consumption was discussed for follow up the Alcohol Star was chosen by the team in January 2011 following some initial piloting. The Alcohol Star was developed by Triangle Consulting and Alcohol Concern and is a key work tool that enables services to measure change and summarise change for patients, both singularly and collectively. The 10 outcome areas are listed are; 1. Alcohol 2. Physical health 3. Use of time 4. Social Networks 5. Drug use 6. Emotional Health 7. Offending 8. Accommodation 9. Money 10. Family and Relationships The team chose this tool as it linked to all areas of a patient s life that alcohol can impact on, and many of these areas were raised in the assessment and risk assessment. The tool is also widely recognised nationally as an outcome measurement tool. The developers of the tool Triangle Consulting provided training for the team on 8 th March. The Alcohol Star is intended to be used with the patient at assessment, then at 3 month and 6 month follow-up visits. The Star has a numerical score against a set of criteria which is chosen by the patient to represent their current situation (1 low 10 high). Dr Schmidt is planning to incorporate the 10 outcome areas onto Vital Pac as part of a case management tool. To date information on the baseline scores and follow up has been limited. At this point in the evaluation only 30 patients have data entered on the database. The team are planning to increase the number of patients completing the Alcohol Star at reviews, a system is needed to help flag the dates when this is to be undertaken. Table 1 Alcohol Star n = 40 STAR criteria Average score at assessment Average score at month follow up Average change Page 24 of 59

34 Table 2 Alcohol Outcome Star n = 40 Positive change No change Negative change Alcohol 100% 0% 0 Physical health 97.5% 0% 2.5% Use of time 97.5% 2.5% 0% Social Networks 92.5% 5% 2.5% Drug Use 17.5% 80% 2.5% Emotional Health 87.5% 7.5% 5% Offending 27.5% 70% 2.5% Accommodation 32.5% 67.5% 0% Money 62.5% 30% 7.5% Family and relationships 85% 15% 0% The patient scores his/herself based on a set of criteria. The patient s scores are entered onto a Star Chart and these are then reviewed and updated at three monthly intervals. The plots are presented in different colours on a star chart so that the patient can see and discuss their progress. The data from each of the scores is entered on an anonymised data base so that scores can be analysed across the service. The two types of analyses are important to interpret the outcome scores. From both data sets there is positive change in all areas. In table 1 the four areas of highest collective change were Alcohol, Family and Relationships, Use of time and Physical health. In table 2 there was no change relating to drug use (80%), offending (70%) or accommodation (67.5%), as many patients did not present with major concerns in these areas. This is supported by the high scoring in table 1. There were 6 outcome areas where positive change was 85%+. These were Alcohol, Use of Time, Social Networks, Physical Health, Emotional Health and Family and Relationships. There was positive change in other four outcome areas but to a lesser degree. Negative change was only registered for small number of patients (1 to 3) in 6 areas. This is not unusual for this outcome tool and reflects challenges when use of alcohol has stopped. Sometimes patients can rate their initial scores too high, and when no longer drinking they have a more realistic view of the criteria. In addition, patient s lives can get worse before they get better; these latter issues can be addressed in review meetings and the additional support offered to patients at the hospital or in the community. A long term view on completing the Alcohol Star is important. Building the scoring system into Vital Pac as part of the case management system will enable the outcome to be measured over time, for example up to a year and give more meaningful data. Page 25 of 59

35 6.18 Alcohol Intervention Team support for alcohol dependent patients In addition to detoxification and follow up interventions, the ASNS also enables patients to access one to one sessions with a member of the AIT as part of relapse prevention. Initially referring to AIT was an ad hoc process, but has now become more formalised on day 6 of detox if patients wish to engage. The AIT team also run the ACT classes in outpatients and on C5 as part of the overall package of on-going care and support. The following pie-chart shows the number of patients accessing this support service and the number of sessions attending. 70 patients attended between 1 and 11 one to one sessions over a nine month period. In addition Portsmouth patients can access the ACT classes in Outpatients 2 days a week. For example, for the three months August to October 2011 Number of classes run = 26 Individual attendance = 75 Total number of attendances 261 Average per class = 10.6 This shows good attendance at the ACT classes, and is also a good use of the AIT staff time in terms of maximising contact with patients. AIT staff also follow-up on Vital Pac screenings each day and undertake one to one work with patients. The ACT classes received very positive feedback in the patient consultation exercise. Page 26 of 59

36 6.19 Referrals to others services Portsmouth Hampshire Service Number Service Number AA 22 AA 27 ACT 30 ACT 4 Alcohol Intervention Team 35 AIT 10 Avalon (CDAT) 3 Avalon (CDAT) 89 Baytrees 4 Baytrees 34 Central Point 1 Central Point 1 AIT workers RP interventions 105 AIT RP workers 26 Cranstoun 106 Cranstoun 5 Dietician 1 Dietician 2 Health Trainer 2 Frequent Flyers Workers 4 Frequent Flyers Workers 29 Parkway 1 GP 1 Health House 3 Health House 0 Kingsway House CDAT 3 Kingsway House 47 Mill House 3 Mill House 5 NA 3 NA 2 Mental Health + EIP 8 Out Patient Mental Health OPMH 9 Orion CDAT 94 Orion (CDAT) 3 Hepatitis C 1 AIT Family support 2 Social Service 2 Social Services 1 Catch 22 Young People s Service 1 SWITCH (YP service) 2 Spencer House CDAT 1 Other 9 Other 51 TOTAL 419 TOTAL 413 As well as detoxification and follow up interventions the ASNS have also reported on referrals to services in the Community. There seems to be under reporting based on observations made during the evaluations e.g. health trainer referrals. It can be seen from the number of community referrals in Hampshire to Avalon and the Orion, the community drug and alcohol teams, that the ASNS have ensured that patients have been able to access on-going support following detox. Currently there is no access to ACT groups or one to one support for Hampshire patients. Other than patients reporting to the nurses at their review meetings and those interviewed in the patient consultation there is no additional information on the outcome of these referrals to Hampshire services. The referrals to Portsmouth community services also include a broad range. The outcome of the referrals is not recorded on the database. However, the ASNS have a weekly meeting with Frequent Flyers workers, meet with the AIT daily, and have input from Kingsway House staff and the health trainer once a week to discuss patient progress, which has probably led to under-reporting on the database as this is seen considered part of the alcohol team activity and not a specific referral. Reporting outcomes following referral need improving to give a more accurate account of the support patients are receiving. Page 27 of 59

