Alcohol Data Collection and Emergency Project

Thematic Work Area: Alcohol and Drugs - reducing the impact on our community

What was the need?

The negative impact of alcohol on our community continues to grow. As a service commissioning body the Devon Drug and Alcohol Action team (DAAT) are keen to improve our evidence base so that services are developed to meet local need and that we continue to adapt our partnership response to local issues around treatment and prevention.

Historically, despite there being some significant public health data available to us, our plans lack detailed evidence of local need around hospital A&E data linked to the provision of alcohol and its misuse in a community/night time economy context. If an incident has been reported to the police, we are able to track incidents of alcohol related violent crime, but incidents not reported are not being monitored and a direct service response not commissioned. We continue to promote to the community the importance reporting all incidents of crime, but needed to do more to collect this valuable health and community information.

Alcohol Related Harms in North Devon
The North West Public Health Observatory’s alcohol related harm profile shows that North Devon scores significantly worse that the England average against the following measures

Alcohol attributable hospital admissions, females. Ranked 324 out of 354
Alcohol attributable hospital admissions, males. Ranked 307 out of 354
Alcohol specific hospital admissions, females. Ranked 330 out of 354
Alcohol specific hospital admissions, males. Ranked 303 out of 354
Alcohol specific hospital admissions, under 18s. Ranked 332 out of 354

There are 354 Local Authorities in England. 354 is the worst performing.

Due to inconsistencies in recording it is not possible at present to produce a baseline for A&E attendances, however it is assumed that the admissions data offers a useful proxy measure of the extent of alcohol related A&E attendances. It is estimated that 35% of all A&E attendances will be alcohol related

The table below estimates the relative cost to health services of alcohol misuse. Figures from Devon and Cornwall Police indicates that 37.7% of all recorded violent crime across Devon is alcohol related. In North Devon this rises to 39.4%. In 2006/07, alcohol related violent crime accounted for 9.8% of all recorded crime in Torridge, 9.7% in North Devon and 7.3% of all recorded crime in Exeter. The average for Devon in 8.1%.

During 2006/07 there were 739 alcohol related recorded violent crimes in North Devon against a total of 7,650 recorded crimes, 9.7%. This compares to 555 alcohol related recorded violent crimes in 2005/06 against a total of 7783, 7.1% of the total.

The Government Office for the South West has made funding and expertise available to develop alcohol related A&E attendance data collection pilots in 5 A&E departments across the Region. The DAAT made a successful pitch that North Devon A&E should be included on the basis of the evidence presented below.

In participating in the pilot, North Devon District Hospital will be share learning and expertise developed with the Region.

John Shepherd, an A&E consultant at Cardiff hospital has been a led the way in demonstrating that A&E departments have the potential to contribute to the management of local crime and disorder problems. Depersonalised A&E intelligence was used to direct assault reduction initiatives in collaboration with the police and local authority partners. The Cardiff model indicates that the approach enables a reduction in A&E alcohol-related violence activity as a result of targeted policing. There is also a consequent reduction in demand for NHS A&E provision. In fact Cardiff have managed to reduce assault activity presenting at the hospital by 40% over the last 5 years.

Northern Devon is looking to replicate best practice and to attempt to benefit from the successful results related to assaults in Cardiff.

What have we done?

A pilot project in North Devon Accident and Emergency Unit was established to collect information on alcohol related attendances.

Aims and objectives
To develop a data collection system to capture information on alcohol related attendances at North Devon District Hospital A&E department.

Capture data on alcohol related hospital admissions
Train staff to administer the system in a consistent manner
Develop a 3 month snapshot baseline of the extent and nature of alcohol related hospital admissions
Turn the data into useful management information to inform planning and resources allocation
Identify from the data the value of delivering brief interventions from A&E
Model a sustainable system that NDDH would be able to mainstream

Leadership

Co-ordination and management of this initiative poses a key problem for the sustainability of data capture. Evidence for Cardiff and elsewhere indicates that local ownership and mainstreaming of the work, as opposed to viewing it as a short-term research/evaluation project, is key to successful implementation.

Training

Ensure that staff involved in the collection of the data are; clear about the rational, understand how the data needs to be recorded and are consistent in the way they record the data

Software

Due to limitations with A&E software the majority of A&E’s implemented a paper-based system of data collection. This is a significant deviation from the Cardiff model and ultimately compromises both volume of data captured and data quality. There is anecdotal evidence that even the paper-based system can provide intelligence on patterns of assaults not known to the police, for example youth-on-youth. Nevertheless, GOSE is pushing for migration from a paper-based system to an electronic method of capture performed by Reception staff. This will be difficult for some who are limited by the software in use;

The roll-out of the national A&E data-set associated with Connecting for Health, however, the national data set does not capture the two critical items – assault type and location – that makes the Cardiff model successful. GOSE is attempting to address this within DH by persuading Connecting for Health to include this in the national A&E data-set.

