Nurse innovations transform trust's approach to alcohol harm
A team of nurses has introduced a raft of initiatives to prevent and treat alcohol abuse. Leader Kerry Lyons explains how they made alcohol harm reduction everyone's business - and convinced nurses that screening children as young as 10 is necessary.
A team of nurses has introduced a raft of initiatives to prevent and treat alcohol abuse. Leader Kerry Lyons explains how they made alcohol harm reduction everyone's business - and convinced nurses that screening children as young as 10 is necessary
Alcohol misuse is the third largest preventable cause of ill health and premature death in England. There are more than a million alcohol-related hospital admissions each year. Nationally, the cost of alcohol to the NHS equates to £21 billion each year – and more than 11 million people drink at hazardous levels.
The scale of alcohol consumption and harmful alcohol use in Tameside is significantly higher than national average. Public Health England has reported that the cost of alcohol to the ‘public purse’ in Tameside is £98.46 million, which equates to £448 per head of population. By this measure, it is the 14th worst area in the UK.
Before I launched the hospital alcohol liaison service (HALS) at Tameside I undertook a baseline assessment, which found inconsistent approaches to acute alcohol management. Clinical outcomes were variable and hospital stays protracted, coupled with high levels of readmissions and reattendances.
No patients were screened for alcohol harm and there was no access to alcohol awareness training for staff.
I wanted to create a skilled and informed trust-wide workforce and improve patient experience - as well as use NHS resources better. A central aim was to identify people with problems with alcohol through alcohol harm screening for all patients attending hospital despite their reason for presentation, and develop a seamless referral pathway into specialist community services.
As nurses, we identify with the discomfort felt at approaching difficult or challenging questions with patients. We have found that education is the key to enabling staff to acknowledge the importance of screening.
As well as creating a service responsive to patient needs, with optimised recovery outcomes, I wanted to reduce risk by creating safe clinical pharmacological pathways for alcohol-related withdrawal. I also wanted to establish a service to aid early, radiological identification of alcohol-related liver damage.
For me, it was about thinking outside the box and I developed a raft of initiatives to achieve my aims (see 'Initiatives in the Tameside Hospital Alcohol Liaison Service', below). I am aware of other alcohol liaison services, but I was intent on this service being different and fully focused on patient need. It was my intention to have an engaged and educated workforce in which alcohol harm prevention is everyone’s business.
I took the original service specification as a platform for innovation, further launching an acute alcohol withdrawal prescribing protocol that has been endorsed by NICE.
As a service, we have tried to acknowledge the chaotic nature of addiction by ensuring that the service is fully operational everyday – including a seven-day nurse response service, a nurse-led seven-day detox clinic and nurse-led liver fibroscan clinics.
Our hospital alcohol liaison service screens all children aged 10 and above because we are actively acknowledging the reality of alcohol and children.
This reflects Public Health England recommendations, but also our knowledge of our community in terms of the need to engage children early in prevention. Screening is approached sensitively as a routine conversation, therefore it is very rare that parents or carers challenge nurses.
When we set our screening age, some nurses initially found it challenging. However, this was addressed through our comprehensive, trust-wide education programme and they are now fully onboard. Training highlights concerns about young people and their drinking, as well as explaining to healthcare professionals the benefits of securing an early teachable moment.
We lean heavily towards a prevention model in my trust and therefore have actively promoted the Hidden Harm campaign undertaken by DrinkWise.
Early screening is not just about speaking to children about their own drinking, but also about looking for opportunities to approach hidden harm. Research shows that 2.1 million children in England are affected by others’ drinking and that 10 to15-year-olds view more alcohol advertisements on TV than adults age 25. Every day, 15 children end up in hospital because of alcohol – hundreds as young as 11. And 250,000 children suffer mental distress due to others drinking, while 170,000 children are neglected.
Through screening, we can help identify cases in our community and offer early support and an opportunity for either the young person or their family to engage in meaningful harm reduction and recovery.
