Evaluation of the Alcohol Identification and Brief Advice Work in Emergency Departments across Manchester. A report commissioned by:

Transcription

1 Evaluation of the Alcohol Identification and Brief Advice Work in Emergency Departments across Manchester A report commissioned by:

2 1. Executive summary The Department of Health estimated that the annual cost to the National Health Service for alcohol-related hospital admissions, emergency department (ED) attendances and primary care was around 2.7 billion in England in 2006/07. However, this is now likely to be an underestimate, with known increases in the prevalence of alcohol-related harm across England; alcohol-attributable admissions rose from 1,384 per 100,000 in 2006/07 to 1,582 in 2008/09 alone. ED presentations are also increasing. Thus in December 2006, NHS Manchester commissioned an alcohol identification and brief advice (IBA) programme to be introduced at the Manchester Royal Infirmary (MRI) ED which is part of the Central Manchester University Hospitals NHS Foundation Trust. The aim of the programme was to improve the health of patients attending the ED through the identification of increasing risk and higher risk drinkers a and subsequent delivery of brief interventions. The programme was evaluated in December 2008 and subsequently re-commissioned as part of the Improving Health in Manchester bid for a further two-years at MRI, University Hospital of South Manchester (UHSM) NHS Foundation Trust and North Manchester General Hospital (NMGH) which is part of the Pennine Acute Trust. In order to support the future development of the IBA programme, NHS Manchester commissioned the Centre for Public Health at Liverpool John Moores University to conduct an evaluation of the IBA programme. The evaluation methods included a range of different approaches in order to more comprehensively assess the programme. This entailed analysis of hospital admission, ED attendance and service-based datasets, alongside analysis of interviews carried out with ED staff in the three hospitals. In total, 21 ED staff were interviewed as part of the project. Key findings included: Since the full roll out of the IBA programme in July 2010, 24,133 patients have received alcohol screening across all three hospitals. Of these, 8,762 (36%) were identified as drinking at increasing or higher risk and so received a brief intervention, including over 600 who received an extended brief intervention. All staff interviewed had screened patients and saw the value of the project. However, not all patients eligible for screening were screened. Interviews with staff highlighted the reasons behind this, and included lack of time, other priorities, and staff assumptions (for example, the AUDIT-C trigger score not always been seen as valid). Considerable variations in screening rates were observed. NMGH screens patients presenting with the top ten alcohol-related conditions b. It has the highest screening rate of the three hospitals (51% of eligible patients were screened in the data collection period). These higher levels of screening may be because NMGH s later introduction of the programme enabled them to learn from the other EDs experiences, leading them to implement some innovative procedures to increase screening rates (such as through tannoy announcements, and incorporating screening in staff development objectives). In comparison, MRI (which screens those presenting with the top 14 alcohol-related conditions c and has been running the programme for the longest period) had the lowest screening rate at 14%. However, MRI has made a significant improvement in its screening rates since AUDIT-C became a mandatory part of the electronic system (screening rates more than doubled from 9% in June 2010 to 25% in July 2010). In the lead up to the introduction of the IBA programme, all three hospitals were experiencing overall increases in hospital admissions generally and in those attributable to alcohol; however, there were considerable month-by-month fluctuations, with no clear annual periodicity. In the two hospitals where the intervention had been established before the end of the data collection period (MRI and UHSM), the a Drinking at increasing or higher risk consumption is here defined as scoring five or above on the AUDIT-C screening tool. b The top 10 alcohol-related conditions are: falls, collapsed, facial injury, head injury, assault, unwell, abdominal pain, mental illness, chest pain, and regular attendees. c In addition to the top 10 alcohol-related conditions, MRI also screen for fits; wounds; limb problems; and overdose/ poisoning. 2

3 intervention period was not long enough to detect an underlying change. For all three hospitals, those who were admitted for an alcohol-specific condition more than once in a financial year were significantly more likely to be older than the single attendees (with odds of admission peaking in age range), resident in Manchester and to have been suffering from chronic (rather than acute) conditions. Considerable progress has been made since the original evaluation was conducted in Patients are followed up in order to understand the longer-term impact of the interventions, screening rates are being or will be fed back to staff, training is available in all hospitals and resources have been expanded in order to maximise the impact of the programme. However, this evaluation has highlighted a number of areas in which the programme could be improved further. In conclusion, the staff interviews showed that IBA was well received by those involved in the project from the three Manchester hospitals and each hospital was working to boost rates of identification and brief advice. A number of issues (such as competing priorities within the ED) were raised by the hospitals which have hindered the delivery of the programme, and these are likely to have contributed to the low screening rates observed (screening rates are considerably lower than commissioner targets of 70%). Nevertheless, 24,133 patients were screened over the data period analysed. It was not possible to identify any immediate impact on, for example, hospital admission. This could be due to both the low screening rates and/or that it may still be too early to identify a sustained and general change (particularly when a significant proportion of admission is due to chronic conditions). Thus, continued monitoring will be required in order to understand the impacts of the IBA programme over the longer-term. Using the findings from this report and to tackle the issues raised, a number of recommendations have been suggested. These are detailed in the report but its main recommendation is to investigate ways of boosting screening rates. This is vital if the programme is to have an effect on alcohol-related hospital admissions. 3

4 Contents 1. Executive summary Background The alcohol identification and brief advice programme in Manchester The aims of this report Methods Emergency Department staff interviews Analysis of screening data Exploration of emergency department data Hospital admissions Supplementary intelligence provided through the hospitals Limitations Findings: staff interviews Emergency departments staff perceptions of the programme Findings: screening data Manchester Royal Infirmary North Manchester General Hospital University Hospital of South Manchester Findings: emergency department presentations Findings: hospital admissions Findings: supplementary intelligence provided by the hospitals Beds occupied in Manchester Royal Infirmary Patients length of stay in Manchester Royal Infirmary Change in emergency department attendance by clinic patients at the Manchester Royal Infirmary Feedback questionnaires from clinic patients attending the University Hospital of South Manchester Patient follow-up from those attending the clinic at the University Hospital of South Manchester Discussion Screening Providing interventions and brief advice The potential for a wider impact Progress to date

5 9.5. Limitations of this evaluation Conclusions and recommendations References Appendices Acknowledgements The authors would like to thank the following for their help and guidance on this project: Clare McCann, Janet Mantle (Public Health Team, NHS Manchester), Barbara Drummond, Anna Wasielewska (Manchester Joint Health Unit, Manchester City Council), Lydia Fleuty (Drug & Alcohol Strategy Team, Manchester City Council) as well as all participating emergency department staff involved in the interviews, in particular the Alcohol Liaison Nurses at the three hospitals. Further, we would like to thank those at the Centre for Public Health (Liverpool John Moores University) for their contributions to the project including Penny A Cook, Paul Duffy, Lindsay Eckley, Caroline Hilliard, Julia Humphreys, Clare Perkins, Kevin Sanderson-Shortt and Elaine Steele. 5

6 2. Background Alcohol misuse is associated with a number of health-related problems including: cancers, liver disease, alcohol poisoning, accidental injuries, road traffic accidents, violence, and premature death [1, 2]. Illnesses and injuries suffered as a result of alcohol misuse are associated with over 945,000 hospital admissions in England every year [3]. The Department of Health estimated that the annual cost to the National Health Service (NHS) for alcoholrelated hospital admissions, emergency department (ED) attendances and primary care was around 2.7 billion in England in 2006/07 [4]. However, this is likely to now be an underestimate with known increases in the prevalence of alcohol-related harm across England; alcohol-attributable admissions rose from 1,384 per 100,000 in 2006/07 to 1,582 in 2008/09 alone [3]. ED presentations are also increasing [5]. Costs extend beyond the financial and health implications, with alcohol misuse having significant effects on the community, the family and the individual [6, 7]. For example, the Big Drink Debate North West survey of over 30,000 people highlighted that 47% of respondents avoided town centres at night because of others drunken behaviour and two fifths were concerned about the impact of alcohol on their weight [7]. Finally, alcohol also has a significant effect on the workplace, contributing to the loss of up to 17 million working days per year due to alcohol-related sickness, and up to 20 million through reduced productivity [8]. Studies have shown that individuals from lower socioeconomic backgrounds are more likely to misuse alcohol (including drinking at higher risk consumption levels d ) and to experience related harms such as alcoholattributable hospital admissions [9]. Manchester, an area with high levels of deprivation, suffers disproportionately from alcohol-related harm compared with other areas in England [3, 10]. The proportion of drinkers estimated to be drinking at higher risk levels in Manchester is 9%, significantly higher than England overall (5%) [3]. Furthermore, the rate of NI39 e hospital admissions in Manchester in 2008/09 was 2,577 per 100,000, 1.6 times higher than the England average of 1,582 [3]. Higher potential for harm can also be demonstrated through assault ED presentations (as victim perceptions suggest that approximately 50% of assaults in England and Wales are thought to be related to alcohol [11] ). In 2010, there were 2,858 assault presentations to Greater Manchester EDs by Manchester residents, representing 21% of assault presentations (where residence was known) [12]. EDs are often the first point of contact for people accessing healthcare and more than 19 million people present to EDs in England every year [13]. It has been estimated that one in three of these will have consumed alcohol immediately prior to their presentation, increasing to more than two in three after midnight [14]. A longitudinal study in the United States (US), which compared a group of intoxicated ED patients with a group of nonintoxicated ED patients, reported that the intoxicated group were more likely to: make at least one alcoholrelated re-presentation; be admitted to an alcohol detoxification unit; and have at least one arrest for drunkdriving in the next five years [15]. Further, the five year mortality rate for the intoxicated patients was 2.4 times higher than the non-intoxicated patients. Thus, those presenting to the ED are an important group with which to engage if alcohol-related harm is to be reduced. The National Institute for Health and Clinical Excellence recommends the use of brief interventions f for reducing the likelihood of increasing risk and higher risk drinking g[17]. Delivered in EDs, these can reduce ED re-attendance d Here, higher risk consumption is defined as consuming over 50 units per week for males, and over 35 units for females [3]. e National Indicator 39 (NI39) provides an indication as to the level of alcohol-related harm locally and nationally. The indicator is used to monitor the potential for change in alcohol-related harm via alcohol-attributable hospital admissions, and is part of the performance framework for local areas. f Brief intervention is an umbrella term that covers a range of different types of interventions that can be delivered in order to reduce, for example, alcohol misuse. It can range from advice provision (for example, verbally, through a leaflet) to structured brief advice and motivational interviewing. Common elements include feedback of assessment, advice, provision of options and encouragement for change [16]. g Increasing risk and higher risk consumption are often defined according to weekly unit consumption (although precise definitions can vary) [3, 7, 29, 30] ; however, throughout the report, unless otherwise stated, increasing and higher risk consumption is defined as scoring five or above on the AUDIT-C screening tool (see Appendix 1 for further details). 6

