Prescribing for substance misuse: alcohol detoxification

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

Contents List of Figures... 3 List of Tables... 4 Executive Summary... 5 Introduction... 15 Method... 19 National Level Results... 20 Trust Level Results... 42 Clinical Team Level Results... 53 Appendix A: Patient demographic and clinical characteristics... 59 Appendix B: Data control... 65 Appendix C: Participating Trusts... 66 Appendix D: Audit data collection tool... 67 Appendix E: POMH-UK Topic 14a project team and expert advisors... 71 Appendix F: References... 72 2

List of Figures Figure 1: Performance in the national sample and your Trust against audit standard 1 assessments and other assessments during admission for alcohol detoxification.... 7 Figure 2: Performance in the national sample and your Trust against audit standard 2 assessments during admission for alcohol detoxification... 8 Figure 3: Performance in the national sample and your Trust against audit standard 5 during admission for alcohol detoxification.... 10 Figure 4: Completion of prescribed alcohol detoxification regimen in the national sample and your Trust.... 10 Figure 5: Distribution of daily alcohol consumption (units) of the total sample and whether alcohol detoxification regimen was completed... 38 Figure 6: Proportion of patients who had a documented assessment of drinking history at admission... 44 Figure 7: Proportion of patients who had a documented physical assessment at admission... 45 Figure 8: Proportion of patients who had documented assessments of the signs and symptoms of Wernicke s encephalopathy... 46 Figure 9: Proportion of patients who had a documented breath alcohol measurement... 47 Figure 10: Proportion of patients who had documented liver function tests during admission... 48 Figure 11: Proportion of patients who were prescribed medication recommended by NICE for managing symptoms of acute alcohol withdrawal... 50 Figure 12: Proportion of patients who had thiamine prescribed parenterally... 51 Figure 13: Proportion of patients whose alcohol detoxification was completed as planned... 52 Figure 14: Proportion of patients who had a documented assessment of drinking history at admission.. 54 Figure 15: Proportion of patients who had a documented physical assessment at admission... 55 Figure 16: Proportion of patients who had documented assessments of the signs and symptoms of Wernicke s encephalopathy... 55 Figure 17: Proportion of patients who had documented liver function tests during admission... 56 Figure 18: Proportion of patients who were prescribed medication recommended by NICE for managing symptoms of acute alcohol withdrawal... 57 Figure 19: Proportion of patients who had thiamine prescribed parenterally... 58 Figure 20: Gender distribution of patients in each Trust and the total national sample... 59 Figure 21: Patients' self assigned ethnicity in each Trust and the total national sample... 60 Figure 22: Distribution of age groups in each Trust and the total national sample... 61 Figure 23: Nature of admission for alcohol detoxification of patients in each Trust and the total national sample... 62 Figure 24: Proportion of patients under general (non-specialist) and specialist psychiatric care during treatment for alcohol detoxification in each Trust and the total national sample... 63 Figure 25: Mental Health Act status of patients in each Trust and the total national sample... 64 3

List of Tables Table 1: Prescribing for substance misuse: alcohol detoxification: Quality Improvement Programme participation... 5 Table 2: Demographic characteristics of the total national sample... 20 Table 3: Clinical service providing care for alcohol detoxification... 21 Table 4: Mental Health Act status at point of admission... 21 Table 5: Documented psychiatric diagnoses... 22 Table 6: Smoking status recorded on admission... 23 Table 7: Documented past history of alcohol detoxification... 24 Table 8: Documented alcohol history for planned admissions (N=462)... 25 Table 9: Documented alcohol history for unplanned admissions (N=735)... 25 Table 10: Physical examination at admission... 26 Table 11: Documented assessments for the signs and symptoms of Wernicke s encephalopathy.. 27 Table 12: Documented assessments for the signs and symptoms of Wernicke s encephalopathy in non-specialist and specialist care... 28 Table 13: Standardised assessments/rating scales used during initial assessment... 28 Table 14: Documented measures within the first 24 hours of admission... 29 Table 15: Laboratory investigations documented at initial assessment... 30 Table 16: Type of benzodiazepine detoxification regimen prescribed... 31 Table 17: Starting daily dose for prescribed drugs to treat the symptoms of acute alcohol withdrawal... 32 Table 18: Other drugs initiated during alcohol detoxification... 33 Table 19: Documented brief intervention... 34 Table 20: Prescription of thiamine in non-specialist and specialist care... 35 Table 21: Specialist advice sought during admission under non-specialist and specialist care... 36 Table 22: Completion of alcohol detoxification regimen... 37 Table 23: Medication for relapse prevention prescribed at the point of discharge... 39 Table 24: Provisions for continuing management of alcohol use/alcohol-related problems at discharge in non-specialist and specialist care... 40 Table 25: Provisions for continuing management of alcohol use/alcohol-related problems at discharge in planned and unplanned care... 41 Table 26: Number of clinical teams and patient records audited from participating Trusts at baseline.... 42 4

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

Audit standards and treatment targets The audit standards shown below were derived from the NICE clinical guidelines on alcohol-use disorders (NICE CG100, 2010 and CG115, 2011). Clinical practice standards for the audit 1. The decision to undertake acute alcohol detoxification of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake b. A physical examination, carried out on admission 2. Blood tests relevant to the identification of alcohol-related physical health problems (e.g. liver function tests including GGT, albumin, full blood count, glucose and renal function tests) should be carried out during the admission 3. Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine, carbamazepine or clomethiazole (derived from NICE CG 100, 1.1.3.1 and NICE CG115, 1.3.5.3) 4. Phenytoin should not be prescribed to prevent or treat alcohol withdrawal seizures (NICE CG 100, 1.1.5.3 and BAP evidence-based guidelines for the pharmacological management of substance abuse, 2012) 5. Thiamine should be prescribed parenterally for inpatients in acute alcohol withdrawal These audit standards were agreed by expert advisors to POMH-UK, and have been primarily extrapolated from relevant recommendations in the NICE guidelines referenced above. In some cases, the evidence for practice recommendations falls short of supporting an audit standard, i.e. being applicable in 100% of cases. However, the evidence may be sufficient to support general guidance for good practice, allowing that deviation may be appropriate in a proportion of cases. For such treatment targets, clinicians may be particularly interested in how their practice benchmarks with their peers. Treatment targets 1. Breath alcohol should be measured as part of the initial assessment for alcohol detoxification (derived from NICE CG 115, recommendation 1.2.2.9). 2. Following alcohol detoxification, initiation of relapse prevention medication should be considered (NICE CG 115, 1.3.6.1). 3. After alcohol detoxification, referral to specialist alcohol services for continuing management and support should be considered (derived from NICE CG 115, 1.3.6.2 and 1.3.6.3, and NICE Quality Standard for Alcohol Dependence and Harmful Alcohol Use, QS 11 statement 3). Benchmarked data on Trust performance are presented for treatment target 1 as this directly relates to prescribing practice for alcohol detoxification. Data for treatment targets 2 and 3 are only presented at national level. 6

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

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

Audit standards 3 & 4: Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine, carbamazepine or clomethiazole (derived from NICE CG 100, 1.1.3.1 and NICE CG115, 1.3.5.3). Phenytoin should not be prescribed to prevent or treat alcohol withdrawal seizures (NICE CG 100, 1.1.5.3 and BAP evidence-based guidelines for the pharmacological management of substance abuse, 2012). Audit standards 3 and 4 were met in almost all cases. See Tables 17 and 18 for analysis relating to these standards. 9

