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A hospital care pathway for alcohol

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Pat Elliott, RN, CertEd; Margaret Davies, RN, DipN; Elaine Scott, BA (Hons), RN, CertEd

Pat-Ward Manager; Margaret-Ward Manager; Elaine-Clinical Governance Co-ordinator, Medical Directorate, Arrowe Park Hospital, Wirral Hospital NHS Trust

The cost to the NHS of alcohol problems is phenomenal (see Boxes 1 and 2). In the Wirral, north-west England, a total of £1.3 million was spent on alcohol-related cases in 1998-1999 between secondary and primary care (Jones, 2001).
The cost to the NHS of alcohol problems is phenomenal (see Boxes 1 and 2). In the Wirral, north-west England, a total of £1.3 million was spent on alcohol-related cases in 1998-1999 between secondary and primary care (Jones, 2001).

The medical directorate within Arrowe Hospital, Wirral Hospital NHS Trust, has two gastroenterology wards. Both ward managers and senior medical staff became concerned about the increased admissions to these wards of patients with alcohol misuse as a secondary diagnosis. This was reducing access to clinic- and GP-referred patients with acute gastroenterology problems and investigations.

Patients with alcohol misuse were staying on the wards for a withdrawal regimen lasting 10 days or more.

Nurses told the ward managers:

- The wards were getting a reputation as 'second class', due to the 'troublesome' patients admitted, with frustration at the increased nursing time spent on these patients

- The lengthy withdrawal regimen was not individualised, resulting in poor medical and nursing management, and putting patients and staff at risk.

- Junior medical staff were reluctant to prescribe additional medication under the current regimen, which did not allow the flexibility for this.

Preliminary audit
A core team of the two gastroenterology ward managers and the clinical governance co-ordinator carried out a three-month audit in 1998. They:

- Looked at how many patients admitted to the medical directorate through the medical receiving ward or A&E via the bed bureau had a primary or secondary diagnosis of alcohol excess

- Checked the extent to which the benzodiazepine withdrawal regimen was being used, according to the patient computer information system

- Conducted a pharmacy audit of the use of ward stock levels of chlordiazepoxide, a benzodiazepine used to relieve alcohol withdrawal symptoms.

The audit indicated that the use of chlordiazepoxide on the gastroenterology wards was significantly higher than in other settings, for example among patients in the community.

Chlordiazepoxide prescribed on the patient computer information system was 'ad hoc' and did not adhere to the agreed prescribing management - a 10-day regime, no loading dose, decreasing from 20mg qds over the ten days.

Admitting patients with alcohol-related problems to the gastroenterology wards had become custom and practice, and improved management of these patients was vital.

A care pathway
A multidisciplinary team was set up in 1999 to develop an alcohol care pathway to address the issues raised. The team comprised two ward managers, the clinical governance co-ordinator, three gastro-enterology consultants, the Wirral Alcohol Service manager, a local GP with an interest in alcohol misuse, a social worker, a pharmacist based on the gastroenterology wards, and a risk management member.

The first steps were to develop:

- Criteria which distinguished between patients with alcoholic liver disease in category one and those with other alcohol-related problems in category two, such as falls, chest pain, respiratory or other medical symptoms

- A patient-centred alcohol withdrawal regimen tailored to individual needs.

The team recognised the need to liaise closely with Wirral Alcohol Service, a community-based information and support service for anyone whose lives are affected by alcohol, based in the centre of Birkenhead.

In the first year a formula for admitting patients from the medical receiving ward was developed using the category protocol. The aim was for anyone in category two - that is not with full liver disease - to be admitted to any general ward rather than the gastroenterology ward. The benzodiazepine regimen was improved using the concept of a front-loading dose (Sullivan et al, 1991). The front-loading dose is given over 48 hours; it is eight doses of 20mg, followed by further doses following one of two regimes, depending on the patient's withdrawal condition. This was modified for use with frail and elderly patients.

The regimen allows clinicians to manage patients with alcohol misuse by identifying symptoms on a severity checklist.

Teaching programme
A series of workshops were held, with 30 nurses, pharmacists and specialist nurses at each, attending from all directorates in the trust. Four sessions were also held for junior doctors and consultants. The aim was to increase awareness of the new categories and how to deal with patients with alcohol-related problems. The importance of the new medication regimen and individualised care for patients were highlighted.

