The benefits of an alcohol liaison nurse in an acute hospital
Author Denise Johnston, PGCE, BSc, RMNH, is an alcohol liaison nurse at the Royal Alexandra Hospital, Paisley, NHS Greater Glasgow and Clyde, Renfrewshire.
Abstract Johnston, D. (2007) The benefits of an alcohol liaison nurse in an acute hospital. This is an extended version of the article published in Nursing Times; 103: 51, 28-29.
Attendance and admission rates to acute general hospitals for alcohol-related health problems are escalating. This article describes the development and implementation of an alcohol liaison service and its role in reviewing practices, the issues and the need for brief interventions with patients whose admission to hospital is alcohol related. It also discusses the relevance, purpose and benefit of the service to an acute hospital.
In 2001 the Royal College of Physicians produced a report highlighting a range of clinical issues relating to patients in acute hospital settings who experience varying degrees of alcohol problems (RCP, 2001). Issues raised in the report included the need for:
- Screening tools to be used to detect problem drinkers;
- A recognised management plan and established protocols to be developed;
- Pharmacology pathways to be used to ensure safe detoxification;
- Concurrent vitamin therapy to be administered to patients with alcohol-related problems;
- Alcohol education and training to be given to hospital staff to improve their practice with and attitudes to this patient group;
- Appropriate counselling and onward referral to be offered to patients;
- Alcohol liaison nurses to be appointed within all acute hospitals to effect the above recommendations and raise the issue of alcohol-related administration and governance.
After publication of the original national Plan for Action on Alcohol Problems in Scotland (Scottish Executive, 2002) – which has since been updated (Scottish Executive, 2007a) – the local alcohol and drug action team developed a local three-year action plan with key stakeholders such as social workers, senior physicians and addiction service managers and consultants. As a result, the need for an alcohol liaison service at the Royal Alexandra Hospital in Paisley was identified and the Scottish Executive gave funding to support its development. The service was initiated in April 2005.
Just prior to the launch of the service, statistics from NHS National Services Scotland (2005) highlighted that, in 2003–2004, 26,000 people were admitted to general hospitals in Scotland with alcohol-related health problems; of these, 41% were admitted specifically for alcohol liver disease. In 2004–2005, the number of admissions rose to 31,000, while there were 2,372 alcohol-related deaths in 2005 (Scottish Executive, 2007b).
Initiating the service
One alcohol liaison nurse was employed at the Royal Alexandra Hospital and one at the Inverclyde Royal Hospital site in Greenock. It was agreed to implement the service initially within three clinical areas – acute medical, surgical and psychiatric receiving wards. Since the service was introduced, it has been observed that people attending hospital who experience health problems related to their level of alcohol consumption fall into three categories:
- Seen at A&E only;
- Admitted with a condition that may result in a regular admission pattern;
- Longer admission for alcohol liver disease, Wernicke’s encephalopathy or alcohol-related brain damage.
It is likely that most wards in acute hospitals will have, on average, at least one patient with an alcohol-related health problem.
At present only people who are admitted to the hospital in whom alcohol is identified as the reason for admission are referred to the liaison service. Referrals to the service are made verbally by nursing, medical or any other allied health professional staff. It was initially envisaged that we would develop a paper referral system but it has become evident that other demands on ward nursing staff time made this impractical. A paper-based system would also mean staff would be unable to contact the alcohol liaison nurse directly to discuss a patient.
Liaison staff promoted the service by visiting the wards on a daily basis, and referrals began to trickle in. Soon staff were regularly asking for guidance on aspects of patient management and drug administration. This usually consists of diazepam, except for older patients or those with liver disease, who receive lorazepam due to its limited half life. Patients can also be prescribed IV (a preparation containing water-soluble predominantly vitamins B and C), which can replace lost vitamins more rapidly than oral vitamins. It is particularly appropriate for those who are malnourished or experiencing cognitive confusion, as it reduces the likelihood of alcohol-related brain damage in those at risk of Wernicke-Korsafoff syndrome
The referral criteria are indicated on a flow chart indicating the pathway staff should follow (Fig 1). This straightforward method was developed because of the high proportion of patients referred to the service while experiencing either severe alcohol withdrawal symptoms or encephalopathy, or who were overly sedated, as these could not be appropriately assessed until fully conscious.
