A&E St. Mary’s 'Scientia Vincit Timorem'

A&E St. Mary’s 'Scientia Vincit Timorem'
Screening and Intervention Programme for Sensible Drinking (SIPS) National Brief Intervention Research Consortium A&E St. Mary’s 'Scientia Vincit Timorem'

Training Objectives Content of this session: Pre-Training Staff Survey
Part 1: Background to the study: Alcohol prevalence, effects and issues in England Hazardous/harmful drinking The AED Trial Alcohol screening and brief interventions The SIPS programme Parts 2 : Triage Stage Provide you with the knowledge and skills to: Implement study procedures in accordance with the protocol Introduce the study and gain verbal consent Administer and score the screening questionnaire (FAST) Part 3: Treating Clinician Stage Obtain consent and check baseline questionnaire Understand requirements of patients involved in the study Part 4 : Clinical interventions training Post-Training Staff Survey This session covers research and screening training. Should take 1hour. Afterwards you will get the clinical training.

Staff survey This is a short survey on your attitudes towards alcohol screening/brief interventions and relevant pre-training experience Your feedback on the experience of alcohol screening and brief interventions will make an important contribution to the study We will ask you to complete the same questionnaire after the training session, and once again after recruitment to the study has been complete Please read through the Information Sheet and sign two copies of the consent form if you agree to fill it in. Briefly go through contents Mention that we need their name on the front because we want to measure how their attitudes change. Emphasise that their ID will be confidential.

Part 1 – Background

What do you think constitutes an alcohol problem?
Do you know what the medically recommended units are for both males and females?

Alcohol Use Definitions
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) Hazardous drinking - a pattern of consumption which increases the risk of harm (physical, psychological or social), i.e., drinking above recommended limits 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 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 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 Drummond et al., 2005 Alcohol Needs Assessment Research Project, 2005 Just over a quarter of the adult population has an alcohol use disorder 38% in men and 16% in women aged 16 to 64 years old

Percentage of people in England with an alcohol use disorder by age
Source: Alcohol Needs Assessment Research Project (ANARP): The 2004 national alcohol needs assessment for England This graph shows the percentage of people in England with an alcohol use disorder by age. For both the hazardous/harmful alcohol users and the alcohol dependent users, the highest percentages are seen in the younger age groups – the 16 to 24 year olds For the alcohol dependent groups, this perhaps goes against general stereotypes . . .Alcohol dependency forms a minority of the population, whereas hazardous/harmful use forms a much greater majority  it would therefore be very useful to target this – firstly because if you intervene early it will reduce the number of alcohol dependents but also because of the problems caused by non-dependent harmful/hazardous drinkers.

Alcohol-related harm: acute
Homicide Suicide Other intentional injuries (i.e., interpersonal violence) Domestic violence Sexual assault Unprotected sex Motor vehicle accidents Other accidents Drowning Burns Public disorder Which of these do you see most?????? Acute negative consequences of drinking account for around 50% of total alcohol-related harm. They are mainly the result of intoxication rather than alcohol dependence. Alcohol associated with 60-70% of homicides (i.e., either perpetrator, victim or both intoxicated) – British Medical Association, Alcohol & Accidents, 1989) Up to 40% of suicides thought to be attributable to alcohol (Interim Analytical Report) Almost ½ of the victims of violent crime say the perpetrator was under the influence of alcohol at the time and 1/5 of violent crimes occur in or around pubs and clubs (ibid) Alcohol plays a role in around 1/3rd of cases of domestic violence (ibid) In a UK survey, 58% of those imprisoned for rape reported drinking in the 6 hrs prior to the rape (ibid) Alcohol intoxication increases the risk of unprotected sex. A survey of students aged in north-east England in 1989/90 showed that, after drinking, 35% had sex without contraception (ibid). Though drink-driving has been declining, in 2001 driving over legal limit accounted for 5% of all road accidents and 17% of road deaths (ibid). Alcohol is linked with up to 1/3 of accidental deaths of all kinds (ibid). Alcohol involved in 23-38% of deaths by drowning and 38-45% of deaths in fires (ibid) Altogether, acute intoxication results in around 23,000 hospital admissions per year in England & Wales (ibid) In the British Crime Survey 2002/03, 70% of respondents said that drinking in public places and on the street was a problem in their neighbourhood

