Developing a new care pathway to enhance responses to alcohol cases

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Alcohol-related emergency care demand needs to be understood and managed if the number of cases is to be reduced, say James Bell and colleagues.

There has been a relentless growth in alcohol related admissions to emergency departments in the UK. During 2009-10 there were 1,057,000 presentations, up 12 per cent on the previous year, and more than double the figure for 2002-03. Of these, 68,400 patients were admitted with a primary diagnosis wholly attributable to alcohol consumption – frequently, alcohol dependence and alcohol withdrawal. Trusts are seeking ways to respond more effectively.

In 2009, King’s College Hospital Foundation Trust established an alcohol working party, comprising key hospital stakeholders and representatives from South London and Maudsley Foundation Trust addiction services. The committee oversaw a series of clinical audits in the wards and A&E, and made three key findings.

Insufficient screening

32%:
Male emergency admissions at King’s College Hospital who were interviewed and screened positive for hazardous drinking in 2009

First, despite National Institute for Health and Clinical Excellence guidelines recommending screening for alcohol problems, alcohol was largely overlooked – more than 80 per cent of inpatients, and 90 per cent of A&E presentations, did not have any documentation of alcohol use, even where an index of suspicion should have suggested alcohol use as contributing to hospitalisation.

Second, while on most inpatient wards alcohol problems were infrequent, nearly a third (32 per cent) of male emergency admissions interviewed did screen positive on the AUDIT, a tool designed to identify hazardous drinking.

Finally, in an audit of A&E admissions over one week, we identified 11 cases of probable alcohol problems, and these patients had 45 presentations to A&E in the previous two years.

This data confirmed the need to improve the response to alcohol, with the potential benefit of reducing pressure on acute beds, and reducing the frequency of recurrent presentations. The 2010 guidance Alcohol Use Disorders: diagnosis and clinical management of alcohol-related physical complications affirmed that patients who present to A&E in acute alcohol withdrawal, with alcohol withdrawal seizures or delirium tremens – or a history of these symptoms – should be admitted to hospital for a medically assisted alcohol withdrawal.

However, A&E and medical wards are over-stimulating environments in which to manage withdrawal, and such medical admissions did not usually result in linking patients to ongoing care.

In a bid to tackle this problem, an innovative clinical pathway was developed between A&E and addiction staff, so that when a patient presented in acute withdrawal requiring admission, but with no other medical problem requiring inpatient care, the patient would be admitted to a specialist detoxification unit, the acute assessment unit, on the Maudsley campus. We expected this to not only improve management of withdrawal and link patients to aftercare, but to be seen by A&E staff as a constructive response to alcohol problems, encouraging staff to address alcohol use.

In the first year of operation, 57 patients were transferred from King’s College Hospital to the alcohol assessment unit. Three of these patients were admitted on two occasions. Twenty-five had presented to A&E with a seizure, 13 with other withdrawal symptoms, and in nine the presenting complaint was “collapse”. The mean age was 47, and 79 per cent were male. The great majority (95 per cent) were single, widowed or separated, and 9 per cent reported being homeless. Around half (46 per cent) had no previous contact with addiction services. Many were recurrent attenders.

Admissions were funded as acute admissions to King’s College Hospital, with South London and Maudsley recharging for the admission to the assessment unit. One concern was whether in frail or severely dependent drinkers a three-day admission might not be adequate. In the first year, 10 patients needed to remain longer, three patients took premature self-discharge and three patients were returned to the hospital. The rest completed detoxification as planned.

Three critical issues were identified in the first year. First, the capacity to identify and transfer patients in acute withdrawal has been enhanced by the availability of addiction nurses, and at times, doctors, to provide advice, consultation, or review patients.

Second, using a nurse to transfer a patient by wheelchair has proved more satisfactory than using an ambulance. Finally, patients had no preparation for admission, and facilitating prompt access to aftercare has been recognised as critical to outcomes and benefits from the admission.

Further studies

A study of the effectiveness of the pathway is being developed, comparing it with elective inpatient admissions for alcohol withdrawal, and with ambulatory alcohol withdrawal for people presenting to A&E. A repeat audit of history-taking is planned, to assess whether this pathway has fostered a more engaged response to alcohol among medical staff.