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

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

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

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

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

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

Acute alcohol withdrawal, if untreated or sub-optimally managed, can be a life threatening condition with a risk of grand mal seizures, delirium tremens, and in extreme cases, preventable deaths. Also in the absence of adequate prophylaxis with thiamine, there is a risk of a rare but serious complication of Wernicke s encephalopathy, which can lead to permanent brain damage in the form of Korsakoff syndrome. Adequate management of alcohol withdrawal requires clinicians to be competent in diagnosis of alcohol dependence and the alcohol withdrawal syndrome, prescribing of medications, and monitoring of response to treatment. Once alcohol withdrawal has been completed, there is an opportunity to prevent relapse through advice and counselling, medication prescribing and referral to specialist alcohol services. The NICE guidelines set out evidence-based methods for clinical management during alcohol withdrawal and beyond. This national audit of the management of alcohol withdrawal for mental health inpatients examines all aspects of clinical assessment and management against NICE guidelines and quality standards. It is intended that this first national audit of alcohol withdrawal will provide a benchmark against which a national quality improvement programme can be developed. Further reading NICE (2010) Alcohol-Use Disorders: Diagnosis and Clinical Management of Alcohol- Related Physical Complications. Clinical Guideline 100. London: NICE. NICE (2011a) Alcohol-Use Disorders: Diagnosis, assessment and Management of Harmful Drinking and Alcohol Dependence. Clinical Guideline 115. London: NICE. NICE (2011b) Alcohol Dependence and Harmful Alcohol Use Quality Standard. Quality Standard 11. London NICE. Schuckit, MA (2009) Alcohol-use disorders. Lancet, 373(9662), 492-501. 16

Clinical practice standards 1 for the audit 12 1. The decision to undertake acute alcohol detoxification of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake b. A physical examination, carried out on admission 2. Blood tests relevant to the identification of alcohol-related physical health problems (e.g. liver function tests including GGT, albumin, full blood count, glucose and renal function tests) should be carried out during the admission 3. Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine, carbamazepine or clomethiazole (derived from NICE CG 100, 1.1.3.1 and NICE CG115, 1.3.5.3). 4. Phenytoin should not be prescribed to prevent or treat alcohol withdrawal seizures (NICE CG 100, 1.1.5.3 and BAP evidence-based guidelines for the pharmacological management of substance abuse, 2012). 5. Thiamine should be prescribed parenterally for inpatients in acute alcohol withdrawal These audit standards were primarily extrapolated from relevant recommendations in the NICE guidelines referenced above and have been agreed by expert advisors to POMH-UK. In some cases, the evidence for practice recommendations falls short of supporting an audit standard, i.e. being applicable in 100% of cases. However, the evidence may be sufficient to support general guidance for good practice, allowing that deviation may be appropriate in a proportion of cases. For such treatment targets, clinicians may be particularly interested in how their practice benchmarks with their peers. Treatment targets 2 For this QIP, there are three such treatment targets: 1. Breath alcohol should be measured as part of the initial assessment for alcohol detoxification (derived from NICE CG 115, recommendation 1.2.2.9). 2. Following alcohol detoxification, initiation of relapse prevention medication should be considered (NICE CG 115, 1.3.6.1). 3. After alcohol detoxification, referral to specialist alcohol services for continuing management and support should be considered (derived from NICE CG 115, 1.3.6.2 and 1.3.6.3, and NICE Quality Standard for Alcohol Dependence and Harmful Alcohol Use, QS 11 statement 3). Benchmarked data on Trust performance is presented for treatment target 1 as this directly relates to prescribing practice for alcohol detoxification. Data for treatment targets 2 and 3 are only presented at national level. 1 The standards have been derived from the following references: 1. National Institute for Health and Clinical Excellence. Diagnosis and clinical management of alcohol-related physical complications. NICE clinical guideline 100, 2010. http://www.nice.org.uk/guidance/cg100 2. National Institute for Health and Clinical Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE clinical guideline 115, 2011. http://www.nice.org.uk/guidance/cg115 3. Lingford-Hughes, Anne R., et al. BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. Journal of Psychopharmacology 26.7 (2012): 899-952. 2 The treatment targets have also been derived from NICE CG 115, and in addition: 1. National Institute for Health and Clinical Excellence. Alcohol dependence and harmful alcohol use quality standard. NICE quality standards QS11, 2011. Quality statement 3: Referral to specialist alcohol services. http://www.nice.org.uk/guidance/qs11/chapter/quality-statement-3-referral-to-specialist-alcohol-services 17

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

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

National Level Results Patient demographic and clinical characteristics The table below provides demographic information on the total national sample of patients who were admitted for alcohol detoxification. The table also shows the characteristics of the sub-samples of those patients whose admission for alcohol detoxification was either planned or unplanned. Of those under the care of a general adult psychiatrist (non-specialist), 16% of admissions for alcohol detoxification were planned. The respective figure for those under the care of a specialist in alcohol detoxification was 93%. Table 2: Demographic characteristics of the total national sample Key demographic characteristics Gender Ethnicity Age Sub-sample of patients whose admission for alcohol detoxification was planned Baseline N=1,197 Sub-sample of patients whose admission for alcohol detoxification was unplanned Total sample All patients who were admitted for alcohol detoxification N = 462 (39%) N = 735 (61%) N = 1,197 n (% of subsamplesample) n (% of sub- n (% of total sample) Female 162 (35%) 205 (28%) 367 (31%) Male 300 (65%) 530 (72%) 830 (69%) White British/Irish or White Other 408 (88%) 624 (85%) 1,032 (86%) Black/Black British 4 (1%) 25 (3%) 29 (2%) Asian/Asian British 9 (2%) 13 (2%) 22 (2%) Mixed 6 (1%) 5 (1%) 11 (1%) Other ethnic group 3 (1%) 15 (2%) 18 (2%) Not stated/refused 14 (3%) 23 (3%) 37 (3%) Not collected 18 (4%) 30 (4%) 48 (4%) Median age in years 44 44 44 Range (min max): years 19-73 19-78 19-78 Age bands 18-30 years 40 (9%) 87 (12%) 127 (11%) 31-40 years 145 (31%) 199 (27%) 344 (29%) 41-50 years 159 (34%) 263 (36%) 422 (35%) 51-60 years 100 (22%) 143 (19%) 243 (20%) 61+ years 18 (4%) 43 (6%) 61 (5%) The demographic characteristics of the two sub-samples are similar. 20

Table 3: Clinical service providing care for alcohol detoxification Alcohol detoxification was overseen by a specialist in less than a third of cases. Baseline N=1,197 Sub-sample of patients whose admission for alcohol detoxification was planned Sub-sample of patients whose admission for alcohol detoxification was unplanned Total sample All patients who were admitted for alcohol detoxification Clinical service providing care Acute adult psychiatric ward - detoxification overseen by a nonspecialist adult psychiatrist Acute adult psychiatric ward - detoxification overseen by a specialist in alcohol/substance misuse Psychiatric intensive care ward (PICU) - detoxification overseen by a non-specialist adult psychiatrist Psychiatric intensive care ward (PICU) - detoxification overseen by a specialist in alcohol/substance misuse N = 462 (39%) n (% of subsample) N = 735 (61%) n (% of subsample) N = 1,197 n (% of total sample) 139 (30%) 694 (94%) 833 (70%) 321 (69%) 24 (3%) 345 (29%) 0 (0%) 15 (2%) 15 (1%) 2 (<1%) 2 (<1%) 4 (<1%) Table 4: Mental Health Act status at point of admission In just under a quarter of unplanned admissions, the patient was either detained under the Mental Health Act or brought to hospital by the police (Section 136). This is in contrast to planned admissions, where the vast majority of patients were informal. Sub-sample of patients whose admission for alcohol detoxification was planned Baseline N=1,197 Sub-sample of patients whose admission for alcohol detoxification was unplanned Total sample All patients who were admitted for alcohol detoxification Mental health act status N = 1,197 N = 735 (61%) N = 462 (39%) n (% of n (% of n (% of total subsample) subsample) sample) Informal 446 (97%) 569 (77%) 1,015 (85%) Via Section 136 1 (<1%) 65 (9%) 66 (6%) Formal - recall from Community Treatment Order (CTO) 1 (<1%) 3 (<1%) 4 (<1%) Other formal (e.g. detention under the Mental Health Act, 14 (3%) 98 (13%) 112 (9%) Section 2 or 3) 21

