Transcript Slide 1

Screening and Intervention Programme
for Sensible Drinking (SIPS)
National Brief Intervention
Research Consortium
A&E St. Mary’s
'Scientia Vincit
Timorem'
Training Objectives
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Content of this session:
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Pre-Training Staff Survey
Part 1: Background to the study:
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Alcohol prevalence, effects and issues in England
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Hazardous/harmful drinking
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The AED Trial
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Alcohol screening and brief interventions
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The SIPS programme
Parts 2 : Triage Stage
Provide you with the knowledge and skills to:
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Implement study procedures in accordance with the protocol
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Introduce the study and gain verbal consent
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Administer and score the screening questionnaire (FAST)
Part 3: Treating Clinician Stage
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Obtain consent and check baseline questionnaire
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Understand requirements of patients involved in the study
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Part 4 : Clinical interventions training
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Post-Training Staff Survey
Staff survey
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This is a short survey on your attitudes towards alcohol
screening/brief interventions and relevant pre-training experience
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Your feedback on the experience of alcohol screening and brief
interventions will make an important contribution to the study
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We will ask you to complete the same questionnaire after the
training session, and once again after recruitment to the study has
been complete
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Please read through the Information Sheet and sign two copies of
the consent form if you agree to fill it in.
Part 1 – Background
What do you think constitutes an
alcohol problem?
Alcohol Use Definitions
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Low-risk drinking - below medically recommended limits (2-3 units
per day for women; 3-4 units per day for men, with at least two
alcohol free days a week)
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Hazardous drinking - a pattern of consumption which increases the
risk of harm (physical, psychological or social), i.e., drinking above
recommended limits
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Harmful drinking - a pattern which is likely to have already led to
harm (physical, psychological or social) or, for some purposes,
drinking at “very heavy” levels
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Binge drinking – originally episodic heavy drinking but now heavy
drinking in a single session, i.e., twice the daily limit, above 6 units
for women 8 units for men
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Alcohol dependence – a cluster of physiological, behavioural and
cognitive phenomena conforming to the “alcohol dependence
syndrome”
Alcohol use disorders: prevalence
 26%
of the adult population have an alcohol
use disorder (AUD)
 Includes 38% of men & 16% of women
aged 16-64
 23% of the adult population are hazardous
or harmful alcohol users (7.1 million people
in England)
 21% of men and 9% of women engage in
binge drinking
Percentage of people in England
with an alcohol use disorder by age
Alcohol-related harm: acute
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Homicide
Suicide
Other intentional injuries (i.e., interpersonal
violence)
Domestic violence
Sexual assault
Unprotected sex
Motor vehicle accidents
Other accidents
Drowning
Burns
Public disorder
Alcohol-related harm: chronic
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Liver cirrhosis and other forms of alcoholrelated liver disease
Hypertension
Cancers of the mouth, larynx, pharynx and
oesophagus
Other cancers, including breast cancer
Foetal Alcohol Syndrome (FAS) and foetal
alcohol effects
Mental illness
Alcohol Dependence Syndrome
Alcohol-related harm: social
problems
 Lower
workplace productivity
 Unemployment
 Family & social networks
 Homelessness
 Economic costs
Alcohol and AEDs
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24 hour prevalence survey of alcohol-related
attendances at 32 AEDs in England
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40% of AED attendances are alcohol related
Between midnight and 5am this number increases to
70%
Reasons for alcohol related attendance were
significantly more commonly:
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a violent assault
incident involving weapons
road traffic accidents
psychiatric emergencies
deliberate self harm episodes
St Mary’s AED Trial
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Screening and Brief Interventions for alcohol misuse in
an accident & emergency department is:
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feasible
associated with lower levels of alcohol consumption over the
following 6 months
reduces reattendance
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Those referred to the alcohol health worker had a mean
of 0.5 fewer visits to the AED over the following 12
months
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For every 2 patients referred to an AHW there is one
less reattandence in the following year!
