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ACTS – new opportunities?
(Alcohol Care and Treatment Service)
Nick Sharer
May 2015
Hogarth’s Gin Lane and Beer Street 1751 – total chaos
Addressing liver disease in the UK
Ten key recommendations ……..
1. Strengthen detection of early liver disease
and its treatment by improving the level of
expertise and facilities in primary care
Time period between referral to a liver clinic and
first admission with cirrhosis or liver failure
The Big Three
•Alcoholism
•Obesity
•Viral hepatitis (hepatitis B & C)
NCEPOD: measuring the units
a review of patients who died from alcoholic liver disease
• Jan – June 2011 deaths from alcohol-related liver disease
• 2454 patients from 218 hospitals
• 1752 patients (71%) had a previous admission in last 2 years to that
hospital
• 62% of these (1082/1752) were with ARLD
• 18% had presented to other hospitals
• Advisors felt that for many patients opportunities had been missed in
previous admissions that had the potential to influence outcome.
• The majority of these would have been referral to alcohol support
agencies
PGH study:
Data collection
Cohort:
• Patients over 65 years admitted with wholly attributable alcohol
ICD-10 diagnosis e.g. alcohol intoxication, alcoholic liver disease
/ myopathy / pancreatitis etc.
• June 2013 - June 2014 (253 patients)
• 18 died as in-patients (14M : 4F)
Retrospective study:
• Review of admissions in ~30 years preceding death
PGH study
Results (18 patients)
• Age range 65 - 77 (average 69)
• 155 admissions over 30 years:
• 6 admitted 6-15 times
• 2 admitted >15 times
• One attended A&E 98 times in 20 years (database goes back
to 1993)
• Remaining 17 patients totalled 145 A&E attendances
PGH study:
Reasons for admission
Department
Example
Percentage
Surgical
Fracture, epistaxis,
abdominal pain,
pancreatitis,
35%
Medical
Confusion, LOC, SOB, chest
pain, AF,
65%
Difficulties in categorising:
• Paper notes
• Multiple co-morbidities
PGH study:
Results continued
Alcohol History:
• Only 4 patients had history taken every admission
• Examples of inadequate history (‘occasionally / a couple‘)
• Correlation between specialty and full alcohol history – a need to
target surgical specialties!
• None of the patients were found on the drug and
addictions services database. Any referrals,
appointments offered or contacts should be
recorded (since 2007)
• 14/18 (77%) patients had correspondence with GP
(Clinic letter, IDS) who was asked to review alcohol
intake of detox regime on discharge
Case history
•
•
•
•
77 yr old female
12 admissions (one elective)
11 A&E attendances
5/11 alcohol history was taken
1995
Epistaxis
2002
Epistaxis
No history or
f/u
No history or
f/u
2006
Haematemesis PUD
2010
Haemetemesisvarices
History taken
No f/u
History taken
No f/u
1999
Epistaxis
2004
Epistaxis
2010
NOF #
No history or
f/u
No history or f/u
No history
or f/u
2012
Gen unwell
2013
Confusion
No history or
f/u
History taken
No f/u
2011
Elective
femoral Nail
2012
Sepsis
2014
Pneumonia
No history or
f/u
History
taken
No F/U
Alcohol history
taken
Died
Cause of death: I a Bronchopneumonia
b Decompensated alcoholic liver disease
II Type 2 diabetes
2002
2004
2006
2010
2014
Hb
144
137
94
93
115
MCV
104.4 108.4 103.4 102
Plts
152
INR
104
193
111
1.2
1.6
1.8
Creat
68
68
63
108
ALT
26
25
15
14
ALP
120
128
98
97
Bil
19
15
34
139
Alb
38
34
24
20
gGT
722
578
Epistaxis
• 2002/2004 - Missed
opportunity early on for
intervention despite
high MCV and GGT
• 2006 – no mention of
alcohol on IDS despite
gGT and MCV results
Haematemesis: Variceal bleed Decomp ALD
USS: Cirrhosis USS: Cirrhosis,
PUD
and ascites
splenomegaly, ascites
NCEPOD recommendations:
Acute hospital model for an alcohol care team
A consultant-led, multidisciplinary, patient-centred alcohol care team
to be integrated across primary and secondary care
7 day alcohol specialist nurse service
Coordinated policies for the emergency department and acute
medical units
Rapid assessment, interface, and discharge liaison psychiatry service
An alcohol assertive outreach team for frequent attender to hospital
Formal links with local authority, clinical commissioning groups, public
health, and other stakeholders
Hughes NR, Houghton N et al.
Salford alcohol assertive outreach team: a new model for
reducing alcohol-related admissions.
Frontline Gastroenterol. 2013: 4; 130 - 4
Multi-disciplinary team: medical, psychiatric, drug misuse worker,
nurse, social worker
54 patients for 6 months
Comparing 3 months pre
and post intervention
Admissions 151 -> 50
A&E attendances 360 -> 146
Poole AAOT: pilot started Sept 14
• 2 workers appointed
• Local, generic and specific training
• Risk management issues (lone workers)
• 31 patients taken onto case load as of April 2015
6 months Pre AO
6 months Post AO
Ambulance
91
47
Other
62
14
153 (£11,894)
61 (£4,612)
97 (£104,454)
27 (£34,264)
96/225
47/93
Mode of conveyance to ED
Total
Inpatient admissions
GP / Practice contacts
Alcohol related problems /
All conditions
Take home messages:
1. Liver disease is rising exponentially
2. Consider alcohol excess in multitude of presentations
3. Use screening (AUDIT C tool) and ACT on it
4. Utilise resources available