Prescribing for substance misuse: alcohol detoxification

Transcription

1 Prescribing for substance misuse: alcohol POMH-UK Quality Improvement Programme. Topic 14b (re-audit) Prepared by the Prescribing Observatory for Mental Health-UK for Non-participating Trusts Published date: 06/2016 Please use the following to cite this report: Prescribing Observatory for Mental Health (2016). Topic 14b: Prescribing in substance misuse: Alcohol. Prescribing Observatory for Mental Health, CCQI233 (data on file) The Royal College of Psychiatrists. For further information please contact

2 POMH-UK (2016) Topic 14b: Prescribing for substance misuse: alcohol Data control statement for POMH-UK quality improvement programme on Topic 14b: Prescribing for substance misuse: alcohol Data ownership and control In line with the original memorandum of understanding between POMH-UK and member healthcare organisations (predominantly mental health NHS Trusts), the following statement outlines the agreement regarding ownership of the audit data in this quality improvement programme. Control of the local data submitted to POMH-UK is retained by the healthcare organisation that submitted them. These data have been made available to POMH-UK in a way that is anonymous, with the exception of the identity of the source organisation. The aggregate data from all participating organisations have been analysed by POMH-UK, to produce this customised report. This report summarises the national results, and local results at organisation and clinical team level, benchmarked anonymously against the other organisations taking part. Data Sharing There is a publication strategy allowing POMH-UK to publish the anonymous aggregated data on its web site and/or in appropriate scientific journals. Any organisations requesting these audit data will be referred to the POMH-UK reports appearing in the public domain or provided with a list of member healthcare organisations and asked to approach them individually. It is each organisation s decision whether, and with whom, to share their data. Data for Quality Improvement Given that the data are collected for the purpose of quality improvement they are not necessarily representative of performance across the Trust. The use of data for ranking or judgement at an organisational level may therefore not be appropriate. Participation in POMH QIPs can be considered to indicate engagement in quality improvement. Relative and absolute performance against the practice standards should always be considered with the above caveats in mind. Reflection by clinical teams on their benchmarked performance is perhaps the most potent element of POMH-UK programmes. In addition to performance against the clinical standards, the audit data include demographic, diagnostic and other relevant clinical information that provide a context for interpretation and understanding of practice, which can inform local strategies and systems to achieve improvement. The data collected are designed to be suitable for this clinical purpose, and not for objective ranking of healthcare organisations, for which they are untested and would not necessarily be appropriate.

3 POMH-UK (2016) Topic 14b: Prescribing for substance misuse: alcohol How to read this report The term Trust has been used throughout this report to refer to all healthcare organisations that participated. Executive summary An executive summary of this report starts on page 4. This provides an overview of national performance against the practice standards and how your Trust compares. It also provides some broader observations relating to national prescribing practice (page 11) that may usefully prompt local reflection and discussion. Practice standards Page 16 of this report defines the standards against which prescribing practice was measured in this quality improvement programme (QIP). These practice standards were derived from evidence-based guidelines and agreed by an expert advisory group. Method Page 17 provides an outline of the methodology of the QIP. This includes the nature of the clinical audit data collected and how these were checked. National level results This section begins on page 18. The demographic and clinical characteristics of the total patient audit sample are described. The findings of the data analyses are presented in graphs and tables, primarily to show the extent to which clinical prescribing across the participating services is meeting the practice standards. Trust level section The analyses presented in this section, starting on page 44, allow Trusts to compare the quality of their local practice, in absolute terms, with the practice standards and, in relative terms, with that of the other, anonymous, participating Trusts. Each of the benchmarked graphs in this section provides evidence of performance on a particular aspect of prescribing practice across all Trusts individually and the total national sample (TNS). In all figures, the Trust(s) on the far left hand side is closest to meeting the relevant standard while the Trusts on the right are further away from meeting the standard.

4 POMH-UK (2016) Topic 14b: Prescribing for substance misuse: alcohol Executive Summary Background The Prescribing Observatory for Mental Health (POMH-UK) runs national audit-based quality improvement programmes open to all secondary mental health services in the UK. The aim is to help mental health services improve prescribing practice in discrete areas ( Topics ). This Topic 14b re-audit report presents data on prescribing practice for alcohol conducted in acute adult psychiatric inpatient settings. In this report, data are presented at national, Trust and individual Trust team levels. Specifically, benchmarked performance against best practice standards is presented to inform reflective practice. Audit sample Trusts were asked to include patients who had been admitted to an acute adult or intensive care psychiatric ward in the past year (prior to January 2016) and who had undergone alcohol whilst an inpatient The Royal College of Psychiatrists. 4

5 POMH-UK (2016) Topic 14b: Prescribing for substance misuse: alcohol Results For this re-audit in 2016, data were submitted for 1,143 patients from 177 clinical teams across 43 Trusts. Of the 1,143 patients in the total national sample, 801 (70%) were admitted for an unplanned alcohol, while 343 (30%) for a planned alcohol. The majority of patients (n=901, 79%) under the care of a general adult psychiatrist (non-specialist), whilst 242 (21%) were admitted under the care of a psychiatrist with a specialist knowledge of alcohol/substance use. The demographic and clinical characteristics of the patient samples from all the individual, participating Trusts are presented in Appendix B. Compared with the baseline audit, a higher proportion of the re-audit sample underwent alcohol during an unplanned admission while under the care of a general adult psychiatrist. Table 1: Prescribing for substance misuse, alcohol : participation in the quality improvement programme and nature of admission Planned or unplanned admission Clinician overseeing care Number of Trusts that submitted data Number of clinical teams Total number of patients patients whose admission for alcohol was unplanned patients whose admission for alcohol was planned patients who under nonspecialist care (acute or PICU) Sub-sample of patients who were admitted under specialist care (acute or PICU) Baseline , (61%) 462 (39%) 848 (71%) 349 (29%) Re-audit , (70%) 342 (30%) 901 (79%) 242 (21%) 2015 The Royal College of Psychiatrists. 5

6 POMH-UK (2016) Topic 14b: Prescribing for substance misuse: alcohol Practice standards and treatment targets for audit The practice standards shown below were derived from the NICE clinical guidelines on alcohol-use disorders (NICE CG100, 2010 and CG115, 2011). The NICE recommendations to which the standards relate are shown in brackets in the boxes below. Clinical practice standards for the audit 1. The decision to undertake acute alcohol of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake b. A physical examination, carried out on admission. 2. Blood tests relevant to the identification of alcohol-related physical health problems (e.g. liver function tests including GGT, albumin, full blood count, glucose and renal function tests) should be carried out during the admission. 3. Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine, carbamazepine or clomethiazole (derived from NICE CG 100, and NICE CG115, ). 4. Phenytoin should not be prescribed to prevent or treat alcohol withdrawal seizures (NICE CG 100, and BAP evidence-based guidelines for the pharmacological management of substance abuse, 2012). 5. Thiamine should be prescribed parenterally for inpatients in acute alcohol withdrawal. These audit standards were agreed by expert advisors to POMH-UK, and have been primarily extrapolated from relevant recommendations in the NICE guidelines referenced above. In some cases, the evidence for practice recommendations falls short of supporting an audit standard, i.e. being applicable in 100% of cases. However, the evidence may be sufficient to support general guidance for good practice, allowing that deviation may be appropriate in a proportion of cases. For such treatment targets, clinicians may be particularly interested in how their practice benchmarks with their peers. Treatment targets 1. Breath alcohol should be measured as part of the initial assessment for alcohol (derived from NICE CG 115, recommendation ) 2. Following alcohol, initiation of relapse prevention medication should be considered (NICE CG 115, ) 3. After alcohol, referral to specialist alcohol services for continuing management and support should be considered (derived from NICE CG 115, and , and NICE Quality Standard for Alcohol Dependence and Harmful Alcohol Use, QS 11 statement 3) Benchmarked data on Trust performance are presented for treatment target 1 as this directly relates to prescribing practice for alcohol. Data for treatment targets 2 and 3 are only presented at national level The Royal College of Psychiatrists. 6

7 Baseline Re-audit Baseline Re-audit Baseline Re-audit Baseline Re-audit Proportion of patients POMH-UK (2016) Topic 14b: Prescribing for substance misuse: alcohol Key audit findings for the Total National Sample (TNS) and your Trust Audit Standard 1: The decision to undertake acute alcohol of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake b. A physical examination, carried out on admission. Figure 1: Performance in the national sample and your Trust against audit standard 1 assessments* and other assessments during admission for alcohol at baseline and re-audit. For the TNS, the sample size was n=1, % 90% 80% Not documented 70% 60% 50% 40% 30% Patient declined assessment 20% 10% 0% Documented assessment or measure Smoking status Alcohol history* Breath alcohol Physical examination* Assessment N.B. if your Trust s performance, as indicated by the diamond, is in the red area of the bar, this means that practice in your Trust is nearer to the standard than in the total national sample (TNS) The Royal College of Psychiatrists. 7

