The Alcohol Liaison Team at the Royal Free Hospital in London has developed its service provision from the basic traditional model to one that is better able to meet patient demand. It has developed the parts of the service that have been effective for patient outcomes, and this work was the main rationale for submitting the team for the Gastrointestinal Nurse of the Year Award in the BJN Awards 2023. The team, which has increased its remit and is now named the Alcohol and Drug Liaison Service, was delighted to win the Gold Award. It consists of two nurses, myself and my colleague Kevin Reaburn.
The team has offered individuals with alcohol dependency the option of being followed up by the service in outpatients or being referred to their local service. Having this choice has been important for those attending. The Alcohol Liaison Service Outpatients Service has expanded the number of clinics it runs weekly from one to three, including one in Barnet General Hospital. Patients are offered a service that can assess, plan care and treat them in a single appointment. This simple concept has proved popular, with high numbers seen by the team, with the vast majority having positive outcomes.
Another development has been to move patient assessments and note-keeping from a paper to an electronic system. This has streamlined the administration process and also made the notes more visible to other hospital staff by being directly entered into the electronic patient record (EPR). This means our assessments and advice are more easily accessible to other staff. Also, staff are aware who they should contact if there is a query. This was a simple yet effective change.
Substance misuse was an area that needed more nursing input. It is a specialist area and the team has the expertise and knowledge to help treat and manage this cohort of patients.
Ambulatory detoxification from same-day emergency care (SDEC) is planned in 2023 and will be a valuable service for the hospital. This will create a pathway out of the hospital for people admitted for alcohol dependency as inpatients. This can potentially reduce the number of hospital stays, freeing up beds. Individuals can now be offered an alcohol detox as an outpatient. This prevents potential inpatient admissions in the future.
Finally, the service has also created a presence and provides a more consistent service in Barnet General Hospital, working with the local drug and alcohol service. This will be expanded further when and if the team grows.
Two major developments formed the basis for this year's BJN Awards submission.
Inpatient developments
Before 2022, the hospital's Alcohol Liaison nurse only saw patients referred through the EPR system, generally averaging 22 people a month. However, in 2022, with extra resources, the service was able to expand and cover areas where those with alcohol misuse problems often present, such as the emergency department (ED) and outpatient hepatology services. This has more than doubled the average number of individuals seen to 50-plus new patients a month.
In the last months of 2022 more than 70 patients were assessed within 24 hours of admission.
Many patients who present at the hospital have dependency problems with drugs or pain medications. This is an area the team has long believed the service should cover and has been an area of further expansion.
Since the beginning of 2022, an in-service leaflet has been developed and circulated at the Royal Free Hospital, and this has further established and publicised the Alcohol and Drug Liaison Team in the hospital, and it is now more visible than before. These factors have led to an increase in the referral rate to the team.
Figure 1 shows that there has been a jump in the number of patients seen since December 2021 This has been largely achieved by making the service more visible, accessible and responsive to the needs of other staff at the hospital. To increase visibility of the service, team members now attend the ED four days a week at handover times Members of the team also attend outpatient clinics. Team members support drug and pain medication misuse patients with substitute medication. There is expertise within the team in this area and there is a small but significant need for this resource.
This group of patients need a great deal of support on the ward and reviewing them is an intensive process. The number of referrals of such patients is currently 10-15-plus each month. This appears to be a larger number than is routinely dealt with by other in-reach services for alcohol liaison that have expanded to deliver drug and alcohol provision nationally.
This comprehensive service is now run by a knowledgeable team offering advice and treatment for patients experiencing problems with drug, alcohol and pain medication misuse. This more comprehensive service is easier for staff to understand and provides support for the staff managing a large cohort of such patients at the hospital.
As an alcohol liaison nurse, I had not considered working in drug misuse before, but taking on such patients means my role has expanded, and the areas of alcohol and drug misuse often overlap. Expansion into the area of substance misuse therefore has been a logical step because patients often present with poly-drug use. Therefore, the inpatient service has expanded and developed to treat a wider population than simply alcohol misuse patients. This has been valuable for the hospital and the patient population.
Outpatient developments
The service has also developed its outpatients service to meet patient needs.
This has been a well-received feature of the service. Frequent attenders to the ED, and the hospital in general, often do not engage with local services when they return home. Therefore, the service has been proactive in developing its outpatient service to engage and treat this cohort of patients who often, on discharge from hospital, do not stay ‘dry’ because they never engage with any planned follow-up.
When patients are assessed by the team, they are offered the opportunity to engage with the outpatients service. Recent data has shown that the service is seeing a growing and significant number of individuals engaging with the outpatient service (at least 33% of them assessed in a 6-month period).
Currently around 95 patients are being cared for by the outpatient service.
These patients are offered:
- Brief interventions
- Motivational interviewing: used to increase a patient's insight into their dependency pattern
- Prescribing through the non-medical prescribing function
- Prescribing through the consultant
- Prescribing through good links in primary care (for long-term treatment)
- A comprehensive overview.
This has been an important feature of the service and patients have already shown great benefits from this approach. Of the 95 individuals seen in outpatients, the majority have made positive changes to their alcohol consumption, by drinking less and also using prescription medications to address long-term depression and insomnia.
Positive change
These two main developments have expanded the service and made a positive difference to patients. This has led to a team that is confident and there are plans to expand further, with ambulatory detoxification being the next development planned. The service now has an ethos to develop patient-centred services and will adapt as needs change. Audit and research will further inform the team about services they may need to develop in the future.