Table 5: Documented psychiatric diagnoses Table 5 reflects the diversity in the clinical coding of patients in this sample. There was no clinical coding related to alcohol use in 15% of cases. This may have implications for care planning and the information that is communicated to the patient s GP 3. There was a higher prevalence of mental illness and personality disorder in those whose admission was unplanned. Documented psychiatric diagnoses: ICD-10 Sub-sample of patients whose admission for alcohol detoxification was planned N = 462 (39%) n (% of subsample) Baseline N=1,197 Sub-sample of patients whose admission for alcohol detoxification was unplanned N = 735 (61%) n (% of subsample) Total sample All patients who were admitted for alcohol detoxification N = 1,197 n (% of total sample) Psychiatric disorders Mental and behavioural disorders due to use of alcohol (F10) 430 (93%) 590 (80%) 1,020 (85%) Mood disorder, other than bipolar affective disorder (F30-F39) 51 (11%) 135 (18%) 186 (16%) Bipolar affective disorder (F31) 8 (2%) 28 (4%) 36 (3%) Personality disorder (F60-F69) 27 (6%) 117 (16%) 144 (12%) Schizophrenia spectrum disorder (F20-F29) 14 (3%) 98 (13%) 112 (9%) Alcohol/substance misuse disorders Mental and behavioural disorders due to use of opioids (F11) 72 (16%) 37 (5%) 109 (9%) Mental and behavioural disorders due to multiple drug use and use of other psychoactive 9 (2%) 66 (9%) 75 (6%) substances (F19) Mental and behavioural disorders due to use of tobacco (F17) 25 (5%) 39 (5%) 64 (5%) Alcohol-related liver disease (K70.9) 23 (5%) 24 (3%) 47 (4%) Mental and behavioural disorders due to use of cannabinoids (F12) 7 (2%) 38 (5%) 45 (4%) Mental and behavioural disorders due to use of cocaine (F14) 5 (1%) 15 (2%) 20 (2%) Benzodiazepine dependence (F13.2) 11 (2%) 7 (1%) 18 (2%) Korsakoff syndrome 4 (1%) 7 (1%) 11 (1%) Delirium tremens 5 (1%) 4 (1%) 9 (1%) Wernicke's encephalopathy (E51.2) 3 (1%) 2 (<1%) 5 (<1%) Other disorders Epilepsy (G40) 6 (1%) 4 (1%) 10 (1%) Neurotic, stress related and somatoform disorders (F40-48) 14 (3%) 82 (11%) 96 (8%) Other behavioural syndromes associated with physiological disturbances and physical factors 3 (1%) 3 (<1%) 6 (1%) (F50-59) Organic mental disorder (F00-F09) 1 (<1%) 4 (1%) 5 (<1%) ADHD (F90) 3 (1%) 1 (<1%) 4<1%) Traumatic brain injury (S06-S07) 2 (<1%) 2 (<1%) 4 (<1%) Sleep disorders (G47) 1 (<1%) 1 (<1%) 2 (<1%) Other 5 (1%) 11 (1%) 16 (1%) 3 It may also lead to an under-estimate of clinical activity by managers and commissioners. 22

Initial assessment Table 6: Smoking status recorded on admission The NICE guidelines for Alcohol dependence and harmful alcohol use (pg. 32, CG115) recommend that: 1.3.8.4 For comorbid alcohol and nicotine dependence, encourage service users to stop smoking and refer to 'Brief interventions and referral for smoking cessation in primary care and other settings'. These data suggest that there is a low level of recording of smoking status on admission for alcohol detoxification, which must be seen as a missed opportunity for appropriate intervention, considering the morbidity and mortality related to smoking in this population. Smoking status Sub-sample of patients whose admission for alcohol detoxification was planned N = 462 (39%) n (% of subsample) Baseline N=1,197 Sub-sample of patients whose admission for alcohol detoxification was unplanned N = 735 (61%) n (% of subsample) Total sample All patients who were admitted for alcohol detoxification N = 1,197 n (% of total sample) Recorded 271 (59%) 485 (66%) 756 (63%) Not recorded 191 (41%) 250 (34%) 441 (38%) 23

Table 7: Documented past history of alcohol detoxification In a quarter of cases, this was the first known alcohol detoxification, while more than 1 patient in 20 had been detoxified from alcohol on at least 5 previous occasions. Where the admission was unplanned, there was no documentation of whether or not this was the first detoxification in more than a third of cases, compared with less than a fifth where the admission was planned. Such information is central to generating an effective clinical management plan. Documentation of previous detoxifications Sub-sample of patients whose admission for alcohol detoxification was planned Baseline N=1,197 Sub-sample of patients whose admission for alcohol detoxification was unplanned Total sample All patients who were admitted for alcohol detoxification N = 462 N = 735 (39%) (61%) N = 1,197 n (% of subsamplesample) n (% of sub- n (% of total sample) 1-4 previous alcohol detoxifications 224 (48%) 270 (37%) 494 (41%) 5 or more previous alcohol detoxifications 34 (7%) 40 (5%) 74 (6%) First known alcohol detoxification 130 (28%) 175 (24%) 305 (25%) Not documented 74 (16%) 250 (34%) 324 (27%) 24

Audit standard 1: The decision to undertake acute alcohol detoxification of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake (derived from NICE CG 115, recommendation 1.3.4.5) b. A physical examination, carried out on admission (derived from NICE CG 115, 1.2.2.10). During the initial assessment, there was no documented information regarding alcohol history for 22% (n=260) of the TNS. Documentation of alcohol history was considerably closer to the audit standard when the admission was planned. Table 8: Documented alcohol history for planned admissions (N=462) Sub-sample of patients whose admission for alcohol detoxification was planned N = 462 (39%) Number of cases where this information was Type of information documented Median Range unknown Alcohol history Number of years since alcohol use problem was first identified Number of months of harmful drinking on this occasion Number of units of alcohol consumed each day n (% of subsample) 11 <1-58 130 (28%) 12 <1-456 174 (38%) 29 1-112 49 (11%) Table 9: Documented alcohol history for unplanned admissions (N=735) Sub-sample of patients whose admission for alcohol detoxification was unplanned N = 735 (61%) Number of cases where this information was Type of information documented Median Range unknown Alcohol history Number of years since alcohol use problem was first identified Number of months of harmful drinking on this occasion Number of units of alcohol consumed each day n (% of total sample) 10 <1-50 474 (65%) 3 <1-193 477 (65%) 28 2-100 252 (34%) 25

Table 10: Physical examination at admission On admission to the ward, there was a documented physical examination in the vast majority (88%) of cases. Physical examination Baseline N=1,197 Total sample All patients who were admitted for alcohol detoxification N = 1,197 n (% of total sample) Documented on 1,053 (88%) admission Not documented 115 (10%) Patient declined physical 29 (2%) examination 26