The referral criteria are now fully implemented, and staff advise the liaison nurse of a pending referral and of a patient’s physical and mental health status.
After discussions with nurses and observation of their practice, a month-long audit was conducted in May 2006 on their recording of alcohol consumption, use of the alcohol withdrawal protocol, concurrent vitamin therapy and use of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) (Bridgers, 2002; Sullivan et al, 1989), a symptom-triggered method of detoxing patients safely from alcohol.
The CIWA enables practitioners to take an individualised approach to care, as staff have to actively assess patients and score them hourly initially rather putting them on a standard fixed regimen similar to a chlordiazepoxide detox. If a patient’s score is under 10 it is deemed that they do not require medication, although it can be administered if the score changes.
It is crucial that patients are assessed early with the CIWA to reduce the risk of delirium tremens commencing. One problem picked up by the audit was that failure to commence using the CIWA even after the patient has waited several hours to be seen at A&E then be admitted. In many instances this has led to patients experiencing several withdrawals on admission to a ward.
The audit included recording of 52 patients admitted with alcohol-related conditions; the findings are listed in Box 1.
Box 1: Results of the audit
The audit highlighted the need to improve practice related to alcohol-related admissions. Alcohol liaison staff therefore approached ward managers and arranged staff education sessions, then provided managers with feedback on attendance rates and any particular issues raised.
Education sessions were conducted at ward level. These covered issues raised in the audit, such as how to assess and record the level of alcohol consumption, the use of an alcohol withdrawal scoring chart, medication administration and concurrent vitamin therapy. The sessions also incorporated focus group discussions, which allowed staff attitudes, knowledge, current practice and specific issues to be aired, all of which highlighted future training needs.
It is widely acknowledged that both acute service nursing and medical staff would benefit from alcohol education and training and the development of standardised good practice guidelines and protocols (Raistrick et al, 2006; Touquet and Paton, 2006; Alcohol Concern, 2002; Royal College of Physicians, 2001). This in turn would enhance their skills in recognising potential problems and lead to a safer pathway of care and onward referral.
Alcohol withdrawal protocol
The current protocol incorporates the CAGE alcohol screening tool (Smart et al, 1991; Mayfield et al, 1974) although, in the two years the service has been in operation, there has been little evidence that it has been used, either verbally or in nursing or medical documentation. Research literature highlights the fact that a screening process should be used to guide the care plan, including onward referral to specialist services (Gentilello, 2005; Malone and Friedman, 2005; Crawford et al, 2004).
Following on from the outcomes of the audit and staff focus group discussion sessions, liaison staff have reviewed and amended the existing alcohol withdrawal protocol to improve patient safety and nurse accountability. The Alcohol Use Disorders Identification Test (AUDIT) (Babor et al, 2001), which was developed by the World Health Organization, has been incorporated into the revised protocol because it has greater capacity for capturing various groups of problematic drinker than the CAGE tool, and is acknowledged as the gold standard in alcohol screening (Link Pharmaceuticals, 2005; Morgan and Ritson, 2003; Babor et al, 2001).
The new protocol was ratified by the drug and therapeutics committee of the RAH in May 2007, since when the liaison service has conducted ward-based education sessions with nursing staff on the new protocol and its impact on nursing practice. This is in keeping with the RCP (2001) report, which recommends that clear alcohol withdrawal policies should be established and monitored within acute hospitals.
Table 1. Referrals to the alcohol liaison service
April 2005-March 2006
April 2006-March 2007
Referred and assessed 460
Referred and assessed 575
Most common reasons for admission
Alcohol liver disease
Most common reasons for admission
Alcohol related seizure
Alcohol liver disease
Referred to alcohol services 199
Uptake of alcohol services (122)
Referred to other services 5
Brief interventions 39
Patient died; no intervention 9
Referred to alcohol services 238
Uptake of alcohol? services (125)
Referred to other services 23
Brief interventions 24
Patient died; no intervention 26
Table 1 shows the number of referrals to the service. The majority came directly from nursing staff, who would discuss the need for the referral with the patient. Due to the high volume of patients referred to the service, a bid was accepted for another liaison nurse at the Royal Alexandra Hospital site.
