Health Committee - The Government's Alcohol StrategyWritten evidence from Professor Robin Touquet (GAS 02)

Emergency Departments

I highlight successful implementation of the above—having recently completed 25 year as A&E (Emergency Medicine) Consultant/Professor at St Mary’s Hospital, Paddington, Emergency Department (ED)—Imperial College Healthcare Trust—where ED work led to the inception of the Paddington Alcohol Test, together with ED based Alcohol Health Workers from 1994.

1. Brief Advice (BA) is relatively unthreatening for ED staff to implement as it takes only one to two minutes by definition; if longer it is no longer true Brief Advice. It is unstructured (NOT using any specific format)—giving simple feedback on “cause” (drinking alcohol) and “effect” (ED attendance), to stimulate reflection by the patient (“contemplating change”)—with the offer of further help from an Alcohol Health Worker (AHW)—who may be present in the ED at the time.

2. Brief Intervention (BI) is much longer, being structured (may be based on “FRAMES”), given by those trained to give it (and who are specifically paid to give BI, having the allocated time), ie by AHW’s (who may or may not be qualified RMN or SRN nurses: then Alcohol Nurse Specialists, ANS’s) and lasts 20–30 minutes (or longer). This should include, for the truly dependent drinker, arrangements for the patient to be followed up in the community (Patton R, 2011)

3. “Clinical Inertia” is “a reluctance to update practice”, and “NIMBYism” is “not my job”. The key point is ED doctors and nurses have a wariness of anything that they perceive to slow down patient through-put, because ED staff are under such pressures of time, space and staffing—remembering that the ED workload is both variable and unpredictable. Using the term “Screening” risks precipitating negative responses because screening—implying for every patient—will inevitably slow patient through-put. If clinicians muddle BA (one to two minutes) with BI (20–30 minutes) such that they perceive that they, and their staff, will have to spend in excess of say even five extra minutes with every patient, quite simply there will be great resistance to implementing even the simplest of “Early Identification and Brief Advice” (EIBA). However, if it is clearly understood that all that it expected is one to two minutes of BA for those presentations likely to be associated with alcohol misuse (ie fall, collapse, head injury, assault, accident), that there are readily available AHWs to be of stress-relieving support (and are the ONLY staff who enact BI), and vitally that as a consequence unscheduled alcohol-related re-attendance will be reduced—then negative attitudes by ED leaders will be changed to being positive. Hence why it is vital that BA (very short and unstructured) is differentiated from BI (Huntley et al, 2001; Huntley et al, 2004).

4. For ED staff and indeed patients it matters far less what basic questionnaire is used (eg PAT, FAST, AUDIT C or RAPS4), rather that question(s) are indeed actually asked about alcohol—this may be only one question eg SASQ, effective as SIPS has shown (www.sips.iop.kcl.ac.uk). What is used depends on what suits that particular ED. Key for successful implementation are Education, Audit and on-going Feed-back (together with BI from the AHW, forming the anagram “BEAF”) with support from ED senior doctors and nursing sisters themselves. It must be remembered that in the majority of ED’s junior doctors change (ie move to another job) every four months now—so it is constant and unending Education, Audit and Feed-back. ED senior support (Consultants, Nurses) is the pre-requisite for success, again as SIPS has shown (www.sips.iop.kcl.ac.uk).

5. With PAT, Paddington Alcohol Test—PAT(2009) being the latest edition—please note the following (Touquet, Brown WHO 2009):

(a)Patient Information Leaflet (PIL). PAT(2009) states: “Give alcohol advice leaflet to all PAT+ve patients, especially if they decline ANS appointment”. The cost effectiveness of this advice has been confirmed by SIPS ED research results (www.sips.iop.kcl.ac.uk). Together with PIL (Patient Information Leaflet)—as used in SIPS—feed-back is given, which is equivalent to Brief Advice—and which is what BA actually is—cause/effect relating to the precipitating unpleasant episode that necessitated the inconvenience of an ED attendance.

(b)PAT(2009) is used “back-ended”, ie it is applied at the end of the consultation by the busy clinician who, hopefully by relieving pain, showing care and compassion etc, has generated “the gratitude factor”. The patient’s agenda (reason for attendance) is dealt with first.

(c)It is applied by the specific clinician who has seen the patient, to emphasize cause and effect with the relationship emphasized (to generate “contemplation of change” by the patient).

(d)It is applied using the word “routinely” (for all of “the top ten” presentations as shown on PAT) so it does not appear to the patient to be judgmental (Touquet & Brown. A&A, 2009).

(e)It is focused—ie it is selective to be applied only to the top ten alcohol-related conditions (eg fall, collapse, head injury, assault, accident), unless alcohol misuse is suspected for other reasons. (Huntley et al 2001) The word screening (a public health term) is never used as this implies universal application of whatever questionnaire is used.

(f)An appointment with the AHW is offered within a maximum of 48 hours of ED attendance to make best use of the “Teachable Moment” for “Opportunistic Intervention” (Williams et al, 2006)—even better if in real time providing the patient is sober.

(g)The pay off for the busy Clinician is to reduce alcohol-related unscheduled re-attendance—important for those working in an ED for say years (ie ED seniors)—less so for those relatively transitory staff only working 4/12 in the department (Crawford et al, 2004).

(h)PAT is an evolving clinical and educative tool to facilitate change—it is much more than a simple questionnaire—see information printed on the back of PAT2009, including:—A. History. B. Physical Signs of alcohol use. C. Resuscitation Room requested Blood Alcohol Concentrations (BACs)—patients unable to speak. (Touquet & Brown. A&A, 2009).

(i)Senior support from both ED Consultants and ED Nursing Sisters is vital for success as SIPS has shown (www.sips.iop.kcl.ac.uk ).