Table 11: Documented assessments for the signs and symptoms of Wernicke s encephalopathy Untreated Wernicke s encephalopathy can lead to permanent brain damage (Korsakoff syndrome). Documentation of assessment of at least one sign or symptom of Wernicke s encephalopathy was recorded for 752 (63%) patients in the total sample. Of these 752, 111 (15%) had at least one sign and symptom of Wernicke s encephalopathy present. This suggests that of the 445 (37%) patients where assessments for the signs and symptoms of Wernicke s encephalopathy were not documented, up to 67 may have screened positive for at least one sign or symptom of Wernicke s encephalopathy. The table below shows that all three signs and symptoms of Wernicke s encephalopathy were assessed in approximately a third of patients in the total sample. Signs and symptoms assessed (total n of cases, % of TNS) 1 documented assessment = 153 (13%) Baseline N=1,197 2 documented assessments = 154 (13%) 3 documented assessments 0 documented assessments Orientation/confusion Ataxia Ophthalmoplegia and/or nystagmus Total number of cases n (% of TNS) 128 (11%) 12 (1%) 13 (1%) 95 (8%) 30 (3%) 29 (2%) 445 (37%) 445 (37%) Teams that submitted data for twelve or more cases were more likely than teams that submitted data for five or fewer cases to have documented neurological assessments related to the detection of Wernicke s encephalopathy. One possible explanation for this is that the former teams had greater clinical experience in providing care for patients with alcohol problems and were more familiar with the potential complications of alcohol detoxification. 27

Table 12: Documented assessments for the signs and symptoms of Wernicke s encephalopathy in non-specialist and specialist care The table below shows that all three assessments were more likely to be done in specialist care than non-specialist care. Whether or not the admission for detoxification was planned or unplanned did not seem to have a strong influence on the assessment of Wernicke s encephalopathy. Number of signs and symptoms assessed None Baseline N=1,197 1-2 documented assessments 3 documented assessments Sub-sample of patients who were admitted under non-specialist care (acute or PICU) N=848 (71%) Sub-sample of patients who were admitted under specialist care (acute or PICU) N (% of subsample) N (% of subsample) N (% of subsample) 374 (44%) 229 (27%) 245 (29%) 71 (20%) 78 (22%) 200 (57%) N=349 (29%) Table 13: Standardised assessments/rating scales used during initial assessment The CIWA-Ar (Sullivan et al., 1989), SADQ (Stockwell et al., 1983) and AUDIT (Saunders et al., 1993) are all standardised assessments/scales recommended in the NICE Alcohol dependence and harmful use guideline CG 115 4. There was no documented use of any of these standardised tools in 58% of cases. Baseline N=1,197 Total sample All patients who were Standard assessments/rating scales admitted for alcohol detoxification N = 1,197 n (% of total sample) CIWA-Ar (prior to starting detoxification regimen) 170 (14%) CIWA-Ar (during detoxification regimen) 170 (14%) SADQ 113 (9%) AUDIT 80 (7%) APQ 11 (1%) LDQ 7 (1%) None of the above 690 (58%) Other 65 (5%) 4 Details of these assessments/rating scales can be found in the guidance notes of the audit tool. 28

Treatment target 1: Breath alcohol should be measured as part of the initial assessment for alcohol detoxification (derived from NICE CG 115, recommendation 1.2.2.9). Only 22% (265) of the TNS had their breath alcohol measurement documented. This suggests that breath alcohol measurement is not part of routine physical examination. While the absolute breath alcohol measurement does not directly influence the clinical management plan, it is important to ascertain whether this is continuing to rise or has peaked and is now falling. Table 14: Documented measures within the first 24 hours of admission Baseline N=1,197 Documented measure Total sample All patients who were admitted for alcohol detoxification N = 1,197 n (% of total sample) Pulse rate 1,073 (90%) BP 1,068 (89%) Breath alcohol measurement 265 (22%) 29

Audit standard 2: Blood tests relevant to the identification of alcohol-related physical health problems (e.g. liver function tests including GGT, albumin, full blood count, glucose and renal function tests) should be carried out during the admission (derived from NICE CG 115, 1.2.2.10). There was little difference in the documentation of laboratory investigations between specialist and non-specialist services with the exception of GGT which was more likely to be documented in the former. Given that the majority of planned admissions were under specialist care, the documentation of GGT was also more often seen in planned admissions compared with unplanned. Table 15: Laboratory investigations documented at initial assessment Type of laboratory investigation documented Sub-sample of patients who were admitted under nonspecialist care (acute or PICU) Baseline N=1,197 Sub-sample of patients who were admitted under specialist care (acute or PICU) Total sample All patients who were admitted for alcohol detoxification N= 848 (71%) N= 349 (29%) N = 1,197 n (% of lab n (% of lab n (% of total investigation) investigation) sample) Liver function tests 671 (79%) 301 (86%) 972 (81%) GGT 394 (46%) 263 (75%) 657 (55%) Clotting (PT, PTT or INR) 294 (35%) 86 (25%) 380 (32%) Albumin 612 (72%) 277 (79%) 889 (74%) FBC 687 (81%) 286 (82%) 973 (81%) MCV 598 (71%) 278 (80%) 876 (73%) Renal function tests 672 (79%) 284 (81%) (U&Es) 956 (80%) Glucose 424 (50%) 161 (46%) 585 (49%) None of the above were 137 (16%) 44 (13%) recorded 181 (15%) [Note: Some laboratories report GGT and/or albumin as part of routine LFTs, whereas others do not]. 30

During admission Table 16: Type of benzodiazepine detoxification regimen prescribed Type of benzodiazepine detoxification regimen Sub-sample of patients who were admitted under nonspecialist care (acute or PICU) Baseline N=1,197 Sub-sample of patients who were admitted under specialist care (acute or PICU) Total sample All patients who were admitted for alcohol detoxification N = 1,197 N= 848 (71%) N=349 (29%) n (% of N) n (% of N) n (% of total sample) 600 (71%) 320 (92%) 920 (77%) Fixed-dose reducing regimen Symptom triggered 174 (21%) 6 (2%) 180 (15%) Front loading 16 (2%) 12 (3%) 28 (2%) Unclear 58 (7%) 11 (3%) 69 (6%) A fixed-dose reducing regimen was used in the majority of cases. The NICE guideline 115 recommends [1.3.5.2] the use of fixed-dose or symptom-triggered medication regimens in assisted withdrawal programmes in inpatient or residential settings. If a symptom-triggered regimen is used, all staff should be competent in monitoring symptoms effectively and the unit should have sufficient resources to allow them to do so frequently and safely. One implication of this recommendation is that symptom-triggered programmes are less suitable for use in non-specialist settings although, as can be seen in the table above, that is where they were most commonly used. Of the total sample, 3% (31) patients were transferred to a medical bed because of complications associated with alcohol use of withdrawal. Of this 3%, 22 (71% of those transferred to a medical bed) were under the care of non-specialist services. 31

Audit standard 3: Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine, carbamazepine or clomethiazole (derived from NICE CG 100, 1.1.3.1 and NICE CG 115, 1.3.5.3). Table 17: Starting daily dose for prescribed drugs to treat the symptoms of acute alcohol withdrawal Type of drug Benzodiazepine Total national sample n (%) Chlordiazepoxide 1,025 (86%) Diazepam 216 (18%) Lorazepam 132 (11%) Oxazepam 15 (1%) Other benzodiazepine* Carbamazepine 2 (0.2%) Baseline N=1,197 Dose: range & median 5-300mg, 100mg 2-160mg, 25mg 1-16mg, 4mg 40-160mg, 120mg 16 (1%) - 600-800mg, 700mg Clomethiazole - - Dose: range & median (PRN) 5-600mg, 40mg 0.5-240mg, 20mg 0.5-20mg, 4mg 5-80mg, 20mg - None of the above 71 (6%) - - *Other benzodiazepines prescribed included temazepam, nitrazepam, and clonazepam. - - 32

