Kathryn Oakes Senior Nurse for Viral Hepatitis Kings College Hospital November 2011

Transcription

1 Kathryn Oakes Senior Nurse for Viral Hepatitis Kings College Hospital November 2011

2 Background to the AVT outreach project Referring into the service and the role of the Physical Health Harm Reduction Nurse (PHHRN) Milestones Referral, assessment and treatment data Substance misuse levels Barriers to project success

3 HCV - 85% chronicity rate with 20% cirrhosis 1 rate1 and 3-5% risk per annum HCC2 HCV most common cause transplantation in western population3 40% transplants at KCH = 168 pa Mortality rate planned to triple by with an 8 billion economic burden to the NHS5 HCV prevalence in IDU s up to 66% in London6 Population reluctant to attend secondary care7 LHH 1000 to 1200 clients with new p.w 1. Alter MJ Semin Liver Dis 1995; 15:Management of Hepatitis C NIH Consensus Statement 1997; March 24-26:15(3). 2. Cabrera R, Nelson D R. (2009) Review article: the management of hepatocellular carcinoma. Alimentary Pharmacology and Therapeutics, 31: Lodato et al. (2008) Clinical trial: peg-interferon alfa-2b and ribavirin for the treatment of genotype-1 hepatitis C recurrence after liver transplantation. Alimentary Pharmacology and Therapeutics, 28: Cheruvu et al. (2007) Strategies to control hepatitis C infection among injection drug users. Hot Topics in Viral Hepatitis, 6: British Liver Trust. (2010) Facts about Liver disease (online). 6. Health Protection Agency. (2009) Shooting up. Infections among injecting drug users in the United Kingdom 2008: An update. 7. Foster G. (2008) Injecting drug users with chronic hepatitis C: should they be offered antiviral therapy? Addiction, 103:

4 Kosh Agarwal, Lead Consultant for VHS, KCH Mike Kelleher, Clinical lead for LA Kathryn Oakes, Senior Nurse VHS, KCH Mick Collins, Borough Lead for LA Tony Docherty, Deputy borough Lead for LA Mags O Sullivan, Kristen Stone PHHRN and Integrated Care Nurses, VHS KCH Martin McCusker, service user Dee Cunniffe, Reckitt Benckiser Fenella Jolly, Team Leader BBV/Homeless Team

5 Alcohol intake does not exceed 40 units weekly Ideally no IV Crack Cocaine Client agrees to regularly attend appointments and consents to appropriate drug screening Stable housing with fridge Agree to enter needle exchange programme Stable from a psychological perspective

6 Client tests Positive HCV/HBV Is Client stable? Assessment of client stability re: addiction issues Yes Referral to Hepatitis Team No Contact Hep CNS team for advice Appointment for screening and education with Hep CNS within 14 days REFERRAL Client not suitable for AVT Client suitable for AVT PATHWAY Referral back to Drug/alcohol advisory service Hepatology review Cirrhotic or HBV offer Follow up at Kings Delivery AVT16 to 72 weeks

7 Contact known HCV RNA positive clients BBV testing and HBV vaccination Work with the substance misuse teams to identify clients for treatment and co-ordinate referral into the service Engagement of clients, education and harm reduction advice Acts as a resource and contact for patients on treatment and attends all KCH appointments Strategic role in service development

8 Action plan formulated Working group established Operational Policy and SLA finalised Meet service users Initial appt PHHRN Transfer of PHHRN post 1 st assessment/ education clinic PHHRN appointed Jan 2009 June 2010 Feb 2011 May 2011 July2011 Sept 2011 First treatment clinic First medical clinic RAISING AWARENESS & EDUCATION

9 ReferralSource Number patients Referred to Kings Keyworkers at LHH (29%) FenellaJolly 2 1 (50%) DRR 4 0 (0%) RIOTT at MH 8 8 (100%) Triage 15 0 (0%) Previous bloods (Fenella) 9 1 (11%) WHD + keyworker 3 2 (66%) WHD 3 1 (33%) Relative 1 0 (0%) Total 133 * 39 * 81 known HCV, 52 tested 25 HCV RNA pos and 26 tested RNA negative, 1 HCV ab pos on DBST and refusing venous sample Data collection period 29/06/2011 to 26/10/2011

10 39 Booked for assessment and education with KCH viral hepatitis CNS team 17 completed assessment 16 booked for future assessments 3 DNA d& 1 declined assessment 1 assessment delayed social issues 1 removed unfavourable genotype and IL28

11 Genotype Disease stage

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13 Patient Genotype Treatment week Response One 1 non cirrhotic 9 Complete EVRTW9 Two 1a non cirrhotic 14 RVR Three 1b cirrhotic 0 N/A Four 3a non cirrhotic 19 Complete EVRTW9 Five 3 cirrhotic 5 RVR Six 3a non cirrhotic 14 RVR Seven 3 non cirrhotic 5 5 log drop at TW4 to 9.92 E1 IU/Ml Eight 3 non cirrhotic 5 3 log drop at TW4 to 1.06 E2 IU/Ml Nine 3 non cirrhotic 3 N/A

14 %

15 Alcohol Number Abstinent Substitute Drug Level of drug use Number Substitute Units p.w drugs Prescribing use Prescribing (3 OT) 3 RIOTT 11 Cannabis 3 1 RIOTT 1 No substitutes Heroin or crack smoked once a week 4 (3 OT) 10 substitute 11 substitute IV heroin once or twice a week 1 (1 OT) IV heroin once to three times a week 1 (1 OT) IV heroin two to four times a week RIOTT 4 Cannabis 1 2 substitute Occasional speed 1 (1 OT) Heroin or crack smoked once a week 1 IV heroin use and crack smoked 1-2 wk RIOTT 1 Cannabis and smoking crack 1 RIOTT 2 substitute Heroin/IV skin popping 3 times a week 1 1 substitute Total

16 Lack of awareness amongst substance misuse population; concerns about the side effects; previous experiences in secondary care; chaotic lifestyles competing priorities Resource and time needed for engagement, education and referral Working across two sites; IT, medication dispensing, transportation samples, honorary contracts Different cultures and organisational changes

17 Project is a work in progress We have learnt a lot about this population and working across sites/specialities To date a model that integrates specialist viral hepatitis and addiction services appears to work well Treatment outcomes will give us more insight into the effectiveness of the model The role of the PHHRN has been essential to engage clients and bridge services