7 and alcohol-related injury (although evidence for their impact on alcohol consumption is more mixed) [18-24]. They are most effective when they are delivered opportunistically to patients with low levels of alcohol problems who are not undergoing alcohol treatment rather than patients experiencing more severe problems [25]. Although further evidence is required to understand the long-term impact, their effectiveness amongst women and their most effective means of delivery, a systematic review of US clinical studies recommended that this type of intervention becomes part of normal clinical ED procedure [26]. Their use in healthcare settings such as GP surgeries and EDs has also been recommended by the Department of Health as a means to identify problem drinkers at an early stage [27]. Thus, as part of ongoing work to reduce alcohol-related harm in Manchester [28], NHS Manchester introduced the identification and brief advice (IBA) programme in local EDs in order to address increasing and higher risk drinking amongst ED users The alcohol identification and brief advice programme in Manchester In December 2006, NHS Manchester commissioned the IBA programme at Central Manchester University Hospitals NHS Foundation Trust s (CMFT) Manchester Royal Infirmary (MRI). The programme aimed to improve the health of patients attending the ED through the identification of increasing risk and higher risk drinkers and subsequent delivery of brief interventions. The programme was evaluated in December 2008 [29] and subsequently re-commissioned as part of the Improving Health in Manchester bid for a further two-years at MRI, and in addition at the University Hospital of South Manchester (UHSM) NHS Foundation Trust and North Manchester General Hospital (NMGH) which is part of the Pennine Acute Trust. Patients who scored five or more on the AUDIT-C h received brief verbal advice, a Drink Smart Guide and were offered an extended brief intervention with an Alcohol Liaison Nurse at the Extended Brief Advice clinic (further details on the programme are provided in Appendix 1). In order to support the future development of the programme, NHS Manchester commissioned the Centre for Public Health at Liverpool John Moores University to conduct an evaluation of the IBA programme The aims of this report This report seeks to evaluate the impact of the IBA programme using a multi-method approach. Firstly, interviews were conducted with the staff involved to understand their perceptions and experiences of the project. Secondly, screening data were used to examine the numbers and characteristics of individuals who were eligible and who were screened. Thirdly, ED data were used to assess the overall numbers of individuals presenting for assaults and falls. Fourthly, analyses were performed using hospital admissions data to understand the potential impact of the programme on admissions. Lastly, analyses were performed of the potential for saving bed days and associated cost savings following the introduction of the programme. h AUDIT-C is the shortened version of the AUDIT (Alcohol Use Disorders Identification Test). Further details can be found in Appendix 1. 7

8 3. Methods The evaluation methods entailed a range of different approaches including analysis of hospital and ED datasets, alongside analysis of interviews carried out with ED staff. In this way, researchers hoped to further develop findings from the original MRI evaluation, which was unable to use admissions or presentations data to examine the impact of the programme [29]. The National Research Ethics Service (NRES) confirmed that their approval was not required for this type of study. Ethical approval was gained from Liverpool John Moores University ethics committee to conduct the staff interviews Emergency Department staff interviews Interviews provided insight into staff understandings of the programme, as with the initial evaluation [29]. An interview schedule was drawn up in collaboration with the commissioners (Appendix 2). Alcohol Liaison Nurses (ALNs) were asked to all ED staff involved in programme delivery to identify potential participants from a range of staff groups (e.g. doctors, nurses, consultants). Hospital shift patterns made it difficult to arrange a suitable time; however, interviews with each alcohol team were arranged, and whilst on site, researchers recruited staff on duty. Interviews were conducted by two researchers in a private room in the ED in July and August Interviews were a mix of one-to-one and small group interviews (with up to three participants). Twenty-one staff took part (Table 1). Interviews were recorded and transcribed. Participants provided informed consent prior to interview (Appendices 3-4). Table 1: Characteristics of the programme and the evaluation Manchester Royal Infirmary North Manchester General Hospital University Hospital of South Manchester Programme April 2009 to March 2011 January 2010 to April 2009 to March 2011 commissioned to run December 2011 Screening began April 2009 June 2010 August 2009 (Pilot: December 2006) Dates of screening data used January to August 2010 July to August 2010 August 2009 to August 2010 Method of data collection Computer database Computer database Paper-based (SYMPHONY) (SYMPHONY) Number of interviews Criteria for conducting Patients aged 16 and AUDIT-C above Patients presenting with the top 14 alcohol-related conditions, aged 16 and above* Patients presenting with the top ten alcoholrelated condition, aged 16 and above* *The top 10 alcohol-related conditions are: falls, collapsed, facial injury, head injury, assault, unwell, abdominal pain, mental illness, chest pain, and regular attendees. Fits; wounds; limb problems; and overdose / poisoning were added for the top 14 conditions for Manchester Royal Infirmary. These conditions can account for 77% of patients screening positive for alcohol misuse (using the Paddington Alcohol Test, PAT) [30] Analysis of screening data All hospitals provided the Centre for Public Health with data on screened patients broken down by demographic details (age, gender, ethnicity and first part postcode), day and month of attendance, and AUDIT score. However, differences were apparent in the datasets supplied: MRI: The programme started as a pilot in December 2006 and its current computer system, SYMPHONY, began recording data in its present format at the end of Data prior to this were compiled as summary reports in Word and Excel. As the time periods for these crossed over i, it was not possible to i For example, some reports contained weekly information, while others were full calendar months. 8

9 analyse the data. Therefore, data have been analysed for the whole months of January to August 2010, when raw screening data could easily be extracted from SYMPHONY. Additional data items included presenting complaint. NMGH: The programme began in June 2010; data were only available for the whole months of July and August Time restraints meant that raw data could not be provided; summary data were supplied instead in Excel format. Additional data items included: whether alcohol had been consumed in the last 12 hours, last drink location, the number of clinic appointments booked and attended. UHSM: Alcohol screening began in August 2009, and data were provided for August 2009 to August Raw data were provided in Excel format. Additional data items included last drink location, the number of clinic appointments booked and attended Exploration of emergency department data During the course of the evaluation, the Trauma and Injury Intelligence Group (TIIG), based at the Centre for Public Health, worked with MRI, UHSM and NMGH to include their electronic ED data into the TIIG injury surveillance system (ISS; ED data collected include a range of administrative and clinical items such as demographics, injury type and disposal method (e.g. admitted to hospital). Data analysed covered assaults and falls only because of their strong relationship with alcohol j. During this evaluation, TIIG were only able to access raw and complete electronic ED data from UHSM. Here, data have been analysed to assess whether any changes have occurred in the number of presentations since the IBA programme commenced Hospital admissions Hospital Episodes Statistics (HES) for 2005/06 to 2009/10 were obtained via the North West Public Health Observatory (NWPHO). Due to the provisional nature of the 2009/10 data, the full analysis has been published separately and is available on request. Full methodological details are available in the accompanying report [31]. A summary has been provided in this report. Codes of conditions known to be wholly or partly attributable to alcohol were extracted and the alcohol attributable fraction (AAF) by gender and age band was then applied (using the standard NI39 methodology [2] ). These data were then used to examine changes over time. Admissions were categorised into the following groups according to condition: acute alcohol-attributable conditions (such as road traffic accidents, fall injuries or assaults); chronic alcohol-attributable conditions (such as malignant neoplasm of the larynx or alcoholic liver disease); conditions with a low AAF (such as malignant neoplasm of colon of haemorrhagic stroke, where only a small proportion of cases are thought to be related to alcohol); and mental and behavioural disorders specific to alcohol (such as acute intoxication or dependence syndrome). Single and repeat admissions within a given financial year for alcohol-specific conditions were identified for analysis. Alcoholspecific conditions are those that are wholly attributable to alcohol such as alcoholic liver disease or acute intoxication. For repeat attendees, the first admission within a given financial year was used. As well as examining change over time in single and repeat admissions, researchers analysed the characteristics of the individual admitted and of their admission episode. Demographic details examined included gender, age, ethnicity, resident deprivation quintile and residence in Manchester. Episode characteristics examined included type of condition, length of stay and average time between first and last admission. Because each hospital established its screening programme at a different time and in a different way (Table 1), the analysis varied between hospitals (for example, in the comparison time periods used). j Alcohol is associated with up to one fifth of falls and 27% of assaults [2] and represent two of the conditions which can trigger the AUDIT-C in the two hospitals which use condition as a criteria for doing so. 9

10 3.5. Supplementary intelligence provided through the hospitals A number of supplementary datasets and/or data items were provided by MRI and UHSM (no such data were available from NMGH because of the short time period since the project was established): MRI provided data on bed days (midnight occupancy) and average length of stay for those discharged. Data were broken down into alcohol-related and non-alcohol-related. Here, alcohol-related refers to those admissions where the primary or secondary diagnosis included conditions such as alcohol dependence syndrome, alcoholic liver disease, stroke, suicide and self-inflicted injury k. The analysis examined change over time in bed days and length of stay for alcohol-related admissions as a proportion of all admissions and change in the mean bed days/length of stay (in comparison to non-alcohol-related admissions). MRI provided details of a snapshot of patients attending the clinic in April 2010 (n=28). The number of ED presentations that this group made six months before (November 2009 to March 2010) and six months after (May 2010 to September 2010) their clinic attendance was examined. Whether change had occurred in number of attendances made by frequent flyers (defined as more than two ED presentations in two months) was also examined. It should be noted that these data only show evidence for a small time period and are based only on those individuals who accepted the clinic invitation and subsequently attended. No comparable data are available for individuals who did not accept the clinic invitation or did so but did not subsequently attend. UHSM provided data from feedback questionnaires from clinic attendees (see Appendix 5). A total of 28 patients completed these questionnaires between January and September It is not known to what extent the 28 patients reflect clinic attendees generally and no comparable data are available on those who did not attend the clinic. Further, it is not known to what extent the results might be influenced by the fact that the service provider collected the data rather than an independent body. UHSM also provided summary data from six month follow-ups with 50 patients who attended the alcohol clinic in January and February 2010 (60 attended in total; it was not possible to contact the remaining ten). These data are subject to the same limitations as those highlighted for the feedback questionnaires Limitations Data content and intervention timescales varied between hospitals (Table 2), making comparison difficult. Although MRI and NMGH both used SYMPHONY, there were a number of restrictions that limited NMGH s access to raw data. The fact that all three EDs were run by different hospital trusts added further variations in how each programme was run and how data were collected. Staff and shift capacity, including how and when staff screened, may also have affected the screening rates and how data were collected. Finally, it is not possible to longitudinally monitor individuals through the ED data into HES data because of the lack of NHS numbers in the data files held. A number of limitations were also highlighted in Section 3.5 relating to the supplementary data provided by the hospitals. Whilst these data offered a valuable insight into the impact of the programme, they were limited by the fact that timescales for data collection were short, data were not always available on comparison populations, it was not known to what extent responding individuals reflected service users more generally, and the potential for creating bias if the evaluator is not independent of project delivery. k For the full list of conditions included, please see 10

11 4. Findings: staff interviews In total, 21 interviews were conducted (MRI: 4; NMGH: 6; UHSM: 11). Six of these were conducted with the alcohol teams co-ordinating the project s delivery and 15 with other staff members (such as nurses and consultants). Whilst the service level agreements provided a high degree of consistency in delivery (see Appendix 1), there were differences in the details of this delivery (Table 2). For example: each hospital had a different set of eligibility criteria; two hospitals used a computerised system (known as SYMPHONY) to prompt and record screening details whilst the third used a paper-based system; and two had compulsory staff IBA training whilst the third did not. All three alcohol teams reported that maintaining high levels of IBA trained staff can be problematic due to shift patterns, and rotating and/or high turnover of staff. At UHSM, the length of training varied according to staff: nurses attended a 45 minute training session, whereas the Senior House Officers (SHOs), who rotated every four months, attended a 25 minute session. One-to-one training was also available. Table 2: Differences in the operation of the information and brief advice programme by hospital Eligibility criteria Manchester Royal Infirmary North Manchester General Hospital Originally, patients presenting Patients presenting with the with the top ten alcoholrelated top ten alcohol-related conditions but was conditions are screened, aged expanded to the top 14, aged 16 and above.* 16 and above.* University Hospital of South Manchester Patients aged 16 and above Advertising Posters were displayed. Posters were being ordered. Posters were displayed. Clinic opening times Tue, Wed, Fri and Sun at different times. Screening occurs via Staff training Tue afternoon/evening, Thu morn, Fri aft and (monthly) on Sundays. Patients were reminded by text. Nonattendees were written to. The SYMPHONY computer system recognised the 14 conditions and requested AUDIT-C. Screening could be carried out retrospectively if required. The fields became mandatory in July Staff can enter reasons for noncompletion (if patients are too unwell, intoxicated, unable/ unwilling to answer). Training was advertised in the communications book. It was delivered mainly to nurses but doctors too. Originally training was carried out weekly but this changed to monthly for new starters. Attendance was not compulsory, but the team aimed to train staff within three months of commencement in the ED. Sessions lasted 30 mins. Screening was recorded via SYMPHONY and could be accessed at triage, pre- or post-treatment. The screening tool was not a mandatory field. Staff could indicate when it was not possible to screen a patient so that they could be followed up. IBA training was compulsory for all registered staff in the ED (that is qualified nurses and doctors). Training took approximately 45 minutes. In the future, staff with high screening rates will attend refresher courses with those with low screening rates in order to boost motivation. Mon 3-8pm, Wed 9am-1pm, Fri 1-6pm. A paper version of the AUDIT- C was to be placed with every set of patients details. Once this was completed, it was handed to the Alcohol Liaison Nurse / Alcohol Nurse. The cost of SYMPHONY was prohibitive to its potential installation. Mandatory for all medical staff who screen in the department. It was carried out during induction. Initially twicemonthly sessions were available for nursing staff, but these became less frequent due to workload. Ad hoc or one-to-one training sessions could be arranged. Sessions varied in length. *The top 10 alcohol-related conditions are: falls, collapsed, facial injury, head injury, assault, unwell, abdominal pain, mental illness, chest pain, and regular attendees. Fits; wounds; limb problems; and overdose / poisoning were added to produce the top 14 conditions for Manchester Royal Infirmary. 11