Audit standard 4: Phenytoin should not be prescribed to prevent or treat alcohol withdrawal seizures (NICE CG 100, 1.1.5.3 and BAP evidence-based guidelines for the pharmacological management of substance abuse, 2012). Less than 0.5% of TNS were prescribed phenytoin. Diagnoses of the two cases prescribed phenytoin: Case 1: Wernicke's encephalopathy, Korsakoff syndrome Case 2: Mental and behavioural disorders due to use of alcohol, epilepsy Table 18: Other drugs initiated during alcohol detoxification Type of drug Sub-sample of patients who were admitted under nonspecialist care (acute or PICU) Baseline N=1,197 Sub-sample of patients who were admitted under specialist care (acute or PICU) Total sample All patients who were admitted for alcohol detoxification N= 848 N=349 N = 1,197 Acamprosate 110 (13%) 140 (40%) 250 (21%) An antidepressant 152 (18%) 35 (10%) 187 (16%) An antipsychotic 99 (12%) 5 (1%) 104 (9%) Nicotine replacement 23 (3%) 21 (6%) therapy 44 (4%) Phenytoin 1 (<1%) 1 (<1%) 2 (<1%) None of the above 528 (62%) 175 (50%) 703 (59%) The NICE guidelines do not recommend prescribing antidepressants at initiation of alcohol detoxification but this was the case in 16% (187) of patients in the total sample. Patients under the care of a specialist were more likely to be prescribed medication for the maintenance of abstinence and less likely to have an antipsychotic or antidepressant initiated during detoxification. Note that the prevalence of comorbid psychotic illness was lower in those patients under specialist care. The prevalence of smoking in this population would be expected to be high, however a relatively low proportion of patients was prescribed nicotine replacement therapy. 33

Table 19: Documented brief intervention There is evidence that a brief discussion led by a healthcare professional addressing the harms that alcohol has or can potentially cause can reduce alcohol consumption, for example directly sharing the results of liver function tests. Such a brief intervention was documented in less than half of the total sample. This may reflect a simple failure to document activity, although it could reflect that discussing with the patient the health consequences associated with excessive alcohol use and advice to cut down their intake was not consistently recognised as a discrete brief intervention. Alternatively, it may partly reflect that such an intervention is not occurring routinely due to a lack of staff skills or a failure to appreciate the value of this simple advice. Brief intervention Total sample All patients who were admitted for alcohol detoxification N = 1,197 Documented 505 (42%) Not documented 692 (58%) 34

Audit standard 5: Thiamine should be prescribed parenterally for inpatients in acute alcohol withdrawal (derived from NICE CG 100, 1.2.1.3, NICE CG 115 1.3.8.5, NICE Quality Standard for Alcohol Dependence and Harmful Alcohol Use, QS 11 statement 10 and BAP evidencebased guidelines for the pharmacological management of substance abuse, 2012). Table 20: Prescription of thiamine in non-specialist and specialist care Prescription of thiamine Sub-sample of patients who were admitted under nonspecialist care (acute or PICU) Baseline N=1,197 Sub-sample of patients who were admitted under specialist care (acute or PICU) Total sample All patients who were admitted for alcohol detoxification Daily intake of alcohol in units (median, range) N = 1,197 N= 848 (71%) N=349 (29%) Parenteral Prescribed IM, followed 325 (38%) 223 (64%) 548 (46%) 28, 4-112 by oral Prescribed IM only 78 (9%) 7 (2%) 85 (7%) 28, 6-80 Prescribed IV, followed by oral 10 (1%) 41 (12%) 51 (4%) 30, 7-70 Prescribed IV only 4 (0%) 0 (0%) 4 (<1%) 45, 8-82 Oral Prescribed orally only 359 (42%) 64 (18%) 423 (35%) 28, 4-100 Not prescribed 72 (8%) 14 (4%) 86 (7%) 18, 1-60 Those patients under the care of specialist services were more likely to be prescribed parenteral thiamine than those patients under the care of a general adult psychiatrist (approximately three-quarters and half of the respective subsamples). The data indicate that recent daily alcohol consumption was slightly lower in those patients who were not prescribed thiamine in any formulation. Of the 57% (N=688) that were prescribed thiamine parenterally, 17% (117) refused doses. Refusal may be due in part to the painful nature of parenteral administration of thiamine. While some of the discomfort is due to the volume injected and cannot be avoided, some amelioration may be possible if the medication is removed from the refrigerator and brought to room temperature before injecting. In the total national sample, 5 patients had a diagnosis of Wernicke s encephalopathy, 11 Korsakoff syndrome and 9 delirium tremens. The median number of parenteral doses of thiamine administered were 5 (range: 5-5), 7 (4-8) and 3 (1-20) respectively, which is inadequate for Wernicke s encephalopathy and represents low dosage for the other two conditions. 35

Table 21: Specialist advice sought during admission under non-specialist and specialist care Advice from a physician was sought for just under 20% of the total sample, three-quarters of whom were under the care of a general adult psychiatrist. This suggests that some alcohol detoxifications undertaken in general adult mental health settings are medically complex. Type of specialist advice sought Sub-sample of patients who were admitted under nonspecialist care (acute or PICU) Baseline N=1,197 Sub-sample of patients who were admitted under specialist care (acute or PICU) Total sample All patients who were admitted for alcohol detoxification N = 1,197 N= 848 (71%) N=349 (29%) n (% of N) n (% of N) n (% of total sample) Addiction 102 (12%) 163 (47%) 265 (22%) Medical 151 (18%) 49 (14%) 200 (17%) Alcohol liaison 65 (8%) 15 (4%) 80 (7%) Other 1 (0%) 0 (0%) 1 (0%) None of the above 557 (66%) 131 (38%) 688 (57%) Transfer to inpatient medical care Of the total sample, 7% were transferred to a medical bed during admission. Whether or not a patient was transferred to a medical bed was not related to whether they were under the care of a specialist or non-specialist or whether the admission was planned or unplanned. Transfer because of complications of alcohol use or withdrawal were slightly less common than transfer for other medical reasons. 36

NICE guidelines recommend that in a fixed-dose detoxification regimen, the dose should be reduced over a maximum of 10 days. The duration of the alcohol detoxification regimen in the total national sample was between 1-70 days (median 7 days); in 11% (N=137), the duration of the regimen was over 10 days. In 4% (48) of cases, the length of the alcohol detoxification regimen was unknown. Table 22: Completion of alcohol detoxification regimen Completion of alcohol detoxification regimen Sub-sample of patients who were admitted under nonspecialist care (acute or PICU) Baseline N=1,197 Sub-sample of patients who were admitted under specialist care (acute or PICU) Total sample All patients who were admitted for alcohol detoxification N= 848 (71%) N=349 (29%) N = 1,197 n (% of N) n (% of N) n (% of total sample) Yes, completed as planned 682 (80%) 314 (90%) 996 (83%) No, patient declined detoxification medication and/or selfdischarged 89 (10%) 22 (6%) 111 (9%) No, detoxification was terminated by medical 70 (8%) 13 (4%) 83 (7%) staff Unknown 7 (1%) 0 7 (1%) Patients who were under the care of a specialist were more likely to complete their alcohol detoxification regimen. 37

Figure 5: Distribution of daily alcohol consumption (units) of the total sample and whether alcohol detoxification regimen was completed 40% Proportion of patients 35% 30% 25% 20% 15% 10% 5% Not documented/unknown Patient declined detoxification medication and/or self-discharged Detoxification was terminated by medical staff Completed alcohol detoxificiation regimen as planned 0% 20 or less 21-40 41-60 61-80 More than 80 Unknown Daily intake of alcohol per day (units) Daily alcohol consumption (in units) was not documented in 25% of patients in the total sample. As can be seen, termination of detoxification was more common in patients consuming less than 40 units per day. 38