37 7.0 The Patient Journey 7.1 Case Studies The parallel evaluation process has highlighted that data collection alone cannot truly reflect the work that has been undertaken with patients by the ASNS. As the clinical environment is so busy even general data collection is sometimes overlooked. As part of reviewing the patient journey through treatment, the external evaluator discussed submitting case studies with the ASNS to give a better understanding of the patient care and some of the challenges faced by the team by not having equitable access to services for Hampshire patients. The following four case studies highlight the all round care that patients received by the ASNS. Case study 1 Miss R, a 32 year old, was first referred to the ASNS at 38 weeks gestation of her 4 th pregnancy. Her previous 3 children had been removed from her care. She had been excessively consuming alcohol both prior and during her current pregnancy. Her health and that of the unborn child were of significant concern, combined with the child s father having a diagnosis of a dis-associative disorder (non-epileptic seizures), this triggered concerns from social and child welfare services. The ASNS were requested to attend a multidisciplinary case conference. The aim was to provide an expert opinion in formulating a supportive recovery plan. Our response was to offer immediate assessment, which confirmed she was dependent upon alcohol. We found her to be motivated towards post-delivery detoxification and overall positive in attitude. Formal assessment tools included AUDIT (score 36) and CIWA-Ar (score 32). Star scores ranged between 1 and 2, except those pertaining to relationships; which were 6. A multi-team recovery model was discussed at length. she was keen to accept all avenues of support offered and a thorough plan was subsequently made. Less than 24 hours later Miss R went into labour. We attended the maternity unit at this time to offer support, advice and reassurance to her, her partner and the midwifery staff. With her consent she was re-assessed shortly after childbirth and prescribed most appropriate detox regimen. A member of the ASNS team then saw her twice a day providing continuity of care and support to staff. Additional education was given to maternity unit staff regarding withdrawal signs and medication dosages. Alcohol detoxification was successful and uncomplicated. Miss R and the maternity unit both reported they felt very much supported during this difficult time. Miss R, did, however describe strong cravings and after much discussion we recommended Acamprosate. We liaised on her behalf with her GP regarding this, who provided the prescription. Prior to discharge a Multi Disciplinary Team meeting was held to ensure she had a very structured discharge plan. This included weekly reviews by the ASNS and regular contact with social workers. Miss R has currently been abstinent from alcohol for 4 months. She is engaging with all services, attending ASNS for continued support and appropriately uses Acamprosate. Star scores now range between 7 and 9. Mother and baby are both doing extremely well. Page 24 of 59

38 Case study 2 Mr. A was found lying on a local railway line. Police brought him to the accident and emergency department as it is considered a place of safety. He was intoxicated and distressed. The Mental Health Liaison Team was initially approached by the A&E department however they felt that his problems were alcohol related, therefore a referral to the ASNS was made. Mr. A was clearly withdrawing from alcohol, tearful and anxious. During a comprehensive assessment Mr. A stated that he had a diagnosis of clinical depression. He discussed significant suicidal ideations, which were sustained during periods of alcohol abstinence. He had clear plans on how to end his life, with multiple previous suicide attempts. On this occasion he had left a suicide note including, funeral directions. He had previous admissions with selfharming for which heavy alcohol consumption had acted as a trigger. His assessment, therefore included a high TAG score and a normal MMSE MR A disclosed he had recently been discharged from a psychiatric hospital where had had been sectioned under the MHA (1983) as he was deemed a danger to himself. Once discharged he recommenced drinking alcohol. During the week prior to this presentation he consumed 530 units of alcohol. We were able to correctly identified his inappropriate use of alcohol to self medicate his depression. Despite ongoing alcohol dependency it was felt that this was not his primary problem Given this information the ASNS contacted the relevant CMHT. This was agreed and his care was subsequently transferred to that of the inpatient psychiatric team. Case study 3 Mrs. J, an 80-year-old lady, has been known to the ASNS since April At this time she had been experiencing alcohol withdrawal seizures associated with 210 units per week consumption, and an AUDIT score of 32. She had several presentations to hospital prior to this, and with hindsight may have been alcohol related. However, due to a combination of ineffective questioning and non-disclosure her alcohol misuse had not been identified. Mrs. J stated that she began drinking alcohol in her early 20 s but it was following breast cancer treatment (6 years previously) her drinking become excessive. She had now developed a dependency. She had made efforts to address this by attending voluntary organizations and self help group for substance misuse. Mr. J was clearly angry at his wife addictive behaviour and despite 55 years of marriage was seriously contemplating moving out of the family home. Soon after admission her condition deteriorated and was subsequently diagnosed as delirium tremens. This was successfully treated and since recovery from this condition Mrs. J has fully engaged with the ASNS and has remained abstinent (barring one short lapse) from that date. This was achieved by implementing a multi-factorial strategy which included 1:1 support, problem Page 25 of 59

39 solving, addressing other health concerns and including joint working with Out Patient Mental Health regarding her depression. Mr. J has also required our support to understand the nature of living with a person who has an addiction. He often states this has helped them put their marriage back together. This in turn strengthened her support system and with their relationship much improved she was able to rebuild other family relationships and they started to go on holiday. In November 2011 she was admitted with a seizure. Due to her alcohol related history the initial diagnosis of alcohol withdrawal syndrome was made and the ASNS were made aware of her admission. Due to the long-term support provided by our service we were able to challenge this diagnosis and inform the medical team of her past medical history. As a result of this her differential diagnosis was widened and further investigations carried out. CT and MRI imaging revealed metastatic carcinoma to her liver and brain. We are continuing to support Mr. and Mrs. J in her end of life care. Case study 4 Mr B at 65 years of age has experienced problematic drinking for 40 years, having commenced his alcohol drinking at age 17. At the height of his drinking he was consuming 250units per week. Other medical issues included diabetes mellitus, ischemic heart disease, hypertension, obesity and smoking. Initial AUDIT scores were 40, CIWA-Ar scores were above 20. Prior to the interventions of the ASNS team he was a frequent attendee at A&E and the MAU with multi issues including alcohol withdrawal, however self-discharging against medical advice before adequate management was instigated. In May 2011 he was admitted with severe withdrawal and delirium tremors. Whilst on a medical ward Mr B physically attacked a staff nurse. As a result the nursing team became very scared of his aggressive behaviour and were disengaged from his over management, resulting in suboptimal care. When control of his medical symptoms was achieved the ASNS team spent many hours with Mr B. He was devastated and embarrassed regarding his behaviour. We were able to build a trusting relationship and support him with extreme feelings of guilt. Working with ward team members in this and providing additional education sessions aided the nurses to better understand and manage aggression in the setting of addiction. Since the above episode Mr B has fully engaged in our service and was receptive to our referral to the health trainer for ongoing health and life style support. He now attends all hospital appointments. He is currently waiting a coronary artery bypass grafting, which we are supporting him through. Mr B has been abstinent for 8 months and his Alcohol Star scores have greatly improved. Page 26 of 59