Alcohol-related harm: chronic
Liver cirrhosis and other forms of alcohol-related 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 Regular heavy drinking can affect every physiological system of the body but here are some of the main conditions caused by excessive drinking: Alcohol-related liver disease accounts for 33,000 hospital admissions per year in England & Wales and over 4,500 deaths annually (Interim Analytical Report) Heavy drinking is associated with hypertension which in turn is a leading risk factor for haemorrhagic stroke, accounting for up to 1,200 deaths per year (ibid) Moderate drinking can protect against cardiovascular disease but this applies only to low levels (1 or 2 drinks per day) Alcohol is associated with a dose-related increase in the risk of cancers of the oral cavity, larynx, pharynx and oesophagus, especially if combined with smoking (ibid) It also increase the risk of cancers at other sites including breast cancer, although research on the latter risk is proceeding (ibid) Estimated that babies with FAS represent between 0.4 and 2 live births per 1,000. In addition to the full FAS, drinking in pregnancy is associated with a range of other impairments in the baby (ibid) Heavy drinking can contribute to anxiety and depression and can accelerate, or uncover a predisposition to, the development of psychiatric disorder, including psychosis (ibid) 1/3rd of psychiatric patients have a substance use disorder and ½ of those attending D&A services have a mental health problem (ibid) Latest estimate of the population prevalence of alcohol dependence is 3.6%, with 6% of men and 2% of women meeting criteria nationally (Alcohol Needs Assessment Research Project; Drummond et al., 2005). This equates to 1.1 million people with alcohol dependence nationally. Alcohol dependence is therefore considerably more prevalent than problem drug use in England which is estimated to affect 0.8% of the adult population.

Alcohol-related harm: social problems
Lower workplace productivity Unemployment Family & social networks Homelessness Economic costs Drinking results in lost productivity through sickness absence, industrial accidents, early retirement and premature death Up to 17 million lost each year to alcohol-related absence from work, costing the nation £1.5 billion (Interim Analytical Report) Up to 20 million working days lost annually to alcohol-related reduced employment (ibid) The total cost of alcohol-related lost productivity is estimated at £6.4 billion (ibid) Heavy drinking often affects the drinker’s relationships with family and friends and their participation in society Marriages where one or both partners has an alcohol problems are twice as likely to end in divorce as marriages in which alcohol problems are absent (ibid) Alcohol problems figure in up to 60% of cases of child protection (ibid) Alcohol plays a role in about 20% of cases of school exclusion and is associated with violence, vandalism and truancy (ibid) Around ½ of homeless people are alcohol dependent (ibid) Alcohol dependence can lead to homelessness but also exacerbate problems among homeless people The total costs of alcohol to the UK economy have been estimated at about £20 billion (Interim Analytical Report), although even this figure does not include the human costs in suffering to the drinker, their family and friends which cannot be quantified.

Alcohol and AEDs 24 hour prevalence survey of alcohol-related attendances at 32 AEDs in England 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: a violent assault incident involving weapons road traffic accidents psychiatric emergencies deliberate self harm episodes The 2003 twenty-four hour national prevalence survey of alcohol-related attendances at Accident and emergency Departments in England, Drummond et al 2003, published in abstract only Study ran from 08:00 Sat 28th June to 07:59 Sun 29th June – summer months, and weekend shift to assess maximum burden Logged 4,500 attendees, 40% of whom were eligible to take part, non-eligible reasons – under 18, left AED before approached, too physically unwell (52%) Alcohol related attendances defined – too intoxicated to consent, +ve breath sample, self report of alcohol related attendance, or consumed more than 8/6 units in previous 24hrs Alcohol related attendances (defined as above) total 41%, 43% of all attendees' were FAST +ve Alcohol related attendees' morel likely young, white, male, single, cohabiting or divorced, unemployed or students, living with parents or no fixed abode Alcohol related attendees‘ are greater consumers of AED services in past year, on average 1.6 times as often