Costs/Benefits
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Screening and referral to the AHW has a cost, but this
should be offset against the savings gained by reducing
attendance
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For every 1000 patients screened, costs are
approximately £2500 (including the cost of the AHW for
those referred), and savings of £4000
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Net: £1500 savings
Screening for hazardous &
harmful drinking
 Screening
is necessary to detect risky
drinkers whose level of consumption may not
be apparent
 Short
questionnaires are the most efficient
way of screening
 Screening
for hazardous/harmful alcohol
users, not for dependent drinkers
What is brief alcohol
intervention?
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“… the giving of information, advice and encouragement to
the patient to consider the positives and negatives of their
drinking behaviour, plus support and help to the patient if
they do decide they want to cut down on their drinking.”
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“Brief interventions are usually ‘opportunistic’ – that is, they
are administered to patients who have not attended a
consultation to discuss their drinking”
What is the SIPS Programme
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A national research consortium led by the Institute of Psychiatry,
Kings College London and Newcastle University, with expertise in
screening and brief interventions in the alcohol field
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Funded by the Department of Health; £3.2 million, as part of the
“Alcohol Harm Reduction Strategy for England” (2004)
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To investigate the effectiveness and cost effectiveness of alcohol
SBI in:
Accident & Emergency Departments
Primary Health Care
Criminal Justice Services
Cluster Randomised
Controlled Design
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Within 3 different regions of England – North East, South East and
London, in:
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24 Primary Health Care practices; 9 Accident & Emergency
Departments; 9 probation offices
Cluster = 1 AED, 2-3 PHC sites, 1 probation office
Study is comparing the effectiveness of:
 2 screening approaches (targeted vs. universal)
 3 screening tools (M-SASQ; SIPS-PAT; FAST)
 3 brief interventions (PIL; Brief Advice; Brief Lifestyle
Counselling)
??????????? has been assigned:
 ???????? Screening; ?????; ?????????
 131 Patients to be recruited at this site
Objectives of the AED Trial
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Identify best screening tool
Compare effectiveness and cost
effectiveness of different models of brief
intervention
Assess implementation of different
screening and brief intervention (SBI)
approaches by staff
Identify factors that predict successful
implementation of SBI in routine AED care
Summary of SIPS in your AED
Triage Stage:
• Assess patient for treatment as normal
• Brief introduction of study
• Gain verbal consent to check eligibility and screen
• Screen for alcohol misuse
• If negative end their involvement in the study
• If positive hand them a study pack
Patient in waiting room to read study pack including: the research
participant information sheet, sign both copies of the consent form
if they are happy to participate and complete the baseline survey.
Treating Clinician
Stage:
• Research participant hands over study pack
• Research participant hands over study pack
• Staff ensures both consent form is signed by the research
•participant
Staff ensures
formsthe
areforms,
signed
by the
and both
then consent
countersigns
giving
theresearch
patient a
participant
and
then
countersigns
the
forms,
giving
the
copy of this to take away with the information sheet. patient a
copy to retain along with the information sheet.
• Check baseline survey is completed
• Check baseline survey is completed
• Issue patient information leaflet and conduct brief structured
•advice
Conduct Brief Advice and issue Patient Information Leaflet
•• Store
Store study
study pack
pack in
in secure
secure place
place for
for SIPS
SIPS research
research staff
staff to
to collect
collect
Part 2 – Triage Stage
Participant Baseline
Questionnaire - AED
Introducing the study
“We are currently working with a team of
researchers led by the Institute of Psychiatry,
who are conducting a study on behalf of the
Department of Health. The aim of the study is to
find out how to provide help to people who are
drinking alcohol in ways that might be harming
their health. Would you mind if I asked you a few
questions to see if you meet the eligibility criteria
to take part in the study, and if you do I would
then like to ask you a few questions about your
drinking in the last six months. Would this be
ok?”
Recruiting patients to participate
Eligibility criteria
The patient:
 Is aged 18 or over
 Is alert and orientated i.e. the ability to
understand the information presented, retain
it and make an informed decision –
competence
 Is resident within 20 miles
 Is able to speak, read and write English
sufficiently well to take part in the study
Eligibility continued...