40 7.2 Qualitative Interviews During August 2011 the evaluator conducted patient interviews at QAH. Interview questions were agreed with key stakeholders prior to commencement. The interview focused on the patient s experience of; Screening and intervention within Primary Care Screening and referral via QAH Interventions from the Alcohol Interventions Team Interventions and support from the Alcohol Specialist Nurse Service ACT classes Prior to commencing the interview confidentiality was explained, the purpose of the interview and how the information was to be reported. No members of the AIT or ASNS were present at the interviews Patient profile 45 patients and 6 family members were interviewed (n = 51). 49 were face to face interviews, and 2 telephone interviews. Patients were seen in ED, MAU, C5, and as an ASNS outpatient. 4 patients were seen twice on request to give additional information, but have only been counted once. Patients interviewed were at different stages of their treatment; e.g. just been admitted, starting detoxification, attending reviews, attending ACT, short and long term abstinence and successful discharge from the team. It was important to interview patients new to the service as well as longer term patients. In the first few interviews it was apparent that many of the patients could not recall accurately how they were referred to the team. Interviewing patients on admission or on detox gave insight into how patients engaged and were referred to ASNS, and their reactions to the service. 16 Female 29 Male Age range 21 to 79 Portsmouth 25 Hampshire 20 6 family members The following information is based on the responses given by patients in the interview schedule Primary Care Primary Care example questions Has your GP ever asked you about your drinking? o Generally o As a result of a particular condition What did the GP (or practice nurse HCA) offer following identifying or discussing your drinking? What care and support was offered? (list of agencies) Did patient take up what was offered? If not why? Did GP intervention have an impact on; Page 27 of 59

41 a)drinking pattern b) Up take of services c) Improved health etc What more could GP have done OR do now? Patient feedback; All patients reported that alcohol screening had not been routine or they could not remember. Alcohol was only raised by the GP when; the patient had either asked for help, or it had been raised in relation to a specific health problem, or the GP could smell alcohol. There were three main answers following identification of drinking (in order of frequency); o Referred to community services or in-patient detox o Offered a detox with GP o Nothing told to cut down or stop! Patient s experiences with their GPs were varied; some were reported not to have the knowledge base on what to do or where to refer. Others were described as having a negative attitude, whilst 11 patients reported they had very good support from their GP. A small number of patients gave detailed accounts of the different attitudes within the same practice. In relation to care and support, regular health checks were the most frequently cited level of on-going support from GP s. If a home detox had failed patients reported the GP then referred them to the local community alcohol services. For those not offered GP home detox in the first place the main emphasis was on engaging with specialist services. Three patients had been referred directly to the ASNS. Four people had been referred for counselling either within the primary care practice or in the community. When asked why they had not taken up the services that the GP offered, the majority responses were; o Not ready to stop or change drinking o Previous negative experience of the specialist alcohol services recommended prevented them from re-engaging GP intervention was reported to have an impact on those who were ready to change their drinking, especially those who had no previous experience of specialist alcohol services. Patients said they did listen to their GP s, especially the health advice, but often their confidence was affected when referred to services that didn t want to engage with them felt like pass the parcel or too bad to be accepted, then too well to offer ongoing support. Could GP s do more? 100% yes. Patients said that GPs should have asked earlier, and although they may not have been ready to change, it might have got them thinking. More education on alcohol and addiction, especially the dangers of stopping too rapidly. Other common themes raised were the links with depression, anxiety and bereavement; patients said that GP s should ask about alcohol in relation to these more. Page 28 of 59

42 7.2.3 QAH Admission QAH Admission example questions Was alcohol use identified on admission or at appointments? What care and support offered? Did patient take up what was offered? If not why? What was the outcome of the above hospital and other interventions? Frequency of admissions What worked/made a difference to alcohol consumption? What could have been improved? Staff attitudes (rate and describe, give examples) Patient feedback; Not surprisingly the majority of patients interviewed could not remember much detail about their admission to QAH either due to their presenting condition e.g. overdose, seizure, etc. or because it was a long time ago and they could not remember. A few patients interviewed in the first week of detox had better recall and 9 patients reported being referred by the doctors in ED to ASNS. A couple of patients complained about the doctor attitudes had been very direct, but added it was probably right! No one could recall not wanting to see the ASNS. A small number of people said they had been pleased that they had been offered to see a specialist alcohol nurse, as this had never happened before right place, right time 27 patients interviewed had more than 4+ admissions and were able to give accounts about the different presentations, commenting on the difference with not being offered anything to being referred to the ASNS team. Having been introduced to the team, they were able to ask for them if they were brought in again! Although many felt bad or guilty about a readmission, they felt they were able to ask for support again Experience of ASNS ASNS example questions Experience of initial contact What was offered? Did patient take up what was offered? If not why? What worked/made a difference to alcohol consumption? What could have been improved? ASNS Staff attitudes (rate and describe, give examples) Is the hospital the right place to deliver this type of service? Patient views on alcohol star if completed Was alcohol a contributing factor(cause) to becoming unemployed OR had being unemployed led to drinking Patient feedback; 3 people said their first contact had been with a member of the Alcohol Interventions Team; staff allocated to support alcohol dependents but also to provide brief interventions for Page 29 of 59