Treatment target 2: Following alcohol detoxification, initiation of relapse prevention medication should be considered (NICE CG 115, 1.3.6.1). Discharge Table 23: Medication for relapse prevention prescribed at the point of discharge Relapse prevention medication was more likely to be prescribed for patients who were under the care of a specialist. Type of drug Sub-sample of patients who were admitted under nonspecialist care (acute or PICU) N= 848 (71%) n (% of type of Baseline N=1,197 Sub-sample of patients who were admitted under specialist care (acute or PICU) N=349 (29%) n (% of type of Total sample All patients who were admitted for alcohol detoxification N = 1,197 n (% of total sample) drug) drug) Acamprosate 115 (14%) 133 (38%) 248 (21%) Naltrexone 4 (<1%) 10 (3%) 14 (1%) Disulfiram 14 (2%) 45 (13%) 59 (5%) Nalmefene 0 0 0 Not on any of the 720 (85%) 178 (51%) 898 (75%) relapse medication above 5 Baclofen 2 (<1%) 0 2 (<1%) Not applicable 6 17 (2%) 0 17 (1%) Following alcohol detoxification, 22 (2%) of the TNS were prescribed more than one drug for relapse prevention. 5 included thiamine, vitamin B complex tablets, benzodiazepine, z-hypnotic, carbamazepine, and others 6 patient not discharged/undue 4 weeks since detoxification 39

Treatment target 3: After alcohol detoxification, referral to specialist alcohol services for continuing management and support should be considered (derived from NICE CG 115, 1.3.6.2 and 1.3.6.3, and NICE Quality Standard for Alcohol Dependence and Harmful Alcohol Use, QS 11 statement 3). Continuing care for alcohol-related problems at discharge was most commonly provided by NHS specialist alcohol services. Patients were more likely to be referred to such services if admission for alcohol detoxification had been planned and/or they had been under the care of specialist psychiatric services. This can be seen in Table 24 and 25 below. Around 1 in 4 patients were referred on to non-nhs services, which may reflect local commissioning decisions regarding these services. Failure to document any clear plans to address future alcohol use was more common in patients whose admission was unplanned or who had been under the care of a non-specialist. Table 24: Provisions for continuing management of alcohol use/alcoholrelated problems at discharge in non-specialist and specialist care Type of service Sub-sample of patients who were admitted under nonspecialist care (acute or PICU) N= 848 (71%) Baseline N=1,197 Sub-sample of patients who were admitted under specialist care (acute or PICU) N=349 (29%) Total sample All patients who were admitted for alcohol detoxification N = 1,197 n (% of N) n (% of N) n (%) of total sample NHS specialist alcohol services 327 (39%) 270 (77%) 597 (50%) Continuing care for alcoholrelated problems provided by a mental health team 223 (26%) 41 (12%) 264 (22%) Non-NHS specialist alcohol services 162 (19%) 48 (14%) 210 (18%) Voluntary sector (e.g. Alcoholics Anonymous) 108 (13%) 20 (6%) 128 (11%) Continuing care for alcoholrelated problems provided by 56 (7%) 22 (6%) 78 (7%) the GP Continuing care for alcoholrelated problems provided by a 41 (5%) 10 (3%) 51 (4%) dual diagnosis worker/service No clear plans to address future alcohol use 140 (17%) 13 (4%) 153 (13%) Not yet been discharged 18 (2%) 1 (<1%) 19 (2%) 40

Table 25: Provisions for continuing management of alcohol use/alcoholrelated problems at discharge in planned and unplanned care Type of service Sub-sample of patients whose admission for alcohol detoxification was planned N = 462 (39%) Baseline N=1,197 Sub-sample of patients whose alcohol detoxification was unplanned N = 735 (61%) Total sample All patients who were admitted for alcohol detoxification N = 1,197 n (% of N) n (% of N) n (%) of total sample NHS specialist alcohol 315 (68%) 282 (38%) 597 (50%) services Continuing care for alcoholrelated 62 (13%) 202 (27%) 264 (22%) problems provided by a mental health team Non-NHS specialist alcohol 96 (21%) 114 (16%) 210 (18%) services Voluntary sector (e.g. 38 (8%) 90 (12%) 128 (11%) Alcoholics Anonymous) Continuing care for alcoholrelated 28 (6%) 50 (7%) 78 (7%) problems provided by the GP Continuing care for alcoholrelated 11 (2%) 40 (5%) 51 (4%) problems provided by a dual diagnosis worker/service No clear plans to address 20 (4%) 133 (18%) 153 (13%) future alcohol use Not yet been discharged 3 (1%) 16 (2%) 19 (2%) 41

Trust Level Results Analyses presented in this section were conducted for each Trust individually and for the total sample to allow benchmarking. Data from each Trust are presented by code. Your Trust code is 079 Table 26: Number of clinical teams and patient records audited from participating Trusts at baseline. Baseline 2014 Trust Teams Patients 003 5 15 005 8 22 008 3 21 009 3 9 012 1 1 013 2 21 015 2 14 016 6 54 017 3 49 018 9 156 019 1 22 020 7 9 021 7 42 022 15 49 025 3 9 027 8 52 029 5 75 034 6 21 042 3 70 050 6 8 051 7 15 054 5 17 059 3 19 062 3 15 066 4 22 068 5 27 072 1 27 073 5 27 074 4 35 077 1 2 079 4 7 080 4 19 084 1 23 085 1 1 089 7 57 090 3 15 092 2 5 094 2 12 098 2 47 100 1 10 102 2 40 104 3 28 109 1 8 TOTAL 174 1197 42

Initial assessment Audit standard 1: The decision to undertake acute alcohol detoxification of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake (derived from NICE CG 115, recommendation 1.3.4.5). b. A physical examination, carried out on admission (derived from NICE CG 115, 1.2.2.10). Audit standard 2: Blood tests relevant to the identification of alcohol-related physical health problems (e.g. liver function tests including GGT, albumin and clotting, full blood count, glucose and renal function tests) should be carried out during the admission (derived from NICE CG 115, 1.2.2.10). Treatment target 1: Breath alcohol should be measured as part of the initial assessment for alcohol detoxification (derived from NICE CG 115, recommendation 1.2.2.9). 43

Figure 6: Proportion of patients who had a documented assessment of drinking history at admission 100% 90% 80% Proportion of patients 70% 60% 50% 40% 30% Not documented Documented assessment 20% 10% 0% 012 019 025 085 090 109 013 100 098 020 027 029 018 005 042 059 080 017 104 068 074 092 016 015 084 022 008 021 079 073 102 003 034 051 089 054 094 050 066 077 009 062 072 TNS Trust number The Trusts are ordered on the basis of the proportion of patients in the sample who had a documented assessment of drinking history. The proportion of patients in a Trust sample who had a documented assessment of drinking history varied from 100% to 11%. 44

Figure 7: Proportion of patients who had a documented physical assessment at admission 100% 90% Proportion of patients 80% 70% 60% 50% 40% 30% Not documented The patient declined physical examination 20% 10% Documented assessment 0% 005 012 018 019 066 085 090 092 094 098 062 073 072 084 034 102 080 022 003 051 021 027 016 013 100 059 104 009 020 068 029 109 079 008 089 042 074 015 017 025 054 050 077 TNS Trust number The Trusts are ordered on the basis of the proportion of patients in the sample who did not have a documented physical assessment. The proportion of patients in a Trust sample who did not have a documented physical assessment varied from 0% to 50%. 45

Figure 8: Proportion of patients who had documented assessments of the signs and symptoms of Wernicke s encephalopathy 100% 90% Proportion of patients 80% 70% 60% 50% 40% 30% No signs/symptoms were assessed Some signs/symptoms were assessed 20% 10% All signs/symptoms were assessed 0% 019 018 012 085 098 090 062 013 022 027 003 066 073 042 100 084 080 005 094 102 050 029 034 089 017 059 008 021 074 015 079 104 051 020 025 016 009 092 054 109 068 072 077 TNS Trust code The Trusts are ordered on the basis of the proportion of patients in the sample who did not have any documented assessments for the signs and symptoms of Wernicke s encephalopathy. The proportion of patients in a Trust sample who did not have any documented assessments for the signs and symptoms of Wernicke s encephalopathy varied from 0% to 100%. 46

