1. ‘High Impact Team’ Ealing Hospital/Ealing Primary Care’ Sue Murphy & Adrian Jugdoyal

2. Population breakdown Overall population of 248,000 16 years and above 41% BME majority Sikh Indian 4% Irish largest population of Polish in England (over 1% born in Poland) and 10,000 registered High levels of alcohol consumption within these groups above White British population Younger than average population More males than females

3. Hospital admissions ‘alcohol related harm’ Ealing has the highest level of alcohol related hospital admissions in London NI39 (Hospital Admissions for alcohol related harm): per 100,000 population [2007/08] = 1906 [2008/09] = 2146 increase of 13%. This is above the national average increase of 7.5%.

4. Cont’d Local Alcohol Profiles for England comparative data indicate that Ealing do significantly worse than the national average on other indicators The rank of the local indicator among PCT organisations in England. 1 being the best and 152 the worst. Alcohol attributable hospital admissions male – national rank 131 Alcohol attributable hospital admissions- female – national rank 51 Alcohol specific hospital admissions –male - national rank 113 Alcohol related recorded crimes National rank 130 Alcohol related violent crimes National rank 128

5. Local response September 2008 commissioned – Alcohol Drug Liaison Nurse Specialist (ADLNS) based on ST Mary’s model – SBI/IBA – progressive service 2010 – funding from DoH to lead on the West London Sub Regional Hub and to implement a programme promoting high impact changes. This enabled Ealing to appoint: an ADLNS in Ealing Hospital Acute Wards an ADNLS in Ealing Primary Care GP practice’s an A+E joint data clerk covering alcohol and knife crime data The 3 ADNLS and data clerk formed the ‘High Impact Team’

6. High Impact Team NI 39 Alcohol Intervention In Ealing Hospital Emergency Department The Story So Far!

8. It has been well documented that barriers to screening and implementing brief interventions in an A&E setting appear to be negative attitudes, lack of time, training and support, and lack of confidence and skills (Kanner et al 1999).

9. Opportunities Provision of a screening and referral process of alcohol/drug problems for A&E patients using the Paddington Alcohol Test. Delivery of a model of evidenced based brief interventions to hazardous/harmful drinking/substance misuse, assessment for dependent drinkers. Improved engagement of this client group by offering an immediate appointment on the day or next working day in A&E following presentation and sign post to appropriate services in the community for longer term interventions The provision of provide training and specialist consultation for A&E staff including the use of the screening tool and withdrawal management. Further develop protocols and procedures in line with both Trusts policies and clinical governance structures

10. Opportunities Reduce health inequalities for patients who would not normally access treatment for alcohol problems, through provision of an evidenced based intervention in A&E. To reduce re-attendance rates of patients with alcohol problems attending A&E. To reduce alcohol consumption and alcohol related harm in patients who present to A&E, defined as physical, psychological and social negative consequences of drinking alcohol.

11. Achievements in first year of pilot 2144 patients were screened and had a completed Paddington Alcohol test. 854 patients were PAT +.Of those PAT + patients 686 (80%) requested to be seen by ADNS for BI. A total of 601 patients were seen by the ADNS for BI Increased skills, awareness, attitudes, confidence of workforce. Improved Relationships/communication Training packages/education Ealing Hospital Alcohol Withdrawal Guidelines;  Review of current guidelines/update CNWL/St Mary’s  Set up steering group  Audit of prescribing 

12. Total number of patients screened 6688 in the last year and total patents seen through the year was 990. This is approximately 82 patients per month, and on average 19 per week. Of the patients that screened 2530 were identified as PAT positive, these accounts for 37% of all patients screened.

13. 6% of all patient’s screened in the ED seen by the alcohol nurse specialist, there appeals to be no seasonal trends at present. Alcohol awareness training is conducted every 2 months to the medical team,

14. The age range of PAT positive patient are is between 30-60, the average age being 42. the youngest person was on there 16 th birthday and the eldest was 92

15. Due to Ealing's profile of having a high proportion of people from South Asia, the proportion of people screened is similar to that of White British 16% of white British patients were seen and 18% of Indians

17. 3 months data showing the time of arrival of PAT positive patients, this shows that most patients attend during the day as opposed to traditional knowledge that it is mainly at night. 58% of patients PAT positive attend within the ‘High Impact Team’ hours 7.30-18.00. This also covers the patients that are in CDU from the night before (not medically fit for discharge)

18. High Impact Service An Ealing Hospital and Ealing GP Primary Care service that will deliver high quality alcohol services to people who are admitted to hospital for alcohol related harm and ensuring there are clear pathways to continued treatment into primary care and alcohol specialist services. Aim: To reduce hospital admissions alcohol related harm National Indicator 39 (NI39)

19. Acute Ward Based Alcohol Liaison Nurse Specialist Role To Provide specialist information and advice for patients. To assess compliance to trust approved alcohol withdrawal guidelines. To promote/refer to community aftercare programmes. To provide training to MDT at all levels

20. Ealing Primary Care Alcohol Liaison Nurse Specialist To continue detoxes initiated in the acute hospital in the community. To screen patients in primary care for appropriateness of community detox. To provide uncomplicated detoxes in primary care.

21. Ealing Primary Care Alcohol Liaison Nurse Specialist To promote adjunctive medication to aid prevent relapse. To promote community based aftercare programmes.

22. Patients seen No. of patients referred to GP Alcohol Clinics = 42 No. of patients who attended GP Alcohol Clinics = 33

23. Referrals made Number of detoxes initiated at in primary care = 9 Number of patients referred for inpatient Detox programme = 9 Patients referred for community aftercare programmes = 18 Referred for adjunctive medication = 11

24. Ward nurse Started in post end of July 10. Patients seen 287 Male 92% Average age 52 Ethnicity >50% Indian origin, White British 30%

25. How patients are screened. Emergency department. Medical and surgical clerking MDT referrals Ward round referrals

26. Most common presentation Abdominal pain  Decompensating liver disease  GI bleeding. Chest pains/failure  Alcohol related gastritis  Left ventricular failure/DCM

27. Most common presentation Seizures Moderate electrolyte imbalance Trauma Endocrine issues Mental health (self harm/overdoses).

28. Not admitted to acute wards Primary alcohol withdrawal unless actively fitting, hallucinations evidence of Wernicke-Korsakoff syndrome Patients presenting with a primary alcohol withdrawal are seen by the ED alcohol nurse specialist and referred to the appropriate agency.

29. Link between ward based nurse and GP liaison nurse 3 patients have been referred in 3 months period, this is due to only 8 GP surgeries have been identified at present. Many of the patients seen within the acute hospital are from other surgeries or of NFA.

30. 3 months activities 145 patients seen 287 contacts made 90 detoxes supervised 150 referrals made to aftercare programmes. All 145 patients were given brief intervention work

31. Typical daily tasks for ward based nurse Review past 24 hour/weekend attendances through emergency department data. Review medical/surgical inpatient log Assess and review patient on acute assessment wards. Review patients previously seen before.