43 increasing/high risk drinkers. Patients reported they were given options and time to think ( no pressure ), which they appreciated before deciding to see one of the nurses. These three individuals would have been seen by the AIT as a result of Vital Pac screening. Patients first contact with the ASNS provided many detailed accounts about how positive the first meeting had been; I felt safe,.. they gave me choices.. they told me how it was.. honest.. they gave me time to think, they listened. A few comments were made such as stern, direct told me straight ambushed me, when asked if this was appropriate, all qualified this feedback by saying 100% yes, and expanded by saying that it was what they needed, but was done in a way that was professional and caring. No one complained about being seen by the ASNS. As all patients were engaged with the service at the time of the interview, the answer to the question about taking up what was offered was 100%. Patients did describe why it hadn t worked and why they had to come back e.g. thought I d be OK after detox, bored nothing to do, no aftercare, lack of support from community services, where I live, full of drinkers and addicts, should have gone to counselling. What worked (made a difference) is primarily linked to staff attitude; kind, caring, nonjudgemental, didn t give up on me, honest with me, professional. The accolades were numerous from everyone; they saved my life, she is an angel..couldn t have done it without them. In addition some other key points were repeatedly made by those interviewed; o The blood tests and the health feedback i.e. how people are improving explain it to you properly, like to see I am getting better, the vitamin shakes were a turning point, made me stop and think. o Addressing all needs not just focusing on the detox helped me with my housing, helped me see a psychiatrist, got the registrar to see me immediately (other health conditions), just kept asking is there anything else they could for me, they always do what they say they will, never let you down.. it s not just a job to them, sent someone to see me at home.. and he has been great too!, ringing me on Christmas day to see if I was OK. o Being seen at a point of crisis, not having to wait, seen promptly as an outpatient, no waiting lists, made to feel they can come back for support if needed, no barriers, were frequently cited by patients and family members The patients also reported that the ASNS had given them information and/or helped them access their local services, and had encouraged them to go to AA, counselling and specialist substance misuse services, as well as other organisations e.g. Mental Health services. Take up of AA was mixed; some patients used AA regularly, whilst others said not for me. There were also some positive reports about counselling (with a couple of exceptions) especially the Portsmouth Counselling Service and Options. Page 30 of 59

44 29 patients reported their experience of specialist substance misuse services e.g. Nelson Unit, Baytrees, Cranstoun, Kingsway House, the Orion Centre, Avalon, Spotlight, and Marchwood Priory. 5 patients reported positive experiences usually linked to the support from a keyworker rather the service as a whole. A specific example of this was the role of the Frequent Flyers workers, which was highly rated. There was, however, a considerable amount of negative feedback from this group about specialist substance services. For many Hampshire patients this was based on their current experience of trying to get help and on-going support from the local substance misuse services. The negative comments for both areas are not included in this report, but will be fed back to commissioners separately. However, patient s past and present experiences are having an impact on the ASNS in a number of ways; o The amount of time it is taking for the ASNS to support the Hampshire patients in engaging in local services, dealing with patient s complaints and trying to find other solutions is drawing them away from developments they want to do in the hospital. o The negative experiences, past and present, in both geographic areas are preventing patients from wanting to go back to these services, therefore relying solely on ASNS. o Operating a different level of service for Portsmouth and Hampshire patients due to the disproportionate funding, coupled with little support from Hampshire services, puts extra pressure on the nurses. For Hampshire patients the ASNS are dealing with the frequent flyers, detoxifications, one to one follow-up, and onward referrals, whereas for Portsmouth patients extra support and resources have developed a broader package of care including health trainers, ACT classes, frequent flyer workers, and one to one sessions from AIT to support on-going recovery. In rating the service as a whole and staff attitudes where 0 = Poor and 10 = best service received, with two exceptions (7/10 and 9/10) everyone rated gave 10 out of 10 (a couple higher as well) The patient rating 7 stated that she only did so to highlight a part of the service that was missing for her i.e. counselling (Hampshire patient). In response to the question is the hospital the right place to deliver this service the answer was 100% Yes from patients and family members reminds you why you came in, it s safe here, they care here, not like the other services best service I have ever had If it wasn t for team I would be dead. 13 patients had completed the Alcohol Star (outcome measurement tool). 2 patients reported this had to be completed at the right time not be overwhelming. One patient thought it would be useful for statistical purposes. The remaining 10 described the Star as very good or brilliant Page 31 of 59

45 Asked about improvements to the service, Hampshire patients repeatedly asked for the same level of support as the Portsmouth patients were receiving i.e. able to have more one to one support and attend ACT classes. A number of patients raised the issue of travelling to the hospital as one of the few issues for improvement. There were three main concerns; o Travelling if to unwell to get to the hospital e.g. physical and psychological o The cost of travel to the hospital o Time and distance e.g. Gosport area, so could the service provide some satellite services? Experience of Alcohol Intervention Team Alcohol Intervention Team example questions Experience of initial contact What was offered? Did patient take up what was offered? If not why? What worked/made a difference to alcohol consumption? What could have been improved? ASNS Staff attitudes (rate and describe, give examples) Is the hospital the right place to deliver this type of service? Patient feedback; As most people s experience of meeting members of the AIT would be in ED or MAU, or following screening through Vital Pac, many patients could not recall the name of the service, but when asked who they saw, they gave names of the team. As dependent drinkers are usually seen by the nurses first this would mean many patients had limited contact with the AIT. Patient s perceptions were that they are all one team and did not seem to be aware of the different roles and responsibilities, just very grateful for their help. Patients seen by the AIT in hospital or in Guildhall Walk said that they had been offered choices not forced to do anything, a wake-up call. This initial contact of seeing someone about their alcohol use was seen as positive. Three patients who had seen AIT recently did engage with them directly and/or attended ACT. Two members of the AIT team are also actively involved in giving one to one follow-up during or after detox, and delivering ACT. During the discussion about the ASNS these individuals were frequently mentioned and patients reported their input as an important part of their on-going support. Patients rated staff attitudes 10/10. No improvements were highlighted Page 32 of 59

46 7.2.6 Experience of ACT classes ACT classes Experience of initial contact What was the experience of the classes? rate What was the outcome for him/her of attending? Staff attitudes (rate and describe, give examples) Is the hospital the right place to deliver this type of service? What could be improved? Patient feedback; 20 patients interviewed had attended the ACT classes run on Tuesday and Thursday for Outpatients and run on C5. Of the 20, only 2 people reported this was not for them. The main reason given was the group approach rather than the content, they preferred one to ones. Those who had experienced ACT groups elsewhere in the community all reported ACT was better run in the hospital setting. Examples included more structure, more serious, facilitation, more professional, etc. When asked what they had gained from attending patients reported; made very welcome couldn t wait to go again, if I d known about this when leaving Baytrees things would have been different, makes you think, tool for life, it is where I learn, ACT also helping with smoking too. A couple of different comments were; ACT not enough needs to be more hard hitting and educational, a bit obvious and a bit complicated. A couple of people from Hampshire had experience of ACT classes when it first started at the hospital. As ACT is funded for Portsmouth patients only, Hampshire patients had this service withdrawn. Those interviewed who had attended previously and had no access to ACT were very upset this was no longer available especially as it had really helped. 8 patients rated the service out of 10 (0 low 10 high), there were 7, 10 out of 10, and one 11 out of 10. When asked was the hospital the right place to offer ACT classes, all patients were unanimous - hospital is a very powerful environment to have groups a good reminder why you are here. Page 33 of 59

