A&E St. Mary’s 'Scientia Vincit

Timorem'

Implementation of screening and brief intervention in accident and emergency departments: challenges and solutions

Paolo Deluca, PhDInstitute of Psychiatry, King’s College London

AED study design• 9 AEDs, 3 regions (NE, London, SE)• 3 screening approaches (M-SASQ, SIPS-PAT, FAST)• 3 intervention approaches

– Patient information leaflet– Brief advice (5 min)– Referral to Alcohol Health Worker BLC (20 min)

• 1,179 patients (131 each)• Baseline research interview• 6 & 12 month follow-up research interview• Attitudes, barriers and facilitators factors

Attitudes, barriers and facilitators factors

• The Shortened Alcohol and Alcohol Problems Questionnaire (SAAPPQ)

• Training and experience in dealing with AUDs• Multiple choice assessment• Feedback questions• Implementation questionnaire• T1 vs T2 vs T3

How do we assess implementation?

• Number screened, positives, received intervention

• Factors supporting implementation• Factors impeding implementation• Impact: individual, service, costs and benefits• Acceptability: patient, practitioner,

commissioner• Sustainability

Overview recruitment

• Recruited 9 A&Es – Royal Ham., St Thomas, King’s, North Mid, Central Mid, Newcastle Gen, Darlington Mem., Hexham, South Tyneside.

• Trained 250 (range 5-84) staff (nurses and consultants)

• Recruiting participants from April 08 to April 09• 1202 (102%)

Participants RecruitmentApproached Eligible Screened Positive Recruited

All A&Es N 5992 3737 3676 1491 1202

% 62.4 98.4 40.6 81.4

Approached Eligible Screened Positive Recruited

All PHCs N 3562 2991 2988 900 755

% 83.9 99.8 30.1 83.8

Approached Eligible Screened Positive Recruited

All CJSs N 976 860 856 576 525

% 88.1 99.5 67.2 91.1

A&E Approached Eligible Screened Positive Recruited

St Thomas’ N 592 407 399 184 130

% 68.7 98.0 46.1 70.6

King’s N 914 745 735 175 131

% 81.5 98.6 23.8 74.8

C. Middx N 789 321 313 156 133

% 40.7 97.5 49.8 85.2

N. Middx N 1948 779 758 220 136

% 39.9 97.3 29.0 61.8

Royal Ham N 709 551 544 183 131

% 77.7 98.7 33.6 71.6

Participants Recruitment

A&E Approached Eligible Screened Positive Recruited

Darlington N 214 197 195 139 135

% 92.1 98.9 71.3 97.1

S. Tyneside N 246 218 218 141 135

% 88.6 100 64.7 95.7

Newcastle N 296 253 250 145 132

% 85.5 98.8 58.0 91.0

Hexham N 286 266 264 148 135

% 93.0 99.2 56.1 91.2

Participants Recruitment

Recruitment by month

Recruitment by month for each A&E

Recruitment by month for each A&E

Recruitment by month for each A&E

Training A&E staff• On site training to small and large groups delivered by

RA & AHW • 1 to 2 hrs for screening and BA including role play• No BLC training• Overall positive feedback on training. Research

elements and Units are usually the challenging parts of the training

• Most welcomed receiving training• Adequate space, staff availability, “on call”, turnover,

time and implementation issues slowed training• Booster sessions, launch events, shadowing staff first

few weeks

SAAPPQ

• Staff’s attitude and motivation• SAAPPQ assesses differences in five areas:

– Role adequacy– Role legitimacy– Motivation– Task-specific self-esteem– Work satisfaction

SAAPPQ between groups(preliminary findings)

– Overall A&E staff score significantly better than PHC and CJS staff respectively (p = .000)

– Role security• Staff in A&Es score significantly better that PHC

and CJS respectively– Therapeutic commitment

• Staff in A&Es score significantly better that PHC and CJS respectively

SAAPPQ within group (T1 vs T2)(preliminary findings)

– Overall A&E staff score significantly better than before the training (p = .000). In particular:

– Role security• Staff in A&Es score significantly better after

training (p = .02) – Therapeutic commitment

• Staff in A&Es score significantly better after training (p = .000)

A&E Implementation issues• Protocol: Leaflet-eligibility-screening-informed

consent-baseline-intervention• Ideally delivered by same person (except BLC) in

practice divided by triage/nurses and doctors• Strong local lead (champion)• Consent and contact details put some participants off• Workload/time• Staff turnover (eg August)• Easily forget training if start is delayed• Tendency of targeting dependent drinkers• Weekly support

Implementation issues for screening and BI

• Workload/time• Language/communication barriers• Too intoxicated patients• Patients not wanting to engage

• Time/staffing/resources• Unwillingness of patients to engage• Space/privacy to deliver intervention• No dedicated alcohol health worker/internal A&E

service to refer to.• Dealing with presenting problem

Changes to improve recruitment

• Extra support to staff• Incentives (MHRN)• Deployment of Alcohol Health Workers to

conduct also screening, BA and research assistants to support baseline activities

19

Conclusions• Prevalence of AUDs reflect previous studies in

these settings• Patients are more willing to receive an

intervention than previous studies• Overall staff in these settings are keen to be

trained, have positive attitude and motivation • However, limited time, workload, lack of

privacy and turnover are limiting implementation

• Need for support or dedicated AHWs