St Mary’s AED Trial Screening and Brief Interventions for alcohol misuse in an accident & emergency department is: feasible associated with lower levels of alcohol consumption over the following 6 months reduces reattendance Those referred to the alcohol health worker had a mean of 0.5 fewer visits to the AED over the following 12 months For every 2 patients referred to an AHW there is one less reattandence in the following year! An alcohol health worker is a nurse/counsellor who specialises in alcohol misuse and has been trained to deliver brief interventions designed to inform people of safe consumption levels of alcohol, and to motivate them to change their drinking behaviour Screening and referral for brief intervention of alcohol misusing patients in an emergency department: a pragmatic randomised controlled trial Mike J Crawford, Robert Patton, Robin Touquet, Colin Drummond, Sarah Byford, Barbara Barrett, Ben Reece, Adrian Brown, John A Henry. Lancet 2004; 364:1334– We undertook a single-blind pragmatic randomised controlled trial. Patients received either an information leaflet or an information leaflet plus an appointment with an alcohol health worker Outcome data were collected by patient interview and examination of hospital records at 6 and 12 months 599 patients were randomised over a 12-month period. At 6 months, those referred to an alcohol health worker were consuming a mean of 59·7 units of alcohol per week compared with 83·1 units in the control group At 12 months those referred were drinking 57·2 units per week compared with 70·8 in controls Those referred to the alcohol health worker had a mean of 0·5 fewer visits to the emergency department over the following 12 months

Costs/Benefits Screening and referral to the AHW has a cost, but this should be offset against the savings gained by reducing attendance For every 1000 patients screened, costs are approximately £2500 (including the cost of the AHW for those referred), and savings of £4000 Net: £1500 savings Based on the data on prevalence and AHW referral as presented in our Lancet paper and on service utilisation costs provided by the local NHS trust. Tie in with previous slide, based on the St Marys model of alcohol screening and brief interventions.

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 Taken from Heather, N. et al. (2007) Screening and brief alcohol interventions in primary care. In ‘How much is too much’ programme, Institute of Health and Society, Newcastle University: Newcastle. It is not sufficient to rely on obvious signs of heavy drinking (e.g. alcohol on breath, purple nose etc.) Details of recommended screening tools will be given in the next slide GGT = Gamma-glutamyl transferase MCV = Mean corpuscular volume CDT = Carbohydrate-deficient transferrin In the Alcohol Harm Reduction Strategy for England (AHRSE), the government strongly favoured targeted screening because “recent research has raised questions about the value and effectiveness of universal screening …” (p.37). Targeted rather than universal screening was also favoured by a panel of experts in a Delphi study (HEATHER, N., DALLOLIO, E., HUTCHINGS, D., KANER, E. F. S. & WHITE, M. (2004) Implementing routine screening and brief alcohol intervention in primary health care: a Delphi survey of expert opinion, Journal of Substance Use, 9, 68-85) and also by the health care professionals taking part in the Tyne & Wear HAZ Project.. The last point can be made in response to objections that patients often lie about their drinking – a topic for discussion

What is brief alcohol intervention?
“… 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.” “Brief interventions are usually ‘opportunistic’ – that is, they are administered to patients who have not attended a consultation to discuss their drinking” From the Alcohol Harm Reduction Strategy for England, p.37 Taken from Heather, N. et al. (2007) Screening and brief alcohol interventions in primary care. In ‘How much is too much’ programme, Institute of Health and Society, Newcastle University: Newcastle. The delivery of brief alcohol interventions is now part of official government policy in the AHRSE. The AHRSE says there is no standard definition of a brief intervention. This is correct. But the AHRSE specifies some elements that are common to all brief interventions, in the 1st quotation above. . It might have added to these common elements a follow-up to check if the patient in making progress in cutting down drinking. The word “opportunistic” can be used in different senses. Brief interventions are called opportunistic simply because the opportunity is taken of the patient’s attendance at a general practice facility to identify those who are drinking at levels detrimental to their health and welfare and offer them advice, if appropriate, on why and how they should cut down

What is the SIPS Programme
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 Funded by the Department of Health; £3.2 million, as part of the “Alcohol Harm Reduction Strategy for England” (2004) To investigate the effectiveness and cost effectiveness of alcohol SBI in: Accident & Emergency Departments Primary Health Care Criminal Justice Services SIPS – Screening and Intervention Programme for Sensible Drinking A collaboration of various agencies and organisations across England, including Alcohol Concern and led by the Institute of Psychiatry in London and Newcastle University. Funded by the Department of Health as part of the Alcohol Harm Reduction Strategy for England and is the biggest ever programme of alcohol research in the UK.