47 8. 0 Cost effectiveness The cost savings have been based on savings that have been straightforward to measure i.e. admissions prevented and bed days saved. Savings that cannot be measured are preventative elements such as future admissions or ED attendances as a result of patients engaging with the ASNS e.g. an example relating to this would be a frequent flyer who had 11 admissions one year, but this would drop or cease following intervention. Earlier in the report figures were given on the number of completed detoxifications for both geographic areas. For the following cost saving analysis, Business Intelligence at QAH has used the evaluation database to identify the number of detoxifications from April November 2011, admissions avoided and bed days saved. a) Portsmouth Based on Data from Apr-11 to Dec-11 (Inclusive) Portsmouth Patients Seen 356 Portsmouth Referrals By Source Total MAU 198 IP Ward Med 105 ED 93 Self 43 GP 38 IP Ward - Non Med 34 Outpatients 10 Other 10 Total Referrals 531 Community Service Referrals (Portsmouth Patients) Total Cranstoun 62 AIT 46 ACT 24 Kingsway 20 Other (Various - low individual volumes) 151 Total Referrals 303 Outpatient Only Detox Setting (Portsmouth Patients) 71 Inpatient Only Detox Setting (Portsmouth Patients) 17 Inpatient Start - Outpatient Complete Detox Setting (Portsmouth Patients) 92 Total Detoxing (Portsmouth Patients) 180 Outpatients Completing Detox (Portsmouth Patients) 71 (100%) Inpatients completing detox 15 (88.2%) Inpatients outpatient completing detox 92 (100%) Total completing detox 178 (98.9%) Page 34 of 59

48 Admission Avoidance rates Oct Dec 2011 Total referral by ED and GPs 43 Patients where admission was avoided (post ED referral) 18 Total admissions (post ED/GP referral) 25 Admission avoidance rate 41.9% Bed Days Saved (Portsmouth Patients)*April to December The total number of referrals exceeds the number of patients as some individuals present to QAH on more than one occasion. The number of patients with four or more presentations is highlighted in Section 6.1 and 6.2 of the report. There is a discrepancy between outpatient detox and ED attendees for alcohol excess because not all ED presentations require a detox e.g. binge drinking. Patients are referred to the ASNS and assessed and on the basis of this the nurses make a recommendation about the need for alcohol treatment or not. It is at this point that the nurses can recommend patients are not admitted if it is medically safe, thus saving an admission. This explains why the figure for patients not admitted is higher than number of outpatient detoxifications. 8.1 Cost saving - Portsmouth Cost saving for admissions avoided is 1314 per patient; therefore for the three month period October to December 2011 there were 18 patients = 23,652. Per annum this would equate to 94,608 Cost saving for bed days saved based on Gastro Non-Elective admissions is 273 per patient per day. Bed days saved may not have a financial saving to the commissioners, but will be of benefit to the hospital's efficiency. For 9 month period (April to December 2011) = 226,590 Per annum this would equate to 302,120 b)hampshire Based on Data from Apr-11 to Nov-11 (Inclusive) Hampshire Patients Seen 344 Hampshire Referrals By Source Total MAU 183 IP Ward Med 108 ED 82 Self 38 IP Ward - Non Med 31 GP 14 Outpatients 14 Page 35 of 59

49 Other 6 SAU 2 Total Referrals 478 Community Service Referrals (Hampshire Patients) Total Orion 73 Avalon 71 Baytrees 29 AA 10 Other (Various - low individual volumes) 75 Total Referrals 258 Outpatient Only Detox Setting (Hampshire Patients) 45 Inpatient Only Detox Setting (Hampshire Patients) 17 Inpatient Start - Outpatient Complete Detox Setting (Hampshire Patients) 74 Total Detoxing (Hampshire Patients) 136 Outpatients Completing Detox (Hampshire Patients) 97.8% of patients starting in outpatient setting 44 ED Attendances for Alcohol Excess that were not admitted (Hampshire) 117 Admission avoidance rate - based on the Portsmouth calculation of 41.9% 49 Bed Days Saved (Hampshire Patients)* 152 Average Bed Days Per Month The total number of referrals exceeds the number of patients as some individuals present to QAH on more than one occasion. The number of patients with four or more presentations is highlighted in Section 6.1 and 6.2 of the report. There is a discrepancy between outpatient detox and ED attendees for alcohol excess not being admitted but this is because not all ED presentations require a detox e.g. binge drinking. Patients are referred to the ASNS and assessed and on the basis of this the nurses make a recommendation about the need for alcohol treatment or not. It is at this point that the nurses can recommend patients are not admitted if it is medically safe, thus saving an admission. This explains why the figure for patients not admitted is higher than number of outpatient detoxifications. 8.2 Cost saving Hampshire Cost saving for admissions avoided is 1314 per patient; therefore for 49 patients (April to November = 64,386 Per annum this would equate to 96,579 Cost saving for bed days saved based on Gastro Non-Elective admissions is 273 per patient per day. Bed days saved may not have a financial saving to the commissioners, but will be of benefit to the hospital's efficiency. For 152 days per month@ 273 = 41,496 per month For 8 month period (April November 2011) = 373,464 Page 36 of 59

