Transcript Alcohol policy: research and practice

Implementation of screening and brief
intervention in accident and emergency
departments: challenges and solutions
Paolo Deluca, PhD
Institute of Psychiatry, King’s College London
A&E St. Mary’s
'Scientia Vincit
Timorem'
AED study design
• 9 AEDs, 3 regions (NE, London, SE)
• 3 screening approaches (M-SASQ, SIPS-PAT, FAST)
• 3 intervention approaches
– Patient information leaflet
– Brief advice (5 min)
– Referral to Alcohol Health Worker BLC (20 min)
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1,179 patients (131 each)
Baseline research interview
6 & 12 month follow-up research interview
Attitudes, barriers and facilitators factors
Attitudes, barriers and facilitators factors
• The Shortened Alcohol and Alcohol Problems
Questionnaire (SAAPPQ)
• Training and experience in dealing with AUDs
• Multiple choice assessment
• Feedback questions
• Implementation questionnaire
• T1 vs T2 vs T3
How do we assess implementation?
• Number screened, positives, received
intervention
• Factors supporting implementation
• Factors impeding implementation
• Impact: individual, service, costs and benefits
• Acceptability: patient, practitioner,
commissioner
• Sustainability
Overview recruitment
• Recruited 9 A&Es – Royal Ham., St Thomas,
King’s, North Mid, Central Mid, Newcastle Gen,
Darlington Mem., Hexham, South Tyneside.
• Trained 250 (range 5-84) staff (nurses and
consultants)
• Recruiting participants from April 08 to April 09
• 1202 (102%)
Participants Recruitment
Approached Eligible
All A&Es
N
5992
%
N
3562
%
N
%
976
Recruited
3676
1491
1202
62.4
98.4
40.6
81.4
Screened
Positive
Recruited
2991
2988
900
755
83.9
99.8
30.1
83.8
Approached Eligible
All CJSs
Positive
3737
Approached Eligible
All PHCs
Screened
Screened
Positive
Recruited
860
856
576
525
88.1
99.5
67.2
91.1
Participants Recruitment
A&E
St Thomas’
Approached Eligible
N
592
%
King’s
N
914
%
C. Middx
N
789
%
N. Middx
N
1948
%
Royal Ham
N
%
709
Screened
Positive
Recruited
407
399
184
130
68.7
98.0
46.1
70.6
745
735
175
131
81.5
98.6
23.8
74.8
321
313
156
133
40.7
97.5
49.8
85.2
779
758
220
136
39.9
97.3
29.0
61.8
551
544
183
131
77.7
98.7
33.6
71.6
Participants Recruitment
A&E
Darlington
Approached Eligible
N
214
%
S. Tyneside
N
246
%
Newcastle
N
296
%
Hexham
N
%
286
Screened
Positive
Recruited
197
195
139
135
92.1
98.9
71.3
97.1
218
218
141
135
88.6
100
64.7
95.7
253
250
145
132
85.5
98.8
58.0
91.0
266
264
148
135
93.0
99.2
56.1
91.2
Recruitment by month
Recruitment by month for each A&E
Recruitment by month for each A&E
Recruitment by month for each A&E
Training A&E staff
• On site training to small and large groups delivered by
RA & AHW
• 1 to 2 hrs for screening and BA including role play
• No BLC training
• Overall positive feedback on training. Research
elements and Units are usually the challenging parts of
the training
• Most welcomed receiving training
• Adequate space, staff availability, “on call”, turnover,
time and implementation issues slowed training
• Booster sessions, launch events, shadowing staff first
few weeks
SAAPPQ
• Staff’s attitude and motivation
• SAAPPQ assesses differences in five areas:
– Role adequacy
– Role legitimacy
– Motivation
– Task-specific self-esteem
– Work satisfaction
SAAPPQ between groups
(preliminary findings)
– Overall A&E staff score significantly better than
PHC and CJS staff respectively (p = .000)
– Role security
• Staff in A&Es score significantly better that PHC
and CJS respectively
– Therapeutic commitment
• Staff in A&Es score significantly better that PHC
and CJS respectively
SAAPPQ within group (T1 vs T2)
(preliminary findings)
– Overall A&E staff score significantly better than
before the training (p = .000). In particular:
– Role security
• Staff in A&Es score significantly better after
training (p = .02)
– Therapeutic commitment
• Staff in A&Es score significantly better after
training (p = .000)
A&E Implementation issues
• Protocol: Leaflet-eligibility-screening-informed
consent-baseline-intervention
• Ideally delivered by same person (except BLC) in
practice divided by triage/nurses and doctors
• Strong local lead (champion)
• Consent and contact details put some participants
off
• Workload/time
• Staff turnover (eg August)
• Easily forget training if start is delayed
• Tendency of targeting dependent drinkers
• Weekly support
Implementation issues for screening and BI
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Workload/time
Language/communication barriers
Too intoxicated patients
Patients not wanting to engage
Time/staffing/resources
Unwillingness of patients to engage
Space/privacy to deliver intervention
No dedicated alcohol health worker/internal A&E
service to refer to.
• Dealing with presenting problem
Changes to improve recruitment
• Extra support to staff
• Incentives (MHRN)
• Deployment of Alcohol Health Workers to
conduct also screening, BA and research
assistants to support baseline activities
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Conclusions
• Prevalence of AUDs reflect previous studies in
these settings
• Patients are more willing to receive an
intervention than previous studies
• Overall staff in these settings are keen to be
trained, have positive attitude and motivation
• However, limited time, workload, lack of
privacy and turnover are limiting
implementation
• Need for support or dedicated AHWs