1 Department of Pharmacology, The University of Liverpool, Ashton Street, Liverpool L69 3GE, UK and 2 The Royal Liverpool and Broadgreen University Hospital Trust, Ashton Street, Liverpool L69 3GE, UK
* Author to whom correspondence should be addressed at: Tel: +44 151 794 5549; Fax: +44 151 794 5540; E-mail: munirp{at}liv.ac.uk
(Received 18 May 2005; first review notified 2 June 2005; in final revised form 20 June 2005; accepted 21 June 2005)
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Patients attending hospital with alcohol-related problems fall into two broad categories: (i) those with less severe drinking problems who may be amenable to brief interventions (Heather, 1996, 2002
); and (ii) patients with features of alcohol dependence, requiring detoxification and ongoing treatment. Appropriate management of both types of patients in secondary care is important. For instance, screening for alcohol-related problems has been shown to be effective in identifying opportunities for alcohol-specific interventions (Wright et al., 1998
; Hadida et al., 2001
; Heather, 2002
), including those administered by alcohol specialist nurses (Leslie and Learmonth, 1994
; McManus et al., 2003
). In alcohol-dependent patients, early detection improves patient outcomes (Saitz et al., 1994
; Foy et al., 1997
), and alcohol specialist nurses are well placed to provide advice on detoxification, and to optimize medical management through providing ongoing support, and information for referral for specialist alcohol treatment (Sander, 1997
; Hillman et al., 2001
).
In order to determine whether NHS hospitals are equipped to deal with patients with alcohol-related problems, we have undertaken two surveys: the first was in 2000, while the second was in 2003 after the publication of the Royal College of Physicians report (Royal College of Physicians, 2001). The aims of the survey were to determine the number of general hospitals that employed a dedicated alcohol worker, and what policies they had in place for the treatment and referral of patients with alcohol-related problems.
![]() |
METHODS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Procedure
The phase 1 questionnaire focussed on the availability of specialist nurse support, the use of voluntary agencies, and the availability of guidelines for medical management of patients admitted with alcohol withdrawal (Fig. 1). In phase 2, the questionnaire was amended to determine whether the NHS Trusts were aware of the Royal College of Physicians report on alcohol (Royal College of Physicians, 2001).
|
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The results of the two phases are summarized in Table 1. Only six hospitals employed alcohol specialist nurses in 2000: four (3%) were full-time, and two (1.4%) were part-time (2 and 24 h per week). Qualifications held by the nurses varied: three were registered mental nurses (RMN), one was a general nurse, whereas two had dual qualifications. In 2003, the number of hospitals employing a dedicated alcohol specialist nurse had increased significantly (P = 0.005; 95% CI for the difference 0.1 to 0) to 21 (12.8%). Of these, 4 (19%) were part-time, working 8, 12, 18 and 23 h per week. Seventeen posts were full-time; however, five had other roles and responsibilities, four having responsibility for illicit drugs and one working with liver patients. The percentage of workers employed by Accident and Emergency Departments compared with Psychiatry was significantly greater in the 2003 survey (P = 0.01; 95% CI for the difference 20.1 to 0). The majority of hospitals in both phase 1 (90%) and phase 2 (87%) had no training program for nurses.
|
The other aspects of management of patients with alcohol-related problems, such as availability of care pathways, guidelines for screening for alcohol-related problems, and multidisciplinary working with voluntary agencies did not change between 2000 and 2003 and was disappointingly low.
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
There does seem to be a general increase in awareness of alcohol-related issues in the general hospital setting; 67% of hospital Trusts indicated that they were aware of the Royal College of Physicians report. Encouragingly, the number of hospitals intending to employ a dedicated alcohol worker had risen significantly in the 3 years between the two surveys. Whether this is the result of the Royal College of Physicians report is difficult to say, but importantly, can be taken to indicate that beliefs and attitudes regarding the value of interventions for alcohol-related problems in acute care may be changing. However, there is a long way to go. Although there had been a significant increase in the number of dedicated alcohol nurse specialists in the hospitals surveyed between 2000 and 2003, only 12.8% of hospitals are currently employing such an individual. Such workers are highly effective in different health care settings (Ockene et al., 1999). These nurses can adopt a multidimensional role ranging from optimization of medical management, screening for alcohol-related problems, and training other health-care staff, who generally lack confidence in dealing with these patients (Brown et al., 1997
). However, a minority of the hospitals had nurse training programmes, which is also a crucial element in improving the response of all healthcare professionals to alcohol abusing patients (Gerace et al., 1995
). Alcohol specialist nurses may represent a highly cost-effective mechanism for achieving the targets set out in the Choosing Health White Paper from the Department of Health (2004)
.