50 9.0 Recommendations These recommendations are based on the first 18 month period of the project. This evaluation indicates that the Alcohol Specialist Nurse Service (ASNS) has some development opportunities still to fulfil across the Trust. Many of these recommendations address the next steps in providing a comprehensive and integrated service around patients and the delivery of effective quality care for alcohol patients. Queen Alexandra Hospital (QAH) is committed to delivering alcohol patient care hospital-wide and working with commissioners to ensure the best value from the resources invested in alcohol prevention, intervention and treatment. Commissioners Commissioners should recognise from the data that the workload of the ASNS sees Portsmouth and Hampshire patients largely in equal measures. From this perspective it is essential that Portsmouth City and Hampshire Primary Care Trusts continue to collaborate on the joint-commissioning of the ASNS over the NHS transition period, as this will enable local authorities to take a view on a key aspect of alcohol harm reduction policy. Beyond the balance of funding will need to be addressed, or the level of service delivery for Hampshire patients will have to be reviewed. The joint-commissioning of the ASNS over will look to establish the service on a sustainable platform that will be resilient to NHS changes and able to respond to the increasing stresses placed by alcohol on the NHS. Commissioners should consider the balance of the team s work with dependant drinkers, which is and should remain their primary function, with the need to develop the skills of nurses and doctors across hospital departments to provide identification and brief advice (IBA). Additional resources may be needed to fully implement such IBA capacity building. The Portsmouth model of engagement with their substance misuse community-based service to provide in-reach hospital services which integrate and help the ASNS share the burden of supporting alcohol patients towards recovery is an invaluable development. This model should be investigated by Hampshire commissioners in terms of a likewise approach for Hampshire patients in respect of in-reach from the Hampshire HOMER service to support Hampshire patients. Safer Portsmouth Partnership and QAH To discuss and agree the future data requirements (monitoring and outcomes) for the ASNS before the end of the pilot phase in March Following the end of the evaluation phase in January the ASNS database could be redesigned with support from Business Intelligence to focus on capturing key clinical decisions such as avoiding admissions as well as keeping key activity data e.g. assessment, detox etc. In addition interventions for patients not having detox but who receive a package of care needs to be more explicitly recorded. To improve completion of Vital Pac within MAU, and revisit with ED staff with additional training and support Page 37 of 59

51 To roll out Vital Pac alcohol screening across the hospital with referrals monitored closely to see if additional investment is required for meeting patient s needs. Vital Pac developers and commissioners to agree on the level of investment and a deadline for completing the case management tools for alcohol patients. QAH Senior Management To increase the profile of the QAH Alcohol Steering Group with support from the Chairperson to get representatives from wards and services other than ASNS to contribute to the alcohol agenda hospital-wide. To provide consistency of management for the ASNS to enable further developments within QAH. To provide more formalised management support for the ASNS to resolve operational issues e.g. staffing levels, holiday cover, sickness etc and support the future development e.g. fortnightly meeting with the Sister, monthly meetings with the team To allocate new accommodation for the ASNS to ensure patients have confidential access e.g. separate reception, and the team have sufficient office space to undertake their roles e.g. access to computers and hold team meetings. To review the job description and time allocation for administration in line with the expansion of the service to date and future monitoring and data requirements, plus the time needed for patient management issues e.g. reception duties, telephone calls, meetings etc To assess the training and development needs of staff to enable the nurses to access specialist training (e.g. mental health), attend key conferences and research development forums. As the service has developed into offering a diverse care package staff need to enhance their knowledge and skills to sustain the level of care offered. To improve access to the service for patients in poor physical health via consideration of different transport options, fare reimbursements, home visits or community based clinics. ASNS To develop a system to monitor the Alcohol Star data is completed at assessment, three and six months and nine months for all patients. To develop a patient questionnaire to continuously monitor the quality of service delivery and gain feedback on areas for development or improvement. The team to collate information and report quarterly. To undertake targeted development work with ED to increase referrals via screening and focus on decreasing admissions. Page 38 of 59

52 To develop targeted intervention and support for patients with high dependency scores To update all back dated activity on to the National Alcohol Monitoring System database To continue a monthly programme of training and awareness raising by targeting wards/services linked to alcohol related admissions data from PAS. To develop more formalised care pathways with Mental Services for patients especially following detoxification To continue to promote awareness of the ASNS and the AIT within primary care services. To provide a programme of training and information for primary care practitioners on alcohol consumption, screening and referral pathways. ASNS, AIT and community services to raise the profile of their services within the community to aid appropriate referral and meet patient needs. Page 39 of 59

53 10.0 References Alcohol Harm Reduction Strategy for England, 2004, Prime Minister's Strategy Unit Portsmouth Alcohol Misuse Needs Assessment Study Report, T. Dean & S. Pallikadavath, University of Portsmouth, 2009 Alcohol Harm Reduction Strategy for Portsmouth Reviews of the Effectiveness of Treatment for Alcohol Problems, National Treatment Agency, 2006 High Impact Changes (draft document), 2009, Department of Health Portsmouth Alcohol Strategy , Safer Portsmouth Partnership Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 1989;84: Page 40 of 59

54 Appendix A QAH Staff Audit i) Response by job role Doctor Nurse HCA Pharmacist Total Baseline 8 (5.8%) 99 (71.7%) 31 (22.5%) Follow-up 12 (11.3%) 72 (67.9%) 15 (14.2%) 7 (6.6%) 106 ii) Response by service Baseline Follow up Critical Care Medicine Surgery Orthopaedics Gynae & Maternity Other Not Stated Total % 17.4% 12.3% 19.6% 8.0% 1.4% 13.8% 100% % 22.6% 21.7% 11.3% 0.0% 0.0% 12.3% 100% The ASNS have targeted ED and MAU staff for training as they are key sources of referral. Q1. How many units of alcohol are in? A)Number of units in a 4% pint of beer (568ml)= Answer 2.2units Units Not stated Baseline 1 0.7% 1 0.7% % 6 4.3% 1 0.7% % 2 1.4% % % % Follow up % 1 0.9% % 4 3.8% % 3 2.8% % In the baseline audit (46.4%) and at follow-up (64.2%) the majority of staff were close to the accurate figure of 2.2 units in a pint of 4% beer. Staff tended to give round numbers in the responses. b) Number of units of 750ml of 14% wine = 10.5 units unit Not Stated Base % F/up % Page 41 of 59

55 There was an improvement between baseline (7.2%) and follow up 33% in staff accurately reporting the numbers of units in a bottle of 14% wine. However around 22 % of staff were not reporting an answer. Education on units was addressed via the training and is important for screening. c) Units in a litre of 5.5% cider = 5.5 Uni Ba s % F/u % At baseline only one staff member (0.7%) correctly knew that there are 5.5 units in a litre of 5% cider. This rose to 55.7% at follow up. The unit calculations for beer wine and cider were chosen specifically to see if staff could accurately calculate units. d) 75cl bottle of 40% whisky or vodka = 30 units Unit Base % Unit F/up % Unit lots Base % Unit Lots F/up % % 0% 0% Not stated baseline 47 (34.15), not stated follow-up 29 (27.4%) The estimated units for a 75cl bottle of whisky or vodka at baseline had an enormous range from 1 unit to 70+, with 10 staff (7.2%) identifying this correctly at 30 units. At follow up there was marked improvement in accuracy of reporting up to 49%. However 29 (27.4%) did not give an answer to this question. Not State Page 42 of 59