12 Each hospital had developed different strategies for encouraging screening amongst ED staff and for providing feedback on screening (Table 3). The ALNs from the three EDs regularly met to share best practice. The NMGH alcohol team reported that because their programme started after the other two hospitals, they had been able to learn from others experiences. Table 3: Encouraging screening and providing feedback to staff involved in the information and brief advice programme by hospital Encouraging screening Providing feedback to staff Manchester Royal Infirmary Mandatory screening fields on SYMPHONY. The alcohol team distributed flash cards to remind staff to screen and provide information on scoring and subsequent actions. The Drinks Smart Guide and unit wheel calculator were left in convenient locations around the department. Feedback was provided for staff via monthly updates on the staff notice board and frequent memos in the communications handbook. Quarterly newsletters were provided with details on the programme and its effects on preventing re-admission and reducing length of stay in hospital. North Manchester General Hospital Compulsory training. In the future, a notice-board will display screener of the month. Reminders were regularly sent to staff. ALNs used tannoy announcements, pocket reminder cards and posters in all cubicles to boost screening. In the future, screening rates will be used to target individuals with low rates with additional training. A database recorded screening rates in order to congratulate those who screened consistently. Screening rates also formed part of their personal development objectives. Staff could only progress through their training modules if they provided evidence of screening and patient case study notes Emergency departments staff perceptions of the programme University Hospital of South Manchester Compulsory training. The ALN sent out a monthly bulletin to staff informing them of the current screening rates and thanking them for their efforts. In total, 15 interviews were conducted with ED staff members outside the alcohol team across the three hospitals (MRI: 3; NMGH: 3; UHSM: 9). The interviewees included doctors, nursing staff and consultants General perceptions of the programme All staff interviewed had screened patients and saw the value of the project. No general themes emerged but individual staff perceived that there had been a reduced length of hospital stay for patients, and improved patient support and service referral. At NMGH, whilst it was too soon to see any immediate impact of the programme, it was felt that more patients were being signposted towards community-based alcohol services. Six staff members reported that patients did not understand or know how to calculate units before the programme and two mentioned that the programme had raised awareness of levels of staff s own consumption. Individual staff responses (that is answers that were mentioned by only one interviewee) included that they believed patients appreciated the advice and trusted the health professionals involved, and that patients were used to being screened (for example, from their GP or other healthcare provider). All staff felt that the programme was wellsupported at senior levels and that the alcohol teams were enthusiastic, motivated and committed to the success of the programme. 12

13 Training received Nine staff members reported having received IBA training. A number of individual issues were raised with regards to the training: nurses were thought to be more likely to attend than doctors; training had had to be cancelled in the past due to other commitments; and high staff turnover. However, where training had been received, in general, they reported that the training had provided them with sufficient information to perform screening and brief interventions (n=4), and that it had given them an insight as to why the programme had been introduced (n=6). However, five reported not receiving training: of these, four had obtained information on the programme through staff notice boards and there were opposing views as to whether training would be useful: It would be nice to go over it. I m quite interested in the project. If you re going to do something, do it properly or don t bother. Consultant I don t think [training] would ve made a difference. Doctor Perceived reasons for introducing the programme Interviewees were asked why they thought the programme had been introduced. Two themes emerged that were common across the three hospitals. They were to tackle the cost of alcohol to the health service (therefore saving money and/or resources) and to reduce bed times on wards or ED attendances overall. Both of these were mentioned by three interviewees each. Another theme to emerge was that the programme was introduced as part of a Government initiative (mentioned by two people). Individual responses included: to help patient care; to identify those drinking above recommended limits; to raise awareness of the problems associated with alcohol; to prevent alcoholism; to improve the health of ED patients; to create a better understanding of which patients should/should not be admitted; to provide patients with access to community services; to facilitate early discharge; and to allow alcohol to be discussed more openly generally Perceived target group When asked which population the programme was targeted towards, most commonly (n=5), staff did not know the target population. Other themes to emerge (mentioned by two interviewees each) were higher level drinkers but not dependents, people aged 30-40, (student) binge drinkers, all adults presenting at the ED and those who did not realise they were drinking too much. Individual responses included: future dependent drinkers, young people, alcohol-related presentations and all drinkers. At NMGH, where staff screen those presenting with the top ten conditions (Table 2), the three staff interviewed felt that it would be more appropriate to screen every ED patient, thus capturing patients who may otherwise fall between the cracks. However, it was thought the majority of patients were represented by the top ten conditions Barriers to screening The main reason that screening was overlooked was because of time constraints and/or competing priorities in the ED. Whilst this was mentioned by eight interviewees across the three hospitals, two noted that it did only take a couple of minutes to complete. When A&E is at its worse[sic], it s hard for anyone to do. It s hard enough getting the doctor to say what they ve done and what the diagnosis is Nursing staff There are so many things [to do] that only take a few seconds Nursing staff The problem isn t that I don t agree with the concept it s the practicalities, that I m actually focused on other things. Consultant...I understand it could [have benefits] in the long-term but on a day-to-day basis you don t think about that. Nursing staff A number of other themes also emerged including: The intervention trigger score of five was too easy to obtain (n=5); 13

14 Feeling it was more appropriate for others to screen such as the ALNs, alcohol nurses (ANs), general practitioners, receptionists, leading clinician, nursing staff or patients via a questionnaire (n=9); Factors associated with the systems in place were also mentioned (n=5). In MRI where the screening tool was mandatory on SYMPHONY, it was suggested that staff can avoid screening by indicating that the patient was unable to be screened and that as the screening tool appears at the end of the system, patients may be discharged before screening has occurred. In addition, a lack of computers in some consulting rooms has prevented immediate inputting of screening scores, discouraging screening. In NMGH, it was suggested that because AUDIT-C was not mandatory, staff could avoid the questions if they wished. In UHSM, where screening data are recorded on paper, it was mentioned that screening could be omitted if staff forgot or did not place the screening tool with patients details. Only screening those who they deemed appropriate for the programme (n=2) and/or being worried about the patients reactions (n=3). For example, one staff member felt that patients did not want to hear about the potential harm caused by their drinking and saw the intervention as just preaching. However, 12 interviewees reported that, in general, people did not mind being asked about alcohol as long as the right approach was made (for example, by being non-judgmental). I only ask appropriate patients. Obviously [in] the situations which are un-alcohol related, and it s quite a stressful time for the patient so I wouldn t broach the subject with the patient, [if] it s got nothing to do with the situation, I wouldn t even go there. So I would say unable, or unwilling to answer and bypass it [the screening tool]. But if it s someone who s come in with something, young and approachable, nothing stressful has happened, I d basically broach their drinking. ED staff nurse Whilst the majority of interviewees correctly reported that the trigger score for delivering an intervention was five (n=7), two thought the threshold was higher (one reporting a threshold of eight and another 12). Individual themes to emerge included that patients may underestimate the amounts of alcohol consumed and patients being too intoxicated to be screened Barriers to delivering brief and extended interventions A variety of perceived barriers to intervention delivery were identified: offering appointments based on how the patient presented rather than using the scores as a guide (n=2); and a large proportion of patients did not follow up the appointments and/or accept the leaflets (n=2). Further, at one hospital, there was a period when none of the Drink Smart Guides were available for staff to disseminate. In addition to these barriers as mentioned by general ED staff, the ALNs/ANs noted barriers to the delivery of extended brief interventions. For example, it was mentioned that non-attendees of the clinic were more likely to be heavier drinkers and repeat ED attendees (n=2). In addition, the Drink Smart Guide does not include the phone numbers of the clinic, which could prevent patients from making future contact with the alcohol teams (although MRI has added this) Feedback received Seven participants reported that they had received feedback, two reported not receiving any and one was unsure. Whether or not feedback had been received, it was generally reported as being a good thing (n=5). Staff reported receiving feedback via disseminated staff screening rates, tannoy announcements and internal bulletins. Further suggestions were made as to how to improve feedback included highlighting patient experiences (n=2). Feedback is hugely important because if you know you ve done something good, it reinforces that. Consultant It would encourage you to carry on if you knew the positive outcomes. Other clinician However, two participants thought that feedback was unnecessary. I wouldn t think it [feedback] would be a motivating factor. Doctor 14

15 Percentage Percentage Evaluation of the Alcohol Identification and Brief Advice Work in Emergency Departments across Manchester 5. Findings: screening data 5.1. Manchester Royal Infirmary The IBA programme was introduced as a pilot at MRI ED in December Screening data were available in report format from March 2007 to December However, due to inconsistencies in report type and data coverage, these data have not been analysed here. For previous analyses, see Drummond and Wasielewska (2008) [29]. Between January and August 2010, there were 31,951 eligible patients, of which 14% (n=4,485) were screened, with the highest proportions in July (25%, n=1,049) and August (30%, n=1,662) when AUDIT-C became mandatory (Figure 1). Almost half (49%, n=2,207) of screening took place on Tuesdays to Thursdays (Figure 2). Figure 1: Emergency department screenings of those attending at Manchester Royal Infirmary by month, January to August 2010* 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Not screened Screened Mandatory screening introduced Jan-10 Feb Mar Apr May Jun Jul Aug-10 Month * Data shown are based on eligible patients. Figure 2: Emergency department screenings of those attending at Manchester Royal Infirmary by day of the week, January to August 2010* Sundays Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Day of the week * Aggregated data on eligible patients from MRI are not broken down by day of week. Data on day of week was only provided for screened patients. 15