Only a minority of the hospitals had guidelines for the screening and detection of alcohol-related problems. This is unfortunate as screening is the key to identifying the patients most in need of interventions, and ensuring that interventions are the most appropriate to the patients needs (Conigrave et al., 1991; Holder et al., 2000
; Hillman et al., 2001
). Of concern in both surveys was the reported lack of care pathways for the pharmacological and non-pharmacological management of patients with alcohol withdrawal (13.7 and 17.6%, respectively). Such care pathways would be ideal, but in the absence of such guidelines, it would be important to have clear prescribing advice in the hospital formulary on the pharmacological management of alcohol withdrawal. However, this was also lacking, but encouragingly, there was a significant increase between the two surveys in the availability of such advice. We did not inspect the quality of the advice and cannot therefore comment on its appropriateness. Nevertheless, clear guidelines regarding management of these patients are important and may reduce avoidable complications, such as Wernicke's encephalopathy (Royal College of Physicians, 2001
), and delirium tremens (Inouye et al., 2001
), and are thus important clinical governance issues. They may also have added benefits in decreasing other complications and the length of stay in hospital (Foy et al., 1988
; Wartenberg et al., 1990
).
In summary, this survey has shown that there has been an increase in the number of alcohol specialist nurses in general hospitals, and that hospitals are positive about employing such individuals. Clearly, the ability to fulfill this will depend on the availability of resources. To this end, significant investment is required, which unfortunately has not followed on from the recent publication of the Alcohol Harm Reduction Strategy for England (Department of Health, 2004).
![]() |
ACKNOWLEDGEMENTS |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Brown, C., Pirmohamed, M. and Park, B. K. (1997) Nurses' confidence in caring for patients with alcohol-related problems. Professional Nurse 13, 8386.
Conigrave, K. M., Burns, F. H., Reznik, R. B. et al. (1991) Problem drinking in emergency department patients: the scope for early intervention. The Medical Journal of Australia 154, 801805.[ISI][Medline]
Department of Health. (2004) National Harm Reduction Strategy. Strategy Unit, London.
Foy, A., Kay, J. and Taylor, A. (1997) The course of alcohol withdrawal in a general hospital. The Quarterly Journal of Medicine 90, 253261.
Foy, A., March, S. and Drinkwater, V. (1988) Use of an objective clinical scale in the assessment and management of alcohol withdrawal in a large general hospital. Alcohol Clinical and Experimental Research 12, 360364.[ISI][Medline]
Gerace, L. M., Hughes, T. L. and Spunt, J. (1995) Improving nurses' responses toward substance-misusing patients: a clinical evaluation project. Archives of Psychiatric Nursing 9, 286294.[CrossRef][ISI][Medline]
Hadida, A., Kapur, N., Mackway-Jones, K. et al. (2001) Comparing two different methods of identifying alcohol related problems in the emergency department: a real chance to intervene? Emergency Medicine Journal 18, 112115.
Heather, N. (1996) The public health and brief interventions for excessive alcohol consumption: the British experience. Addictive Behaviours 21, 857868.[CrossRef][ISI][Medline]
Heather, N. (2002) Effectiveness of brief interventions proved beyond reasonable doubt. Addiction 97, 293294.[CrossRef][ISI][Medline]
Hillman, A., McCann, B. and Walker, N. P. (2001) Specialist alcohol liaison services in general hospitals improve engagement in alcohol rehabilitation and treatment outcome. Health Buletin (Edinb) 59, 420423.
Holder, H. D., Cisler, R. A., Longabaugh, R. et al. (2000) Alcoholism treatment and medical care costs from Project MATCH. Addiction 95, 9991013.[CrossRef][ISI][Medline]
Inouye, S. K., Foreman, M. D., Mion, L. C. et al. (2001) Nurses' recognition of delirium and its symptoms: comparison of nurse and researcher ratings. Archives of Internal Medicine 161, 24672473.
Leslie, H. and Learmonth, L. (1994) Alcohol counselling in a general hospital. Nursing Standard 8, 2529.
McManus, S., Hipkins, J., Haddad, P. et al. (2003) Implementing an effective intervention for problem drinkers on medical wards. General Hospital Psychiatry 25, 332337.[CrossRef][ISI][Medline]
Ockene, J. K., Adams, A., Hurley, T. G. et al. (1999) Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work? Archives of Internal Medicine 159, 21982205.
Pirmohamed, M., Brown, C., Owens, L. et al. (2000) The burden of alcohol misuse on an inner-city general hospital. The Quarterly Journal of Medicine 93, 291295.
Royal College of Physicians. (2001) AlcoholCan the NHS afford it? Recomendations for a coherent alcohol strategy for hospitals. RCP, London.
Saitz, R., Mayo-Smith, M. F., Roberts, M. S. et al. (1994) Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. Journal of the American Medical Association 272, 519523.[Abstract]
Sander, W. (1997) Protocol for intervention and treatment of alcohol withdrawal. Axone 19, 1013.[Medline]
Strategy Unit. (2003) Alcohol misuse: How much does it cost? HMSO, London.
Wartenberg, A. A., Nirenberg, T. D., Liepman, M. R. et al. (1990) Detoxification of alcoholics: improving care by symptom-triggered sedation. Alcohol Clinical and Experimental Research 14, 7175.[ISI][Medline]
Wright, S., Moran, L., Meyrick, M. et al. (1998) Intervention by an alcohol health worker in an accident and emergency department. Alcohol and Alcoholism 33, 651656.[Abstract]
|