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Is not severely injured
Is not suffering with a serious mental health problem e.g.
acute psychotic episode or severely distressed
Is not grossly intoxicated
Is not currently seeking help for alcohol problems
Is not involved in any other alcohol research study
Has a fixed abode
Has provided verbal consent to be screened
Patient demographic information
The alcohol screening process
What is a standard unit of alcohol?
Fast Alcohol Screening Test
(FAST)
Examples: Fast Alcohol
Screening Test (FAST)
Example 1:
In response to question 1 of the FAST, the man says:
Most Fridays after work I usually have a
couple of pints of Guinness, and then share
a bottle of wine over dinner with my wife,
followed by a whisky.
1. Calculate the number of standard drinks that the man had:
4 (Guinness) + 4.5 (wine) + 1 (whisky) = 9.5+ standard drinks
2. How would you record and score the answer to this question using the FAST?
More than 8 standard drinks every week = weekly
3. Why would you not continue with the remaining 3 questions?
He has more than 8 units on one occasion every week = positive. Therefore no
need to ask any more questions
Examples: Fast Alcohol
Screening Test (FAST)
Example 2:
In response to question 1
of the FAST, the woman
says:
I normally have a couple of glasses of wine
when I go out, but on my birthday I will get
through a whole bottle!
1) How would you score question 1 on the fast?
Less than monthly = not necessarily positive but scores 1 point and
you need to ask the other questions
In response to question 2
she says:
Only a couple times in the last six months . . .
2) How would you record her response on the FAST?
‘Less than monthly’ = 1 point
Examples: Fast Alcohol
Screening Test (FAST)
Example 2 (continued):
In response to question 3
she says:
A few times I have missed a class at the gym
because of the heavy night before. But this has
happened very occasionally – definitely less than
monthly.
3) How would you record this response?
‘Less than monthly’ = 1 point
In response to question 4
she says:
Nobody has ever expressed any concern about my
drinking habits or suggested that I cut down.
4) How would you record this response?
‘No’ = 0 points
5) Would she screen positive or negative using the FAST?
She has 3 points in total so she would be positive
Examples: Fast Alcohol
Screening Test (FAST)
Example 3:
In response to question 1 of the FAST, a man says:
I have a can of beer every evening and then
3 pints when I watch my team play football
1. Calculate the number of standard drinks that the man had:
3 pints = 6 – 9 standard drinks depending on strength of beer
2. How would you record and score the answer to this question using the FAST?
Need to ask him how often he watches his team and type of beer he drinks. To
which he says:
The wife only lets me out once a month so I
only get to watch my team about once a
month. I always drink Stella.
Examples: Fast Alcohol
Screening Test (FAST)
3. How would you score his response for question 1 of the FAST?
3 pints Stella = 9 standard drinks one a month: answer would be ‘monthly’.
4. What next?
He might not be positive so you give him 2 points and ask the other 3 questions.
In response to question 2 of the FAST, the man says:
Only on my stag night 8 years ago!
5. How would you score his response for question 2 of the FAST?
‘Never’ = 0 points. He therefore still only has 2 points.
Examples: Fast Alcohol
Screening Test (FAST)
In response to question 3 of the FAST, the man says:
It’s never stopped me doing anything as far
as I remember.
6. How would you score his response on question 3 of the FAST?
‘Never’ = 0 points. He therefore still only has 2 points.
In response to question 4 of the FAST, the man says:
No, never.
7. How would you score his response on question 4 of the FAST?
‘Never’ = 0 points. Again he still only has 2 points.
8. Would he screen positive or negative?
He has only 2 points overall and is negative.
SIPS Modified Paddington
Alcohol Test (SIPS-PAT)
Examples: SIPS-PAT
Example 1:
A woman presents to the A&E department with injuries from a fall so you screen her
using the SIPS-PAT. You ask her if she feels her attendance here is related to her
drinking. The woman responds:
No it was the heels on these new shoes.
So what do you do?
It was not drinking related so you go on to ask the woman question 2 of the SIPSPAT and you ask her how often she has 6 or more drinks on one occasion. She
replies:
Examples: SIPS-PAT
Example 1 (continued):
When I go out after work I usually have a
couple of single vodkas, at the weekend
maybe a bit more, say 4 or 5 single vodkas.