In total, the service has seen 3,150 patients for specialist intervention and 82.4% of patients who engaged in detoxification with the HALS service have remained abstinent (6 months +). All eligible emergency department attenders are now screened for alcohol harm and we screen patients from the age of 10.
Of our patients, 39% did not have a primary presentation to hospital with alcohol, illustrating prevention. All patients’ GPs are notified of HALS intervention.
The cost of the service is £260,000, but the savings in LOS alone equate to more than £2million, not including savings of admission avoidance, reduced emergency department attendances and liver harm prevention. And this of course excludes the unquantifiable personal value of being able to rebuild your life.
There are significant and sustained reductions in LOS for alcohol-related admissions, alcohol champions in every clinical area. We also host an annual Alcohol Champion awareness/Education training day.
Training is key and fully evaluated. The 'multigrade' rolling monthly education programme is fully established, and the trust has hosted the RGCP Primary Care certificate in alcohol misuse for local GPs and pharmacists.
Our nurse-led service has received both national and international recognition, but of course we cannot stand still – we continue to strive for excellent outcomes for our patients.
As well as sustaining our achievements so far, we want to further develop and enhance the ambulatory detox clinic and fibroscanning service. We have launched a maternity pathway on fetal alcohol spectrum disorder prevention (read about the pathway here), which has received significant media interest as one of the first pathways of its kind in the UK.
Moving forward we are also working on a pathway for the identification of minimal hepatic encephalopathy. We actively share our practice and experience with our nurse colleagues because we believe this is a highly transferable project.
We are a small team, but we have made a massive impact. I am proud of what we have achieved to shift the focus to sustained recovery by doing things differently, ensuring our patients and quality are at the heart of everything we do.
Feedback from patients and colleagues
‘The service the HALS team provides in the emergency department, on the wards and in aftercare is absolutely first class. Not only does the team care about the addiction, it also understands and cares about underlying mental health issues. Words of gratitude fail me as you have been so good to me.’ Patient
‘Life felt over for me, but after my admission to hospital the HALS team have not only saved me, they have given me a chance at a new life. Since then things are on the up for the first time in years. Their support is terrific, their advice sound. I advise anyone to seek help from them before you feel there is no hope.’ Patient
‘The new HALS service has transformed the acute assessment and treatment of patients with alcohol related problems admitted to the trust. Previous care was patchy and variable with no clear cut pathway. The new service is rapid, reliable and effective. Advice is excellent and the HALS team take responsibility for arranging ongoing care of the patient after discharge, which benefits both patient and the trust. Discharge is both quicker and safer and with patients knowing they have appropriate support in the community. It is a big improvement on previous care – a 5-star service.’ Chris Payne, consultant, general medicine
‘The HALS service is an integral part of managing alcoholism. Its performance provides us with something all can build on. It also serves as a cornerstone on which liver disease and other alcohol related complications can be picked up.’
Vinod Patel, consultant gastroenterologist
Kerry's tips for leading and sustaining change
• Ensure open and transparent reporting mechanisms
• Keep patient involvement and experience at the core of what you do
• Secure early trust executive ‘buy in’
• Strengthen partnership working
• Underpin all your changes with evidence
Initiatives in the Tameside Hospital Alcohol Liaison Service
• A nurse-led fibroscan liver service
• Foetal alcohol prevention pathway
• A nurse-led daily ambulatory detoxification clinic
• Nurse-run mandatory teaching programmes on alcohol harm for all hospital staff and the wider community
• GP and student nurse training spokes for alcohol intervention
• Purely Patient focused flexible service
• Trained alcohol champions to act as ambassadors for best practice in every clinical area
• Formal pathways with community agencies, to ‘collaboratively’ improve patient outcomes
• Safe pharmacological pathways to therapeutically manage patients in withdrawal
Kerry Lyons is hospital alcohol liaison service lead and alcohol specialist nurse at Tameside Hospital NHS Foundation Trust. Her team was a finalist in the Liverpool Victoria-sponsored Innovations in Your Specialty category of the RCNi Nurse Awards 2016