1. Changing attitudes to AH Work insight & understanding Mr Robin Touquet A&E, St Mary’s, Paddington 1. Early identification with brief advice.

2. Diagnosis of Alcohol Misuse  History – Paddington Alcohol Test (PAT)  Examination – clinical signs  Special investigation – Blood Alcohol Conc. [BAC] Early Identification with Brief Advice (by all staff) - Brief Intervention (by Alcohol Nurse Specialist)

3. “The Teachable Moment” 4Do you feel your attendance here is related to alcohol? 5Would you be willing to see our alcohol nurse specialist? “We advise you that this drinking is harming your health”

6. For United Kingdom: 8gms absolute alcohol = 10ml alcohol = 1 unit Standard Alcohol Units (SAU) = % ABV x volume (in litres) where ‘% ABV’ is ‘% of alcohol by volume’ as indicated on bottle or can.

8. Examination (usually before history) for alcohol ? At nurse triage 1. S mell of alcohol. 2. S peech: varying volume & pace; slurring & jumbled. 3. A ffect: variable judgement & inappropriate behaviour; euphoria/depression; decreased co-operation; emotional. 4. F ace: sweating/flushed - cushingoid – chronic. 5. E yes: red conjunctiva, nystagmus, ophthalmoplegia

9. 6. Moves: fine motor control, incoordination (acute cerebellar syndrome). Gross motor control (walking) - truncal ataxia: chronic. 7. ‘D’ isability: variable alertness, confusion, hallucinations, sleepiness. ? GCS. 8. ‘C’ irculation: tachycardia, irregularity. Hypotension; vasodilatation with heat loss. Collapse. Urinary retention or incontinence; but ? dehydration. 9. ‘B’ reathing: slow/shallow, hypoxia with CO2 retention - ? Air entry 10. ‘A’ irway: snoring with obstruction. Inhalation of vomit - ? Mallory-Weiss.

10. COLLAPSE due to ALCOHOL – ‘BAC’ in RESUSC. 1.Primary Alcohol is a direct sedative:Unconsciousness – GCS Respiratory arrest - Death 2.SecondaryA. Medical RSInhalation of vomit (especially the young) CVSArrhythmia CNSFits (or D.T.s) GIOesophageal varices from cirrhosis Pancreatitis BloodClotting MetabolicHypoglycaemia EndocrineDiabetes B. Surgical Trauma- accidents esp. head injury - personal violence 3. Psychiatric self harm: overdose/trauma social problems, self neglect – NFA social problems, self neglect – NFA 4. Drug Interaction legal (medication)/illicit

11. When to order a BAC? - always with a sugar (grey bottle) Resusc. – collapse alcohol/drugs - trauma - intentional self-harm - G.I. bleeding - non-cardiac chest pain For alcohol is a drug – tolerance and dependence as well as being an enjoyable social lubricant

12. BAC: Prevalence by Y90 coding 0 20 40 60 80 100 120 No. of patients Collapse GI Bleed NCCP DSH Trauma Other 11-39mg/ 40-59 60-79 80-99 100-119 120-199 200-239 240+ 100ml Y90.1 Y90.2 Y90.3 Y90.4 Y90.5 Y90.6 Y90.7 Y90.8 Note. DSH denotes deliberate self harm, and NCCP denotes Non Cardiac Chest Pain

14. Teachable Moment’ 2. Alcohol health work – The Alcohol Nurse Specialist  By emphasising the link between PAT+ve and the harm caused, we increase the uptake of app. by 23% (Patton et al, E.M.J., 2003)

15. Percentage Of Patients Attending AHW Follow- up Appointment 0% 10% 20% 30% 40% 50% 60% 70% 80% 0 1 2 3 4 5+ Next Available Appointment Accepted Delayed Appointment Specifically Arranged "Next Available Appointment Accepted" trend line Delay (Days) Attendance Rate

16. The half-life life of the ‘teachable moment’ for alcohol misusing patients in the ED. Drug & Alcohol Dependence Williams S. et al, 2005:77;205-208 is less than 48hrs

17. Symbiosis  Consultant ‘Alcohol Czar’ – ensuring referrals Early Identification & B.A.  Alcohol Nurse Specialist – ‘stress reducer’ by providing AHW for patients perceived as ‘difficult’: B.I. follow-up: BAC >160mgs/100ml !

18. Referrals

19. PAY OFF For every two patients referred to the ANS (app. Accepted) There will be one less reattendance within the next 12 months. Screening and referral for B.I. Lancet 2004;364:1334-9

20. Drunk pedestrian – now contemplating change (struck by sober car driver)