8 Proportion of patients Baseline Re-audit Baseline Re-audit Baseline Re-audit Proportion of patients POMH-UK (2016) Topic 14b: Prescribing for substance misuse: alcohol Figure 2: Performance in the national sample and your Trust against screening for Wernicke's encephalopathy during admission for alcohol at baseline and re-audit. For the TNS, the sample size was n=1, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Not documented Documented assessment or measure Disorientation/ confusion Ataxia Wernicke's encephalopathy Opthalmoplegia and/or nystagmus Figure 3: Performance in the national sample and your Trust against health assessments during admission for alcohol at baseline and reaudit. For the TNS, the sample size was n=1, % 98% 96% 94% Not documented 92% 90% 88% 86% 84% Documented assessment or measure 82% Baseline Re-audit Baseline Re-audit Pulse rate Blood pressure Health check 2015 The Royal College of Psychiatrists. 8

9 Baseline Re-audit Baseline Re-audit Baseline Re-audit Baseline Re-audit Proportion of patients Baseline Re-audit Baseline Re-audit Baseline Re-audit Baseline Re-audit Proportion of patients POMH-UK (2016) Topic 14b: Prescribing for substance misuse: alcohol Audit standard 2: Blood tests relevant to the identification of alcohol-related physical health problems (e.g. liver function tests including GGT, albumin, full blood count, glucose and renal function tests) should be carried out during the admission. None of the recommended blood tests were documented in 17% of the TNS. The respective figure for your Trust was 11%. Figure 4: Performance in the national sample and your Trust against audit standard 2 assessments during admission for alcohol at baseline and re-audit. For the TNS, the sample size was n=1, % 90% 80% 70% Not documented 60% 50% 40% 30% 20% 10% Documented assessment or measure 0% Liver function tests GGT Clotting (PT, PTT or INR)* Albumin * Whilst documentation of clotting levels was recorded in this re-audit, it is recognised that this may not be clinically indicated in all patients. Figure 5: Performance in the national sample and your Trust against audit standard 2 assessments during admission for alcohol at baseline and re-audit. For the TNS, the sample size was n=1, % 90% 80% 70% Not documented 60% 50% 40% 30% 20% 10% Documented assessment or measure 0% FBC MCV Renal function tests (U&Es) Glucose 2015 The Royal College of Psychiatrists. 9

10 Proportion of patients Proportion of patients POMH-UK (2016) Topic 14b: Prescribing for substance misuse: alcohol Audit standards: 3. Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine, carbamazepine or clomethiazole (derived from NICE CG 100, and NICE CG115, ). 4. Phenytoin should not be prescribed to prevent or treat alcohol withdrawal seizures (NICE CG 100, and BAP evidence-based guidelines for the pharmacological management of substance abuse, 2012). 5. Thiamine should be prescribed parenterally for inpatients in acute alcohol withdrawal. Audit standard 4 was met in all but one case. See Table 18 for analysis relating to this standard. Figure 6: Performance in the national sample and your Trust against audit standard 3 during admission for alcohol at re-audit. For the TNS, the sample size was n=1, % Figure 7: Performance in the national sample and your Trust against audit standard 5 during admission for alcohol at baseline and re-audit. For the TNS, the sample size was n=1, % 90% 80% No medication prescribed 90% 80% Not prescribed 70% 60% 50% 40% At least one medication prescribed 70% 60% 50% 40% Prescribed orally Prescribed parenterally 30% 20% 10% Trust 003 At least one medication prescribed 30% 20% 10% Trust 003 Prescribed parenterally 0% Prescription of recommended medication for managing symptoms of acute alcohol withdrawal 0% Baseline Re-audit Prescription of thiamine 2015 The Royal College of Psychiatrists. 10

11 Key findings related to prescribing for alcohol At both baseline and re-audit there was no documented information regarding alcohol history during the initial assessment for 1 in 5 of the total national sample. While the vast majority (87%) of the total national sample had a documented physical examination, results for the range of blood investigations related to the detection of the potential complications of alcohol use were less consistently documented. The recommended monitoring of breath alcohol concentration was not routinely carried out, a breath alcohol measure being documented in only 26% of the total national sample. Wernicke s encephalopathy, a recognised complication of alcohol withdrawal, can lead to permanent brain damage (Korsakoff syndrome) if untreated. Documented evidence of screening for all three signs and symptoms of Wernicke s encephalopathy was available for just over a third of the total national sample, of whom 15% had at least one sign or symptom present. Thus, clinically-significant signs and symptoms of Wernicke s encephalopathy are likely to have been missed in a proportion of cases who were not screened. Parenteral thiamine protects against the development of Wernicke s encephalopathy. Those patients under the care of specialist services were more than twice as likely to be prescribed parenteral thiamine as those patients under the care of a general adult psychiatrist. Of the total national sample, 8% were transferred to a medical bed during admission. This proportion is similar to baseline and confirms that some alcohol s undertaken in general adult mental health settings are medically complex. In the total national sample, the NICE-recommended medication for (i.e. a benzodiazepine) was prescribed in 91% of patients. A fixed-dose reducing regimen was used in around three-quarters (74%) of cases. Symptom-triggered medication regimens were less commonly used (17%), mostly in non-specialist care settings where they perhaps reflected unstructured prn prescribing. There is evidence that a brief intervention, when a healthcare professional discusses with a patient the harms that alcohol has or can potentially cause (for example, directly sharing the results of liver function tests), can reduce alcohol consumption. From baseline to re-audit, use of brief intervention increased from 42% to 58%. Broader observation on prescribing for alcohol, to inform local reflection and discussion Several findings relating to change between the baseline audit and this re-audit, suggest move away from the practice standards: less thorough documentation of drinking history at re-audit; less use of parenteral thiamine at re-audit; a modest fall in the proportion of patients being prescribed acamprosate and other relapse prevention medication; fewer patients being referred on to specialist NHS alcohol services on discharge. The changes listed above may reflect, directly or indirectly, a disinvestment in specialist addiction services in the NHS. Further evidence includes: the reduction in the proportion of admissions where alcohol was overseen by a general adult psychiatrist rather than a specialist in addictions; fewer planned and more unplanned admissions for alcohol, the former being more common under specialist care The Royal College of Psychiatrists. 11

12 Contents Data control statement for POMH-UK quality improvement programme on Topic 14b: Prescribing for substance misuse: alcohol... 2 How to read this report... 3 Executive Summary... 4 Practice standards and treatment targets for audit... 6 Key audit findings for the Total National Sample (TNS) and your Trust... 7 Key findings related to prescribing for alcohol List of figures List of tables Introduction Method National Level Results Trust Level Results Appendix A: Patient demographic and clinical characteristics Appendix B: Participating Trusts Appendix C: Audit data collection tool Appendix D: POMH-UK Central Team and Expert Advisors Appendix E: References The Royal College of Psychiatrists. 12

13 List of figures Figure 1: Performance in the national sample and your Trust against audit standard 1 assessments* and other assessments during admission for alcohol at baseline and re-audit Figure 2: Performance in the national sample and your Trust against screening for Wernicke's encephalopathy during admission for alcohol at baseline and re-audit Figure 3: Performance in the national sample and your Trust against health assessments during admission for alcohol at baseline and re-audit Figure 4: Performance in the national sample and your Trust against audit standard 2 assessments during admission for alcohol at baseline and re-audit Figure 5: Performance in the national sample and your Trust against audit standard 2 assessments during admission for alcohol at baseline and re-audit Figure 6: Performance in the national sample and your Trust against audit standard 3 during admission for alcohol at re-audit Figure 7: Performance in the national sample and your Trust against audit standard 5 during admission for alcohol at baseline and re-audit Figure 8: Distribution of daily alcohol consumption (units) of the total sample and whether the alcohol regimen was completed: baseline and re-audit Figure 9: Proportion of patients who had a documented assessment of drinking history at admission Figure 10: Proportion of patients who had a documented physical assessment at admission Figure 11: Proportion of patients who had documented assessments of the signs and symptoms of Wernicke s encephalopathy Figure 12: Proportion of patients who had a documented breath alcohol measurement Figure 13: Proportion of patients who had documented liver function tests during admission Figure 14: Proportion of patients who were prescribed medication recommended by NICE for managing symptoms of acute alcohol withdrawal Figure 15: Proportion of patients who had thiamine prescribed parenterally Figure 16: Proportion of patients whose alcohol was completed as planned Figure 23: Gender distribution of patients in each Trust and the total national sample Figure 24: Patients' self-assigned ethnicity in each Trust and the total national sample Figure 25: Distribution of age groups in each Trust and the total national sample Figure 26: Nature of admission for alcohol of patients in each Trust and the total national sample Figure 27: Proportion of patients under general (non-specialist) and specialist psychiatric care during treatment for alcohol in each Trust and the total national sample Figure 28: Mental Health Act status of patients in each Trust and the total national sample The Royal College of Psychiatrists. 13

