Background

• Admissions and deaths due to alcohol are increasing• Liver deaths continue to rise while Mortality from

other conditions has been declining.• Greatest increase in Liver deaths have been in

Alcohol Related Liver Disease• Alcohol accounts for 77% of Liver Mortality • 2010 BSG / BASL / Alcohol Health Alliance UK joint

position statement

NCEPOD 2013 National Confidential Enquiry into Patient Outcome and Death

Alcohol Liver Related Deaths

• Care `less than good `in more than half of cases reviewed

• Frequent Attenders – longer admissions – complex needs

• Missed opportunities during previous admissions

• RECOMMENDATIONS

• Screening of hospital patients for alcohol misuse/alcohol history• Provide comprehensive physical and mental assessments, Brief

Interventions and access to specialist services within 24 hours of admission

• The referral and outcomes should be documented in the notes and communicated to the patient’s general practitioner

To improve health and wellbeing of patients presenting to hospital

with alcohol related liver disease (ARLD)

AIM

OUTCOMES

• Reduce Emergency Admissions• Reduce Bed days- length of stay• Reduce Mortality• Improve Patient journey• Improve staff Knowledge

*Increased Rates of early detection of Harmful Alcohol use and associated risk*

Audit sample1. Patients 18 yrs who had a

Liver diagnosis and who had a stay in Hospital of over 24hrs FROM 01/01/15 – 31/03/15

2. K codes (liver disease)

Patient Journey

Admissions• 67 % Admissions to MAU and AAUDischarges• 13% from MAU and AAU• 36% from Gastro wards• 7% from Coronary Care• 12% from Surgery• 12% other beds • 20% Mortality

All Patients Admitted 1st Jan – 31st Mar 2015Basingstoke and Winchester > 24 hrs

18-25 26-45 46-65 66-75 76-85 85+0

5

10

15

20

25

30

35

40

45

50

2

17

43

32

1213

1

7

27

18

9 9

1

10

1614

34

All PatientsMaleFemale

Length of Stay- All Admissions

1-2 days 3-7 days 8-14 days 2-4wks 1-2 mths 2 mth+0

5

10

15

20

25

30

35

40

45

36

41

29

12

8

4

Length of Stay – ARLD Patients

1-2 days 3-7 days 8-14 days 2-4 wks 1-2 mths 2 mths+0

2

4

6

8

10

12

14

16

10

15

13

6

3

1

ED attendances <24 HRS STAY

• 220 ED attendances for Patient Group in previous year

• 78 people attended on average 3 times each during the period

• 10 most frequent attenders accounted for 44% of all of the A&E attendances.

• The most frequent attender visited ED 25 times in the period accounting for 11% of all of the attendances

Continued

ED continued• 12% (26) had a primary diagnosis of Alcoholic

liver disease• Unspecified liver disease 5% (12)• 55% (120 ) presentations resulted in Hospital

Admission

PATIENTS SCREENED JANUARY – MARCH 2015

PATIENTS ADMITTED TO MAU – BASINGSTOKE AND WINCHESTER

JANUARY 5% out of 1,234 patients FEBRUARY 3% out of 1,148 patients

MARCH 3% out of 1,291 patientsSource - Business Intelligence and from Pastplus

Data -Alcohol Intervention Team

35 WITH ALCOHOL

CODES

71 NON ALCOHOL

13 MISSING / NOT FOUND

NOTES SEEN / NOT SEEN

ARLD Admissions (39) NON ARLD Admissions (71)

87% Were asked about their alcohol use

85.9% Were asked about their alcohol use

(61)

38.4% Had units documented(15)

11.4% Had units documented

1/3 Units incorrectly calculated

Units correctly / incorrectly calculated – unknown / not

documented

NON ARLD61 PATIENTS ASKED ABOUT THEIR ALCOHOL INTAKE –

Documented:-

31

13

1

3

4

9

No alcohol intake =50.8%

Occasional =21%

Denied excess use = 1.6%

Audit C score – 1 positive (not re-ferred)=4.9%

Rarely / minimal = 6.5%

Alcohol Qty = 14.75%

Harm / Reduction Advice1 person

Other • 6 x Admitted HX excess alcohol use• 5 x Conflicting accounts from Nursing /