(j)Immediate availability of AHWs to help with difficult patients to relieve Clinicians’ stress is hugely helpful eg to prevent Wernicke’s or withdrawal (or both)—this can only happen if the AHW is a nurse. Thereby the ANS (Alcohol Nurse Specialist) can advise on Clinical Management so as to gain respect from the ED doctors in real time when ED staff are “Harassed, Apprehensive, Lonely and Tired”; anagram “HALT”. ED work can be very stressful, even frightening, for the junior doctor/nurse eg managing the drunk head injury. The AHW is the “stress-reliever”—hence the real advantage for AHW’s being RMN or SRN trained in order to help gain respect from clinicians, encouraging further support for implementing BA.

(k)It hugely helps if the AHW’s office is in the actual ED itself (for availability and profile), and if there is an over-night ED ward so that “drunks” can be seen, when sober, by the AHW in the morning before they goes home.

(l)All of the 20 years plus research (with >20 per-reviewed scientific papers) from St Mary’s Paddington has been pragmatic, by which is meant all of the initial data collection has been (without exception) by jobbing ED doctors and nurses in real time as part of their routine clinical care. Researchers have only been used for patient follow-up—hence, whilst it is only one site, it is truly translational with continuous Education, Audit, Feed-back—ie a lot of background on-going work. What has been achieved (and published) did not develop “over-night”—but was a long-term process that did catalyze attitudes towards drunk patients to become more positive. It was seen that something could be done and that over time it really did work (Huntley et al, 2004; Crawford et al, 2004)).

(m)PAT is embedded in the ED clinical practice—no consent is needed to apply it (especially not written—this is very time consuming) as it is in the patients’ best interests to be asked about alcohol and to be given BA with the offer of an appointment with the AHW for BI as part of high standard clinical care.

(n)What is important is Early Identification of the Hazardous drinker before the patient becomes a Dependent Drinker (even before they have become a true harmful drinker), ie working to facilitate “contemplation of change” early on in the drinking career of the patient. Hence the importance of clinically relevant coding (Touquet & Harris, 2012).

(o)As part of feed-back for the young (who may well not understand that alcohol is actually a drug), the question should be asked, “Why make yourself vulnerable?”. The first effect pharmacologically of alcohol is to depress behaviour inhibitory centres. Advice should be given not to put one’s self in potentially vulnerable situations, eg “date-rape”, where nearly always alcohol is involved. With alcoholic amnesia it can be very difficult for the police to unravel what has actually happened.

(p)Once a patient has become dependent—“change” is so much more difficult to achieve, BA/BI being much less effective in isolation on their own. Here with dependency, on-going follow-up care in the community is vital for success. Once a patient in truly dependent, this dependency is for life—whether or not drinking—because the brain chemistry has become permanently altered such that if the abstinent dependent drinker goes back to drinking alcohol, they are right back where they started as a dependent drinker: craving for alcohol everyday (Touquet & Harris, 2012).

6. It would be a serious omission not to highlight that ED Reception Staff do have a key role to play of recording where “alcohol-related incidents” happen which precipitate ED attendance, followed by close liaison with the community (police and Council) to identify clubs/pubs where drinking is not properly controlled, with specific action then being taken—the key work of Professor Jonathan Shepherd, Cardiff has demonstrated the effectiveness of such.

Conclusion

Every Dependent Drinker was once a hazardous/harmful drinker, ie every drinker has to start somewhere—how quickly the drinker become dependent depends both on their genes (endogenous) and their environment (exogenous).

Hence the importance of Early Identification with Brief Advice (EIBA), before dependence develops, together with understanding of the roles of BA, BI, AHWs with the advantages of ANSs.
(Price and Availability being the other two keys for reducing consumption.)

References

Crawford M, Patton R, Touquet R, et al. Screening and referral for brief intervention of alcohol misusing patients in an emergency department: a pragmatic randomised controlled trial. Lancet 2004; 364:1334–39.

Huntley J S, Blain C, Hood S, Touquet R. Improving detection of alcohol misuse in patients presenting to an A&E department. Emergency Medicine Journal 2001, 18: 99–104.

Huntley J S, Patton R, Touquet R. Attitudes towards alcohol of emergency department doctors trained in the detection of alcohol misuse. Annals of Royal College Surgeons England 2004; 86: 329–33.

Patton R, “Alcohol and the ED. Screening and Interventions to Reduce Harm”. University of London; PhD 2011. http://www.researchgate.net/profile/Robert_Patton2/publication/

Touquet R, Brown A. PAT(2009)—Revisions to the PAT for Early Identification of Alcohol Misuse and Brief Advice. Alcohol & Alcoholism 2009; 44: 284–6. http://alcalc.oxfordjournals.org/cgi/reprint/agp016?ijkey=HImeNEO7f6izT0F&keytype=ref

Touquet R, Brown A. In Alcohol and Injuries; Eds Cherpitel CJ, Borges G, Giesbrecht et al Chapter 12.4, “Pragmatic Implementation of Brief Interventions.” World Health Organization 2009. http://www.who.int/substance_abuse/msbalcinuries.pdf

Touquet R, Harris D. Alcohol Misuse Y91 coding in ICD-11: Rational terminology and logical coding specifically to encourage early identification and advice. Alcohol & Alcoholism 2012;47:213–5. http://alcalc.oxfordjournals.org/cgi/reprint/ags012?ijkey=azBvPIAzIjuf8g0&keytype=ref

Williams S, Brown A, Patton R, The half-life of the “teachable moment” for alcohol misusing patients in the emergency department. Drug and Alcohol Dependence 2005 77:205–208.

May 2012

Prepared 21st July 2012