56 Q2. What is the maximum safe limit of weekly alcohol consumption for; Child under 15 Unit Not Stated Base % 77.5% 0.7% 2.2% 0.7% 18.8% Unit Not Stated Follow-up % 91.5% 0.0% 0.0% 0.0% 8.5% Although there have been few children presenting to the ASNS it is important that staff have knowledge of unit consumption by age. There was a high rating for no units at baseline (77.5%) and follow up (91.5%) Person years Unit Not Stated Base % Unit Not Stated F/up % For young people years there was a varied response (0-21 units). At follow up the staff had taken on the information in the training, as well as putting 1 unit, staff added the guidance about under parental supervision on their questionnaire. Women 18+ Unit Baseline % 0.7% 0.7% 7.2% 6.5% 10.1% 2.9% 0.7% 1.4% 0.7% 1.4% Follow up % 0.0% 0.0% 2.8% 33.0% 2.8% 0.0% 0.0% 0.0% 0.9% 0.9% Unit Not Stated Baseline % 4.3% 0.7% 32.6% 2.2% 0.7% 0.7% 0.7% 0.7% 5.8% 18.8% Follow up % 0.9% 0.0% 33.0% 3.8% 0.9% 0.0% 0.0% 0.0% 12.3% 8.5% At baseline and follow up there around 32.6% and 33 % of staff accurately stated 14 units per week for women 18+. There were 35 (33%) responses to women drinking 3 units at follow up. This is probably in response to daily consumption as some staff marked this as such on their questionnaire. Messages around daily consumption are more important that weekly consumption for future training based on Department of Health guidance. Page 43 of 59

57 Men 18+ Unit Baseline % Follow/up % Unit Not Stated Base % Follow up Not Stated % % % % % There was similar reporting for the correct answer of 21 units at baseline 26.1% and follow up 32.1%. In similarity to rating female units, 36 (34%) staff members gave the answer as daily units 4 rather than weekly. Future training should clarify daily and weekly consumption as the emphasis is now on daily consumption to prevent binge drinking. Page 44 of 59

58 Q3. When do you discuss patient s alcohol consumption with them? Follow up In response to the question When do you discuss the patient s alcohol consumption? the most notable change between baseline audit and follow up is staff reporting they are not involved in screening. This has decreased from 45 staff to 19. This seems to be supported by an increase in the number of staff reporting they screen routinely (61-57%). At baseline the main reason for discussion or screening was initiated by the patient s behaviour, this has been overtaken by routinely screening all patients. Page 45 of 59

59 Q4. What method/tool do you use? Informal Weekly alcohol AUDIT Vital Role discussion calculation PAT C Pac Baseline Doctor Nurse HCA All Follow up Doctor Nurse HCA Pharmacist All Staff were asked to report what method or tool they use to address alcohol consumption. When the baseline audit was completed Vital Pac was not operational. In the follow up group 26 (24%) reported to be using Vital Pac. However informal discussion still remains the highest rated method of ascertaining a patient s level of consumption (51%). Q5. Following your answers to Q 3 and Q4 i.e. when do you discuss and what tool do you use, what do you think should be done with this information? Base line audit N =138 The question what should be done with the information from screening? was designed to look at staff attitudes towards interventions for alcohol patients. Referring to a specialist team was the preferred option at baseline and at follow up, although this had increased from 30 (21%) to 41 (38%) respondents rating it as first preference. In addition the lowest preference ranked 6 th pointless to intevene has increased from 21% to 35% with more staff rating this as the least preference. Page 46 of 59

60 Follow up audit N= 106 Q6. The PAT test determines? Baseline audit n= 138 Follow-up audit n= 106 The Paddington Alcohol Test was updated in 2009 as a tool to be used for screening in A and E and determines daily unit consumption and pattern of consumption. Daily consumption the primary purpose of using PAT was only identified by 25 people at baseline, but increased to 38 at follow-up. Pattern of consumption e.g. weekly was rated the highest at baseline and at follow-up. Page 47 of 59

61 Q7 Would you know when to define the level of alcohol consumption as hazardous (increasing risk) harmful (high risk) or dependent? Baseline Follow up Role n = Yes % n= yes % Doctor 6 75% 11 92% Nurse 23 23% 56 78% HCA 22 71% 12 80% Pharmacist % All 51 37% 81 76% Staff were asked Would you know when to define alcohol consumption as hazardous (increasing risk) harmful (high risk) or dependent? This was a Yes/No answer and staff did have to qualify this answer. There was a marked increase in the number of staff reporting how to distinguish between different consumption patterns of drinking. In the baseline audit only 51 (37%) compared with 81 (76%) at follow up. The ASNS training and the role out of Vital Pac training will have had an impact on increasing staff knowledge of consumption patterns. Q8.a) Do you know who to refer to in QAH if you identify a patient has increasing or dependent alcohol consumption? Baseline Follow up No. = Y % No. =Yes % Doctor 4 50% % Nurse 22 22% 64 89% HCA 24 77% 13 87% Pharmacist % All 50 36% 96 91% Knowledge of where to refer to in QAH for increasing and dependent alcohol consumption patients rose from 36% in the baseline audit to 91% at follow up. Q8 b) If yes to above who or where to? Baseline audit ASNS either Sue Atkins or the nurse team within MAU 39 Alcohol Intervention Team 3 Mental Health Team 2 SHO 1 Nelson Unit 1 At baseline only 39 staff members referred to the ASNS service, at follow up this has increased to 76 which was 71% of those completing the questionnaire (table below). Referrals to AIT remain low but this may be because staff are not distinguishing between increasing risk patients and dependent patients. This needs to be addressed in future training and via Vital Pac screening. Page 48 of 59

62 Follow up audit Alcohol Specialist Nurse Service/Alcohol Team 76 Alcohol Intervention Team AIT 5 Bleep MAU 1 Alcohol withdrawal service 1 Alcohol Awareness Team 1 ETOH 1 Q9 Do you refer to other services? Baseline Follow up No. = Y % No. =Y % Doctor 1 13% 3 25% Nurse 6 6% 19 26% HCA 5 16% 0 0 Pharmacist All 12 9% 21 21% Baseline referral sources o AA o Alcohol Intervention Team - 2 o Avalon Unit (Community Alcohol Team) - 2 (SE Hants) o Kingsway House (Portsmouth) o Nelson Unit (Detox) o Orion Centre Community Alcohol Team (SE Hants) o Psychiatry o CPN Follow up referral sources o AA 5 o External services Fareham and Solent o AIT 2 o Avalon 1 o Baytrees 1 o Cranstoun 3 o Orion 1 o GP 3 o Community Team 1 o Kingsway House -1 o Mental Health 3 o Nutrition Nurse -1 o Social Services 1 o SWITCH Young People s Service 1 Referral to other services remains low; 9% at baseline and only 21% at follow up. Further work needs to be done on promoting the roles of community services within QAH. Page 49 of 59