16 Percenatge Evaluation of the Alcohol Identification and Brief Advice Work in Emergency Departments across Manchester Overall, screening was most commonly carried out between 09:00h and 17:00h (56%, n= 2,511); 24% (n=1,084) occurred between 19:00h and 05:00h. Over half (56%; 2,507) of patients screened were male. The mean age was 46 (26 were under 16 years; Figure 3). Sixty-eight per cent (n=3,039) were white, and 13% (n=569) were Asian. Twelve per cent (n=558) lived in the M14 postcode area l. Thirty-eight per cent (n=1,725) were classed as unwell at presentation; 20% (n=908) had limb problems; 9% abdominal pain (n=397); 2% assault (n=95); and 0.4% apparently drunk (n=18). Two thirds (67%; n=3,011) of those screened scored under five (45% or 2,033 scored zero; Table 4). One third (33%, n=1,474) scored five or more. There were significant differences in the AUDIT-C scores between age and gender. Eighty per cent of females scored under five compared with 59% of males (X 2 =247, p<0.001). Over half (54%) of those aged years scored under five compared with over two thirds of those in the and age groups, and 95% of those in the 70 plus age group (X 2 =427, p<0.001). See Appendix 6 for further details. Figure 3: Emergency department screenings of those attending at Manchester Royal Infirmary by age group, January to August 2010* plus Age group * Aggregated data on eligible patients from MRI are not broken down by age. Data on age was only provided for screened patients. Table 4: Drinking patterns of patients screened Response (%)* Score allocated : How often do you have a drink 2-4 times per 2-3 times per None: Monthly: that contains alcohol? month: week: 46% 16% (n=4,455) 13% 9% 2: How many units of alcohol do you drink on these occasions? (n=4,456) 3: How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? (n=4,452) 1-2: 60% Never: 57% 3-4: 12% Less than monthly: 13% 5-6: 7% Monthly: 5% 7-9: 4% Weekly: 9% 4 or more times per week: 18% 10(+): 17% Daily or almost daily: 15% * Values may not sum to 100% due to rounding. Thirty cases for question 1, 29 cases for question 2 and 33 for question 3 did not have complete data. For each response (e.g. none, monthly), a score of zero to four is awarded, totalling a maximum of 12. For more details of AUDIT-C, see Appendix 1. l 9% lived in M19 (n=403) and 8% M16 (n=369), and 7% each in M13 (n=331) and M18 (n=334). 16

17 Percentage Evaluation of the Alcohol Identification and Brief Advice Work in Emergency Departments across Manchester 5.2. North Manchester General Hospital The IBA programme was introduced at NMGH in June There were 14,897 ED attendances in July and August Of these, 11,272 (76%) presented with at least one of the top ten conditions, thus fulfilling the eligibility criteria. Just over half (51%, n= 5,731) of these were screened (July 53%, n=3,077, August 48%, n=2,654; Figure 4). Of those screened m, 50% (n=2,873) were female and 58% (n=3,383) were aged (Figure 5; Appendix 7). Where ethnicity was recorded (n=5,609), 84% (n=4,694) were white. Where data were collected, the majority lived in the postcode areas directly surrounding the hospital n. Data on peak days were not available. Figure 4: Emergency department screenings of those attending North Manchester General Hospital by eligibility and month, July and August 2010* 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Jul-10 Month Aug-10 ED attendances - not eligible Eligible - not screened Screened * At NMGH, patients presenting with one of the top ten conditions are eligible for screening. Seventy per cent (n=4,007) of those screened scored under five. The remainder (30%, n=1,724) scored five or more and were considered increasing/higher risk (Appendix 7). They received brief interventions and were offered an appointment with the alcohol team o. In total, 110 appointments were made in July and August, resulting in 48 appointment attendances (44% attendance rate); and 16 attended at least one further appointment. Prior to screening, 2% (n=284) of all ED patients were asked if they had drunk alcohol in the last 12 hours: 30% (n=85) had p ; and 40% (n=34) provided last drink locations (13 stating a pub/bar, 10 home, 6 street/car park, and 5 nightclub/restaurant). m Screening data from NMGH have been provided as summary tables which included data from the IBA programme and patients screened on hospital wards (e.g. dependant drinkers, screened by the care facilitator). Whilst the majority of data items (e.g. ethnicity) have been split by screening location (e.g. ED / hospital), age and gender has been provided as a summary of both locations. It has not been possible to break data down further or investigate the presence of any statistically significant relationships between demographic details. n M9 (20%, n=1,025); M40 (17%, n=916); M8 (14%, n=751); and M24 (13%, n=688). o The nature of the data prevented breaking down the scoring data further, or providing any significant statistical analysis. p It was not possible to work out how many of these received the AUDIT-C screening due to how the data were presented. 17

18 Percentage Percentage Evaluation of the Alcohol Identification and Brief Advice Work in Emergency Departments across Manchester Figure 5: Emergency department screenings of those attending North Manchester General Hospital * by age group**, August Under Age group * Aggregated data on eligible patients are not broken down by age. Data on age were only provided for screened patients. Data provided on age was not valid for July 2010 and therefore figures represent August 2010 only (age was missing for two cases).** The age groupings provided by NMGH are not compatible with those by MRI and UHSM University Hospital of South Manchester The IBA programme was introduced in August From August 2009 to August 2010, there were 51,494 eligible patients, of which 27% (n=13,917) received alcohol screening, with the highest proportions in September (34%; n=1,309) and October 2009 (35%; n=1,441; Figure 6; Appendix 8). Half of screening occurred on Mondays to Wednesdays (Figure 7). Of those screened (and where details were provided), 51% were female (n=7,054) and 37% were aged 15 to 35 years (n=5,100; Figure 8). The mean age was 46 years (17 were aged under 16). Ethnicity was recorded in 49% of cases; of these 96% were white (n=4,502) q. The majority lived close to the hospital r. Figure 6: Emergency department screenings of those attending University Hospital of South Manchester by month, August 2009 to August 2010* 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Not screened Screened Month * All adult patients are eligible for screening. q Data are for March to August 2010 as data were missing for August 2009 to February r M20 (6%, n=802); M21 (4%, n=554); M22 (21%, n=2959); and M23 (16%, n=2273). 18

19 Percenatge Percentage Evaluation of the Alcohol Identification and Brief Advice Work in Emergency Departments across Manchester Figure 7: Emergency department screenings of those attending University Hospital of South Manchester by day, August 2009 to August 2010* Sundays Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Day of the week * Aggregated data on eligible patients from UHSM are not broken down by age. Data on age was only provided for screened patients. Figure 8: Emergency department screenings of those attending University Hospital of South Manchester by age, August 2009 to August 2010* plus Age group * Aggregated data on eligible from UHSM are not broken down by age. Data on age was only provided for screened patients. Sixty-three per cent (n=8,823) of those screened scored under five (36% [n=4,944] scored zero; Table 5). A total of 39% (n=5,094) of patients screened who scored five and above were offered an appointment with the alcohol team. Of these, 808 patients booked an appointment and 564 attended (70% attendance rate). Of the appointments attended, 145 were for individuals who attended the clinic on multiple occasions. There were significant differences in the AUDIT scores between age and gender. Seventy-six percent of females scored under five compared with 51% of males (p<0.001) s. Around half of those aged years scored under five (15-35, s Levels of significance can be explained as follows: p<0.05 statistically significant, p<0.01 highly statistically significant, and p<0.001 very highly statistically significant. 19

20 53%; 36-50, 56%) compared with two thirds (66%) of those aged and 92% of those aged 71 plus (p<0.001). See Appendix 8 for further details. Table 5: Drinking patterns of patients screened at University Hospital of South Manchester* Response (%) Score allocated : How often do you have a drink Monthly: 2-4 times per 2-3 times per that contains alcohol? None: 36% 14% month: 25% week: 15% (n=13,908) 2: How many units of alcohol do you drink on these occasions? (n=13,908) 3: How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? (n=13,907) 4 or more times per week: 11% 1-2: 46% 3-4: 18% 5-6: 14% 7-9: 9% 10(+): 13% Never: 56% Less than monthly: 15% Monthly: 11% Weekly: 12% Daily or almost daily: 5% * Values may not sum to 100% due to rounding. For question 1 and 2, nine cases did not include completed data, and ten in question 3. For each response (e.g. none, monthly), a score of zero to four is awarded for each question, totalling a maximum of 12. For more details of AUDIT-C, see Appendix 1. 20

21 Number of attendances Evaluation of the Alcohol Identification and Brief Advice Work in Emergency Departments across Manchester 6. Findings: emergency department presentations Data on emergency department presentations were available for UHSM only. Due to the data provided, data could not be broken down into the top ten conditions. Instead, two conditions were identified: assaults and falls. Figure 9 shows the number of assault and fall-related ED attendances at UHSM from October 2008 to June 2010 (see Appendix 9). Since August 2009 (when screening began), the average number of recorded assault and fall attendances per month had increased at UHSM (pre August 2009: assault, 26; falls, 125 / post: assault, 58; falls, 340). A comparison of October 2009 to June 2010 with the same period in the previous year showed that the monthly mean number of recorded assault and falls attendances had significantly increased t. In August 2009 to June 2010, 12% of assault attendances were admitted to hospital and 21% of falls. Figure 9: Number of emergency department attendances at University Hospital of South Manchester categorised as assault and fall by month, October 2008 to June Fall Assault Screening implemented Month t Assaults monthly mean: October 2009 to June 2010 = 62 / October 2008 to June 2009 = 25 (p<0.001). Falls monthly mean: October 2009 to June 2010 = 369 / October 2008 to June 2009 = 121 (p<0.001). 21

22 7. Findings: hospital admissions Data extracted from hospital episode statistics between 2005/06 and 2009/10 were used to provide an insight into the possible impact of the IBA programme on alcohol-attributable admissions. Because the interventions were established at different times and in different ways (MRI introduced the IBA as a pilot before it was recommissioned in April 2009), time periods used in the data analysis varied between the hospitals. Key findings from the analysis included: In the lead up to the introduction of the IBA programme, all three hospitals were experiencing overall increases in hospital admissions generally and in those attributable to alcohol; however, there were considerable month-by-month fluctuations, with no clear annual periodicity. MRI had the highest proportion of hospital admissions that were attributable to alcohol, significantly higher than the other two hospitals. Of alcohol-attributable admissions overall, admissions for alcohol-attributable chronic conditions have been increasing across all three hospitals and in two hospitals (UHSM and NMGH), increases can also be seen in admissions relating to mental and behavioural disorders specific to alcohol. (The majority of alcohol-attributable admissions in all three hospitals were due to chronic conditions.) Between 2005/06 and 2009/10, the proportion of admissions for alcohol-attributable conditions for repeat attendees increased significantly in MRI and UHSM. For NMGH, the proportion remained stable. In the two hospitals where the intervention had been established before the end of the data collection period (MRI and UHSM), the intervention period was not long enough to detect an underlying change in the trend. Across the three hospitals, analysis suggested that the majority of admissions for alcohol-specific conditions were for males, white British, living in the most deprived quintile and living in or around Manchester. The average age was mid-40s. For all three hospitals in 2009/10, a considerable proportion of admissions for alcohol-specific conditions were repeat admissions. Those who were admitted for an alcohol-specific condition more than once in a financial year were significantly more likely to be older than the single attendees (with odds of admission peaking in age range), resident in Manchester and to have been suffering from chronic (rather than acute) conditions. 22

23 Average number of beds occupied per patient Average number of beds occupied per patient Evaluation of the Alcohol Identification and Brief Advice Work in Emergency Departments across Manchester 8. Findings: supplementary intelligence provided by the hospitals 8.1. Beds occupied in Manchester Royal Infirmary Between 2008/09 and 2009/10, the proportion of alcohol-related beds occupied in MRI increased significantly from 8% to 10% of all beds occupied u,v. The proportion of patients occupying beds whose condition was related to alcohol also increased significantly from 6% to 7% of all patients occupying beds w. The average number of bed days occupied per patient in MRI for non-alcohol-related conditions remained stable in the months April to December between 2008/09 and 2010/11 (Figure 10). However, in January, February and March, there was a significant decrease in the monthly averages from 2008/ /10 to 2010/11. When alcohol-related conditions are examined, no significant change was identified in any month over the three year time period (Figure 11). Figure 10: Average number of beds occupied in Manchester Royal Infirmary (midnight occupancy, non-alcohol related conditions) / / /11 Month Error bars represent the 95% confidence intervals. Figure 11: Average number of beds occupied in Manchester Royal Infirmary for alcohol-related conditions (midnight occupancy) / / /11 Month Error bars represent the 95% confidence intervals. u Where the 95% confidence intervals (95%CI) do not overlap, the difference between two data points is said to be significant. v The 95%CIs are as follows: 2008/09: 8.1% (95%CI: %) and 2010/11: 10.2% (95%CI: ). w The 95%CIs are as follows: 2008/09: 5.8% (95%CI: %) and 2010/11: 7.2% (95%CI: ). 23