Data Protection

Although there is sufficient guidance available around the sharing of depersonalised data, many A&E Departments are still reluctant to release anonymous assault data. More work needs to be undertaken with hospital Information Departments to facilitate the flow of this type of data to local criminal justice agencies.

Using the Data

Even when data is available from local A&E’s this does not necessarily mean that Crime and Disorder reductions Partnerships (CDRP’s) and others will utilise it in directing local crime prevention and other initiatives. Cross organisational work is required to help all partners to make the most of intelligence that is available in particular using it alongside other analytical products in relation to Tasking and Co-ordinating, Violent Crime and Alcohol Licensing;

CDRP’s also need to consider including this intelligence in the analysis in a range of secondary and supporting partnership data sources, e.g. trading standards, Pubwatch, walk in centres, ambulance, drug litter;

Benefits of collecting alcohol related attendance data

In Kent information was used to identify new areas used for underage drinking. In addition, Ambulance data has also been made available to both CDRP’s and the A&E group is used as part of the Strategic Needs Assessment process;

Following reports of high levels domestic violence via the Minor Accident & Injury Units, additional funding is being accessed from CDRP’s in East Kent to support a volunteer based Domestic Violence advisory service based;

Improving NHS engagement in both data collection, prevention and treatment services has had benefits in focusing the development of alcohol brief intervention service. In addition, Kent and Medway NHS and Community Safety Strategic Group is emerging that will involve representatives from all NHS bodies in Kent as well as CDRP’s, KCC, Kent DAAT and Kent Children’s Trust to embed community safety throughout the NHS in Kent and Medway;

A&E data has been fed in to Portsmouth 'Licensed Premises Management System', which assesses premises on a range of measures. This system has enabled the police and Local authority to restrict the opening hours of premises who generate high volumes of assaults.

In Worthing A&E data is useful at this stage in terms of determining which licensed premises are causing concern. This information is being used amongst other data to target a priority list of premises for action.

The data is also useful in demonstrating the low level of referrals to alcohol and drug services and the need to develop further work around this. Until more reports are completed, the data will however be limited.

Improving Patient Care and Support Services

A&E data is identifying patterns and trends in the A&E Department. For instance, patients presenting following Domestic Violence are more likely to self discharge if not seen within one hour. Improving triage protocols is maintaining patients in care;

Through the data, low rates of follow up were associated with maternity patients and this has led to the improved working relationship between the midwife specialists for Domestic Abuse, teenage pregnancy, alcohol and substance misuse who are now willing to take referrals directly from the A&E;

The initiative is also highlighting the needs of vulnerable adults (self harm, psychiatric patients, domestic abuse, alcohol & substance misuses) presenting to the A&E who often had dependant children at home with questionable carers. This has improved referral pathways for this patient group and allowed the triage nurses to screen vulnerable adults for dependant children not in the department. In Oxford this has identified approximately 300 children who needed follow up in the community. This project has been recommended for use in other A&E s and Minor Injury Units further afield;

Statistics around alleged drink spiking incidents have prompted the development of forensic testing of urine samples for alleged spiking – now underway in two Oxford hospitals;

Identifying trends in injuries through monitoring A&E injury patterns has revealed, among other things, a spate of people being pushed off bikes and intoxicated young men swallowing coins. Trends in types of weapons involved has informed local practice – injuries from street debris, object from skips or loose kerbs led to the CDRP liasing with the city council to influence rubbish-skip and building applications;

The A&E initiative is identifying numerous Domestic Violence assaults which allows retrospective referrals to Health visitors, GP s and midwives. This has also resulted in an improved liaison with the local MARAC service around victims and prompted more research from the A&E Department on their specific.

Establishing a Data Sharing Initiative in an Accident and Emergency Department
Set out below, in rough chronological order, are the actions associated with establishing a data sharing initiative within an acute hospital Accident and Emergency Department

1. Formal launch of the initiative within the A&E department and Trust which could involve local media – would anticipate this being done with Crime and Disorder Reduction Partnership key stakeholders like police and Community Safety rather than a low-key affair involving clinical staff confined to the A&E department. This assumes that there is an explicit sign-up from acute hospital Trust management should reinforce initiative being deployed in A&E

2. Produce posters and leaflets for A&E reception area to inform patients and staff about new focus on assaults (examples are available);

3. Establish the data set to be collected

4. Assess if A&E software can be changed to capture data electronically – if not use manual collection (a number of formats exist);

5. Change software to collect agreed data-set if possible;

6. Train A&E staff involved in data collection to ensure clarity and consistency and data-set – probably the single most important step in the process;

7. Educate/train all A&E staff about assaults and the importance of the initiative. Bring a new focus on assaults which can have potential impact on their workload and improved patient care, i.e. clinical care pathways