14 List of tables Table 1: Prescribing for substance misuse: alcohol : Quality Improvement Programme participation... 5 Table 2: Demographic characteristics of the total national sample Table 3: Clinical service providing care for alcohol Table 4: Mental Health Act status at point of admission Table 5: Documented psychiatric diagnoses Table 6: Smoking status recorded on admission Table 7: Documented past history of alcohol Table 8: Documented alcohol history for planned admissions Table 9: Documented alcohol history for unplanned admissions Table 10: Physical examination at admission Table 11: Documented assessments for the signs and symptoms of Wernicke s encephalopathy.. 26 Table 12: Documented assessments for the signs and symptoms of Wernicke s encephalopathy in non-specialist and specialist care Table 13: Standardised assessments/rating scales used during initial assessment Table 14: Documented measures within the first 24 hours of admission Table 15: Laboratory investigations documented at initial assessment Table 16: Type of benzodiazepine regimen prescribed Table 17: Starting daily dose for prescribed drugs to treat the symptoms of acute alcohol withdrawal Table 18: Other drugs initiated during alcohol Table 19: Documented brief intervention Table 20: Prescription of thiamine in non-specialist and specialist care Table 21: Specialist advice sought during admission under non-specialist and specialist care Table 22: Completion of alcohol regimen Table 23: Medication for relapse prevention prescribed at the point of discharge Table 24: Provisions for continuing management of alcohol use/alcohol-related problems at discharge in non-specialist and specialist care Table 25: Provisions for continuing management of alcohol use/alcohol-related problems at discharge in planned and unplanned care Table 26: Number of clinical teams and patient records audited from participating Trusts at baseline and re-audit The Royal College of Psychiatrists. 14

15 Introduction POMH-UK The Prescribing Observatory for Mental Health (POMH-UK) runs national audit-based quality improvement programmes open to all specialist mental health services in the UK. The aim is to help mental health services improve prescribing practice in discrete areas ( Topics ). Those interested in learning more about the role of POMH-UK should visit the website: There are also reviews of the POMH-UK quality improvement methodology in the following publications: Barnes TRE, Paton C. The role of the Prescribing Observatory for Mental Health (Editorial). British Journal of Psychiatry 2012; 201: Barnes TRE, Paton C. Improving prescribing practice in psychiatry. International Review of Psychiatry 2011; 23: This Topic 14b re-audit report presents prescribing data that have been collected about patients who were detoxified from alcohol during an admission to an acute adult psychiatric ward. The results presented in this report will allow comparison of your team s/trust s practice against: a. Treatment recommendations in nationally recognised guidelines, including the NICE guidelines for alcohol-use disorders; b. The practice of other participating Trusts; c. The practice of other participating teams in your Trust (unless only one team participated). Clinical background Please refer to the baseline report (Topic 14a) for the clinical background. This can also be found in the member s area of the POMH website: Log-in details can be obtained from your Trust POMH-UK lead The Royal College of Psychiatrists. 15

16 Practice standards 1 for audit The decision to undertake acute alcohol of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake b. A physical examination, carried out on admission. 2. Blood tests relevant to the identification of alcohol-related physical health problems (e.g. liver function tests including GGT, albumin, full blood count, glucose and renal function tests) should be carried out during the admission. 3. Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine, carbamazepine or clomethiazole (derived from NICE CG 100, and NICE CG115, ). 4. Phenytoin should not be prescribed to prevent or treat alcohol withdrawal seizures (NICE CG 100, and BAP evidence-based guidelines for the pharmacological management of substance abuse, 2012). 5. Thiamine should be prescribed parenterally for inpatients in acute alcohol withdrawal. These audit standards were primarily extrapolated from relevant recommendations in the NICE guidelines referenced above and have been agreed by expert advisors to POMH-UK. In some cases, the evidence for practice recommendations falls short of supporting an audit standard, i.e. being applicable in 100% of cases. However, the evidence may be sufficient to support general guidance for good practice, allowing that deviation may be appropriate in a proportion of cases. For such treatment targets, clinicians may be particularly interested in how their practice benchmarks with their peers. Treatment targets 2 For this QIP, there are three such treatment targets: 1. Breath alcohol should be measured as part of the initial assessment for alcohol (derived from NICE CG 115, recommendation ). 2. Following alcohol, initiation of relapse prevention medication should be considered (NICE CG 115, ). 3. After alcohol, referral to specialist alcohol services for continuing management and support should be considered (derived from NICE CG 115, and , and NICE Quality Standard for Alcohol Dependence and Harmful Alcohol Use, QS 11 statement 3). Benchmarked data on Trust performance are presented for treatment target 1 as this directly relates to prescribing practice for alcohol. Data for treatment targets 2 and 3 are only presented at national level. 1 The standards have been derived from the following references: 1. National Institute for Health and Clinical Excellence. Diagnosis and clinical management of alcohol-related physical complications. NICE clinical guideline 100, National Institute for Health and Clinical Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE clinical guideline 115, Lingford-Hughes, Anne R., et al. BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. Journal of Psychopharmacology 26.7 (2012): The treatment targets have also been derived from NICE CG 115, and in addition: 1. National Institute for Health and Clinical Excellence. Alcohol dependence and harmful alcohol use quality standard. NICE quality standards QS11, Quality statement 3: Referral to specialist alcohol services The Royal College of Psychiatrists. 16

17 Method The Prescribing Observatory for Mental Health (POMH-UK) invited all National Health Service (NHS) Trusts and other healthcare organisations (hereafter referred as Trusts) in the United Kingdom providing specialist mental health services to participate in this reaudit as part of a QIP on prescribing for alcohol. All Trusts and clinical teams were self-selected in that they chose to participate. All participating Trusts are listed in alphabetical order in Appendix B: Participating Trusts. Subjects and settings Each Trust was invited to include as many clinical teams as they wished. Each participating team was asked to collect data from the clinical records of a sample of patients on their caseload who had been detoxified from alcohol during an admission to an adult psychiatric ward in the year prior to data collection (from February 2015 to January 2016). Data collection A copy of the data collection form can be found in Appendix C. Submission of data Each Trust was allocated an identifying (code) number that was known only to the Trust and POMH-UK. Trusts were asked to allocate codes to participating services and eligible patients and, if they wished, individual consultants. The key to these codes is held by the Trust and is not known to POMH-UK. Data coded in this way were entered onto an internetbased form and submitted to POMH-UK via a secure website. Data cleaning Data were cleaned to correct instances of obvious data entry error. Details of corrections are held on file by POMH-UK; please contact pomh-uk@rcpsych.ac.uk if you wish to examine these. Data analysis The data were analysed and results presented at three levels; national, Trust and clinical team. Data were collected, stored and analysed using Formic Fusion (electronic survey software) and IBM SPSS Statistics. All figures presented are rounded to zero decimal places for clarity of presentation. Therefore, the total percentages for some charts or graphs may not add up to 100%. The abbreviation TNS on some charts refers to the combined data set of the total national sample. The local POMH-UK lead for each participating Trust has been sent an Excel dataset containing their Trust s data. This allows Trusts to conduct further analyses on their own data should they wish The Royal College of Psychiatrists. 17

18 National Level Results Patient demographic and clinical characteristics The table below provides demographic information on the total national sample of patients who, at re-audit, were detoxified from alcohol during an admission to an acute adult psychiatric ward. The table also shows the characteristics of the sub-samples of those patients whose admission was either planned or unplanned. The demographic characteristics of the two sub-samples are similar. Table 2: Demographic characteristics of the total national sample Re-audit N=1,143 Key demographic characteristics patients whose admission for alcohol was planned patients whose admission for alcohol was unplanned Total sample All patients who for alcohol Gender Ethnicity Age N = 342 (30%) N = 801 (70%) N = 1,143 n (% of subsamplesample) n (% of sub- n (% of total sample) Female 114 (33%) 267 (33%) 381 (33%) Male 228 (67%) 534 (67%) 762 (67%) White British/Irish or 264 (77%) 696 (87%) 960 (84%) White Other Asian/Asian British 5 (1%) 19 (2%) 24 (2%) Black/Black British 5 (1%) 18 (2%) 23 (2%) Mixed 0 (<1%) 5 (1%) 5 (<1%) Other ethnic group 1 (<1%) 20 (2%) 21 (2%) Not stated/refused 1 (<1%) 10 (1%) 11 (1%) Not collected 66 (19%) 33 (4%) 99 (9%) Median age in years Range (min max): years Age bands years 21 (6%) 98 (12%) 119 (10%) years 93 (27%) 219 (27%) 312 (27%) years 114 (33%) 242 (30%) 356 (31%) years 81 (24%) 178 (22%) 259 (23%) 61+ years 33 (10%) 64 (8%) 97 (8%) The demographic characteristics of the re-audit sample were very similar to those of the baseline sample (not shown) The Royal College of Psychiatrists. 18