24 Average number of days stayed for discharged patients Average number of days stayed for discharged patietns Evaluation of the Alcohol Identification and Brief Advice Work in Emergency Departments across Manchester 8.2. Patients length of stay in Manchester Royal Infirmary Between 2008/09 and 2010/11, the proportion of patients discharged from MRI whose condition was related to alcohol increased significantly from 3.8% to 4.5% of all patients discharged x. Their length of stay also increased in relation to the total length of stay observed in the hospital overall: the proportion of days spent in hospital for those discharged with alcohol-related conditions increased significantly from 8% in 2008/09 to 10% in 2010/11 of total length of stay y. There was no significant change in average length of stay in MRI by month between 2008/09 and 2010/11 for those with a non-alcohol-related condition (Figure 12) or those with an alcohol-related condition (Figure 13). Confidence intervals between months were overlapping. Figure 12: Average length of stay for those discharged from Manchester Royal Infirmary for non-alcohol-related conditions / / /11 Month Error bars represent the 95% confidence intervals. Figure 13: Average length of stay for those discharged from Manchester Royal Infirmary for alcohol-related conditions / / /11 Month Error bars represent the 95% confidence intervals. x The 95%CIs are as follows: 2008/09: 3.8% (95%CI: %) and 2010/11: 4.5% (95%CI: ). y The 95%CIs are as follows: 2008/09: 8.2% (95%CI: %) and 2010/11: 9.9% (95%CI: ). 24

25 8.3. Change in emergency department attendance by clinic patients at the Manchester Royal Infirmary In April 2010, 28 patients attended the alcohol clinic. In the five months prior to their clinic attendance (November 2009 to March 2010), they presented a total of 85 times. In the five months after their clinic attendance (May to September 2010), they presented a total of 62 times. The mean number of attendances decreased from 3.0 to 2.2. This represents a 27% decrease in attendance. In the six months prior to clinic attendance, six patients were identified as being frequent ED attenders (attending more than twice in a six week period; 21% of the sampled population). In the six months after attendance, no patients were identified as attending frequently. However, without 95% confidence intervals for these figures, it is not known whether these changes were statistically significant Feedback questionnaires from clinic patients attending the University Hospital of South Manchester A total of 28 ED patients attending the clinics completed the UHSM feedback questionnaires between January and September 2010 (see Appendix 5). Of these, 26 strongly agreed that the programme had been of benefit to them (93%), 22 (79%) strongly agreed that their time with the ALN had helped them manage their drinking and/or reported that following their appointment(s) they planned to reduce/stop their drinking. These patients cited that the most useful aspects of the programme included: learning to stay off alcohol ; someone to talk to and understand me ; information/knowledge ; encouragement and support to start to reduce my drinking ; advice in a non-judgemental fashion ; and feeling that they were not alone Patient follow-up from those attending the clinic at the University Hospital of South Manchester Fifty clinic patients (who attended in January and February 2010) were followed up six months after their attendance. Their average AUDIT score decreased from 32 to

26 9. Discussion Levels of alcohol-related harm are rising: alcohol-attributable hospital admissions in England increased by 65% between 2003/04 and 2008/09 [3]. ED attendances are also increasing, although the extent of alcohol s involvement is less well documented at a national level [5]. Because of the rises in alcohol harm, IBA programmes, such as those implemented in Manchester, are fast becoming a standard means of identifying and supporting increasing and higher risk drinkers. Screening tools such as the AUDIT and AUDIT-C are widely used across the North West region [32] and it has been suggested that the ED is the ideal place to perform screening techniques, for example, because of the interpersonal skills of staff available [33, 34]. However, screening tools need to be quick and easy to use in such an environment [29, 35]. Further, studies have evidenced the effectiveness of brief interventions in EDs in England in reducing both ED re-attendance and alcohol-related injury (although evidence around their impact on alcohol consumption is more mixed) [18-22]. In 2008, an initial evaluation was conducted of the IBA programme in MRI, which provided a valuable insight into staff perceptions of the intervention [29]. Since then, the programme has been rolled out to two further hospitals (NMGH and UHSM), and has been running in MRI for four years overall. Thus, using the information from the original evaluation, further stakeholder interviews, and data analysis of both the data available within the Centre for Public Health and those supplied by the hospitals themselves, this evaluation seeks to take the next step in understanding the programme s potential impact. This discussion has been divided into the following sections in order to discuss the themes identified: screening; providing interventions and brief advice; staff training and experiences; potential impact; progress to date; limitations; and conclusions and recommendations Screening Since the full roll out of the IBA programme, 24,133 patients have received alcohol screening across all three hospitals, representing between 14% and 51% of eligible patients (Table 6). However, variations in screening criteria and data collection periods make comparisons between hospitals difficult (Table 6). NMGH screens patients presenting with the top ten alcohol-related conditions. It has the highest screening rate of the three hospitals (51% of eligible patients were screened in the data collection period). These higher levels of screening may be because NMGH s later introduction of the programme enabled them to learn from the other EDs experiences, leading them to implement some innovative procedures to increase screening rates (such as through the tannoy announcements, monitoring and using feedback from staff screening rates to reward those doing well and re-train those who might be struggling, and incorporating screening in staff development objectives). In comparison, MRI (which screens those presenting with the top 14 alcohol-related conditions and has been running the programme for the longest period) has the lowest screening rate at 14%. However, MRI has made a significant improvement in its screening rates since AUDIT-C became a mandatory part of the electronic system (with screening rates more than doubling from 9% in June 2010 to 25% in July 2010). Further monitoring is required to see if these trends continue beyond the immediate introduction of the IBA programme in NMGH and the mandatory system in MRI. Nevertheless across all hospitals, levels of screening are considerably lower than commissioner targets of 70%. Elsewhere, similar programmes have shown considerable variation in the proportion being screened through IBA-style programme. For example, in a project examining the effects of AUDIT feedback following the use of the PAT in a London hospital, screening rates ranged from 35% to 64% across the four months examined [30]. In comparison, a programme established in seven EDs in the US, screened 9% of patients seen; however screening was only carried out by health promotion advocates rather than any ED staff member [36]. Interviews from this study highlighted possible reasons eligible patients are not always screened: Staff reported that screening is less likely when staffing and/or time are limited. Thus, data analysis in this report show that screening was less likely to occur at weekends; however this may also be because of the alcohol teams shift patterns, for example, if they do not work at weekends. As the MRI has the highest number of ED attendances, this puts additional pressures on staff [5]. Lack of time was also highlighted as 26

27 a possible reason for non-referral both in EDs [29, 37], and in general practice elsewhere [38]. This is clearly a key issue in health settings. Yet, AUDIT-C is a short questionnaire, with only three questions in total. Staff may be reluctant to screen if they feel it is irrelevant to the patient, or inappropriate. However, internationally, alcohol is known to be strongly related to ED presentations [39], and in England and Wales, alcohol is associated with 35% of ED presentations (rising to up to 70% at peak times [40] ). Potentially, staff may be perceiving that alcohol is only involved in a presentation when the patient is visibly intoxicated; yet, alcohol-related conditions such as liver cirrhosis can develop even after relatively low levels of alcohol consumption [2]. Because ED patients may not access healthcare in any other heath setting [39], such individuals need to be engaged whilst they are in the ED. The trigger score of five for delivery of brief advice was seen by at least some staff in all three hospitals as being too easy to achieve. Yet this criteria successfully identifies alcohol misuse [41, 42] and in fact, some sources recommend the use of a lower score [43], especially for females [44]. If staff are drinking at levels perceived to be similar to those of their patients, this may affect whether they feel screening is appropriate. For example, a recent study of healthcare professionals in the North West (n=2,219) identified that those drinking above the recommended limits were significantly more likely to believe that the Government guidelines were too low (and therefore that the public should be able to drink more) when compared with lower risk or non-drinkers [45]. This is despite the fact that drinking above the recommended limits is strongly associated with a range of chronic and acute conditions [2], and that 85% of those surveyed recognised alcohol to be a problem in the North West [45]. Data collection issues. At UHSM the screening system relies on a member of staff placing the paper-based screening tool with the patient s notes, which is sometimes overlooked. This was highlighted as an issue for MRI in the initial evaluation but has since been tackled through the use of SYMPHONY [29]. NMGH have experienced problems with computerised screening, where the screening tool is not a mandatory field on the patient s record and may be omitted. At MRI, where completion is mandatory [29], it was perceived that staff may falsely record that the patient was unable to be screened to avoid completing the screening tool, and also screening may be obstructed because computers are not available in all consulting rooms. In the primary care IBA pilot programme, one practice had established an alert on their computer system, which appears when an eligible patient presents to the surgery and prevents prescriptions from being issued before the screening tool is conducted [38]. Similar methods could be investigated for applicability in the ED setting. Limited training. Most staff interviewed had attended at least one training session. However, high staff turnover means that regular training sessions are vital [29]. Refresher sessions could also be used to boost compliance, as recommended by staff involved in this evaluation and in the primary care IBA programme in Manchester, although the time taken to do so could hinder attendance [38]. Refresher sessions are particularly important as research in the US has shown that whilst training boosts confidence in ability to deliver programmes such as IBA in ED staff and use of skills gained, this can decrease after 12 months [46]. Where data were available, most screening took place on Mondays to Wednesdays and during daytime hours (9am to 5pm) when members of the alcohol team were on duty, suggesting that staff are more likely to screen when members of the team were there. Interviews revealed that males and younger groups were more likely to be screened. International studies support this showing that those presenting to ED with injuries related to alcohol are more likely to be under 35 years old and male [39]. However, this only relates to injuries and not the full range of conditions associated with alcohol [2]. Thus, the hospital admissions analysis showed that for all three hospitals, those who were admitted for an alcohol-specific condition more than once in a financial year (and who were therefore key groups for the IBA programme) were significantly more likely to be older than the single attendees (with odds of admission peaking in age range), resident in Manchester and to have been suffering from chronic (rather than acute) conditions [31]. Thus despite staff perceptions, at MRI screening data 27

28 28 Table 6: Overview of the hospitals involved in the identification and brief advice programme (using data from this report to provide an understanding of screening since the IBA programme was fully rolled out) Hospital Manchester Royal Infirmary North Manchester General Hospital University Hospital of South Manchester Data available from January 2010 July 2010 August 2009 Screening criteria Top 14 conditions Top ten alcohol conditions All adult ED patients Number of patients screened 4,485 (14% of those eligible) 5,731 (51% of those eligible) 13,917 (27% of those eligible) Total/All ,133 Number of increasing /higher risk drinkers 1,474 (33% of those screened) 1,724 (30% of those screened) 5,494 (39% of those screened) 8,692 (36% of those screened) Number of appointments booked No data available 110 (6% of those scoring at least five) 808 (15% of those scoring at least five) 918* (13%* of those scoring at least five) Number of appointments attended No data available 48 (44% of those booked) 564 (69% of those booked) 612* (67% of those booked) Examples of good practice Screening questions are mandatory. Drink Smart guides include the clinic s telephone number. Compulsory training for ED staff. Reminders for screening include: tannoy announcements, staff pocket reminder cards, and posters in all cubicles. Monthly bulletin to staff with feedback of screening rates. Posters inform patients that everyone will be asked about alcohol use Areas for development Consider whether training could be made mandatory for ED staff. Investigate whether the screening tool could be made mandatory for eligible patients. Ensuring the screening tool is placed with the CASCARD. Boosting screening rates and proportion of appointments kept. Training to further demonstrate evidence base for the screening tool *Data are for University Hospital of South Manchester and North Manchester General Hospital only (data were unavailable for Manchester Royal Infirmary).