63 Appendix B Primary Care Audit Response by job role No. of Responses baseline GP Nurse HCA Total % 30.5% 8.5% 100.0% No. of Responses at follow up GP Nurse HCA Total % 17.0% 8.5% 100.0% Q1. How many units of alcohol are in? a) Number of units in a 4% pint of beer (568ml) - answer 2.2units The correct number of units for a 4% pint of beer is 2.2 and responses decreased from 55 (67%) baseline audit to 26 (55%) at follow up. b) Number of units of 750ml of 14% wine answer 10.5units The reporting of units in a 750 ml bottle of 14% wine was; 11 (13%) individuals reported the closest amount at 10 units, and 3 (0.3%) accurately reported 10.5 units at baseline, whereas 12 (25%) reported it as 10 units at follow up and 5 (10%) staff reported the correct at amount at 10.5 units. Page 50 of 59

64 c) Units in a litre of 5.5% cider - answer 5.5units There was not much difference in the numbers pre and post audit. At baseline 6 (7%) staff reported 5 units, 10 (12%) stated 6 units, and 8 (9.7%) responses accurately reported 5.5 units. At follow up the 8 (17%) people stated 5 units, 7 (14%) stated 6 units and only 4(8.5%) people accurately stated 5.5 units. d) 75cl bottle of 40% whisky or vodka = 30 units 20 (24%) practitioners at baseline accurately reported 30 units, and only 12 (25%) at follow up, a similar reponse rate. There was also a range of answers at follow up 9 reporting 20 units and below. There is clearly a need for the AIT to do more education with primary care practitioners to improve accurate unit calculation which in turn will assist practioners to calculate patients levels of consumption and make the appropriate intervention and or referral. Page 51 of 59

65 Q2.What is the maximum safe limit of weekly alcohol consumption for; - Answer 0 Baseline Follow up years answer 1-2 units under supervsion Baseline Follow up With 2 exceptions all practitioners recorded that for the under 16 s no alcohol consumption was the recommended guidance. However at baseline audit and at follow up there were a number of practitioners who were unaware of the Department of Health guidance for year olds. 15 people reports 2.6 or more units for this age group. Women answer 14 units per week Page 52 of 59

66 Overall reporting on women s weekly consumption was accurate at baseline and follow up. 7 practitioners were reporting the old unit recommendation of 21 units, but this did decrease at follow up. Men answer 21 units Overall reporting on men s weekly consumption was accurate at baseline and follow up. However there were still a number of practitioners reporting the old unit recommendation of 28 units. Q3. When do you discuss a patient s alcohol consumption with them? Baseline Follow up Page 53 of 59

67 The method of consulting patients was similar at baseline and follow up, however the number of practitioners screening all patients routinely has decreased from 30% to 23%. This is an area for future development as patients surveyed at the hospital when asked could GP s do more there was a 100% yes response. Q4. What method or tool do you use for screening? Baseline Follow up Informal discussion and weekly alcohol calculation remained the preferred methods of discussing alcohol consumption rather than a specific tool such as AUDIT. Page 54 of 59

68 Q5. What do you think should be done with this information (screening)? (Rank preference 1 to 6) Baseline Follow up The question what should be done with the information from screening/discussing consumption? was designed to look at attitudes towards interventions for alcohol patients. Pointless intervening as patients rarely changed their habits remained the lowest preference at both baseline and follow up. Being referred to a specialist team was the highest preference. However the second preference was for the screening information to be recorded in the notes, but not to be made know to anyone other than the primary health care team. Page 55 of 59

69 Q6 Would you know when to define the level of alcohol consumption as hazardous (increasing risk) harmful (high risk) or dependent? Baseline Follow up 77% of respondents at follow up stated they would know when to define the different drinking patterns (hazardous, harmful, dependent) compared with 60% at baseline. It would be useful to explore this further as only 8 practitioners reported using AUDIT for screening which enables the different patterns of drinking to be scored. However in the question What method or tool do you use for screening? 31 practitioners reported that weekly calculation of alcohol consumption was the preferred method of discussing alcohol with a patient. If practitioners know the DOH guidance on weekly units they would be able to distinguish between hazardous (increasing risk), harmful (high risk) and possible dependency, but this still needs clarifying. Page 56 of 59

70 Q7 Do you know who to refer to in QAH if you identify a patient has increasing or dependent alcohol consumption prior to admission? YES or NO Baseline Follow up At the baseline audit only 13% of repondents knew who to refer to at QAH for increasing or dependent alcohol consumption. This had risen to 49% with the largets increase in reporting by GPs. Despite the reported increase in who to refer to, only 9 responses stated ASNS, and 7 the AIT. Where referrals are made to; Baseline QAH Referral source No. QAH Referral source No. MAU 2 Alcohol Advisory Service 1 AIT 2 A and E 1 Alcohol Nurse 1 Liver department 1 Alcohol Dependency 1 Early Intervention Unit 1 Team TOTAL 10 Page 57 of 59

71 Where referrals are made to; Follow up QAH Referral source No. QAH Referral source No. ASNS/Alcohol Team 9 AIT 7 MAU 1 CDA Cranstoun 1 Get the patient to self refer 1 Despite the reported increase in who to refer to only 9 responses stated ASNS, and 7 the AIT. Q8. Do you refer to any other service? Baseline Follow up Where referrals are made to: Baseline Referral source No. Referral source No. AA 14 Cranstoun CDA 25 AIT 23 Early Intervention Team 2 Alcohol Advice Team 1 GP 3 Alcohol Team at the practice 1 Kingsway House 18 Alcohol Portsmouth Safe 2 Portsmouth Counselling 2 Alcohol Advisory Service 1 Counselling 2 Al-Anon 1 Orion 2 Alcohol Prevention Team 2 Spolight 1 Baytrees 4 Safer Portsmouth Partnership 2 Cavendish House 1 Talking Therapies 1 Cranmer Terrace 1 Follow up Referral source No. Referral source No. AA 2 Kingsway House 3 AIT 11 Orion 2 Cranstoun CDA 11 Counselling 1 Early Intervention Team 2 Page 58 of 59