Wessex AHSN - Alcohol Related Liver Disease, Audit and Pathway
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Transcript of Wessex AHSN - Alcohol Related Liver Disease, Audit and Pathway
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