29 showed that of presentations made, those screened were more likely to be older attendees Providing interventions and brief advice In the Manchester hospitals examined, 65% of screened patients scored under five on AUDIT-C (and had a low risk of alcohol harm), leaving 36% screened who were identified as increasing or higher risk drinkers (Table 6). This proportion is three times higher than that of a similar pilot programme established in primary care in Manchester, where 11% triggered the score for brief intervention delivery (of 4,159 screened) [38]. However, whilst the comparisons provide a useful insight into the potential reach of the ED, it should be remembered that the populations involved are likely to be very different. The proportion identified as being increasing or higher risk drinkers in the present study was similar to the proportion identified as being at risk of substance use in the programme established in seven EDs in the US (via a health and safety survey, 32% of those screened); however, this proportion also included illegal drug users [36]. Nevertheless, findings from the Manchester primary care IBA programme suggest that success in reducing consumption could be high with 31% of patients reporting changed drinking habits after the intervention [38] ; however, the sample size is small. Other studies have tried to gauge the potential effect of screening. Based on their calculations, which assume that for every eight people screened, one would reduce their alcohol consumption [21], this means that a potential 1,087 people on the IBA programme have reduced their alcohol use to lower risk consumption. However, long-term impact is unknown and booster sessions may be required to maintain such a reduction [21]. Further, such estimates need to be viewed with caution as it is not known to what extent this calculation applies to those individuals who have received the IBA programme in these three Manchester hospitals and it is not known whether every person who screened positive for alcohol misuse was provided with brief advice. As part of the IBA programme, those scoring five and over were offered an appointment with the ALN for further support and an extended brief intervention. The proportion booking an appointment was low: 15% of those scoring five or more at UHSM and 6% at NMGH (Table 6). When appointments were made, 69% attended at UHSM and 44% did so at NMGH. This is higher than in a similar programme at St Mary s ED, London, where 35% of those being screened for alcohol use attended an appointment they had booked with an alcohol health worker [47]. Thus, over six hundred individuals z were known to have received extended brief interventions through the programme since it was fully rolled out (Table 6). A randomised controlled trial evaluating a similar intervention in a hospital in London showed that when individuals identified as misusing alcohol were referred to an alcohol health worker, this resulted in significantly fewer visits to the ED over the next 12 months compared with those who were not referred (1.2 compared with 1.7; P<0.05) [18]. In fact, data obtained from MRI and highlighted in this report showed a 27% reduction in ED re-presentations in clinic attendees (although numbers involved were small) The potential for a wider impact In England from 1989/90 to 2009/10, there was a 32% increase in numbers presenting at emergency departments, from almost 14 million to 20.5 million [5]. Hospital admission is also increasing [3, 48]. In this context, it would be difficult for the IBA programme to lead to an immediate trend reversal of alcohol-related hospital admission and/or ED presentation so soon into project delivery, especially considering the low levels of screening already discussed (see Section 9.1). However, any reduction in ED presentations or hospital admissions would represent a considerable cost saving to local health services, with ED attendances estimated to cost 80 per visit and an individual hospital admission estimated to cost 1,800 [49]. In fact, the Alcohol Ready Reckoner suggests that the cost savings of employing six alcohol health workers in EDs to work with non-dependent drinkers (as the IBA programme provided) from 2009/10 to 2011/12 per year could result in 3,300 ED admissions averted, 220 hospital admissions averted and a cost benefit of 405,000 per year in Manchester [50]. This is important z At UHSM and NMGH only. MRI did not have clinic information. 29

30 considering the potential for change outlined in the snapshot data presented by MRI (where data have shown that clinic attendance could be associated with a 27% reduction in ED attendance). However, numbers involved were small, no confidence intervals were available with which to assess significant change and larger-scale datasets presented in this report have not shown a clear impact of the programme. Instead, the number of assaults and falls presentations at UHSM increased significantly between October 2008 to June 2009 and October 2009 to June Whilst alcohol is strongly associated with both assaults and falls aa, other factors may have contributed to this rise, including the impact of the severe winter weather conditions in 2009/10 on falls [51]. Similar to the ED data, the analysis of hospital admissions and alcohol-attributable admissions showed an overall increase in the three hospitals in the lead up to the programme s establishment, reflecting national trends [3]. In the two hospitals where the intervention had been established before the end of the data collection period (MRI and UHSM), the intervention period was not long enough to detect an underlying change. Whilst no impact on hospital admission or ED presentation was observed, the hospital admission analysis did provide a useful insight into the types of people most likely to be affected by repeat admission for alcohol-specific conditions in the three hospitals and these those who were middle-aged, lived in Manchester and were admitted for alcohol-specific chronic conditions and mental and behavioural disorders. Consideration should be given to further developing strategies to target these people in order to reduce alcohol specific re-admission Progress to date The original evaluation of the IBA programme run in MRI from 2006 provided recommendations as to how to improve the IBA [29]. As can be shown by this report, progress has been made on a number of these: To maintain accurate and up-to-date monitoring, it was recommended that data requirements and definitions be agreed at the outset. All hospitals involved were able to provide a minimum dataset, but differences were still evident between them, which makes comparison difficult. To determine the impact of the intervention, it was recommended that patients be followed up. The service specification has since detailed that patients are to be followed up, thus for example, UHSM were able to provide data on the experiences of their patients. To prevent staff from forgetting to ask the screening questions, it was recommended that computerised systems be used and that such systems should ensure these questions were mandatory. Two of the hospitals (MRI and NMGH) were using SYMPHONY to record the screening questions, and for one (MRI), it was possible to list the questions as mandatory. To boost motivation, it was recommended that screening rates be fed back to staff. UHSM provided feedback on screening rates in their monthly bulletins; however, in staff interviews not all reported receiving this. In NMGH, staff screening rates were recorded on the database and screening rates formed part of staff s personal development objectives. In MRI, it was intended that feedback would be provided in the future. The continuation of training was recommended as a means to overcome any misunderstandings of who delivered the screening and to address unease in screening black and minority ethnic groups. Training was available for staff in all three hospitals. However, some of the staff interviewed for this evaluation thought that others (such as clinicians, GPs and the patients themselves) should deliver the screening. Further, training should continue to evolve to tackle the issues identified (such as the false perception among some staff that a score of five was not high enough to warrant a brief intervention). To raise the profile of the IBA programme, it was recommended that posters be displayed in the ED departments. All three hospitals were using posters in this way. aa Alcohol is associated with up to one fifth of falls and 27% of assaults [2]. 30

31 To expand the resources available to provide a care facilitator and a second nurse. The former to manage any dependent drinkers identified and the latter to support the existing ALNs. In addition, the authors recommended that their working hours should reflect the need to engage with staff on different shifts. At the time of data collection for this evaluation, the teams at all three hospitals consisted of one band seven ALN, one band 6 alcohol nurse and one Care Facilitator. Further, in all three hospitals, shifts mainly covered weekdays with some provision into evenings and/or weekends Limitations of this evaluation There were a number of limitations to this evaluation, which may affect the validity of the findings. The number of staff members who were interviewed was small and so the opinions they expressed may not reflect all ED staff. Also staff were, to a certain degree, self-selected as they were recruited from those who were available on the day of interview. However, the researchers strove to ensure that participants from different roles were interviewed. Due to the resource limitations of the evaluation brief, it was not possible to interview or survey the patients involved to investigate change in consumption. This would have provided a valuable insight into the effectiveness of the service delivered. However, researchers used a wide range of intelligence available to examine characteristics of those being screened and trends in hospital attendance. A final limitation was the data used. Data analysis was limited to what was shared with researchers and as each hospital s data varied in content (and screening criteria), it was difficult to directly compare each programme. The extent of the data collected also had limitations for each programme, as this affected how success could be measured. For example, clinic data, and patient follow-up (e.g. attendance at extended brief intervention clinics) were not necessarily completed as part of the data collection process (e.g. MRI) Conclusions and recommendations In conclusion, the staff interviews have shown that IBA was well received by those involved in the project from the three Manchester hospitals and each hospital was working to boost rates of identification and brief advice. Methods of delivery of identification and brief advice have been adapted by the hospital to suit their individual needs where appropriate. A number of issues (such as competing priorities within the ED) were raised by the hospitals which have hindered the delivery of the programme, and these are likely to have contributed to the low screening rates observed. Nevertheless, 24,133 patients were screened over the data period analysed. It was not possible to identify any immediate impact on hospital admission or ED presentation. This could be due to both the low screening rates and/or that it may still be too early to identify a sustained change (particularly when a significant proportion of admission is due to chronic conditions). Thus, continued monitoring will be required in order to understand the impacts of the IBA programme over the longer-term. Using the findings from this report and to tackle the issues raised, a number of recommendations have been suggested. These are detailed below; however the main recommendation of the report is to investigate ways of boosting screening rates. This is vital if the programme is to have an effect on hospital admissions and ED presentations Primary recommendation: To investigate ways of boosting screening rates The main recommendation of this report is for stakeholders to work together to identify realistic ways of boosting screening rates. This will improve the numbers receiving brief advice, being seen in the clinic and subsequently increase the potential for impact on the health outcomes and health care demand (such as ED presentations and hospital admissions). Stakeholders could look to boost screening rates through the following suggested actions: To continue to motivate staff to deliver screening and brief interventions on the spot, where applicable. To explore options to increase screening rates at peak times such as providing extra resources at these times. Data from this report and seasonality trends published elsewhere show that Mondays tend to be the busiest days following weekends [52] and that peak months tend to be September to December [53]. 31

32 To consider restricting screening to ED attendances presenting with the top ten conditions. Currently, across all three hospitals, a considerable proportion of patients are being missed and it is important to target those most at risk first and foremost, and to ensure screening of such patients is routine before expanding beyond the top ten. NMGH, which only targets those presenting with the top ten conditions, currently has the highest screening rate. To consider how to improve training for maximum effect and whether it should cover in more detail the evidence base for the screening tool, in particular the appropriateness of the cut off point as being five, whether training should be mandatory and whether booster sessions could be run at fixed intervals. Training could also be used to encourage staff to screen individuals who are middle-aged and are presenting for chronic conditions and/or mental and behavioural disorders specific to alcohol as these individuals represent the population most likely to be re-admitted. To further develop opportunities to share good practice to motivate staff, such as by providing regular feedback to staff on screening rates, listing the most prolific screeners or providing case studies of individuals who have reduced their alcohol consumption following an intervention. To consider implementing the IBA programme in hospital wards outside the ED, where individuals with chronic conditions may be more likely to be present Secondary recommendations A number of other recommendations could also be employed in order to improve the programme overall: To improve patient follow up, for example by tracking individual patient scores over time (such as, if they are screened more than once) to evaluate the success of the programme. Further, staff should continue to build on and improve the existing follow up procedures by focusing on a cohort of individuals. To continue to develop creative ways to increase uptake of extended brief advice sessions by increasing and higher risk drinkers, for example, by considering whether sending text messages as reminders before appointments and letters to patients who did not attend would boost attendance rates at UHSM and NMGH. To standardise data collection. Although each hospital had different ways of screening (e.g. through SYMPHONY as a mandatory field, or a non-mandatory or on paper), the core data should still be collected across all three hospitals. These items should include: all patient demography (gender, age, ethnicity, postcode); date and time of attendance; presenting complaint (e.g. top ten condition); individual score to each AUDIT-C question and total score; risk category (e.g. low or increasing risk and high risk); clinic attendance outcomes where relevant (e.g. attendance at extended brief intervention clinic or nonattendance); reasons for non-screening (for example, too intoxicated, too unwell, patient refusal and department too busy). Data on clinic attendances should also be seen as a routine part of data collection and the screening process as this will help add validity to the programme. Such data should be shared in raw case-by-case format to ensure data can be analysed easily and in the same manner across the three hospitals (see Appendix 10). To continue to monitor the impact of the IBA programme in order to understand its potential impact. This is particularly important in the case of the hospital admissions analysis where it is recommended that the analysis is repeated in one or two years time to re-assess the potential for change across the three hospitals. This analysis should investigate route of admission and individual admissions over time (to assess whether individuals presenting with alcohol-related acute conditions now might present with alcohol-related chronic conditions at a later date). In addition, monitoring could include examining screening rates, ED presentations, consumption levels, other health outcomes and cost effectiveness. 32