Figure 9: Proportion of patients who had a documented breath alcohol measurement 100% 90% 80% Proportion of patients 70% 60% 50% 40% 30% No record Documented measure 20% 10% 0% 019 017 013 018 077 094 029 025 098 109 062 042 073 104 034 005 051 059 022 027 074 015 090 054 080 084 068 102 021 016 100 092 089 085 079 072 066 050 020 012 009 008 003 TNS Trust code The Trusts are ordered on the basis of the proportion of patients in the sample who had a documented breath alcohol measurement. The proportion of patients in a Trust sample who had a documented breath alcohol measurement varied from 100% to 0%. 47

Figure 10: Proportion of patients who had documented liver function tests during admission 100% 90% 80% Proportion of patients 70% 60% 50% 40% 30% 20% No record Documented assessment 10% 0% 003 009 012 019 077 085 090 092 094 098 018 084 015 102 100 080 050 109 089 029 005 022 034 027 074 059 016 066 062 013 017 054 072 104 020 051 021 042 073 008 079 025 068 TNS Trust code The Trusts are ordered on the basis of the proportion of patients in the sample who had documented liver function tests during admission. The proportion of patients in a Trust sample who had documented liver function tests varied from 100% to 56%. 48

During admission Audit standard 3: Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine, carbamazepine or clomethiazole (derived from NICE CG 100, 1.1.3.1 and NICE CG 115, 1.3.5.3). Audit standard 4: Phenytoin should not be prescribed to prevent or treat alcohol withdrawal seizures (NICE CG 100, 1.1.5.3 and BAP evidence-based guidelines for the pharmacological management of substance abuse, 2012). As only 2 patients were prescribed phenytoin in the total national sample, we have not provided a trust level graph for this standard. Audit standard 5: Thiamine should be prescribed parenterally for inpatients in acute alcohol withdrawal. 49

Figure 11: Proportion of patients who were prescribed medication recommended by NICE for managing symptoms of acute alcohol withdrawal 100% 90% 80% Proportion of patients 70% 60% 50% 40% 30% No medication prescribed At least one medication prescribed 20% 10% 0% 005 009 012 013 015 019 020 025 027 029 034 042 050 051 062 066 072 077 079 085 090 092 094 098 100 102 018 074 073 059 080 016 054 003 104 022 089 109 008 017 021 084 068 TNS Trust code The Trusts are ordered on the basis of the proportion of patients in the sample who were prescribed at least one drug to treat the symptoms of acute alcohol withdrawal. The proportion of patients in a Trust sample who were prescribed at least one drug to treat the symptoms of acute alcohol withdrawal varied from 100% to 0%. 50

Figure 12: Proportion of patients who had thiamine prescribed parenterally 100% 90% 80% Proportion of patients 70% 60% 50% 40% 30% Not prescribed Prescribed orally Prescribed parenterally 20% 10% 0% 012 019 085 090 016 018 098 094 104 027 080 073 042 003 079 017 013 025 072 022 077 029 074 068 059 062 021 008 005 050 102 051 066 089 084 015 054 009 092 109 034 100 020 TNS Trust code The Trusts are ordered on the basis of the proportion of patients in the sample who were prescribed thiamine parenterally. The proportion of patients in a Trust sample who were prescribed thiamine parenterally varied from 100% to 0%. 51

Figure 13: Proportion of patients whose alcohol detoxification was completed as planned 100% 90% 80% Not documented/ unknown Proportion of patients 70% 60% 50% 40% 30% Patient declined detoxification and/or self-discharged Detoxification was terminated by medical staff 20% 10% Completed alcohol detoxification regimen as planned 0% 019 059 077 085 090 092 018 003 062 072 094 013 098 009 025 073 042 016 051 027 005 074 079 068 017 029 104 084 066 054 034 050 021 008 100 102 080 020 089 109 015 012 022 TNS Trust code The Trusts are ordered on the basis of the proportion of patients whose alcohol detoxification was completed as planned. The proportion of patients in a Trust sample whose alcohol detoxification was completed as planned varied from 100% to 0%. 52

Clinical Team Level Results Analyses presented in this section were conducted for each clinical team from your Trust individually, for your total Trust sample and for the total national sample to allow benchmarking. Data from each Trust clinical team are presented by code only. The POMH-UK Central Project Team does not know the identity of individual clinical teams. Only the Local POMH lead for your Trust or organisation has the key to clinical team codes. You should contact this person if you need to identify data for your own particular clinical team. Charts in this section are ordered by frequency of key results so the position of teams in each figure will vary according to practice. 53

Initial assessment Audit standard 1: The decision to undertake acute alcohol detoxification of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake (derived from NICE CG 115, recommendation 1.3.4.5). b. A physical examination, carried out on admission (derived from NICE CG 115, 1.2.2.10). Figure 14: Proportion of patients who had a documented assessment of drinking history at admission 100% Proportion of patients 90% 80% 70% 60% 50% 40% 30% 20% 1 1 1 2 1 1 2 5 260 937 Not documented Documented assessment 10% 0% Team code 54

Figure 15: Proportion of patients who had a documented physical assessment at admission Proportion of patients 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 3 1 1 1 1 1 115 29 6 1053 No record The patient declined physical examination Documented assessment 0% Team code Figure 16: Proportion of patients who had documented assessments of the signs and symptoms of Wernicke s encephalopathy 100% Proportion of patients 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 1 1 2 1 1 4 2 1 445 307 445 No signs/symptoms were assessed Some signs/symptoms were assessed All signs/symptoms were assessed Team code 55

Audit standard 2: Blood tests relevant to the identification of alcohol-related physical health problems (e.g. liver function tests including GGT, albumin, full blood count, glucose and renal function tests) should be carried out during the admission (derived from NICE CG 115, 1.2.2.10). Figure 17: Proportion of patients who had documented liver function tests during admission 100% 90% 225 Proportion of patients 80% 70% 60% 50% 40% 30% 20% 10% 1 2 2 1 1 3 4 972 No record Documented measure 0% Team code 56

During admission Audit standard 3: Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine, carbamazepine or clomethiazole (derived from NICE CG 100, 1.1.3.1 and NICE CG 115, 1.3.5.3). Figure 18: Proportion of patients who were prescribed medication recommended by NICE for managing symptoms of acute alcohol withdrawal 100% 90% 71 Proportion of patients 80% 70% 60% 50% 40% 30% 20% 3 1 1 2 7 1126 No medication prescribed At least one medication prescribed 10% 0% Team code 57

Audit standard 5: Thiamine should be prescribed parenterally for inpatients in acute alcohol withdrawal Figure 19: Proportion of patients who had thiamine prescribed parenterally 100% 90% 86 Proportion of patients 80% 70% 60% 50% 40% 30% 20% 3 1 1 1 1 3 423 4 688 Not prescribed Prescribed orally Prescribed parenterally 10% 0% Team code 58

Appendix A: Patient demographic and clinical characteristics Figure 20: Gender distribution of patients in each Trust and the total national sample 100% 90% 80% Proportion of patients 70% 60% 50% 40% 30% Male Female 20% 10% 0% 100 066 051 089 016 015 098 073 092 059 005 054 022 021 025 034 094 042 102 080 018 008 013 019 017 084 074 027 109 020 003 062 090 104 029 068 072 050 009 012 077 079 085 TNS Trust code 59