Cluster Randomised Controlled Design
Within 3 different regions of England – North East, South East and London, in: 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 The SIPS study is taking place across 3 different regions of England – NE; SE and London. Define cluster Explain the different approaches, tools and interventions the study is comparing. Say that each site is assigned 1 screening approach, 1 screening tool and 1 brief intervention Winchester has been assigned…… This is what you will get training on today, training on the other conditions is offered after the study has been completed.

Objectives of the AED Trial
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 Cost effectiveness work conducted by specialists at York University. Emphasise staff feedback on the process of implementation, importance also of staff surveys. Hoping to conduct post study staff focus groups

Summary of SIPS in your AED
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 Triage Stage: 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. Research participant hands over study pack Staff ensures both consent form is signed by the research participant and then countersigns the forms, giving the patient a copy of this to take away with the information sheet. Check baseline survey is completed Issue patient information leaflet and conduct brief structured advice Store study pack in secure place for SIPS research staff to collect Treating Clinician Stage: Research participant hands over study pack Staff ensures both consent forms are signed by the research participant and then countersigns the forms, giving the patient a copy to retain along with the information sheet. Check baseline survey is completed Conduct Brief Advice and issue Patient Information Leaflet Store study pack in secure place for SIPS research staff to collect From now on all training is taken from the AED manual, which you will have copies of around the department in ringbinders, and as personal copy from today. Emphasise that is patient is severely unwell, or the department is too busy, do not attempt research. Also instruct them to look at flow chart in the procedural summary.

Part 2 – Triage Stage

Participant Baseline Questionnaire - AED
This will be presented to you by the patient, and the majority of it will be completed by the patient, give them all copies of baseline. Fill front page before you start speaking to patient.

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?” This is also in manual. Verbal consent to take personal details, check eligibility and screen. We have scripts because it all needs to presented consistently.

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 criteria is on Page 2 of the Participant Baseline Questionnaire You may feel that some people who are not eligible to take part should be screened Be aware that we are not allowing these people to take part either because of practical reasons of data collection or because they may not be able to give informed consent to take part  which is a key ethical obligation for collecting this data. Resident in England and of fixed abode: the research team need to follow-up and contact these people in 6 months time so it is necessary that they will be contactable. Should be able to read/write/speak English sufficiently well because the study involves filling out several questionnaires and it will be important that they understand these. In post study clinical practice it may be that you do screen these people but not for the purposes of the SIPS project. Alert and orientated: i.e. the ability to understand the information presented, retain it and make an informed decision – competence

Eligibility continued...
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 The key point to remember is that the patient must be able to give Informed consent. Some criteria will therefore require your own judgement: Is alert and orientated Is not suffering with a serious mental health problem e.g. not severely distress or experiencing a psychotic episode. Is not grossly intoxicated ***EMPHASIS VERBAL CONSENT POINT!!!!!***

Patient demographic information
This has to be completed by the clinical staff – just collects a few pieces of demographic information on the patient

What is a standard unit of alcohol?
The alcohol screening process What is a standard unit of alcohol? The concept of a standard unit of alcohol is necessary for defining hazardous and harmful drinking in terms of medically-recommended limits of drinking. Many trainees will already be familiar with the definition of a standard unit but it will do no harm to remind them. A standard unit of alcohol is defined in the UK as 8 grammes (or roughly 10ml) of ethyl alcohol. It so happens that standard measures of a range of drinks in the UK contain roughly this amount of pure (ethyl) alcohol. abv means “alcohol by volume” and is simply the proportion of pure alcohol in a beverage. It is a much more convenient way of specifying the alcoholic strength of drinks than the old-fashioned “proof” method. But BEWARE - this established way of defining a standard unit can be very misleading. For example: The strength of many beers, lagers and cider is more than 3.5% abv. Best-selling lagers are 4.4%. And “strong” lagers or special beers and ciders may be up to twice the strength of beer used to calculate the standard unit. One pint of 5% lager contains 3 standard units. A 125ml glass of wine is a very small glass. A typical glass of wine in a pub contains 175ml and a large glass contains 250ml (i.e., 2 units). Also, most wines these days are stronger than 8% abv – up to 12% or more. Thus a typical 175ml pub glass of 11.5% wine contains 2 units. The most common measure of sprits in England and Wales is 25ml but some pubs and clubs now serve a larger 35ml measure (already the common measure in Scotland and Ireland) One “double” of the larger measure at standard 40% strength contains nearly 3 standard units. And, NB, drinks poured at home are frequently larger than pub measures.