But never more than that on one occasion.
1) Calculate the number of standard drinks the woman has.
4 – 5 standard drinks
2) What box would you cross in question 2?
Never
3) Would she screen negative or positive using the SIPS-PAT?
Negative
Examples: SIPS-PAT
Example 2:
A man comes into the A&E department with head injuries so you screen him using
the SIPS-PAT. You ask him if he feels his attendance here is related to his drinking.
The man responds:
No, it isn’t to do with drink, I tripped on an
uneven pavement and hit my head.
1) So what do you do?
It was not drinking related so you go on to ask the man question 2 of the SIPSPAT and you ask him how often he has 6 or more drinks on one occasion. He
replies:
Examples: SIPS-PAT
Example 2 (continued):
I go out to the pub most weeks and I usually
only drink about 3 pints, very rarely more
than that.
2) Calculate the number of standard drinks the man has.
6 standard drinks if regular strength beer but more if strong/premium
strength so you ask him what pints he normally drinks, he replies:
Kronenbourg, if they’ve got it.
Examples: SIPS-PAT
Example 2 (continued):
3) Taking into account this new information recalculate the number of
standard drinks the man has.
9 standard drinks
4) What box would you cross in question 2?
Weekly
5) Would he screen negative or positive using the SIPS-PAT?
Positive
Examples: SIPS-PAT
Example 3:
A man presents to the A&E department with injuries from a fall so you screen him
using the SIPS-PAT. You ask him if he feels his attendance here is related to his
drinking. The man responds:
No I fell off a ladder whilst decorating
So what do you do?
It was not drinking related so you go on to ask the man question 2 of the SIPSPAT and you ask him how often he has 8 or more drinks on one occasion. He
replies:
Examples: SIPS-PAT
Example 3 (continued):
I usually go out after work and have a couple
of pints of Stella and 2 double whiskey and
cokes.
1) Calculate the number of standard drinks the man has.
2 pints of Stella = 6 standard drinks; Whisky = 4 standard drinks
2) What box would you cross in question 2?
Weekly
3) Would he screen negative or positive using the SIPS-PAT?
Positive
Modified Single Alcohol Screening
Questionnaire
(M-SASQ)
Examples: M-SASQ
Example 1:
In response to the M-SASQ question, the man says:
I normally have a glass of wine with dinner
most nights, but on a Saturday I have a whole
bottle.
1) Calculate the number of standard drinks the man consumes.
1-2 units per day and 9 at the weekend
2) What response would you give him on the M-SASQ?
weekly
3) Would he screen negative or positive using the M-SASQ?
positive
Examples: M-SASQ
Example 2:
In response to the M-SASQ question, the woman says:
I usually drink about 3 or 4 pints on a Friday
night after work, but never more than this.
1) Calculate the number of standard drinks the woman has.
6 – 12 standard drinks (depending whether ordinary or strong beer)
2) What response would circle on the M-SASQ?
Weekly
3) Would she screen negative or positive using the M-SASQ?
Positive
Examples: M-SASQ
Example 3:
In response to the M-SASQ question, a man says:
I have about 4 beers a night and about 8 on a
Saturday night. After all man’s not a camel!
1) Calculate the number of standard drinks the man consumes.
4 beers = 8+ units; 8 beers = 16+; Total = 24+ per week
2) What response would you give him on the M-SASQ?
Daily
3) Would he screen negative or positive using the M-SASQ?
Positive
Screening Results
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If patient is negative, thank them for their interest in the
study and terminate their involvement at this point
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If patient is positive, provide with Research Participant
Information Sheet and attempt to obtain written consent
Issuing Research Participant
Information Sheet
“I have looked over the results of your questionnaire, and from your
answers it appears that you may be drinking at a rate that increases
your risk of harm. The research team are trying to find ways of helping
people who may be drinking in ways that are harmful to health. They
would like about 10 minutes of your time to help with their research, by
completing a short questionnaire for which you will receive a £10
voucher. You will then receive an information leaflet [about alcohol] / and
5 minutes brief advice about alcohol/ and we will arrange an
appointment for you to see an Alcohol Health Worker to discuss your
drinking further (delete as appropriate) The research team will contact
you again in 6 months and 12 months to complete another short
questionnaire, for which you will receive another £10 voucher for each
time. Please take the time to read this information leaflet carefully, and
feel free to ask any questions you wish.”