Figure 21: Patients' self assigned ethnicity in each Trust and the total national sample 100% 90% Proportion of patients 80% 70% 60% 50% 40% 30% 20% 10% 0% 012 019 050 051 054 077 085 092 094 018 104 073 013 003 016 100 059 080 098 009 025 017 089 084 090 005 066 034 042 027 074 068 029 062 015 020 072 008 022 021 102 109 079 TNS Not collected Not stated/refused Other ethnic group Mixed Asian/Asian British Black/Black British White British/Irish or White Other Trust code 60

Figure 22: Distribution of age groups in each Trust and the total national sample 100% 90% 80% Proportion of patients 70% 60% 50% 40% 30% 20% 10% 61+ years 51-60 years 41-50 years 31-40 years 18-30 years 0% 012 020 025 051 077 085 090 094 073 005 029 054 098 003 021 016 042 066 034 102 080 089 104 009 074 018 027 109 084 019 013 015 022 079 068 072 059 017 008 092 100 062 050 TNS Trust code 61

Figure 23: Nature of admission for alcohol detoxification of patients in each Trust and the total national sample 100% 90% 80% Proportion of patients 70% 60% 50% 40% 30% Unplanned Planned 20% 10% 0% 077 090 019 098 042 017 089 018 074 016 059 094 029 073 008 021 025 015 100 022 034 079 005 062 084 050 068 066 102 003 051 013 104 009 012 020 027 054 072 080 085 092 109 TNS Trust code 62

Figure 24: Proportion of patients under general (non-specialist) and specialist psychiatric care during treatment for alcohol detoxification in each Trust and the total national sample 100% 90% 80% Proportion of patients 70% 60% 50% 40% 30% Specialist Care General Care 20% 10% 0% 019 098 017 089 042 090 018 029 059 084 021 015 062 008 022 068 003 005 009 012 013 016 020 025 027 034 050 051 054 066 072 073 074 077 079 080 085 092 094 100 102 104 109 TNS Trust code 63

Figure 25: Mental Health Act status of patients in each Trust and the total national sample 100% 90% 80% Proportion of patients 70% 60% 50% 40% 30% 20% 10% 0% 077 092 098 017 042 019 018 016 062 090 015 029 094 009 020 068 027 109 089 079 104 102 073 013 100 059 074 054 050 022 066 034 072 080 025 051 084 005 008 021 003 012 085 TNS Trust code Informal Via Section 136 Formal - recall from Community Treatment Order (CTO) Other Formal (e.g. detention under the Mental Health Act, Section 2 or 3) 64

Appendix B: Data control Data control statement for POMH-UK quality improvement programme 14a: Prescribing in substance misuse: alcohol detoxification. In line with the original memorandum of understanding between POMH-UK and member healthcare organisations (predominantly mental health NHS Trusts), the following statement outlines the agreement regarding control of the audit data in this quality improvement programme. Control of the local data submitted to POMH-UK is retained by the healthcare organisation that submitted them. These data have been made available to POMH-UK in a way that is anonymous, with the exception of the identity of the source organisation. The aggregate data from all participating organisations have been analysed by POMH-UK, to produce this customised report. This report summarises the national results, and local results at organisation and clinical team level, benchmarked anonymously against the other organisations taking part. There is a publication strategy allowing POMH-UK to publish the anonymous aggregated data on its web site and/or in appropriate scientific journals. Any requests from other organisations for the audit data will be referred to the POMH-UK reports appearing in the public domain or provided with a list of member healthcare organisations and asked to approach then individually. It is each organisation s decision whether, and with whom, to share their data. Reflection by clinical teams on their benchmarked performance is perhaps the most potent element of POMH-UK programmes. In addition to performance against the clinical standards, the audit data include demographic, diagnostic and other relevant clinical information that not only provide a context for interpretation and understanding of practice, but can also inform local strategies and systems to achieve improvement. The data collected are designed to be suitable for quality improvement purposes, and not for objective ranking of healthcare organisations, for which they are untested and would not necessarily be appropriate. 65

Appendix C: Participating Trusts The Trusts that participated in this audit are listed below in alphabetical order. Avon & Wiltshire Mental Health Partnership NHS Trust 5 Boroughs Partnership NHS Foundation Trust Abertawe Bro Morgannwg University Health Board Berkshire Healthcare NHS Foundation Trust Betsi Cadwaladr University Health Board Birmingham and Solihull Mental Health NHS Foundation Trust Bradford District Care Trust Cambridgeshire and Peterborough NHS Foundation Trust Central and North West London NHS Foundation Trust Cumbria Partnership NHS Foundation Trust Derbyshire Healthcare NHS Foundation Trust Devon Partnership Trust Dorset Healthcare University NHS Foundation Trust Dudley and Walsall Mental Health Partnership Trust East London NHS Foundation Trust Kent and Medway NHS and Social Care Partnership Trust Leeds and York Partnership NHS Foundation Trust Leicestershire Partnership NHS Trust Manchester Mental Health & Social Care NHS Trust Mersey Care NHS Trust NAViGO Health and Social Care CIC North East London NHS Foundation Trust North Essex Partnership NHS Foundation Trust North Staffordshire Combined Healthcare NHS Trust Northumberland Tyne and Wear NHS Foundation Trust Nottinghamshire Healthcare NHS Trust Oxford Health NHS Foundation Trust Oxleas NHS Foundation Trust Pennine Care NHS Foundation Trust Rotherham, Doncaster and South Humber Mental Health NHS Foundation Trust Sheffield Health & Social Care NHS Foundation Trust Solent NHS Trust Somerset Partnership NHS Foundation Trust South Essex Partnership University NHS Foundation Trust South London and Maudsley NHS Foundation Trust South Staffordshire and Shropshire Healthcare NHS Foundation Trust South West London and St George's Mental Health Trust South West Yorkshire Partnership NHS Foundation Trust Southern Health NHS Foundation Trust Sussex Partnership NHS Foundation Trust Tees, Esk and Wear Valleys NHS Foundation Trust West London Mental Health NHS Trust Worcestershire Health & Care Trust 66

Appendix D: Audit data collection tool 67

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Appendix E: POMH-UK Topic 14a project team and expert advisors POMH-UK Central Team: Professor Thomas Barnes Sonya Chee Suzie Lemmey Carol Paton Oda Skagseth Krysia Zalewska Topic 14a Expert Advisors: Professor Colin Drummond Professor Anne Lingford-Hughes Dr. Ignatius Loubser 71

Appendix F: References References Lingford-Hughes, Anne R., et al. BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. Journal of Psychopharmacology 26.7 (2012): 899-952. National Institute for Health and Clinical Excellence. Alcohol dependence and harmful alcohol use quality standard. NICE quality standards QS11, 2011. Quality statement 3: Referral to specialist alcohol services. http://www.nice.org.uk/guidance/qs11/chapter/quality-statement-3-referral-tospecialist-alcohol-services National Institute for Health and Clinical Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE clinical guideline 115, 2011. http://www.nice.org.uk/guidance/cg115 National Institute for Health and Clinical Excellence. Diagnosis and clinical management of alcohol-related physical complications. NICE clinical guideline 100, 2010. http://www.nice.org.uk/guidance/cg100 Saunders, J.B., Aasland, O.G., Babor, T.F., de la Fuente, J.R. & Grant, M. (1993). Development of the Alcohol Use Disorders Screening Test (AUDIT). WHO collaborative project on early detection of persons with harmful alcohol consumption. II. Addiction 88, 791-804. Stockwell, T., Murphy, D. & Hodgson, R. (1983). The severity of alcohol dependence questionnaire: Its use, reliability and validity. British Journal of Addiction, 78(2), 45-156. Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C.A.; and Sellers, E.M. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 84:1353-1357, 1989. 72

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