Fast Alcohol Screening Test (FAST)
Four-item questionnaire The first question is a filter question (show patient the ‘ready-reckoner’ as a guide to standard drinks/units) most patients will respond positive anyway, and you wont need to progress through last 3 questions. It’s a shorter version of the Alcohol Use Disorder Identification Test (AUDIT) – which is the gold standard Designed for use in busy health care settings – such as A&D departments If positive on question 2 – ie score 3 or 4 – terminate the screening If negative on question 1 – i.e. score either 0, 1 or 2 – complete the remaining questions An overall score of 3 or more = FAST positive for harmful/hazardous drinking

Examples: Fast Alcohol Screening Test (FAST)
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. Calculate the number of standard drinks that the man had: 4 (Guinness) (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

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! 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 . . . How would you record her response on the FAST? ‘Less than monthly’ = 1 point

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. How would you record this response? ‘Less than monthly’ = 1 point Nobody has ever expressed any concern about my drinking habits or suggested that I cut down. In response to question 4 she says: 1. Stress fact that this person is clearly not drinking at classically heavy levels, but she screens positive, and research shows she will benefit for a brief intervention. 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

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 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.

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’. 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.

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. 1. This example shows that this man appeared initially to be quite a heavy drinker but ended up negative. 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)
Scoring the SIPS-PAT If a patient is attending the department for any of the TOP 10 reasons for attendance (as detailed on the PAT) you should screen them. The patient should be asked question 1 first and their response should be circled. If their answer is “YES” they would automatically score PAT positive and no further questions need to be asked. If they answer “NO” proceed to question 2. For question 2, the patient should be asked the question relevant to their gender (Male – EIGHT or more drinks, Female – SIX or more drinks), and their response should be circled in the most suitable category. If the patient answers ‘Monthly’, ‘Weekly’ or ‘Daily or almost daily’, this indicates hazardous or harmful drinking, and you should place a cross in the ‘Positive’ box. This is a PAT positive score. Any other response is a PAT negative score, and you should place a cross in the ‘Negative’ box.

Examples: SIPS-PAT No it was the heels on these new shoes. 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 SIPS-PAT 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. Calculate the number of standard drinks the woman has. 4 – 5 standard drinks 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 SIPS-PAT 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 No I fell off a ladder whilst decorating 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 SIPS-PAT 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. Calculate the number of standard drinks the man has. 2 pints of Stella = 6 standard drinks; Whisky = 4 standard drinks 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)
Scoring the SASQ If the patient's response is 'Monthly', 'Weekly' or 'Daily or almost daily' the score is M-SASQ positive. If their response is 'Never' or 'Less than monthly' the score is M-SASQ negative.

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. Calculate the number of standard drinks the man consumes. 1-2 units per day and 9 at the weekend 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 If patient is negative, thank them for their interest in the study and terminate their involvement at this point If patient is positive, provide with Research Participant Information Sheet and attempt to obtain written consent Because someone has a positive screening result, doesn’t mean that he/she is an alcoholic; but he/she may benefit from a brief intervention.

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.” Patient to read information sheet, sign consent forms, fill in baseline pack in waiting area, ready to present to clinician

AED Research Participant Information Sheet
Read it thorough so that they understand what we are doing. Emphasise they will receive a £10 voucher for completing the baseline research pack, and another £10 voucher for taking part in the 6 month follow up interview

Part 3 – Treating Clinician Stage

Consent 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. 1. Reiterate that they understand what is involved in study and consent to take part.

Consent Forms Consent if important because of ethical obligations of the study and because the patient is providing confidential information. Both copies of the form need to have cross in each of the six boxes And each copy needs to be signed by both the patient/participant and the Member of staff If the patient hands the form back and one or more of the boxes haven’t been crossed – hand back and asked to reread question If the patient hands back form and not signed or dated – ask them if they would mind signing and dating Please note that at the bottom of the research copy there is a hospital number (i.e. patient id number) Tear off the patient copy and give it to them Research copy stays in the baseline questionnaire to be separated and collected by research staff later on.