AED Research Participant Information Sheet
Part 3 – Treating Clinician
Stage
Consent
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Patient will hand baseline pack to clinician who will
check consent form.
Informed consent is an agreement entered into with
complete knowledge of all relevant facts.
Ensure they have read through the consent form
and signed both copies.
If they consent make sure you countersign both
copies and detach patient copy.
Consent Forms
Consent
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If the patient does not consent to participate
in the study, offer them the Patient
Information Leaflet and no further action is
taken.
Instructions to patients
Patient personal information sheet
Alcohol Use Disorders Identification
Test (AUDIT)
EQ5D – health status questionnaire
Service Use Questionnaire (SUQ)
Readiness to Change Ruler (RCR)
Please check participants have filled in all
sections of the baseline questionnaire!
Patient Information Leaflet
How Much Is Too Much?
The Principles of the PIL
 an
intervention in itself
 contains useful information regarding
personal alcohol use
 is not confrontational or judgmental.
 free resource for people to take away
 easy to read format
How to issue the Patient
Information Leaflet (PIL)
•Brief Advice and the PIL must be delivered in the same
manner for each patient.
•When handing over the PIL please say:
“This leaflet describes what we have just discussed
in more detail. Please take this away and read
through it. There are contact details on the back
should you need further help/advice”.
•Thank the patient, inform them they will receive a letter
from the research team in 2 weeks that will contain a £10
voucher.
Pilot Days
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An opportunity to practice screening and providing Brief Advice
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Triage nurse to screen patients and refer those positive to the study
doctors/ENPs
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Doctors/ENPs will have a go at offering the Brief Advice
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No research materials will be used
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Ensures potential problems can be solved before active recruitment
to study begins
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Sam, Malcolm and Lisa will be on site during pilot for support and
feedback
Winchester Flow Chart
Patient
Participant baseline
questionnaire – Front page
Introducing the
patient to the
study and
obtaining verbal
consent
NO
NO FURTHER
ACTION
YES
Inclusion
criteria
NO
NO FURTHER
ACTION
YES
Demographic Information
Screening
FAST
POSITIVE
NEGATIVE, NO
FURTHER
ACTION
Research Participant
Information Sheet
Obtain
informed
written consent
NO
PIL
YES
PARTICIPANT BASELINE QUESTIONNAIRE
CONDITION 2: BRIEF ADVICE (BA) AND PIL
THANK YOU LETTER & £10 VOUCHER (within two weeks)
REMINDER LETTER (1 month and a week before 6 month follow up assessment)
6/12 MONTH FOLLOW-UP QUESTIONNAIRES (6 and 12 months after screening)
THANK YOU LETTER & £10 VOUCHER (within one month)
Support and supervision
Who to contact if I’m worried about a patient in the study?
Please contact your alcohol health worker:
Lisa Rail
Tel: 020 7848 5848
Email: [email protected]
Julia Reid
Tel: 020 7848 0656
Email: [email protected]
Or refer patients to alcohol services as outlined in the Patient Information Leaflet:
Drinkline
Tel: 0800 917 8282
Alcoholics Anonymous
Tel: 0845 769 7555
Alternatively instruct the patients to contact their GP for referral to local alcohol services
Who do I contact if I’m worried about the research processes?
In the first instance please contact your designated member of the research team:
Sam Keating
Tel: 020 7848 0437
Email: [email protected]
Malcolm Hobbs
Tel: 020 7848 0442
Email:[email protected]
Katherine Perryman
Tel: 020 7848 0825
Email: [email protected]
Useful links
 www.sips.iop.kcl.ac.uk/
 www.alcoholconcern.org.uk
 www.dh.gov.uk
 www.nhs.uk