33 10. References 1. Gronback M, Deis A, Sorenson TIA et al. (1995). Mortality associated with moderate intakes of wine, beer, or spirits. British Medical Journal (Clinical Research and Education). 310: Jones L, Bellis M, Dedman D et al. (2008). Alcohol-attributable fractions for England: alcohol-attributable mortality and hospital admissions. North West Public Health Observatory, Centre for Public Health, Liverpool John Moores University, Liverpool. 3. North West Public Health Observatory (2010). Local Alcohol Profiles for England. North West Public Health Observatory, Liverpool John Moores University. ( Accessed 27 September 2010). 4. Department of Health (2008). The cost of alcohol harm to the NHS in England: an update to the Cabinet Office Department of Health, London. 5. Department of Health (2010). Archive - A&E Attendances. Department of Health. ( DH_ Accessed 2 December 2010). 6. Hughes K, Bellis MA, Tocque K et al. (2004). Taking measures - a situational analysis of alcohol in the North West. Public Health North West Alcohol Strategy Group, Centre for Public Health, Liverpool John Moores University, Liverpool. 7. Cook P, Tocque K, Morleo M et al. (2008). Opinions on the impact of alcohol on individuals and communities: early summary findings from the North West Big Drink Debate. Centre for Public Health, Liverpool John Moores University, Liverpool. 8. Strategy Unit (2003). Alcohol misuse: how much does it cost? Prime Minister's Strategy Unit, London. 9. Morleo M, Spalding J, Carlin H et al. (2010). Alcohol pen portraits: segmentation series 4. North West Public Health Observatory, Centre for Public Health, Liverpool John Moores University, Liverpool. 10. Wood J, Hennel T, Jones A et al. (2006). Where wealth means health: illustrating inequality in the North West. North West Public Health Observatory, Liverpool John Moores University, Liverpool. 11. Hall P, Innes J (2010). Violent and sexual crime. In Crime in England and Wales 2009/10: findings from the British Crime Survey and police recorded crime (third edition), J Flatley, C Kershaw, K Smith et al. (Eds.). Home Office, London. 12. Morleo M (2011). The impact of alcohol in Greater Manchester: report number 8. Centre for Public Health, Liverpool John Moores University, Liverpool. 13. Department of Health (2010). Hospital activity statistics: A&E attendances data 2007/08. ( Accessed 26 January 2011). 14. Cabinet Office Prime Minister's Strategy Unit (2004). Alcohol harm reduction strategy for England. Cabinet Office, London. 15. Davidson P, Koziol-McLain J, Harrison L et al. (1997). Intoxicated ED patients: a 5-year follow-up of morbidity and mortality. Annals of Emergency Medicine. 30 (5): Royal College of Physicians (2001). Alcohol - can the NHS afford it? Royal College of Physicians, London. 17. National Institute for Health and Clinical Excellence (2010). Alcohol-use disorders: preventing the development of hazardous and harmful drinking. NICE public health guidance 24. National Institute for Health and Clinical Excellence, London. 18. Crawford MJ, Patton R, Touquet R et al. (2004). Screening and referral for brief intervention of alcohol-misusing patients in an emergency department: a pragmatic randomised controlled trial. Lancet. 364 (9442): Peters J, Brooker C, McCabe C et al. (1998). Problems encountered with opportunistic screening for alcohol-related problems in patients attending an Accident and Emergency department. Addiction. 93: Green M, Setchell J, Harnes P et al. (1993). Management of alcohol abusing patients in accident and emergency departments. J R Soc Med. 86: Raistrick D, Heather N, Godfrey C (2006). Review of the effectiveness of treatment for alcohol problems. National Treatment Agency for Substance Misuse, London. 33

34 22. Havard A, Shakeshaft A, Sanson-Fisher R (2008). Systematic review and meta-analyses of strategies targeting alcohol problems in emergency departments: interventions reduce alcohol-related injuries. Addiction. 103 (3):368-76; discussion Freemantle N, Gill P, Godfrey C et al. (1993). Brief interventions and alcohol use: effectiveness bulletin. Quality in Health Care. 2: Bien TH, Miller WR, Tonigan JS (1993). Brief interventions for alcohol problems:a review. Addiction. 88 (3): Heather NI (1995). Interpreting the evidence on brief interventions for excessive drinkers: the need for caution. Alcohol & Alcoholism. 30 (3): D'Onofrio G, Degutis L (2002). Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review. Academic Emergency Medicine. 9 (6): Department of Health (2009). Signs for Improvement: commissiong interventions to reduce alcohol-related harm. DH, London. 28. Manchester City Council (2008). Manchester alcohol strategy Manchester City Council, Manchester. 29. Drummond B, Wasielewska A (2008). Initial evaluation of the introduction of an alcohol screening and brief intervention programme at Manchester Royal Infirmary accident and emergency department. Manchester Joint Health Unit, Manchester. 30. Huntley JS, Blain C, Hood S et al. (2001). Improving detection of alcohol misuse in patients presenting to an accident and emergency department. Emergency Medicine Journal. 18: Morleo M, Cook PA (2011). Evaluation of the alcohol identification and brief advice work in emergency departments across Manchester: an analysis of Hospital Episode Statistics. Centre for Public Health, Liverpool John Moores University, Liverpool. 32. Burrows M, Elliott G, Morleo M et al. (in press). Offender health: alcohol services review. Centre for Public Health, Liverpool John Moores University, Liverpool. 33. Charalambous M, P. (2002). Alcohol and the accident and emergency department: a current review. Alcohol and Alcoholism. 37 (4): Sanderson-Shortt K, Morleo M, Cook PA et al. (2010). Understanding the route to and from hospital for underage drinkers on the Wirral. Centre for Public Health, Liverpool John Moores University, Liverpool. 35. Thom B, Herring R, Judd A (1999). Identifying alcohol-related harm in young drinkers: the role of the accident and emergency departments. Alcohol and Alcoholism. 34 (6): Bernstein E, Topp D, Shaw E et al. (2009). A preliminary report of knowledge translation: lessons from taking screening and brief intervention techniques from the research setting into regional systems of care. Academic Emergency Medicine. 16 (11): Huntley JS, Patton R, Touquet R (2004). Attitudes towards alcohol of emergency department doctors trained in the detection of alcohol misuse. Annals of the Royal College of Surgeons of England. 86 (5): Mantle J, McGann C, Wall L (2010). Alcohol identification and brief advice pilot in primary care report: June December NHS Manchester, Manchester. 39. World Health Organization (2007). Alcohol and injury in emergency departments: summary report from the WHO Collaborative Study on Alcohol and Injuries. World Health Organization, Geneva. 40. Strategy Unit (2003). Strategy Unit Alcohol Harm Reduction Project: interim analytical report. Strategy Unit, London. 41. Aertgeerts B, Buntinx F, Ansoms S et al. (2001). Screening properties of questionnaires and laboratory tests for the detection of alcohol abuse or dependence in a general practice population. British Journal of General Practice. 51 (464): Gordon AJ, Maisto SA, McNeil M et al. (2001). Three questions can detect hazardous drinkers. Journal of Family Practice. 50 (4): Bush K, Kivlahan DR, McDonell MB et al. (1998). The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Archives of Internal Medicine. 158 (16):

35 44. Bradley KA, Bush KR, Epler AJ et al. (2003). Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population. Archives of Internal Medicine. 163 (7): Harkins C, Morleo M, Cook PA et al. (2010). Understanding the views of health care professionals towards alcohol consumption and the provision of alcohol advice. Centre for Public Health, Liverpool John Moores University, Liverpool. 46. Bernstein E, Bernstein J, Feldman J et al. (2007). An evidence based alcohol screening, brief intervention and referral to treatment (SBIRT) curriculum for emergency department (ED) providers improves skills and utilization. Substance Abuse. 28 (4): Williams S, Brown A, Patton R et al. (2005). The half-life of the 'teachable moment' for alcohol misuing patients in the emergency department. Drug and Alcohol Dependence. 77: HES online (2010). Headline figures, HES online. ( Accessed 18 May 2011). 49. Acute Chief Executive's Group (2010). Alcohol: a case for secondary care change. Greater Manchester Public Health Network, Manchester. 50. Alcohol Learning Centre (2010). Alcohol Ready Reckoner v.5. Alcohol Learning Centre. ( Accessed 4 January 2011). 51. Mason J, Perkins C, Bellis MA et al. (2010). Falls involving ice and snow, transport accidents and respiratory conditions: the impact of winter (2009/10) on emergency hospital admissions in the North West. North West Public Health Observatory, Centre for Public Health, Liverpool John Moores University, Liverpool. 52. Wargon M, Guidet B, Hoang T et al. (2009). A systematic review of models for forecasting the number of emergency department visits. Emergency Medicine Journal. 26 (9): HES online (2010). Health and seasons. HES online. ( Accessed 2 December 2010). 54. Saunders JB, Aasland OG, Babor TF et al. (1993). Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption II. Addiction. (88):

36 AUDIT only questions AUDIT-C (and AUDIT) 11. Appendices Appendix 1: The alcohol identification and brief advice programme in Manchester In December 2006 NHS Manchester commissioned the alcohol identification and brief advice (IBA) programme at the Central Manchester University Hospitals NHS Foundation Trust (CMFT) Manchester Royal Infirmary (MRI). The programme aimed to improve the health of ED patients by delivering brief interventions to increasing and higher risk drinkers bb. After an initial evaluation [29], the programme was re-commissioned as part of the Improving Health in Manchester bid for a further two years at MRI and also at the University Hospital of South Manchester (UHSM) NHS Foundation Trust, and North Manchester General Hospital (NMGH) which is part of the Pennine Acute Trust. In the initial pilot, ED staff (such as doctors, the Alcohol Liaison Nurse, Alcohol Nurse and other nursing staff) opportunistically screened all patients attending the ED if they had drunk alcohol in the last 12 hours. A positive answer triggered the Paddington Alcohol Test (PAT). In the second phase of the project, AUDIT-C replaced the PAT after being recommended by NICE (Table 7) [17]. The AUDIT-C is the shortened version of the AUDIT [54] and has been internationally validated for identifying individuals at risk of alcohol misuse (Table 7) [41, 42]. Also, screening was restricted to patients presenting with at least one of the top ten alcohol conditions leading to an admission cc, as these conditions can account for 77% of patients screening positive for alcohol misuse (using PAT) [30]. Patients scoring five or more received brief verbal advice, a Drink Smart Guide, and an offer of an extended brief intervention at the extended brief advice clinic. The aim of the clinic appointment depends on the individual s goal (such as abstinence or reduced consumption). Appointments aim to be within 48 hours of the patient s ED presentation. Patients are screened using the AUDIT and may be asked to work through an exercise (e.g. self-test, drink diary) to bring back to the clinic. If dependent drinkers are identified (either by medical examination or through a detailed history), they are referred to the Community Alcohol Team (CAT) or other community-based alcohol support. Table 7: AUDIT-C and AUDIT questions with scores allocated [43] Question Possible response Score allocated How often do you have a drink that contains 2-4 times 2-3 times 4(+) times Never Monthly alcohol? per month per week per week 2. How many units of alcohol do you drink on these occasions? (+) 3. How often have you had 6 units if female or 8 Less than Daily or Never Monthly Weekly if male on a single occasion in the last year monthly almost 4. How often in the last year have you found that Less than Daily or you were unable to stop drinking once you had Never Monthly Weekly monthly almost started? 5. How often in the last year have you failed to do what was normally expected from you because of drinking? 6. How often in the last year have you been unable to remember what happened the night before because you had been drinking? 7. How often in the last year have you needed an alcoholic drink first thing in the morning to get yourself going after a night of heavy drinking? 8. How often in the last year have you had a feeling of guilt or remorse after drinking? 9. Have you or someone else been injured as a result of your drinking? 10. Has a relative, friend, doctor or other health professional expressed concern about your drinking or suggested you cut down? Never Never Never Never No No Less than monthly Less than monthly Less than monthly Less than monthly Monthly Monthly Monthly Monthly Yes, not in the last year Yes, not in the last year Weekly Weekly Weekly Weekly Daily or almost Daily or almost Daily or almost Daily or almost Yes, in the last year Yes, in the last year Those scoring a total of 0-4 on the AUDIT-C are classed as non-drinkers or lower risk drinkers. No action is required. Those scoring 5-12 are classed as increasing/higher risk drinkers, and are offered a brief intervention. The full AUDIT is completed at the clinic appointment. bb Increasing and higher risk consumption is defined as scoring five or above on the AUDIT-C screening tool. cc These are falls, collapsed, facial injury, head injury, assault, unwell, abdominal pain, mental illness, chest pain, and regular attendees.

