Transcript Alcohol Misuse The opportunity for A&E/ER

PAT 2009
with clinical signs and blood alcohol concentrations.
‘Make the Connection’
Prof. Robin Touquet & Adrian Brown RMN
1
St Mary’s Hospital, Imperial College HCT,
Paddington, London, England.
Early Identification of Alcohol Misuse
 History – Paddington Alcohol Test (PAT)
 Examination – “SAFE Moves, ABCD”
 Special Investigation – Blood Alcohol
Concentration (BAC)

Leads to
- Brief Advice
(B.A.)(by all staff) + offer of referral
- Brief Intervention (B.I.) (by Alcohol Nurse Specialist)
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PAT is a clinical tool for early
identification:
1 to 3 Brief focused history.
4 Introduces relationship
between drinking and A&E
attendance.
5 Offering appointment for
Brief Intervention (B.I.)
3
SAFE Moves
Back of
PAT 2009
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All new A&E SHOs
 1 hour Education Alcohol Misuse DAY 2!
Early detection in natural history of misuse
- noting clinical signs of alcohol
- use of PAT & Alcohol Health Work
- ? BAC if not ‘PAT-able’
 Every SHO gives RT 5 PATs 1st 2/52
- once you ‘give me 5’, symphony will suffice
for patients who do not accept referral
 Each month feedback presented as a
league table of referrals
5
1 year Resuscitation Room positive BACs Prevalence by Y90 coding
120
100
No. of
patients
80
Collapse
GI Bleed
NCCP
DSH
Trauma
Other
110/291 (38%)
> 240 mg/100ml
60
40
20
0
20-39
Y90.1
40-59
Y90.2
60-79
Y90.3
80-99 100-119 120-199 200-239
Y90.4 Y90.5
Y90.6
Y90.7
240+ mg/100ml
Y90.8
Note. DSH denotes deliberate self harm, and NCCP denotes Non Cardiac Chest Pain
From “Resuscitation Room blood alcohol concentrations: one year cohort study”
Touquet et al, Emergency Medicine Journal 2008: 25: 752-6
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Symbiosis to counter ‘clinical inertia’
 Alcohol Nurse Specialist –
‘stress reducer’ for staff:
seeing patients perceived as
‘difficult’ - B.I. (20 mins +)
Consultant Alcohol Support
ensuring referrals, supporting
education/audit/feed-back for
giving simple B.A. (1/2 -2 min)
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Role of the Alcohol Nurse Specialist
Brief intervention following referral – both by appointment
and in real time if on observation/admission ward; liaison with
local services.
Education,e.g. for brief advice (by all staff) with resulting
referral rate increase, withdrawal, detox. regimes, etc.
Audit – improving practice.
Feedback – patient outcomes. CHANGING ATTITUDES.
ANS attends every weekday 8am
including CDU & DAAU
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30 months in A&E
(initial research done in resusc only)
 174,764 adult attendances at A&E
52% 84,024 had PAT possible condition
1% (1,714) “apparently drunk”
 2.0% (1,812*)
diagnosed “alcohol problem”
 2.6% (2,191)
referred to ANS
 5,384 had BAC carried out on
2,315 BAC < 10 mg/100ml) ie NEGATIVE
 2,554 BAC > 120 mg/100ml
 31% (804)
referred to ANS
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Reminder:
PAT possible conditions
as recorded on A&E database
 Apparently Drunk
 Falls
 Collapsed adult
 Fits
 Head Injury
 Assault
 Abdominal Pain
 Chest pain
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 Mental Illness
 Deliberate self harm
 Overdose & Poisoning
 Behaving strangely
 Unwell Adult
 Limb problems
 Wounds
Outcome of ANS referrals
(PAT possible conditions)
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31% of referrals to ANS have positive BAC (679 out of 2179)
12% have BAC <10 (259 out of 2179)
Outcome of ANS referrals
(where BAC done)
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 NB among BACs <10,
54 previous contact, 168 referred to ANS
Patient TG, 30 y.o. male
 Feb 2009 to July 2009: 23 attendances
 16 times “apparently drunk”
 15 occasions, BAC tested
 all > 250 mg/100ml (only two below 400)
 mean 474 mg/100ml
 highest 652 mg/100ml
 Admitted to hospital three times
 Observed in Clinical Decisions Unit twice
 Referred to ANS ten times, seen eight*
 *always when in hospital!
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Patient EF, 51 y.o. male
 Never previously attended A&E
 Head injury after bicycle accident
 Initially reluctant to admit he’d been drinking
 BAC tested
 Did not want to stay in hospital, discharging
doctor advised him of BAC score and he then
accepted referral to ANS.
 Attended ANS appointment 2 days later
 Admitted his drinking had been a problem, and
agreed to referral to community services.
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BAC level vs PAT test
Where PAT completed, self
report <15 units per day but
BAC score suggests more !
mg/
100ml
15
Maximum units per day, reported on PAT
PAY OFF
For every two patients referred to
the Alcohol Nurse Specialist
There will be one less reattendance
within the next 12 months.
Screening and referral for B.I.
Lancet 2004;364:1334-9
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When to order a BAC?
- always with a sugar (grey bottle)
1. If in Resuscitation Room.
- Collapse
- Trauma
- Self-harm & overdose
- G.I. & Abdominal
- Chest pain
2. If giving IV B vitamins (pabrinex) for chronic alcohol misuse
with poor diet
- ? Signs of Wernicke’s
3. If clinical signs of withdrawal
- patient in majors
(on trolley needing bloods being taken)
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BAC score vs PAT test
No reason for PAT ?
Q At what level should PAT be
deemed +ve ? 240 is evidence
of drinking > twice UK
recommended limits!
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BAC score vs Referral to ANS
Unfortunately the majority in
the “hazardous” range are
not referred, but there is
evidence that these patients
leave (intoxicated) before
result is known.
Increasing likelihood that
referral will be made.
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BAC score vs Age group
Younger adults (20-40) tend
toward higher consumption,
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BAC score vs gender
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