Consent If the patient does not consent to participate in the study, offer them the Patient Information Leaflet and no further action is taken. 1. Hold up PIL!!! 2. Leaflet giving advice on sensible drinking limits and advice on cutting down, DO NOT GIVE THEM ANY ADVICE OR GUIDANCE ON USING THE PIL

Instructions to patients

Patient personal information sheet
Contact details are very important for follow up This is the last part of the baseline staff members will fill out

Alcohol Use Disorders Identification Test (AUDIT)
WHO gold standard to assess alcohol use disorders Stress importance of this particular questionnaire to the study, we evaluate the new screening tools against it

EQ5D – health status questionnaire
1. Few questions about patients general health and well being

Service Use Questionnaire (SUQ)
1. Few questions about patients use of health and social services, used to assess their monetary burden on statutory services.

Readiness to Change Ruler (RCR)
1. Designed to assess patients current attitude towards changing their drinking habits.

Please check participants have filled in all sections of the baseline questionnaire!
If you can check anything check the AUDIT!

Patient Information Leaflet How Much Is Too Much?
Winchester Alcohol Service This is the PIL – it is produced by the Department of Health. I am going to briefly go through what it contains. Drinking and you explains the recommended maximum daily limit of alcohol intake by Men and Women. How Drinking affects your health gives brief definitions of health related problems due to excessive alcohol drinking, both short term and long term risks. The People around you describes social/interpersonal / occupational problems that arise through excessive alcohol drinking. Over the Limits? Looks at legal repercussions of excessive alcohol drinking. Worried you’re drinking too much? describes a list of indicators of possible hazardous/ harmful drinking. Where to get help provides contact details of National Alcohol Services. the last parts How Much Is Too Much?- reveals the units of popular alcoholic beverages And Knowing your units- is an interactive, multiple choice questionnaire that aims to raise self awareness. A sticker containing information of local services will be on the back of each leaflet. You will probably be familiar with much of the information in this leaflet but we feel it is important that you read it to familiarise yourself with the content.

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 The PIL is considered an intervention in itself. It is being used as another condition in the SIPS trial which means some services are handing it out on it’s own as an intervention. People that are in the brief advice condition receive it at the end of the brief advice. The PIL contains useful information regarding personal alcohol use. The information is provided in a real and down to earth manner that people can relate and identify with. The PIL is a therapeutic tool which contains non direct, non confrontational and non judgmental advice. It offers information rather than telling people what they should do which is beneficial in empowering people to make choices regarding their drinking. It is a free resource for people to take away and look at in their own time. This is beneficial as it continues to reinforce the intervention you have provided. The language used in the PIL should be accessible to the general population.

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: Thank the patient, inform them they will receive a letter from the research team in 2 weeks that will contain a £10 voucher. “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”. It is really important for the research project that the brief advice and PIL are delivered in the same way for each patient As you hand over the PIL, please say the following….. To rap up the 5 minute intervention please thank the client and inform them that a member of the research team will be in contact with them in the next two weeks at which time a £10 voucher and a thank you letter will be mailed to them.

Pilot Days An opportunity to practice screening and providing Brief Advice Triage nurse to screen patients and refer those positive to the study doctors/ENPs Doctors/ENPs will have a go at offering the Brief Advice No research materials will be used Ensures potential problems can be solved before active recruitment to study begins Sam, Malcolm and Lisa will be on site during pilot for support and feedback

Winchester Flow Chart This flow chart is also on the back of your laminate And is a quick summary of all of the study procedures that we have just been through. Recaps what we’ve just talked about – any questions?

Support and supervision
Who to contact if I’m worried about a patient in the study? Please contact your alcohol health worker: Lisa Rail Julia Reid Tel: Tel: Or refer patients to alcohol services as outlined in the Patient Information Leaflet: Drinkline Tel: Alcoholics Anonymous Tel: 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 Malcolm Hobbs Tel: Tel: Katherine Perryman Tel:

Useful links www.sips.iop.kcl.ac.uk/ www.alcoholconcern.org.uk

A&E St. Mary’s 'Scientia Vincit Timorem'

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A&E St. Mary’s 'Scientia Vincit Timorem'

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