Alcohol – What Can Secondary Care Do Better?

1. Alcohol – What Can Secondary Care Do Better? Dr Paul Richardson Consultant Hepatologist Clinical Alcohol Lead Royal Liverpool University Hospital NHS Trust

2. What is the Scale of the Problem – Liver deaths

3. Hospital Admissions for Liver Disease

4. Alcohol Related Hospital Admissions

5. We All Know The Scale of the Problem! • Recognition / Screening • Risk stratification - alcohol and end organ damage • Integrated management by multi-faceted teams • Patient central and locally centred

6. Shifting drinking categorisation as a treatment aim 10% reduction in units in a dependent and high risk drinker will produce significant health and social benefits Derived from ONS data for England 2012

7. Alcohol Specific Treatment PathwaysFrom Neighbourhoods to and through appropriate domains

8. Pathways 1. Alcohol Interventions Pathway in Acute Care This pathway signposts to all other pathway options 2. Management of Acute Alcohol Withdrawal 3. Early Discharge Policy (EDP) 4. Frequent attender (FA) pathway 5. End of Life (EOL) pathway 6. Prescribing to maintain alcohol abstinence: Adjunct Pharmacotherapy Management (APM) 7. Medical Alcohol Clinic (MAC) And anything else to improve quality and access to timely, appropriate, effective management

9. Case 1 • 36y Male • First presentation to AMU – Alcohol withdrawal fit • Referred to alcohol team • Full history • Short period IV drug use • Low platelets / Mild jaundice • Managed in Early Discharge Clinic • Referred to Medical alcohol clinic for clinical work-up

10. Case 1 cont. • Hepatitis C positive • High Fibroscan score – Cirrhosis – started in surveillance programs. • Pharmacotherapy for maintenance of abstinence • 3 months later treated for his Hepatitis C • Surveillance ultra-sound scan focal lesion in liver – hepato-cellular cancer • Seen in satellite transplant clinic – listed for liver transplantation.

11. A UNIQUE TECHNOLOGY FibroScan product range

12. Fibroscanner Screen

13. Correlation Between TE and Fibrosis Stage

14. Underutilisation of proven pharmacological benefits

15. Case 2 • 45y F • Long history alcohol abuse triggered by life changing event • Died July 2012 • July 2011 – April 2012 • 86 days in hospital • 5 CT scans • 8 US scans • 17 X-rays • 8 Endoscopies

16. Case 2 cont • May – July • End of life care approach • Multi-disciplinary approach • Support for hostel workers – clear management plan • Early intervention if patient admitted • Full and open discussion with patient and agreement of plan • 12 hospital days • 8 day case management days • 3 X-rays • Comfortable and dignified death

17. Case 3 • 42y M • Multiple A+E attendances /MAU • Medical and trauma related • Banned from numerous homeless hostels • “Frequent Flyer” / Recidivist etc • Alcohol team – liaison psychiatrist review • Patient does not have capacity • Placed for long-term management.

18. Integrated Care Pathways

19. Summary • Alcohol services moving in the right direction • Identify / Stratify / Manage • End organ damage – medical and social – the top 5-10% of the pyramid. • Integration paramount – in primary / secondary care • Need to lower the barriers – localism is key