Medics• Documented not significant – elsewhere

documented >20 / 30 a week• 1 x Elective admission, not on Endoscopy

admission• 10 Patients not asked about their alcohol

use

ARLD – 33 PATIENTS (39 Admissions)

3 ITU

34 Asked

2 Not asked

ARLD PATIENTS – 34 ASKED ALCOHOL HISTORYDOCUMENTED:-

6

6

7

15

Stopped drinking / Not current 17.6%

Quantities documented 17.6%

Vague History 20.5%

Unit History 44.1%

34 Asked (above)

6 x Stopped drinking / Not current

6 x Quantities documented eg • Bottle of vodka a day• 2 Glasses wine a day• Bottle gin a day• 2-3 bottles wine or ½ bottle vodka• 300mls a day• 3.5 litres cider

7 x Vague History eg • Couple whiskies a day• Drinks one box• High intake prior to fall• Known to drink• Multiple bottles of alcohol

15 x Unit History • 5 Incorrect• 2 Conflicted• 5 Correct• 3 Not known

ISSUES IDENTIFIED

• Frequent attendances.• Poor Alcohol History- vague • Not Using Screening tool• Risk of Withdrawal – longer admissions• Lack of knowledge around units- reduced

confidence• Limited referral to Specialist nurses• More collaboration• Specialist Liver nurse input

ALCOHOL RELATED LIVER DISEASE

INPATIENT PATHWAY

Questions

Scoring system Your score 0 1 2 3 4

How often do you have a drink containing alcohol?

How many units of alcohol do you drink on a typical day when you are drinking?

How often have you had 6 or more units if female or 8 or more if male, on a single occasion in the last year?

AVERAGE WEEKLY UNIT INTAKE – TOTAL...

ARLD DIAGNOSIS + POSITIVE ‘AUDIT C’ AT INITIAL ASSESSMENT - SCORE

8+

ALCOHOL TEAM LIVER CONSULTANT

(A) CARE BUNDLE IF DECOMPENSATED LIVER CIRROHIS

TRANSFER TO GASTRO WARD

(A) DISCHARGE PLAN – INTERAGENCY CARE PLAN -

SUMMARY TO GP

MAU 1ST

24 HOURS

MANAGE AS PER POLICY IF THE RISK WITHDRAWAL CIWA – PABRINEX – CONSIDER

ADJUNCTIVE PHARMALOGICAL THERAPY

ALCOHOL R/U HEPATOLOGY R/U (A) WARD / MDT

(A) HEPATOLOGY OPA

(A) ALCOHOL FOLLOW UP

(A) =Auditable

PT LABEL

CHALLENGES

• Screening tool removed from Nursing Assessment• Liver nurse not commissioned for ARLD• Time lost – Non effective• Screening for PH – Different procedure• Limited In-Reach From Specialist services• Not a 7 day week service• Referrals• Across two sites

NEXT STEP

• Training- Units awareness – staff MAU /AAU• Screening• B.I• Referral !• MDT attendance and Integrated Discharge Planning• Working Party• Promote In –Reach• OPA – With Gastro - Joint ARLD clinic• Medical Training Re Documentation

Coding

Clinicians to be clear and detailed.Harmful Use Code F101 – Not defined in ICD 10 ? Changes to Local Hospital Policy for clear definitionNeed a clear diagnosis documented - No ‘impressions’, no ‘queries’ and no ‘likely’.Semantics –Possible can not be coded – Probable is acceptableAlcohol codes not documented unless:

Clearly written alcohol excess• Secondary to alcohol• Diagnosis is clear• Units• Advice given needs to be documented

On-going Service Development• Co-ordination and Collaboration between interface of services• Working party across both sites – to include Housing Social services ,Mental Health ,Older Persons, Specialist services• Pilot involvement with High Impact User Group – involving Police , Probation

Mental Health , Ambulance• Joint Assessment with Patients presenting with Mental Health issues and

Psychiatric Liaison• Integrated pathways between hospital and community services- • Identification of patients who can finish treatment with community services• Professionals Meeting prior to discharge to devise care plan at D/C so can be

on clinical tag if were to be readmitted either site• Attendance at Gasto Ward MDT – enable early discharge planning• Development of joint ARLD – Consultant / Alcohol Follow up