Feedback was positive. The sessions dispelled myths such as that people with alcohol misuse are 'down and outs' or 'losers' or from low socioeconomic groups. They also allayed fears regarding drug dosage.

Alcohol liaison nurse
An alcohol liaison nurse post was created, funded from Health Action Zone money, in March 2000. The initial idea came from the medical directorate, supported by the clinical director. But the post was funded externally, working with the Wirral Alcohol Service, psychiatry and acute areas. The idea was for this nurse to see patients in the acute setting and for later support to be offered via Wirral Alcohol Service after discharge, due to time constraints facing the nurse.

More men than women were referred to the alcohol liaison nurse during 2000-2001, with an age range of 34-59 years.

About 400 referrals were made, mainly from A&E, the medical receiving ward and the gastroenterology wards, with a few from surgery.

The number of patients attending the Wirral Alcohol Service following acute admission has not significantly increased.

The culmination of the two years' work resulted in a recognised and validated FAST track tool (Hodson et al, 1999) for assessment of alcohol misuse. This identified symptoms of alcohol withdrawal and provided an agreed benzodiazepine regimen, tailored to meet individual patients' needs.

The care pathway was piloted in the medical receiving ward, where patients with alcohol problems are first identified.

Audit of pathway
Despite increased training, some medical and nursing staff resisted the change. A retrospective audit was carried out on patients admitted between October 2001 and February 2002 to determine if the alcohol care pathway had been used during admission.

Three hundred case notes of patients admitted via the bed bureau were examined. They had all had a previous or present history of alcohol misuse, or alcoholic liver disease.

Compliance with the pathway was poor, from clinicians and nurses. Many patients were still being inappropriately admitted to the gastroenterology ward.

The next steps
We are aware of our clinical governance responsibilities, and in line with this, incidents involving patients with alcohol excess will be monitored. We are drawing up a plan to deal with recurring incidents by reporting them to the risk management department. This is in its early stages but forms part of our clinical governance agenda.

The care pathway has had a role in transcending primary and secondary care boundaries. It has involved a multidisciplinary team, and needs more development. The audit data indicated larger numbers of patients with a secondary diagnosis of alcohol misuse than previous figures had suggested.

There has been some resistance to the use of the care pathway. Clinicians need constant reminding that category one patients must be admitted when possible to gastroenterology wards, while category two patients should be admitted to any medical ward. Despite this, the old tradition of admitting patients with any alcohol problem to the gastroenterology wards persists. However, the pathway has had a positive impact on direct care in relation to:

- Improved management of patients as individuals

- Management of alcoholic liver disease patients

- Guidelines for medical and nursing staff for patient management

- Improved links with Wirral Alcohol Service, including funding for the alcohol liaison nurse.

Despite improved awareness, medical and nursing staff in the medical receiving ward need ongoing training to identify and manage patients with alcohol misuse appropriately.

The medical directorate has incorporated into its business plan the need to appoint a dedicated alcohol specialist nurse to provide an interface with GPs and the hospital, advise on patient management and work closely with the multidisciplinary teams to improve care. This post would be in addition to the existing alcohol liaison nurse, if it continues to be externally funded. The new post would be based in the hospital. While it is high on the priority list, funding has not yet been agreed.

Alcohol Concern. (2001) Alcohol and Mortality (Factsheet 18). London: Alcohol Concern. Available at

Alcohol Concern. (2002) Your Very Good Health. London: Alcohol Concern. Available at:

Godfrey, C., Maynard, A. A health strategy for alcohol: setting targets and choosing policies. York: Centre for Health Economics.

Hodson, R., Alywyn, T., John, B. et al. (1999) The Fast Assessment Screening Tool. Cardiff and London: University of Wales, College of Medicine and Middlesex University.

Jones, M. (2001) Appraisal of services provided to people who misuse alcohol in Wirral. Wirral: Wirral Drug Action Team on behalf of Wirral Health Authority.

Sullivan, J.T., Swift, R.M., Lewis, D.C. (1991) Benzodiazepine requirements during alcohol withdrawal syndrome: clinical implications of using standardised withdrawal scale. Journal of Clinical Psychopharmacology 11: 5, 291-295.
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