19 Table 3: Clinical service providing care for alcohol Compared with the baseline total sample (N=1,197), a slightly larger proportion of admissions were unplanned. Of those under the care of a general adult psychiatrist (nonspecialist), 39% of admissions for alcohol were planned. The respective figure for those under the care of a specialist in substance misuse/alcohol was 61%. Alcohol was overseen by a specialist in less than a quarter of cases; a reduction from 29% at baseline to 21% at re-audit *. This is consistent with the known disinvestment in specialist alcohol services in the NHS. Re-audit N=1,143 patients whose admission for alcohol was planned patients whose admission for alcohol was unplanned Total sample All patients who for alcohol Clinical service providing care Acute adult psychiatric ward - overseen by a nonspecialist adult psychiatrist Acute adult psychiatric ward - overseen by a specialist in alcohol/substance misuse Psychiatric intensive care ward (PICU) - overseen by a non-specialist adult psychiatrist Psychiatric intensive care ward (PICU) - overseen by a specialist in alcohol/substance misuse N = 342 (30%) n (% of subsample) N = 801 (70%) n (% of subsample) N = 1,143 n (% of total sample) 133 (39%) 749 (94%) 882 (77%) 208 (61%) 34 (4%) 242 (21%) * 1 (0%) 18 (2%) 19 (2%) The Royal College of Psychiatrists. 19

20 Table 4: Mental Health Act status at point of admission The proportion of patients who were detained under the Mental Health Act and underwent an unplanned increased from 23% at baseline to 29% at re-audit. This is in contrast to planned admissions, where the vast majority of patients continue to be informal. patients whose admission for alcohol was planned Re-audit N=1,143 patients whose admission for alcohol was unplanned Total sample All patients who for alcohol Mental health act status N = 342 (30%) N = 801 (70%) N = 1,143 n (% of n (% of n (% of total subsample) subsample) sample) Informal 327 (96%) 568 (71%) 895 (78%) Via Section (2%) 76 (9%) 82 (7%) Formal - recall from Community Treatment Order (CTO) 0 9 (1%) 9 (1%) Other formal (e.g. detention under the Mental Health Act, 9 (3%) 148 (18%) 157 (14%) Section 2 or 3) 2015 The Royal College of Psychiatrists. 20

21 Table 5: Documented psychiatric diagnoses Table 5 reflects the diversity in the clinical coding of patients in this sample. There was no clinical coding related to alcohol use in 22% of cases, an increase from 15% at baseline. This may have implications for care planning and the information that is communicated to the patient s GP. It may also lead to an under-estimate of clinical activity by managers and commissioners. There was a higher prevalence of psychotic illness and personality disorder in those whose admission was unplanned. Given the known association between alcohol misuse/abuse and bipolar disorder, the proportion of patients in the TNS with bipolar disorder could be considered to be low. patients whose admission for alcohol was planned Re-audit N=1,143 patients whose admission for alcohol was unplanned Total sample All patients who for alcohol Documented psychiatric diagnoses: ICD-10 N = 342 (30%) N = 801 (70%) N = 1,143 n (% of subsamplesample) n (% of sub- n (% of total sample) Psychiatric disorders Mental and behavioural disorders due to use of alcohol (F10) 320 (94%) 575 (72%) 895 (78%) Mood disorder, other than bipolar affective disorder (F30-F39) 82 (24%) 163 (20%) 245 (21%) Personality disorder (F60-F69) 22 (6%) 177 (22%) 199 (17%) Schizophrenia spectrum disorder (F20-F29) 12 (4%) 130 (16%) 142 (12%) Bipolar affective disorder (F31) 6 (2%) 38 (5%) 44 (4%) Alcohol/substance misuse disorders Mental and behavioural disorders due to use of tobacco (F17) 26 (8%) 84 (10%) 110 (10%) Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances (F19) 10 (3%) 92 (11%) 102 (9%) Mental and behavioural disorders due to use of opioids (F11) 29 (8%) 33 (4%) 62 (5%) Mental and behavioural disorders due to use of cannabinoids (F12) 9 (3%) 25 (3%) 34 (3%) Alcohol-related liver disease (K70.9) 12 (4%) 19 (2%) 31 (3%) Mental and behavioural disorders due to use of cocaine (F14) 3 (1%) 16 (2%) 19 (2%) Benzodiazepine dependence (F13.2) 3 (1%) 10 (1%) 13 (1%) Korsakov's syndrome 5 (1%) 4 (0%) 9 (1%) Wernicke's encephalopathy (E51.2) 3 (1%) 3 (0%) 6 (1%) Delirium tremens 0 (0%) 2 (0%) 2 (0%) Other disorders Epilepsy (G40) 5 (1%) 11 (1%) 16 (1%) Neurotic, stress related and somatoform disorders (F40-48) 22 (6%) 85 (11%) 107 (9%) Other behavioural syndromes associated with physiological disturbances and physical factors (F50-59) 4 (1%) 5 (1%) 9 (1%) Organic mental disorder (F00-F09) 2 (1%) 7 (1%) 9 (1%) ADHD (F90) 1 (0%) 3 (0%) 4 (0%) Traumatic brain injury (S06-S07) 3 (1%) 1 (0%) 4 (0%) Sleep disorders (G47) 0 (0%) 2 (0%) 2 (0%) Other 52 (15%) 84 (10%) 136 (12%) 2015 The Royal College of Psychiatrists. 21

22 Initial assessment Table 6: Smoking status recorded on admission The NICE guideline for Alcohol dependence and harmful alcohol use (pg. 32, CG115) recommends that: For comorbid alcohol and nicotine dependence, encourage service users to stop smoking and refer to 'Brief interventions and referral for smoking cessation in primary care and other settings'. At re-audit, there was a marked increase in the proportion of patients whose smoking status was documented. However, smoking status was still not documented for a quarter of the sample, which must be seen as a missed opportunity for appropriate intervention, considering the morbidity and mortality related to smoking in this population. Baseline N=1,197 Re-audit N=1,143 Smoking status patients whose admission for alcohol was planned patients whose admission for alcohol was unplanned Total sample All patients who for alcohol patients whose admission for alcohol was planned patients whose admission for alcohol was unplanned Total sample All patients who for alcohol N = 462 (39%) n (% of subsample) N = 735 (61%) n (% of subsample) N = 1,197 n (% of total sample) N = 342 (30%) n (% of subsample) N = 801 (70%) n (% of subsample) N = 1,143 n (% of total sample) Recorded 271 (59%) 485 (66%) 756 (63%) 256 (75%) 590 (74%) 846 (74%) Not recorded 191 (41%) 250 (34%) 441 (38%) 86 (25%) 211 (26%) 297 (26%) 2015 The Royal College of Psychiatrists. 22

23 POMH-UK (2016) Topic 14b: Prescribing for substance misuse: alcohol Table 7: Documented past history of alcohol In a quarter of cases at re-audit, this was the first known alcohol, while more than 1 patient in 20 had been detoxified from alcohol on at least 5 previous occasions. These data are very similar to baseline. Where the admission was unplanned, there was no documentation of whether or not this was the first in more than a third of cases, compared with a tenth of cases where the admission was planned. Such information is central to generating an effective clinical management plan. Documentation of previous s patients whose admission for alcohol was planned Re-audit N=1,143 patients whose admission for alcohol was unplanned Total sample All patients who for alcohol N = 342 (30%) N = 1,143 N = 801 (70%) n (% of subsamplesample) n (% of sub- n (% of total sample) 1-4 previous alcohol s 161 (47%) 291 (36%) 452 (40%) 5 or more previous alcohol s 33 (10%) 41 (5%) 74 (6%) First known alcohol 113 (33%) 172 (21%) 285 (25%) Not documented 35 (10%) 297 (37%) 332 (29%) 23

24 Audit standard 1: The decision to undertake acute alcohol of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake (derived from NICE CG 115, recommendation ) b. A physical examination, carried out on admission (derived from NICE CG 115, ). At initial assessment, 80% of the TNS had a documented assessment of drinking history. The re-audit data (tables 8 and 9) suggest that some aspects of drinking history were less frequently documented than at baseline for both planned and unplanned admissions. Table 8: Documented alcohol history for planned admissions patients whose admission for alcohol was planned Baseline N = 462 (39%) Re-audit N = 342 (30%) Type of information documented Median (range) Number (%) of cases where this information was known Median (range) Number (%) of cases where this information was known Alcohol history Number of years since alcohol use problem was first identified Number of months of harmful drinking on this occasion 11 (<1-58) 12 (<1-456) 332 (72%) 288 (62%) 10 (<1-55) 10 (<1-240) 227 (66%) 191 (56%) Number of units of alcohol consumed each day 29 (1-112) 413 (89%) 24 (5-81) 306 (89%) At both baseline and re-audit, documentation of alcohol history was considerably closer to the audit standard when the admission was planned The Royal College of Psychiatrists. 24

25 Table 9: Documented alcohol history for unplanned admissions patients whose admission for alcohol was unplanned Baseline N = 462 (39%) Re-audit N = 801 (70%) Type of information documented Alcohol history Number of years since alcohol use problem was first identified Number of months of harmful drinking on this Occasion Number of units of alcohol consumed each day Median (range) 10 (<1-50) 3 (<1-193) 28 (2-100) Number of cases where this information was known 261 (36%) 258 (35%) 483 (66%) Median (range) 10 (1-44) 3 (<1-120) 27 (1-320) Number of cases where this information was known 262 (29%) 258 (32%) 581 (73%) Table 10: Physical examination at admission On admission to the ward, there was a documented physical examination in the vast majority of cases. Practice at re-audit was similar to baseline. Physical examination Baseline N=1,197 Re-audit N=1,143 Documented on admission 1,053 (88%) 996 (87%) Not documented 115 (10%) 101 (9%) Patient declined physical examination 29 (2%) 46 (4%) 2015 The Royal College of Psychiatrists. 25