8. Announce and sell initiative to other hospital departments who may have relationship with A&E in respect of patients who are assaulted - principally Obstetrics & Gynaecology, mental health especially Child and Adolescent Mental Health Teams, maxillofacial, X-ray and the psychology dept. Consider developing cross-department referral protocols

9. Agree and sign-off data sharing protocols between A&E and CDRP via hospital Trust data protection manager

10. Establish system to collate data from A&E – IT Dept. task ideally but overseen by senior member of A&E team. Some colleagues have found that with the electronic systems there is benefit in asking IT to send the data reports with the patient identifiers (e.g. patient number) and then A&E staff remove this column. It enables any subsequent audits of some notes to be found quickly;

11. Establish regular interrogation, by a member of the A&E team, of collated data for relevance to care pathways, e.g. follow-up especially for referral to domestic abuse support services and the police. Again, some areas have a policy about proactive referral to services for victims of domestic abuse, which could be made available also. Other referrals to mental health, CAMH’s, child protection should also be considered;

12. Establish system to transfer depersonalised aggregate data package as soon as possible, i.e. weekly, to analysts in CDRP for further scrutiny;

13. Establish regular feedback or briefing sessions to A&E staff in relation to the data being transferred – patterns and type of assault activity with locations. This maintains profile of the initiative and sensitises A&E staff to clinical presentations related to assaults, e.g. serial presentations that are DV etc. Can also enhance existing CPD by linking clinical activity of ED to wider social phenomena like binge drinking, youth violence etc.;

14. Senior A&E staff member attends local CDRP(s) to comment on nature of data transferred and learn how it is being used in crime reduction efforts. This liaison is important for a number of reasons (see Shepherd papers) but senior clinicians can have a significant impact on local alcohol licensing committees in respect of patterns of injuries, e.g. glassings. Other areas have set up standard project management framework with A&E representation;

15. Establish reflexive process in the A&E associated with the alcohol data. Critically evaluate A&E department's ability/efficiency in detecting and responding to the different presentations of assault. Assess also relationships with other agencies in responding to patients needs particularly onward referral to specialist agencies;

16. Regularly peer review all the above actions with colleagues at least annually.

17. CDRP’s should endeavour to:

Receive data: ensure data will always be received even if staff are on leave;
Set up analytical framework/system to analyse and contextualise the data;
Distribute raw data and analysis to stakeholders – PCT, A&E, Trading Standards, Licensing Teams (police and council);
Ensure the analytical product is actioned within CDRP for example, by Tasking and Co-ordinating groups, Violent Crime Groups, Licensing;
Consider including in the analysis a range of secondary and supporting partnership data sources, e.g. trading standards, Pubwatch, walk in centres, ambulance, drug litter;
Some thought should be given to link with national intelligence model.

What are the results of our work?

The pilot is under way and has now been agreed to become part of daily ongoing practices for all A&E staff. All staff have been trained, the collection form has been trialled and revised responding to staff feedback, and a formal launch taken place.

The initial pilot began during the busy time for alcohol-related injuries and therefore data collection over the Christmas and New Year period, and continues on an ongoing basis.

The initial data will be reviewed during March to assess any difficulties in collecting and collating the findings and to look at any early trends which may allow us to put some short term measures in place to prevent further ongoing harm to members of our local communities.

Further ongoing assessments and adjustments are anticipated over the coming months to ensure the project produces meaningful data and can be responded to with positive interventions. This case study will be updated, as the results become available.

A “spin-off” project has been established from this pilot as it became clear that all staff had little access to information on Community Support Services for patients. This became a particular issue when they either disclosed a complex need, such as Alcohol or Drug Misuse or Domestic Violence or when the staff saw the same patients on a regular basis presenting with similar symptoms likely to be related to a more complex need. See Community Services Directory case study for more information.

Launch Event at North Devon Hospital with representatives from
Devon DAAT, Devon PCT, Devon and Cornwall Constabulary, Y-Smart (Young Persons Substance Misuse Service Provider), Addaction (Adult Treatment Service Provider) and Safer North Devon

For more information contact:

Amanda Palmer
Community Safety Manager
Safer North Devon
01271 341200
amanda.palmer@northdevon.gov.uk

Kristian Tomblin
Devon DAAT Manager
kristian.tomblin@nhs.net
01392 449818

Fionn Bellis
Consultant in Emergency Medicine
Accident and Emergency Department
North Devon District Hospital
01271 311527
fionn.bellis@ndevon.swest.nhs.uk

Date of Case Study: 03 March 2009

Indications of Public Health in the English Regions – 8:Alcohol. Association of Public Health Observatories. 2007

Strategy unit Alcohol Harm Reduction Project. Interim Analytical Report. 2004

Centre for Public Health, WHO Collaborating Centre for Violence Prevention. 2007

Devon Drug and Alcohol Action Team, Alcohol Needs Assessment and Service Development Framework. 2007