Initially it was agreed that nursing staff would approach patients with alcohol-related admissions and gain their consent to be referred to an alcohol liaison nurse. However, many of these patients did not see a need to be seen by an alcohol nurse and declined the referral. Through focus group discussions with staff and observation of practice, it became apparent that in many cases these patients were not fully aware that their hospital admission had been related to their level of alcohol consumption or dependence. It was agreed, therefore, that like other specialist health practitioners alcohol liaison staff would approach referred patients directly and explain that a member of nursing or medical staff had made the referral during the admission process.
This change in the referral process has allowed liaison nurses to conduct educational sessions that are directly related to the reason for patients’ admission to hospital, provide information on their current physical health status and blood results, and explain procedures they will be having such as an endoscopy or liver biopsy. It also allows the nurses to conduct a brief intervention and to assess patients’ mental health status, their need for medication and vitamin therapy, their motivation to change and potential for referral to appropriate community-based alcohol agency.
The service is currently developing an online educational programme for first-year medical students, which aims to highlight the subject of alcohol withdrawal and provide points of reference. The rationale for this came again from observed practice, as it is frequently junior doctors who prescribe detox medication, often without adequate knowledge of the patient’s history or potential problems.
Senior nursing and medical practitioners recognise that there is a training deficit for both medical and nursing students learning in relation to assessing alcohol problems and secondary ailments (RCP, 2001; Wallace, 2000; Watson, 2000).
Due to new Scottish Executive policy and feedback from nursing students, the liaison service is also in discussions with the local university about providing input into the teaching of second- and third-year adult branch nursing students.
The Paisley alcohol liaison nurses are also attempting to develop a Scotland-wide alcohol liaison forum to enable healthcare professionals to discuss, review and share best practice. An alcohol awareness day is planned within the local Renfrewshire area. This has involved liaising with local NHS, voluntary and social work alcohol agencies, enhancing joint working relationships.
The service is considering including the number of patients admitted to the acute hospital and subsequently diagnosed with alcohol-related brain damage into its next audit.
There are currently no services in the local area for these patients, as there is ongoing debate within its hospitals about who should take responsibility for them. It is envisaged that their inclusion in the audit may highlight the extent of the problem and its impact on overstretched acute hospital resources and lead to a review of local service provision to provide focused services for these patients.
In order to gather evidence of the effectiveness of the alcohol liaison service, it will be necessary to conduct a cohort study of patients referred over 1–2 years. The number of patients with dual addictions and the ramifications of their care may also be audited in future.
In addition to the lack of service provision for patients experiencing alcohol-related brain damage and the resulting increased occurrence of bed blocking within acute medical care areas, the following issues have arisen in relation to patients referred to the liaison service:
- The need for individual discussion with patients regarding child protection issues within an adult service;
- The impact on statutory and voluntary services of numbers of patients referred to them from the alcohol liaison service.
Discussions on child protection are now only initiated in acute wards via alcohol or psychiatric liaison services when they are conducting more in-depth assessments, as the ward nurses’ workloads make it unlikely that they can attend training on the issue. The voluntary agencies to which the service refers patients experienced increased waiting lists and have approached the local community health partnership for funding to employ two more counsellors that the liaison service can use as direct referral routes. Funding approval is still awaited.
The majority of the patients referred to the alcohol liaison service have never approached their GP or any alcohol service for help. It may be that many do not perceive the harm they are storing up for themselves or the impact their drinking has on family members.
The alcohol liaison service offers the opportunity for acute hospital patients to be provided with a brief intervention and education on their alcohol use and, for those who need it, the opportunity to be fast-tracked to appropriate community services. The role of the alcohol liaison nurse means patients can be offered health promotion, education and advice on their alcohol consumption. They can also reduce patients’ risk of future alcohol-related admissions by discussing the reason for their admission, addressing lifestyle behaviour and choices and giving a direct link to community services to those who need it.
Slattery et al (2003) suggested that alcohol liaison nurses can provide a range of services including:
- Training hospital staff;
- Identifying hazardous drinkers;
- Safely managing alcohol withdrawal;
- Providing interventions aimed at reducing patients’ alcohol intake;
- Reviewing protocols;
- Supporting staff in providing appropriate assessment and care;
- Referring patients for post-discharge treatment;
- Supporting family members.
Excessive consumption of alcohol is associated with numerous major health risks, and the number of patients who are admitted predominantly for alcohol problems represents a significant financial burden on acute hospital services. It is therefore recommended that an alcohol liaison service is incorporated within all acute general hospitals.
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