26 POMH-UK (2016) Topic 14b: Prescribing for substance misuse: alcohol Table 11: Documented assessments for the signs and symptoms of Wernicke s encephalopathy Between baseline (Table 11a) and re-audit (Table 11b), there has been no change in the proportion of patients who have been assessed for one or more signs and symptoms of Wernicke s encephalopathy. Untreated Wernicke s encephalopathy can lead to permanent brain damage (Korsakoff s syndrome). Documentation of assessment of at least one sign or symptom of Wernicke s encephalopathy was recorded for 727 (64%) patients in the total sample. Of these, 111 (10%) had at least one sign and symptom of Wernicke s encephalopathy present. This suggests that of the 416 (36%) patients where no assessments for the signs and symptoms of Wernicke s encephalopathy were documented, up to 64 may have screened positive for at least one sign or symptom of Wernicke s encephalopathy. The table below shows that all three signs and symptoms of Wernicke s encephalopathy were assessed in just over a third of patients in the total sample. a) Signs and symptoms assessed 1 documented assessment = 153 (13%) Baseline N=1,197 2 documented assessments = 154 (13%) 3 documented assessments Disorientation/confusion 0 documented assessments Ataxia Ophthalmoplegia and/or nystagmus Total number of cases n (% of TNS) 128 (11%) 12 (1%) 13 (1%) 95 (8%) 30 (3%) 29 (2%) 445 (37%) 445 (37%) b) Signs and symptoms assessed 1 documented assessment = 157 (14%) Re-audit N=1,143 2 documented assessments = 160 (14%) 3 documented assessments 0 documented assessments Disorientation/confusion Ataxia Ophthalmoplegia and/or nystagmus Total number of cases n (% of TNS) 122 (11%) 26 (2%) 9 (1%) 94 (8%) 33 (3%) 33 (3%) 410 (36%) 416 (36%) 26

27 Table 12: Documented assessments for the signs and symptoms of Wernicke s encephalopathy in non-specialist and specialist care The table below shows that assessment for all three signs and symptoms of Wernicke s encephalopathy was approximately twice as likely to be completed in specialist as nonspecialist care. Between baseline and re-audit, there was an improvement in the proportion of such assessments in specialist care. This improvement was not seen in non-specialist care. Baseline N=1,197 Re-audit N=1,143 Number of signs and symptoms assessed None 1-2 documented assessments 3 documented assessments None 1-2 documented assessments 3 documented assessments N (% of sub-sample) patients who were admitted under nonspecialist care (acute or PICU) patients who were admitted under specialist care (acute or PICU) 374 (44%) 71 (20%) 229 (27%) 78 (22%) 245 (29%) 200 (57%) 393 (44%) 23 (10%) 254 (28%) 63 (26%) 254 (28%) 156 (64%) 27

28 Table 13: Standardised assessments/rating scales used before and during initial assessment The CIWA-Ar (Sullivan et al., 1989), SADQ (Stockwell et al., 1983) and AUDIT (Saunders et al., 1993) are all standardised assessments/scales recommended in the NICE Alcohol dependence and harmful use guideline CG 115. There was markedly greater use of the CIWA-Ar at re-audit to inform the need for and to monitor the effectiveness of the regimen. Standard assessments/rating scales Baseline N=1,197 Re-audit N=1,143 n (% of total sample) CIWA-Ar (prior to starting regimen) 170 (14%) 331 (29%) CIWA-Ar (during regimen) 170 (14%) 235 (21%) SADQ 113 (9%) 169 (15%) AUDIT 80 (7%) 177 (15%) APQ 11 (1%) 0 (0%) LDQ 7 (1%) 8 (1%) None of the above 690 (58%) 531 (46%) Other 65 (5%) 25 (2%) There was no documented use of any of the above standardised tools in 46% of cases at re-audit, an improvement from 58% at baseline. 28

29 Treatment target 1: Breath alcohol should be measured as part of the initial assessment for alcohol (derived from NICE CG 115, recommendation ). Only a minority of the TNS had their breath alcohol measurement documented at re-audit with little evidence of change since the baseline audit. This suggests that breath alcohol measurement is not part of routine physical examination in this context. While the absolute breath alcohol measurement does not directly influence the clinical management plan, it is important to ascertain at initial assessment whether this is continuing to rise or has peaked and is now falling. Table 14: Documented measures within the first 24 hours of admission Documented measure Baseline N=1,197 Re-audit N=1,143 n (% of total sample) Pulse rate 1,073 (90%) 1,066 (93%) BP 1,068 (89%) 1,063 (93%) Breath alcohol measurement 265 (22%) 298 (26%) One potential explanation for the lack of measurement of breath alcohol may be that the use of a breathalyser is seen as a policing role rather than something that informs the detail of the treatment plan on the ward. 29

30 Audit standard 2: Blood tests relevant to the identification of alcohol-related physical health problems (e.g. liver function tests including GGT, albumin, full blood count, glucose and renal function tests) should be carried out during the admission (derived from NICE CG 115, ). As at baseline, there was little difference in the documentation of laboratory investigations between specialist and non-specialist services with the exception of GGT which was more likely to be documented in the former. Given that the majority of planned admissions were under specialist care, the documentation of GGT was also more often seen in planned admissions than unplanned admissions (Table 15). 30

31 Table 15: Laboratory investigations documented at initial assessment Baseline N=1,197 Re-audit N=1,143 Type of laboratory investigation documented patients who under nonspecialist care (acute or PICU) N= 848 (71%) patients who under specialist care (acute or PICU) N=349 (29%) Total sample All patients who for alcohol N = 1,197 patients who under nonspecialist care (acute or PICU) N=901 (79%) patients who under specialist care (acute or PICU) N=242 (21%) Total sample All patients who for alcohol N = 1,143 n (%) n (%) n (%) n (%) n (%) n (%) Liver function tests 671 (79%) 301 (86%) 972 (81%) 687 (76%) 209 (86%) 896 (78%) GGT 394 (46%) 263 (75%) 657 (55%) 378 (42%) 170 (70%) 548 (48%) Clotting (PT, PTT or INR) 294 (35%) 86 (25%) 380 (32%) 275 (31%) 57 (24%) 332 (29%) Albumin 612 (72%) 277 (79%) 889 (74%) 561 (62%) 188 (78%) 749 (66%) FBC 687 (81%) 286 (82%) 973 (81%) 704 (78%) 202 (83%) 906 (79%) MCV 598 (71%) 278 (80%) 876 (73%) 587 (65%) 193 (80%) 780 (68%) Renal function tests (U&Es) 672 (79%) 284 (81%) 956 (80%) 683 (76%) 195 (81%) 878 (77%) Glucose 424 (50%) 161 (46%) 585 (49%) 452 (50%) 136 (56%) 588 (51%) None of the above were recorded 137 (16%) 44 (13%) 181 (15%) 167 (19%) 25 (10%) 192 (17%) [Note: Some laboratories report GGT and/or albumin as part of routine LFTs, whereas others do not. For this reason, liver function tests and GGT are reported separately in the table above.] 31

32 During admission Table 16: Type of benzodiazepine regimen prescribed Type of benzodiazepine regimen patients who under nonspecialist care (acute or PICU) N= 901 (79%) Re-audit N=1,143 patients who under specialist care (acute or PICU) N= 242 (21%) Total sample All patients who for alcohol N=1,143 n (% of N) n (% of N) n (% of total sample) Fixed-dose reducing regimen 626 (69%) 223 (92%) 849 (74%) Symptom triggered 177 (20%) 14 (6%) 191 (17%) Front loading 30 (3%) 1 (0%) 31 (3%) Unclear 67 (7%) 4 (2%) 71 (6%) A fixed-dose reducing regimen was used in the majority of cases. The NICE guideline 115 recommends the use of fixed-dose or symptom-triggered medication regimens in assisted withdrawal programmes in inpatient or residential settings. If a symptom-triggered regimen is used, all staff should be competent in monitoring symptoms effectively and the unit should have sufficient resources to allow them to do so frequently and safely. One implication of this recommendation is that symptom-triggered programmes are less suitable for use in non-specialist settings although, as can be seen in the table above, that is where they were most commonly used. Of the total sample, 3% (35) patients were transferred to a medical bed because of complications associated with alcohol withdrawal. Of these 35 patients, 23 (66%) were under the care of non-specialist services. This suggests that some s that were undertaken by non-specialists were medically complex. 32

33 Audit standard 3: Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine, carbamazepine or clomethiazole (derived from NICE CG 100, and NICE CG 115, ). Table 17: Starting daily dose for prescribed drugs to treat the symptoms of acute alcohol withdrawal Type of drug Benzodiazepine Total national sample Baseline N=1,197 Dose: range & median Dose: range & median (PRN) Total national sample Re-audit N=1,143 Dose: range & median Dose: range & median (PRN) n (%) n (%) Chlordiazepoxide 1,025 (86%) 5-300mg, 5-600mg, mg, mg, (78%) 100mg 40mg 80 mg mg Diazepam 216 (18%) 2-160mg, mg, 0-100mg, mg, (14%) 25mg 20mg 40 mg mg Lorazepam 132 (11%) 1-16mg, mg, 4mg 0.5-8mg, mg, 104 (9%) 4mg 2 mg 2 mg Oxazepam 15 (1%) mg, 5-80mg, 0-160mg, 1-90mg, 16 (1%) 120mg 20mg 120 mg 40 mg Other benzodiazepine* 16 (1%) (2%) - - Carbamazepine 2 (0.2%) mg, mg, - 2 (0%) 700mg 180 mg - Clomethiazole None of the above 71 (6%) (9%) - - *Other benzodiazepines prescribed included temazepam, nitrazepam, and clonazepam. 33

34 Audit standard 4: Phenytoin should not be prescribed to prevent or treat alcohol withdrawal seizures (NICE CG 100, and BAP evidence-based guidelines for the pharmacological management of substance abuse, 2012). Only 1 patient in the TNS was prescribed phenytoin; this patient did not have a documented diagnosis of epilepsy. Table 18: Other drugs prescribed during alcohol Type of drug patients who under nonspecialist care (acute or PICU) Baseline N=1,197 patients who under specialist care (acute or PICU) Total sample All patients who for alcohol patients who under nonspecialist care (acute or PICU) Re-audit N=1,143 patients who under specialist care (acute or PICU) Total sample All patients who for alcohol N= 848 N=349 N = 1,197 N= 901 N= 242 N= 1,143 Acamprosate 110 (13%) 140 (40%) 250 (21%) 104 (12%) 63 (26%) 167 (15%) An antidepressant 152 (18%) 35 (10%) 187 (16%) 178 (20%) 33 (14%) 211 (18%) An antipsychotic 99 (12%) 5 (1%) 104 (9%) 176 (20%) 10 (4%) 186 (16%) Nicotine replacement therapy 23 (3%) 21 (6%) 44 (4%) 66 (7%) 4 (2%) 70 (6%) Phenytoin 1 (<1%) 1 (<1%) 2 (<1%) 1 (<1%) 0 1 (<1%) None of the above 528 (62%) 175 (50%) 703 (59%) 476 (53%) 142 (59%) 618 (54%) The NICE guidelines do not recommend prescribing antidepressants at initiation of alcohol but this was the case in 18% (211) of patients in the total sample, a similar proportion to baseline. Patients under the care of a specialist were more likely to be prescribed medication for the maintenance of abstinence and less likely to have an antipsychotic or antidepressant initiated during. Note that the prevalence of comorbid psychotic illness was lower in those patients under specialist care. The prevalence of smoking in this population would be expected to be high, however at both baseline and re-audit, a relatively low proportion of patients was prescribed nicotine replacement therapy. 34

35 Table 19: Documented brief intervention There is evidence that a brief discussion led by a healthcare professional, addressing alcohol-related harm, can reduce alcohol consumption; for example, directly sharing the results of liver function tests. Between baseline and re-audit, documentation that a brief intervention had been delivered increased from two-fifths to three-fifths of all cases. While this represents an improvement in practice, it could also reflect that discussing with the patient the health consequences associated with excessive alcohol use and advice to cut down their intake is still not consistently recognised as a discrete brief intervention. Alternatively, it may partly reflect that such an intervention is not occurring routinely due to a lack of staff skills or a failure to appreciate the value of this simple advice. Brief intervention Baseline Total sample All patients who for alcohol Re-audit Total sample All patients who for alcohol N = 1,197 N=1,143 Documented 505 (42%) 660 (58%) Not documented 692 (58%) 483 (42%) Audit standard 5: Thiamine should be prescribed parenterally for inpatients in acute alcohol withdrawal (derived from NICE CG 100, , NICE CG , NICE Quality Standard for Alcohol Dependence and Harmful Alcohol Use, QS 11 statement 10 and BAP evidencebased guidelines for the pharmacological management of substance abuse, 2012). At both baseline and re-audit, those patients under the care of specialist services were more likely to be prescribed parenteral thiamine than those patients under the care of a general adult psychiatrist. Of those patients not prescribed parenteral thiamine, only 30% had a full assessment for the signs and symptoms of Wernicke s encephalopathy. Of the 49% (N=560) of patients in the total sample at re-audit who were prescribed thiamine parenterally, 18% (102) refused at least 1 dose. Refusal may be due in part to the painful nature of parenteral administration of thiamine. While some of the discomfort is due to the volume injected and cannot be avoided, some amelioration may be possible if the medication is removed from the refrigerator and brought to room temperature before injecting. In the total national sample at re-audit, 6 patients had a diagnosis of Wernicke s encephalopathy, 9 Korsakoff syndrome and 2 delirium tremens. The median number of parenteral doses of thiamine administered during alcohol withdrawal were 3 (range: 3-6), 5 (3-12) and 0 respectively, which is inadequate for Wernicke s encephalopathy and represents low dosage for the other two conditions. 35

36 Table 20: Prescription of thiamine in non-specialist and specialist care Baseline N=1,197 Re-audit N=1,143 Prescription of thiamine patients who under nonspecialist care (acute or PICU) patients who under specialist care (acute or PICU) Total sample All patients who were admitted for alcohol patients who under nonspecialist care (acute or PICU) patients who under specialist care (acute or PICU) Total sample All patients who were admitted for alcohol Parenteral Prescribed IM, followed by oral Prescribed IM only Prescribed IV, followed by oral Prescribed IV only Oral Prescribed orally only Not prescribed N= 848 (71%) N=349 (29%) N = 1,197 N= 901 (79%) N= 242 (21%) N = 1, (38%) 223 (64%) 548 (46%) 305 (34%) 178 (74%) 483 (42%) 78 (9%) 7 (2%) 85 (7%) 50 (6%) 4 (2%) 54 (5%) 10 (1%) 41 (12%) 51 (4%) 16 (2%) 0 16 (1%) 4 (<1%) 0 4 (<1%) 7 (1%) 0 7 (1%) 359 (42%) 64 (18%) 423 (35%) 399 (44%) 52 (21%) 451 (39%) 72 (8%) 14 (4%) 86 (7%) 124 (14%) 8 (3%) 132 (12%) 36

37 Table 21: Specialist advice sought during admission under non-specialist and specialist care Advice from a physician was sought for 15% of the total sample, four-fifths of whom were under the care of a general adult psychiatrist. This suggests that some alcohol s undertaken in general adult mental health settings are medically complex. Type of specialist advice sought patients who under nonspecialist care (acute or PICU) Re-audit N=1,143 patients who under specialist care (acute or PICU) Total sample All patients who were admitted for alcohol N= 1,143 N= 901 (79%) N= 242 (21%) n (% of N) n (% of N) n (% of total sample) Medical 143 (16%) 28 (12%) 171 (15%) Addiction 85 (9%) 75 (31%) 160 (14%) Alcohol liaison 91 (10%) 39 (16%) 130 (11%) Other 26 (3%) 9 (4%) 35 (3%) None of the above 585 (65%) 110 (45%) 695 (61%) Of the total re-audit sample, 8% were transferred to a medical bed during admission. Whether or not a patient was transferred to a medical bed was not related to whether they were under the care of a specialist or non-specialist or whether the admission was planned or unplanned. Transfers because of complications of alcohol use or withdrawal were less common than transfers for other medical reasons. 37

38 Table 22: Completion of alcohol regimen NICE guidelines recommend that in a fixed-dose regimen, the dose should be reduced over a maximum of 10 days. The duration of the alcohol regimen in the total national sample was between 1-41 days (median 7 days); in 10% (N=113), the duration of the regimen was more than 10 days. In 7% (N=77) of cases, the length of the alcohol regimen was unknown. At both baseline and re-audit, from alcohol was completed in the vast majority of cases. Completion of alcohol regimen patients who under nonspecialist care (acute or PICU) N= 848 (71%) Baseline N=1,197 patients who under specialist care (acute or PICU) N=349 (29%) n (% of N) n (% of N) Total sample All patients who for alcohol N = 1,197 n (% of total sample) patients who under nonspecialist care (acute or PICU) N= 901 (79%) Re-audit N=1,143 patients who under specialist care (acute or PICU) N= 242 (21%) n (% of N) n (% of N) Total sample All patients who for alcohol N = 1,143 n (% of total sample) Yes, completed as planned 682 (80%) 314 (90%) 996 (83%) 728 (81%) 210 (87%) 938 (82%) No, patient declined medication and/or selfdischarged 89 (10%) 22 (6%) 111 (9%) 81 (9%) 15 (6%) 96 (8%) No, was terminated by medical 70 (8%) 13 (4%) 83 (7%) 91 (10%) 17 (7%) 108 (9%) staff Unknown 7 (1%) 0 7 (1%) 1 (<1%) 0 1 (<1%) At both baseline and re-audit, patients who were under the care of a specialist were more likely to complete their alcohol regimen. 38

39 Baseline Re-audit Baseline Re-audit Baseline Re-audit Baseline Re-audit Baseline Re-audit Baseline Re-audit Proportion of patients POMH-UK (2016) Topic 14b. Prescribing for substance misuse: alcohol Figure 8: Distribution of daily alcohol consumption (units) of the total sample and whether the alcohol regimen was completed: baseline and re-audit In both the baseline and re-audit samples, daily alcohol consumption (in units) was not documented for almost 1 in 4 patients. 40% 35% Not documented/unknown 30% 25% 20% Patient declined medication and/or selfdischarged 15% 10% Detoxification was terminated by medical staff 5% 0% Completed alcohol detoxificiation regimen as planned 20 or less More than 80 Unknown Daily intake of alcohol per day (units) 39

40 Treatment target 2: Following alcohol, initiation of relapse prevention medication should be considered (NICE CG 115, ). Discharge Table 23: Medication for relapse prevention prescribed at the point of discharge Relapse prevention medication was more likely to be prescribed for patients who were under the care of a specialist. Type of drug patients who under nonspecialist care (acute or PICU) N= 848 (71%) Baseline N=1,197 patients who were admitted under specialist care (acute or PICU) N=349 (29%) Total sample All patients who for alcohol N = 1,197 patients who under nonspecialist care (acute or PICU) N= 901 (79%) Re-audit N=1,143 patients who under specialist care (acute or PICU) N= 242 (21%) Total sample All patients who for alcohol N=1,143 n (% of type of drug) n (% of type of drug) n (% of total sample) n (% of type of drug) n (% of type of drug) n (% of total sample) Acamprosate 115 (14%) 133 (38%) 248 (21%) 112 (12%) 64 (26%) 176 (15%) Naltrexone 4 (<1%) 10 (3%) 14 (1%) 3 (0%) 10 (4%) 13 (1%) Disulfiram 14 (2%) 45 (13%) 59 (5%) 20 (2%) 37 (15%) 57 (5%) Not on any of the relapse medication 720 (85%) 178 (51%) 898 (75%) 772 (86%) 138 (57%) 910 (80%) above 3 Baclofen 2 (<1%) 0 2 (<1%) 1 (0%) 1 (0%) 2 (0%) Not applicable 4 17 (2%) 0 17 (1%) Following alcohol, 16 (1%) of the TNS were prescribed more than one drug for relapse prevention. Nalmefene was prescribed for 3 (1%) patients who under specialist care at re-audit; this medication is not indicated in those who require from alcohol. 3 included thiamine, vitamin B complex tablets, benzodiazepine, z-hypnotic, carbamazepine, and others 4 patient not discharged/undue 4 weeks since 40

41 Treatment target 3: After alcohol, referral to specialist alcohol services for continuing management and support should be considered (derived from NICE CG 115, and , and NICE Quality Standard for Alcohol Dependence and Harmful Alcohol Use, QS 11 statement 3). The data in Tables 24 and 25 suggest that continuing care for alcohol-related problems at discharge is most commonly provided by NHS specialist alcohol services although the proportion of patients accessing such services dropped markedly between baseline and re-audit. At both audits, patients were more likely to be referred to NHS specialist alcohol services if admission for alcohol had been planned and/or they had been under the care of specialist psychiatric services. 41

42 Table 24: Provisions for continuing management of alcohol use/alcohol-related problems at discharge in non-specialist and specialist care Baseline N=1,197 Re-audit N=1,143 Type of service patients who under nonspecialist care (acute or PICU) patients who under specialist care (acute or PICU) Total sample All patients who were admitted for alcohol patients who under nonspecialist care (acute or PICU) patients who under specialist care (acute or PICU) Total sample All patients who were admitted for alcohol N= 848 (71%) N=349 (29%) N = 1,197 N= 901 (79%) N= 242 (21%) N = 1,143 n (% of N) n (% of N) n (%) of total n (%) of total n (% of N) n (% of N) sample sample NHS specialist alcohol services 327 (39%) 270 (77%) 597 (50%) 276 (31%) 121 (50%) 397 (35%) Continuing care for alcoholrelated problems provided by a 223 (26%) 41 (12%) 264 (22%) 265 (29%) 55 (23%) 320 (28%) mental health team Non-NHS specialist alcohol services 162 (19%) 48 (14%) 210 (18%) 188 (21%) 32 (13%) 220 (19%) Voluntary sector (e.g. Alcoholics Anonymous) 108 (13%) 20 (6%) 128 (11%) 100 (11%) 41 (17%) 141 (12%) Continuing care for alcoholrelated problems provided by 56 (7%) 22 (6%) 78 (7%) 66 (7%) 24 (10%) 90 (8%) the GP Continuing care for alcoholrelated problems provided by a 41 (5%) 10 (3%) 51 (4%) 41 (5%) 36 (15%) 77 (7%) dual diagnosis worker/service No clear plans to address future alcohol use 140 (17%) 13 (4%) 153 (13%) 168 (19%) 13 (5%) 181 (16%) Not yet been discharged 18 (2%) 1 (<1%) 19 (2%) 19 (2%) 0 19 (8%) 42

43 Table 25: Provisions for continuing management of alcohol use/alcohol-related problems at discharge in planned and unplanned care Type of service patients whose admission for alcohol was planned N = 462 (39%) Baseline N=1,197 patients whose alcohol was unplanned N = 735 (61%) Total sample All patients who were admitted for alcohol N = 1,197 patients whose admission for alcohol was planned N = 342 (30%) Re-audit N=1,143 patients whose alcohol was unplanned N = 801 (70%) Total sample All patients who were admitted for alcohol N = 1,143 NHS specialist alcohol services 315 (68%) 282 (38%) 597 (50%) 192 (56%) 205 (26%) 397 (35%) Continuing care for alcoholrelated problems provided by a 62 (13%) 202 (27%) 264 (22%) 84 (25%) 236 (29%) 320 (28%) mental health team Non-NHS specialist alcohol services 96 (21%) 114 (16%) 210 (18%) 48 (14%) 172 (21%) 220 (19%) Voluntary sector (e.g. Alcoholics Anonymous) 38 (8%) 90 (12%) 128 (11%) 46 (13%) 95 (12%) 141 (12%) Continuing care for alcoholrelated problems provided by the 28 (6%) 50 (7%) 78 (7%) 27 (8%) 63 (8%) 90 (8%) GP Continuing care for alcoholrelated problems provided by a 11 (2%) 40 (5%) 51 (4%) 34 (10%) 43 (5%) 77 (7%) dual diagnosis worker/service No clear plans to address future alcohol use 20 (4%) 133 (18%) 153 (13%) 9 (3%) 172 (21%) 181 (16%) Not yet been discharged 3 (1%) 16 (2%) 19 (2%) 4 (1%) 15 (2%) 19 (2%) 43

44 Trust Level Results Analyses presented in this section were conducted for each Trust individually and for the total sample to allow benchmarking. Data from each Trust are presented by code. Charts in this section are ordered by performance against the practice standards so the position of your Trust will vary in each figure relative to other Trusts. 44

45 Table 26: Number of clinical teams and patient records audited from participating Trusts at baseline and re-audit Baseline 2014 Re-audit 2016 Trust Teams Patients Teams Patients

46 Baseline 2014 Re-audit 2016 Trust Teams Patients Teams Patients , ,143 46

47 Initial assessment Audit standard 1: The decision to undertake acute alcohol of an inpatient should be informed by: a. A documented assessment of drinking history and current daily alcohol intake (derived from NICE CG 115, recommendation ) b. A physical examination, carried out on admission (derived from NICE CG 115, ). Audit standard 2: Blood tests relevant to the identification of alcohol-related physical health problems (e.g. liver function tests including GGT, albumin and clotting, full blood count, glucose and renal function tests) should be carried out during the admission (derived from NICE CG 115, ). Treatment target 1: Breath alcohol should be measured as part of the initial assessment for alcohol (derived from NICE CG 115, recommendation ). 47

48 TNS Proportion of patients POMH-UK (2016) Topic 14b. Prescribing for substance misuse: alcohol Figure 9: Proportion of patients who had a documented assessment of drinking history at admission 100% 90% 80% 70% 60% 50% Not documented Documented assessment 40% 30% Documented assessment at baseline 20% 10% 0% Trust number Trusts are ordered on the basis of the proportion of patients in the sample who had a documented assessment of drinking history. The proportion of patients in a Trust sample who had a documented assessment of drinking history varied from 100% to 43%. 48

49 TNS Proportion of patients POMH-UK (2016) Topic 14b. Prescribing for substance misuse: alcohol Figure 10: Proportion of patients who had a documented physical assessment at admission 100% 90% 80% The patient declined physical examination 70% 60% Not documented 50% 40% 30% Documented assessment 20% 10% 0% Documented assessment at baseline Trust number Trusts are ordered on the basis of the proportion of patients in their sample who had a documented physical assessment. The proportion of patients in a Trust sample who had a documented physical assessment varied from 100% to 57%. 49

50 TNS Proportion of patients POMH-UK (2016) Topic 14b. Prescribing for substance misuse: alcohol Figure 11: Proportion of patients who had documented assessments of the signs and symptoms of Wernicke s encephalopathy 100% 90% 80% No signs/symptoms were assessed 70% 60% 50% 40% 30% 20% 10% Some signs/symptoms were assessed All signs/symptoms were assessed All signs/symptoms assessed at baseline 0% Trust code The Trusts are ordered on the basis of the proportion of patients in the sample who had all three documented assessments for the signs and symptoms of Wernicke s encephalopathy. The proportion of patients in a Trust sample who did not have any documented assessments for the signs and symptoms of Wernicke s encephalopathy varied from 0% to 93%. 50

51 TNS Proportion of patients POMH-UK (2016) Topic 14b. Prescribing for substance misuse: alcohol Figure 12: Proportion of patients who had a documented breath alcohol measurement 100% 90% 80% 70% No record 60% 50% 40% 30% Documented measure Documented at baseline 20% 10% 0% Trust code The Trusts are ordered on the basis of the proportion of patients in the sample who had a documented breath alcohol measurement. The proportion of patients in a Trust sample who had a documented breath alcohol measurement varied from 84% to 0%. 51

52 TNS Proportion of patients POMH-UK (2016) Topic 14b. Prescribing for substance misuse: alcohol Figure 13: Proportion of patients who had documented liver function tests during admission 100% 90% 80% 70% No record 60% 50% 40% Documented assessment 30% 20% Documented at baseline 10% 0% Trust code The Trusts are ordered on the basis of the proportion of patients in the sample who had documented liver function tests during admission. 52

53 During admission Audit standard 3: Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine, carbamazepine or clomethiazole (derived from NICE CG 100, and NICE CG 115, ). Audit standard 4: Phenytoin should not be prescribed to prevent or treat alcohol withdrawal seizures (NICE CG 100, and BAP evidence-based guidelines for the pharmacological management of substance abuse, 2012). As only one patient was prescribed phenytoin in the total national sample, we have not provided a trust level figure for this standard. Audit standard 5: Thiamine should be prescribed parenterally for inpatients in acute alcohol withdrawal. 53

54 TNS Proportion of patients POMH-UK (2016) Topic 14b. Prescribing for substance misuse: alcohol Figure 14: Proportion of patients who were prescribed medication recommended by NICE for managing symptoms of acute alcohol withdrawal 100% 90% 80% No medication prescribed 70% 60% 50% At least one medication prescribed 40% 30% 20% At least one medication prescribed at baseline 10% 0% Trust code Trusts are ordered on the basis of the proportion of patients in the sample who were prescribed at least one drug to treat the symptoms of acute alcohol withdrawal. 54

55 TNS Proportion of patients POMH-UK (2016) Topic 14b. Prescribing for substance misuse: alcohol Figure 15: Proportion of patients who had thiamine prescribed parenterally 100% 90% 80% Not prescribed 70% 60% Prescribed orally 50% 40% Prescribed parenterally 30% 20% Prescribed parenterally at baseline 10% 0% Trust code Trusts are ordered on the basis of the proportion of patients in the sample who were prescribed thiamine parenterally. The proportion of patients in a Trust sample who were prescribed thiamine parenterally varied from 100% to 0%. 55

56 TNS Proportion of patients POMH-UK (2016) Topic 14b. Prescribing for substance misuse: alcohol Figure 16: Proportion of patients whose alcohol was completed as planned 100% 90% 80% Not documented/ unknown 70% 60% Patient declined and/or self-discharged 50% 40% Detoxification was terminated by medical staff 30% 20% Completed alcohol regimen as planned 10% 0% Completed as planned at baseline Trust code Trusts are ordered on the basis of the proportion of patients whose alcohol was completed as planned. 56

57 TNS Proportion of patients POMH-UK (2016) Topic 14b. Prescribing for substance misuse: alcohol Appendix A: Patient demographic and clinical characteristics Figure 17: Gender distribution of patients in each Trust and the total national sample 100% 90% 80% 70% 60% 50% 40% Male Female 30% 20% 10% 0% Trust code 57

58 TNS Proportion of patients POMH-UK (2016) Topic 14b. Prescribing for substance misuse: alcohol Figure 18: Patients' self-assigned ethnicity in each Trust and the total national sample 100% 90% 80% 70% 60% 50% 40% 30% Not collected Not stated/ refused Other ethnic group Chinese Mixed Asian/Asian British 20% Black/Black British 10% White British/Irish or White Other 0% Trust code 58

59 TNS Proportion of patients POMH-UK (2016) Topic 14b. Prescribing for substance misuse: alcohol Figure 19: Distribution of age groups in each Trust and the total national sample 100% 90% 80% 70% 60% 50% 40% 30% 20% 61+ years years years years years 10% 0% Trust code 59

60 TNS Proportion of patients POMH-UK (2016) Topic 14b. Prescribing for substance misuse: alcohol Figure 20: Nature of admission for alcohol of patients in each Trust and the total national sample 100% 90% 80% 70% 60% 50% 40% Unplanned Planned 30% 20% 10% 0% Trust code 60

61 TNS Proportion of patients POMH-UK (2016) Topic 14b. Prescribing for substance misuse: alcohol Figure 21: Proportion of patients under general (non-specialist) and specialist psychiatric care during treatment for alcohol in each Trust and the total national sample 100% 90% 80% 70% 60% 50% Specialist Care 40% General Care 30% 20% 10% 0% Trust code 61

62 TNS Proportion of patients POMH-UK (2016) Topic 14b. Prescribing for substance misuse: alcohol Figure 22: Mental Health Act status of patients in each Trust and the total national sample 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Trust code Informal Via Section 136 Formal - recall from Community Treatment Order (CTO) Other Formal (e.g. detention under the Mental Health Act, Section 2 or 3) 62

63 Appendix B: Participating Trusts The Trusts and organisations that participated in this audit are listed below in alphabetical order. 5 Boroughs Partnership NHS Foundation Trust Avon & Wiltshire Mental Health Partnership NHS Trust Barnet, Enfield & Haringey MH NHS Trust Berkshire Healthcare NHS Foundation Trust Betsi Cadwaladr University Health Board Birmingham and Solihull Mental Health NHS Foundation Trust Bradford District Care Trust Cambridgeshire and Peterborough NHS Foundation Trust Camden and Islington NHS Foundation Trust Central and North West London NHS Foundation Trust Cheshire and Wirral Partnership NHS Foundation Trust Cornwall Partnership NHS Foundation Trust Cumbria Partnership NHS Foundation Trust Derbyshire Healthcare NHS Foundation Trust Greater Manchester West Mental Health NHS Foundation Trust Isle of Wight NHS Primary Care Trust Lancashire Care NHS Foundation Trust Leeds and York Partnership NHS Foundation Trust Leicestershire Partnership NHS Trust Manchester Mental Health & Social Care NHS Trust Mersey Care NHS Trust NAViGO Health and Social Care CIC North East London NHS Foundation Trust North Essex Partnership NHS Foundation Trust North Staffordshire Combined Healthcare NHS Trust Northumberland Tyne and Wear NHS Foundation Trust Nottinghamshire Healthcare NHS Trust Oxford Health NHS Foundation Trust Oxleas NHS Foundation Trust Partnerships in Care Rotherham, Doncaster and South Humber Mental Health NHS Foundation Trust Sheffield Health & Social Care NHS Foundation Trust Somerset Partnership NHS Foundation Trust South Essex Partnership University NHS Foundation South London and Maudsley NHS Foundation Trust South Staffordshire and Shropshire Healthcare NHS South West London and St George's Mental Health Trust South West Yorkshire Partnership NHS Foundation Trust Southern Health NHS Foundation Trust St. Patrick's University Hospital Sussex Partnership NHS Foundation Trust Tees, Esk and Wear Valleys NHS Foundation Trust West London Mental Health NHS Trust 63

64 Appendix C: Audit data collection tool 64

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71 Appendix D: POMH-UK Central Team and Expert Advisors POMH-UK Central Team: Professor Thomas Barnes Elizabeth Fagan Amy Lawson Carol Paton Haroldas Petkus Krysia Zalewska Topic 14 Expert Advisors: Professor Colin Drummond Professor Anne Lingford-Hughes Dr. Ignatius Loubser 71

72 Appendix E: References References Lingford-Hughes, Anne R., et al. BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. Journal of Psychopharmacology 26.7 (2012): National Institute for Health and Clinical Excellence. Alcohol dependence and harmful alcohol use quality standard. NICE quality standards QS11, Quality statement 3: Referral to specialist alcohol services. National Institute for Health and Clinical Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE clinical guideline 115, National Institute for Health and Clinical Excellence. Diagnosis and clinical management of alcohol-related physical complications. NICE clinical guideline 100, Saunders, J.B., Aasland, O.G., Babor, T.F., de la Fuente, J.R. & Grant, M. (1993). Development of the Alcohol Use Disorders Screening Test (AUDIT). WHO collaborative project on early detection of persons with harmful alcohol consumption. II. Addiction 88, Stockwell, T., Murphy, D. & Hodgson, R. (1983). The severity of alcohol dependence questionnaire: Its use, reliability and validity. British Journal of Addiction, 78(2), Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C.A.; and Sellers, E.M. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 84: ,

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