37 In each site, staff have been recruited to facilitate and manage the IBA programme. These include one alcohol liaison nurse (ALN; band 7 dd ), one alcohol nurse (AN; band 6) and a care facilitator (CF; Band 6). Their roles, as defined by the service specification, are displayed in Table 8. Details may vary between hospitals: In UHSM, the team are responsible for covering the ED department at all times and so try not to be on duty at the same time. Duty days and times vary according to shift patterns but the ALN and AN aim to cover Monday to Friday and two out of every three weekends. The CF works weekdays from 9.30am to 5.30pm. In NMGH, the alcohol team are available from Sunday to Friday (not Saturday). On weekdays (except Wednesday), the team will provide cover from 8am to 7pm. On Wednesdays, they cover 7.30am to 9.30pm. On a Sunday, they work from 11am to 7pm. In MRI, the ALN and AN worker have shift working patterns between 8am to 8pm Monday to Friday. The CF works weekdays from 9am to 5pm. Table 8: The responsibilities and personnel involved in the identification and brief advice programme Alcohol Liaison Nurse (ALN) Band 7 Alcohol Nurse (AN) Band 6 Care Facilitator (CF) Band 6 1. To manage the project and the other posts involved. 2. To ensure data collection and provide monthly reports to the steering group. 3. To train and support ED staff to deliver the IBA programme. 4. To develop and maintain links with community-based alcohol services. 5. To carry out patient screening with AUDIT-C and deliver extended brief advice and refer to communitybased treatment services where appropriate. 6. To evaluate the IBA programme and staff training. 1. To carry out patient screening with AUDIT-C and deliver extended brief advice and refer to communitybased treatment services where appropriate. 2. To work with the hospital wards to ensure timely and safe discharge. 1. To identify patients who have been admitted. 2. To perform an assessment of needs on discharge. 3. To develop a discharge plan with staff. 4. To facilitate access to communitybased alcohol services where required, including escorting individuals to their appointments. dd NHS salaries are divided into nine groups known as bands. The higher band numbers indicate more senior staff.

38 Appendix 2: Interview schedule An asterisk (*) indicates where questions are specifically for the Alcohol Liaison Nurse. Job role Details of their role and time split between other duties. IBA programme Date of implementation of the IBA programme. Their understanding of why the IBA programme was introduced, its aims/objectives and target population. How was the IBA programme introduced? Were staff members not involved with the delivery of the programme also made aware of its implementation? Are they kept informed about the progress the programme is making? Do they feel that the programme is championed at senior level?* Briefly outline the IBA procedure. Discuss patients / staff reactions to the programme. Are they clear about the referral process? Discuss the procedure which is followed for those patients who cannot receive the IBA at the time of attendance. How much later is it provided? Does the information provided at a later stage have the same impact as when it is provided at the time of attendance? Is there a follow-up procedure? If so what is it?* The extended interview how long is the waiting time for appointments? Are reminders sent out? How are outcomes measured? Can we have access to the data?* Daily/weekly/monthly averages? Discuss the benefits and / or problems of the programme. Is there a system in place for staff to report / discuss any problems and / or benefits they encounter? Have there been any additions or changes made to the programme, or any impacts at your hospital which can be shared with the other hospitals? How can the procedures be maximised? Any other issues regarding the IBA programme? Staff training Outline content of training sessions.* Are the sessions organised on a regular basis or as and when required? In-house training or other? Easy to organise? Any issues? Is the training satisfactory? If not how do you think it could be improved?* Does the training help staff to address potential barriers to implementing the programme (e.g. improving participant s confidence to ask the patients about their alcohol use)? Number of staff who have undergone training, and the range of job roles of these.* Are these adequate to deliver the IBA effectively?* Was the training well-received by staff?* Have any staff been unable to attend training sessions due to staffing levels on particular shifts? Outline training sessions received. Have these been sufficient? If not, what additional training is required? Could the training be improved upon? Any other issues regarding the IBA training they wish to discuss.

39 Appendix 3: Information sheet Improving health in Manchester: Alcohol identification and brief advice work in emergency departments across Manchester Dear Participant We would like to invite you to take part in either a one-to-one interview or focus group to discuss the Alcohol and Brief Advice (IBA) Programme which has been introduced at the emergency department where you work. Interviews and focus groups will take place in a private room within the hospital. Interviews will take approximately 30 minutes and focus groups approximately 45 minutes to complete. NHS Manchester has commissioned the Centre for Public Health at Liverpool John Moores University to undertake an evaluation of the IBA Programme introduced at emergency departments of three hospitals in Manchester. The interviews and/or focus groups will form part of this evaluation and your participation is therefore very important to us. Findings from these will allow us to gain an understanding of the experiences of staff involved in the delivery of the IBA Programme, identify any barriers to its effective implementation and to develop potential solutions to these. These will be used to make recommendations to the commissioners in the form of a report and will also allow for good practice to be shared within the three hospitals. If you agree to take part in either an interview or focus group you will be asked to discuss your understanding and experiences of implementing the IBA programme. For ease of transcription, all interviews and focus groups will be recorded using a digital voice recorder. In order to protect anonymity, no names or job titles will be recorded by the researcher and if these are referred to within the discussion they will be removed during the transcription process and will not be included in the report. Participants in focus groups are also asked to maintain their co-participants confidentiality. Thank you very much for your valuable participation. Further information If you would like any more information, please contact the lead researchers using the contact details attached.

40 Appendix 4: Consent form LIVERPOOL JOHN MOORES UNIVERSITY CONSENT FORM Improving health in Manchester: Alcohol identification and brief advice work in emergency departments across Manchester Researchers: Gill Elliott, Michela Morleo, Zara Quigg, and Penny Cook, Centre for Public Health Research Directorate, Faculty of Health and Applied Social Sciences, Liverpool John Moores University. Please confirm the following by ticking the boxes I confirm that I have read and understand the information provided for the above study. I have had the opportunity to consider the information, ask questions and have had these answered satisfactorily. I understand that my participation is voluntary and that I am free to withdraw at any time, without giving a reason. I understand that any personal information collected during the study will remain confidential. I understand that verbatim quotes may be used in the finalised reports, and that these will be anonymised. I therefore confirm that I am willing to take part in either an interview or focus group discussion Initials of participant Date Signature Name of Researcher Date Signature

41 Appendix 5: University Hospital of South Manchester patient feedback form Below is a voluntary questionnaire for all patients that attend an appointment with the Alcohol Liaison Nurse. We will use the data to examine the experience patients using the service receive and therefore improve the service where possible. Please complete as much of the questionnaire as you are able. All information provided will be confidential and the identity of those who reply will be kept anonymous Please indicate the degree to which you agree with the following statements. The service you received: 1. I was able to schedule a convenient appointment with the Alcohol Liaison Nurse. Strongly Disagree Disagree Uncertain Agree Strongly Agree 2. There was an appointment slot available within 48 hours of me attending the Emergency Department. Strongly Disagree Disagree Uncertain Agree Strongly Agree 3. The Alcohol Liaison Nurse Clinic is easy to access. Strongly Disagree Disagree Uncertain Agree Strongly Agree 4. I was satisfied with the amount of time the Alcohol Liaison Nurse spent with me. Strongly Disagree Disagree Uncertain Agree Strongly Agree The Alcohol Liaison Nurse: 5. The Alcohol Liaison Nurse acted professionally. Strongly Disagree Disagree Uncertain Agree Strongly Agree 6. The Alcohol Liaison Nurse was knowledgeable. Strongly Disagree Disagree Uncertain Agree Strongly Agree 7. I trusted that my information would be handled confidentially. Strongly Disagree Disagree Uncertain Agree Strongly Agree 8. The Alcohol Liaison Nurse listened to what I had to say Strongly Disagree Disagree Uncertain Agree Strongly Agree 9. The Alcohol Liaison Nurse respected me. Strongly Disagree Disagree Uncertain Agree Strongly Agree 10. The Alcohol Liaison Nurse was non-judgemental Strongly Disagree Disagree Uncertain Agree Strongly Agree Outcome of your visit[s] 11. I understood what the Alcohol Liaison Nurse explained to me. Strongly Disagree Disagree Uncertain Agree Strongly Agree 12. My time with the Alcohol Liaison Nurse has helped me manage my drinking. Strongly Disagree Disagree Uncertain Agree Strongly Agree 13. Following my appointment[s] I plan to reduce/stop my drinking. Strongly Disagree Disagree Uncertain Agree Strongly Agree 14. Overall I feel this service has been of benefit to me. Strongly Disagree Disagree Uncertain Agree Strongly Agree 15. What one thing could the Alcohol Liaison Nurse do differently to improve your experience? 16. What did you find most useful from you visit[s] to the Alcohol Liaison Nurse? Please Complete the Following Details: Gender: Age: Ethnicity No. of visits to the Alcohol Liaison Nurse: Name of Alcohol Liaison Nurse: Adapted from Agosta LJ (2005) Patient satisfaction with nurse practitioner delivered primary health care services (unpublished Doctoral Dissertation) Louisiana State University and Agricultural & Mechanical College

42 Appendix 6: Number of patients screened and screening score = 5+, and patient demography, by month, January to August 2010, Manchester Royal Infirmary Emergency Department Month Total number Total screening Gender Age group screened Score 5 M F January February March April May June July , August , Appendix 7: Number of patients screened and screening score = 5+, and patient demography, by month, July to August 2010, North Manchester General Hospital Emergency Department Month Total number Total screening Gender Age group screened Score 5 M F Under (+) July , August , *Data provided on age was not valid for July Age was missing for two cases in August Appendix 8: Number of patients screened and screening score = 5+, and patient demography, by gender and age group August 2009 to August 2010, University Hospital of South Manchester Month Total number Total screening Gender Age group screened Score 5 M F August September October November December January February March April May June July August *Gender was missing for 21 cases. Age was missing for 278 cases. Appendix 9: Emergency department attendances categorised as assault and fall by month, October 2008 to June 2010, University Hospital of South Manchester Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Assaults Falls Appendix 10: Example template of standardised case-by-case data (with selected fields only) Case Gender Age Ethnicity Postcode Date / time of AUDIT AUDIT AUDIT Presenting attendance score Q1 score Q2 score Q3 complaint 1 Male 26 White M56 5SK Fall 2 Female 58 White M90 7UK Collapsed 3 Male 63 Asian M20 1QT Assault

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44 Authors: Michela Morleo, Gill Elliott, Gayle Whelan, Zara Quigg Centre for Public Health Research Directorate Faculty of Health and Applied Social Sciences Liverpool John Moores University 2nd Floor, Henry Cotton Campus Webster Street Liverpool L3 2ET Tel: Published: September 2011 ISBN: (web version) A report commissioned by: