1. No category

The Alcohol Treatment Centre is an innovative and necessary response to the demand
placed on health and police services by severe alcohol intoxication exhibited by patrons of
the night time economy in Cardiff. It successfully diverts intoxicated patients away from the
Emergency Department and therefore reduces their impact on this clinical environment. The
consequence is that ambulance services benefit as do the police. The Alcohol Treatment
Centre is a necessary response to acute intoxication in the night time economy.
Cardiff University
Violence & Society Research Group
School of Dentistry
Cardiff
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1 Executive Summary
The Cardiff Alcohol Treatment Centre (ATC) aims to provide additional capacity to offset the
high volume of acutely intoxicated individuals currently attending University Hospital of
Wales Emergency Department and who, in consequence, reduce service capacity across
ambulance, police and health services with broader implications for the Cardiff community.
The ATC is open two evenings each week, targeted at times when attendance for alcoholrelated harm is expected to be high.
The ATC pilot successfully diverted patients away from the Emergency Department and was
therefore associated with a significant reduction in alcohol-related attendances, a significant
reduction in ambulance referrals to the Emergency Department and a significant decrease in
ambulance handover times at the Emergency Department. However, evidence also
suggests that the additional capacity provided by the ATC across the pilot period was
associated with an increase in demand for health services, possibly due to pre-existing
unmet need in the night time economy.
Data suggests that across the pilot period use of the ATC increased, suggesting a beddingin period where partnership awareness of the ATC increased over time.
Across the pilot, clearly defined and effective management structures and procedures were
developed, a strong multi-partner approach to acute alcohol intoxication was demonstrated
and the Centre benefited from strong leadership and enthusiastic staff. Similarly,
communication between partners improved across the pilot period resulting in greater
awareness of the ATC, clearer referral pathways and collaboration. The ATC is an
exemplary model of service innovation and partnership working that yielded tangible benefits
to the local community.
The ATC provides a relaxed, orderly environment that benefited from the presence of a
police officer. In comparison, ED could become overwhelmed during evening periods, lower
priority patients left to wait for long periods who, in turn, could become anxious or
aggressive. This is compounded by friends of patients also attending, interfering and
impacting on the care environment. Diverting patients to the ATC resulted in the ED
becoming less chaotic. The ATC therefore was of benefit to both patients, those escorting
them and next of kin.
The Civil Contingencies Act 2004 requires that Health Boards make plans and prepare for
major emergencies, or major incidents; occurrences that present a threat to the health of the
community or disruption to services. The volume of those attending the Emergency
Department with alcohol related harm could be defined as sufficient to meet this definition of
a major incident, albeit one that has become normalised. The ATC is an essential
innovation.
Evidence suggests that police officers, working in pairs, were required to escort patients to
ED on occasion. This would deplete police resources in the night time economy. The
availability of the ATC adjacent to the city centre would mean officers are able to return to
duties more rapidly.
The administration of patients was paper-based and practitioners were unable to refer to
patients’ prior history using data systems. This delayed patient data being entered onto
patient management systems.
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Both Police Officers and Street Pastors play an important role in determining who should be
referred into unscheduled care although neither have clinical expertise. In consequence
factors unrelated to patients’ presenting symptoms can influence the decision to refer or not.
The ATC extends clinical expertise into the night time environment and therefore provides an
accessible and potentially safer referral pathway. This is coupled with the general
observation that unscheduled care is misused with numerous examples of unnecessary
attendances generally. The ATC provides clinical expertise that is effective in providing early
and rapid opportunities for triage without requiring attendance at the Emergency
Department.
Irrespective of the ATC’s success, the development and collaboration that created the pilot is
an exemplary example of partnership working. Leadership, innovation, expertise and
communication between partners contributed to the identification and service requirements
required to offset the impact of alcohol-related harm on the community.
The ATC provides a good opportunity to develop systems to address the causes of alcoholrelated harm. There are therefore opportunities for further innovation in terms of intervention
and referral and the provision of data concerning patients place of last drink to partners so
that both individual and contextual contributors to alcohol related harm can be addressed.
However, there is only minimal intervention and referral activity evident in the ED and ATC.
Drunk and incapable is no longer a criminal offence and police officers refer the intoxicated
into unscheduled care where they typically sober up and are discharged home.
It is concluded that the ATC pilot resulted in a net benefit to Health, Ambulance and Police
services as well as patients, their families and the community generally.
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2 Authors
Professor Simon Moore is a member of the Violence and Society Research Group based in
the School of Dentistry and DECIPHer (Centre for the Development and Evaluation of
Complex Interventions for Public Health Improvement) a UKCRC Public Health Research
Centre of Excellence, both at Cardiff University.
Dr Vas Sivarajasingam is Reader in oral and maxillofacial surgery at Cardiff University and
honorary consultant in the Cardiff and Vale NHS Trust.
Marjukka Heikkinen is a registered nurse with expertise in the area of substance misuse.
All authors declare that they have no conflicting interests that would affect the conclusions
presented in this report.
Contact details:
SC Moore
Violence & Society Research Group
School of Dentistry
Cardiff University
Heath Park
Cardiff CF14 4XY
Email: mooresc2:cardiff.ac.uk
Telephone: 029 2074 4246
3 Acknowledgements
The authors would like to thank the following for their assistance with the work presented
here.
Sarah-Jane Bailey
Claire Bevan
James Brewster-Liddle
Susan Brown
Tim Davies
Nici Evans
Conrad Eydmann
Dennis Gray
Britt Hallingberg
Morgan Hart
Brian Hayes
Chris Holloway
Greg Lloyd
Iain MacAllister
Cardiff Youth Offending Service
Divisional Nurse Medicine, Cardiff and Vale University Health
Board
Cardiff & Vale University Health Board A&E Department
Welsh Ambulance Services Headquarters
South Wales Police
Cardiff Partnership Board
Substance Misuse Strategy and Development, Cardiff and Vale
University Health Board
Deputy Director, National Drug Research Institute, Perth,
Australia
Violence & Society Research Group, Cardiff University
Students Union, Cardiff University
London Ambulance Trust
Cardiff and Vale University Health Board
Welsh Ambulance Service Trust
Principal Researcher (Alcohol), Scottish Government
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Karen McNeil
Jo Mower
Claire O’Brien
James O’Donnell
Nick Page
Mike Parfitt
Wayne Parsons
Andrew Phillips
Stephen Porter
Loretta Reilly
Jonathan Shepherd
Tim Stockwell
Mel Westlake
Mo Williams
South Wales Police
Cardiff & Vale University Health Board A&E Department
Violence & Society Research Group, Cardiff University
South Wales Police
Violence & Society Research Group, Cardiff University
Cardiff County Council
Cardiff & Vale University Health Board A&E Department
Cardiff & Vale University Health Board
NHS Wales Informatics Service
Cardiff & Vale University Health Board A&E Department
Director, Violence & Society Research Group, Cardiff University
Centre for Addictions Research, University of Victoria, Canada
Cardiff & Vale University Health Board Corporate Governance
St John’s Ambulance
Senior Research Fellow, Applied Social Science, University of
Rowdy Yates
Stirling
And all those who willing gave their time to this project
4 Glossary of Terms
AAI
AHW
ATC
BAI
CDM
ED
ENP
ISB
LARC
PCSO
PCT
QMAE
UHB
WAST
Acute alcohol intoxication
Alcohol Health Worker
Alcohol Treatment Centre
Brief Alcohol Intervention
Clinical Decision Maker
Emergency Department
Emergency Nurse Practitioner
Information Standards Board
London Alcohol Recovery Centre
Police Community Support Officers
Primary Care Trust
Quarterly Monitoring Accident and Emergency Central Returns
Cardiff and Vale University Health Board
Welsh Ambulance Service Trust
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5 Contents
1
2
3
4
5
Executive Summary ............................................................................................. 1
Authors ................................................................................................................ 3
Acknowledgements.............................................................................................. 3
Glossary of Terms ............................................................................................... 4
Contents .............................................................................................................. 5
5.1
Figures.................................................................................................................... 6
5.2
Tables ..................................................................................................................... 6
6
Introduction .......................................................................................................... 7
6.1
The Need for Healthcare in the Night Time Economy ............................................. 7
6.2
Acute Alcohol intoxication and NHS Targets ......................................................... 14
7
8
9
Defining Success ............................................................................................... 16
Design and Methods .......................................................................................... 17
Findings ............................................................................................................. 18
9.1
Observational and Interview Data ......................................................................... 18
9.2
Descriptive Statistics ............................................................................................. 24
9.3
Analyses ............................................................................................................... 25
9.4
Cost Analysis ........................................................................................................ 33
10 Discussion ......................................................................................................... 35
10.1
11
12
13
14
General Discussion ............................................................................................... 37
Conclusion ......................................................................................................... 41
Recommendations ............................................................................................. 41
References ........................................................................................................ 43
Appendices ........................................................................................................ 47
14.1
NHS Reference Costs ........................................................................................... 47
14.2
Ambulance Handover Costs ................................................................................. 47
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5.1 Figures
Figure 1 – Histogram of breathalyser scores by gender from a survey of the Night Time
Economy ............................................................................................................................... 8
Figure 2 – Out-take from the original document presented to Cardiff and Vale Health Board
(January 2012) that eventually motivated the partnership commitment to the Alcohol
Treatment Centre ................................................................................................................ 11
Figure 3 – Overview of the interrelationships between services in managing acute alcohol
intoxication in the Night Time Economy............................................................................... 12
Figure 4 – A trolley bay in the Alcohol Treatment Centre .................................................... 18
Figure 5 – Patient pro-forma for paramedics ...................................................................... 19
Figure 6 – Distribution of Emergency Department recorded assault related injury and severe
alcohol intoxication attendances by arrival time................................................................... 24
Figure 7 – Proportion of total attendances, between 8pm and 4am, designated as assaultrelated or presenting with alcohol intoxication as the primary symptom by day of week ...... 24
Figure 8 – Episode duration for patients attending the Emergency Department by patients
already in attendance at the Emergency Department at time of arrival ................................ 25
Figure 9 – Density histogram for episode duration for those attending between 8pm and
4am, 16 years of age or older, and excluding patients who did not wait to be seen ............. 28
Figure 10 – Total number of attending patients in the Alcohol Treatment Centre by day ..... 30
Figure 11 – Ambulance handover duration for ambulances attending the Emergency
Department by patients already in attendance at the Emergency Department at time of
arrival .................................................................................................................................. 31
5.2 Tables
Table 1 – Daily descriptive statistics for attendances during evening periods (8pm to 4am)
from 31 December 2009 to 1 January 2013 ........................................................................ 26
Table 2 – Time-series regression models assessing the association between ATC being
open and control variables on ED attendance outcome measures ...................................... 26
Table 3 – Regression model assessing the association between ATC being open and patient
episode duration in ED ........................................................................................................ 28
Table 4 – Mode of arrival at the Alcohol Treatment Centre (where referrer noted) .............. 29
Table 5 – Discharge route from the Alcohol Treatment Centre (where discharge route noted)
........................................................................................................................................... 29
Table 6 – Daily descriptive statistics for evening periods (8pm to 4am) ............................... 32
Table 7 – Association between Alcohol Treatment Centre operation and log ambulance
handover time at ED in the evening period.......................................................................... 32
Table 8 – Descriptive statistics for Street Pastor activity ..................................................... 33
Table 9 – Itemised costs for the Alcohol Treatment Centre ................................................. 33
Table 10 – ICD-10 codes for blood alcohol level ................................................................. 40
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6 Introduction
The purpose of this report is to evaluate the pilot of an Alcohol Treatment Centre (ATC) in
Cardiff. The evaluation covers the period September 2012 up to and including New Years
Eve 2012. This report does primarily considers whether the ATC successfully diverts
patients from the Emergency Department and the systems in place to achieve this. The
report does not consider clinical outcomes.
6.1 The Need for Healthcare in the Night Time Economy
According to official violence data Cardiff continues to be one of the safest cities in the UK
[1]. Like most cities, however, Cardiff is characterised by a high density of premises licensed
for the on- and off-sale of alcohol. The dominance of licensed premises attracts visitors from
across the UK and, accordingly, rates of alcohol-related harm have a significant impact on
health services in the local area. The influx of the acutely intoxicated is clustered around
Friday and Saturday evenings and other key times [2, 3], and, as with cities across the
world, it is further associated with significant events such as sporting events and national
holidays [3, 4]. The costs of alcohol misuse in Wales are increasing with the NHS in Wales
spending £70M-£85M each year on alcohol-related health problems [5]. Alcohol misuse is
one of the most serious public health challenges in Wales. It effects individual health
outcomes, local communities and promotes crime. It impacts on health service use and there
is now a policy focus in Wales on tackling the health and wider harms associated with
alcohol [6]. Approximately 70% of admissions to Emergency Departments (ED) are alcoholrelated at peak times [7]. These additional attendances cause overcrowding in ED and
accordingly impact on all patients, staff and the community generally. This increased burden
on health services places all patients at greater risk, prolongs pain and suffering, increases
patient waits, increases patient dissatisfaction, increases ambulance handover times,
decreases physician productivity, increases frustration among staff and promotes violence
[8-11].
Alcohol is available in many countries across the world and recent estimates suggest alcohol
misuse is accountable for 2.3 million premature deaths each year worldwide [12] plus many
other non-fatal conditions including disease, injury and violence [13, 14]. There are
numerous immediate risks associated with acute alcohol intoxication (AAI). Alcohol is a
central nervous system depressant and therefore promotes irregular breathing, confusion
and if left untreated AAI ultimately leads to seizures, coma, respiratory, cardiac arrhythmia
and arrest. An attenuated gag reflex can lead to aspiration of the vomitus into the lungs,
asphyxiation, pulmonary edema and death. AAI further causes vasodilation at the skin level
and therefore increases the rate of heat lost from the body in turn increasing the risk of
hypothermia. Alcohol also affects judgement and increases the likelihood of accidents,
injury, violence, antisocial behaviour, unsafe sex and therefore sexually transmitted infection.
Survey data, collected across the South Wales, suggests that alcohol misuse is normalised.
Figure 1 presents breathalyser data from respondents to a survey of alcohol use (N = 1,997)
in South Wales [15]. The top 10% of the most intoxicated drinkers surveyed yielded an
average BrAC of 106.37μg/100ml (n = 183), three times the UK and US drink driving limits
(35 μg/100ml) and above the threshold of severe intoxication (70 μg/100ml) [16]. Of the
respondents, 35.93% were female, although this is not a sampling bias as typically there are
more men than women in Cardiff’s NTE [3]. For the purposes of this report we define AAI as
a state that places individuals at immediate risk of harm and as such require medical
assistance. These harms are included above but also include risk of injury and assault [17,
18] and therefore indicate that they should be removed to a place of safety.
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Figure 1 – Histogram of breathalyser scores by gender from a survey of the Night Time
Economy
Although the consumption of alcohol is legal for those aged five years and older there exists
legislation that both restricts the sale and consumption of alcohol [19], criminalises the
misuse of alcohol and the effects of alcohol are further implicated in a range of statutory
offences including acts of violence and criminal damage. Alcohol use and misuse therefore
figures prominently in the criminal justice system. While the 2003 Licensing Act is currently
the primary legislation governing alcohol use and supply the fact that alcohol is implicated in
a range of criminal acts means AAI also falls within the 1998 Crime and Disorder Act, 2001
Criminal Justice and Police Act, 2006 Violent Crime Reduction Act, 2003 Anti-social
Behaviour Act and others.
Alcohol-specific crimes include being drunk and incapable or drunk and disorderly in a public
place or on licensed premises, being drunk in charge of a child under seven years of age,
buying alcohol for someone who is already drunk, and selling alcohol to a drunken person.
For those exhibiting AAI there are a number of referral and awareness schemes available.
Currently there are on-going efforts to develop the use of Sobriety Schemes in England and
Wales. These Schemes find their origins in the Violent Crime Reduction Act 2006 and the
Violent Crime Reduction Act 2006 (Drinking Banning Orders) Regulations 2009. Those who
have behaved in a disorderly manner or who have committed a criminal offence while under
the influence of alcohol are given the option of a civil court imposed period of sobriety or a
tougher criminal punishment. This conditional caution scheme targets low-level offences
including drunk and disorderly, criminal damage and public disorder affray and will be
facilitated through the Legal Aid, Sentencing and Punishment of Offenders Bill currently
progressing through Parliament1.
Legislation and associated guidance encourages a partnership approach to managing areas
in which alcohol use is prolific. These attempts to control behaviour and respond to the
symptoms of alcohol misuse within particular areas further involves partnerships between
those who supply alcohol, private security, resident groups, local authorities, and health
boards, partnerships that are not necessarily harmonious in their view of the severity, extent
and causes of alcohol-related harm [20]. For example, Local Government will often highlight
1
http://www.webcitation.org/6ELrO8vVa
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a “vibrant” NTE as a positive feature of a city whereas health services might highlight the
harms generated in such locations.
Of the principal statutory partners involved with managing the NTE only the police will visibly
work to reduce levels of disorder and are therefore the only partner engaged directly with
crime reduction. In addition to this role, the police are also able to refer onwards those
whose behaviour falls under the remit of drunk and disorderly and drunk and incapable. In
South Wales this includes the Integrated Offender Interventions Service, that can include
treatment for alcohol abuse and substance misuse, developed through partnerships between
the Welsh Government, Wales Probation Trust, NOMS Cymru and South Wales Police.
However, in terms of managing AAI in the NTE, and irrespective of any offense committed,
welfare is primary. Guidance issued by the Association of Chief Police Officers and the
National Policing Improvement Agency [21] states “[d]runk and incapable means that an
individual has consumed alcohol to the point of being unable to either walk unaided or stand
unaided or is unaware of their own actions, or unable to fully understand what is said to
them." “As a guide, it is suggested that, if someone appears to be drunk and showing any
‘aspect’ of incapability which is perceived to result from that drunkenness, then that person
should be treated as being drunk and incapable.” “A person found to be drunk and incapable
should be treated as being in need of medical assistance and hospital and an ambulance
should be called.” “If a drunk and incapable person who is under arrest declines or is refused
medical treatment, they should, only as a last resort, be taken into custody at a police
station.” "The fact that a person has declined or has been refused treatment does not
absolve the police or medical services of their responsibility." One reason for the need of
clinical expertise in managing AAI is that head injury victims and people with diabetes may
appear to be drunk.
The risks associated with AAI are, as already noted, numerous and an eleven year audit of
deaths in custody by the Independent Police Complaints Commission found a significant
proportion involved alcohol or alcohol and drugs (60% in 2008/9) [22]. The first
recommendation in this report being “[p]olice forces and local health service providers and
commissioners should adopt the ACPO Safer Detention Guidelines (2006) and develop
protocols on the care of drunken detainees. Given the strong link between alcohol and
deaths in custody the Home Office and Department of Health should pilot alternative
facilities for intoxicated people with access to medical provision, with a view to developing a
national scheme.” This relationship between deaths in custody and alcohol is not unique to
England and Wales, similar patterns are documented in Australia [23], Canada [24] and
housing the intoxicated in custody is strongly opposed in Scotland [25].
A systematic review of violence in emergency departments documented an association
between increased violence against staff and longer waiting times [11] and, as discussed
(Section 6), ED bottlenecks attributable to increased attendances for alcohol-related harm,
coupled with a general increase of pressure on available resources [26], contributes to a
range of effects including reduced ambulance capacity. It is further known that unnecessary
attendances undermine the provision of care in ED [26].
A report ordered by the House of Commons into NHS ambulance services contained the
observation that “[d]elays in handing over patients from ambulances to hospitals lead to poor
patient experience and reduced capacity in ambulance services. Over one-fifth of patient
handovers from ambulance crews to ED staff at hospitals take longer than the 15 minutes
recommended in guidance. If ambulances are queuing in hospitals, they are not available to
take other calls. Commissioners should take a consistent approach to penalising hospitals
that do not adhere to the guidance of 15 minute handovers and the Department should also
develop a quality indicator for hospital trusts on hospital handover times” [27]. Opportunities
to reduce impact on ED attendances include diverting low priority emergency ambulance
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(999) calls to NHS Direct and enabling paramedics to either discharge patients or transport
them to alternative sources of care [28]. However, the presence of minor injury services and
introduction of NHS walk-in centres and NHS Direct has not been shown to have any effect
on emergency department attendances [28].
While partnerships are necessary in managing the NTE, the health needs of those exhibiting
AAI are urgent leading ACPO to recommend facilities alternative to custody that are able
provide healthcare. In Cardiff the only facility offering healthcare is the local ED. This is not
the case in some countries, however.
There is a long history of “sobering up centres” where those exhibiting public intoxication are
diverted into noncustodial quasi-medical detoxification services until sober. The earliest
schemes are found in Russia (from 1904), "catch-stations" in the former Czechoslovakia and
"drop-in" centres in Denmark and Switzerland. Some are specific to alcohol intoxication,
while, for example, those in Denmark and Switzerland also offer needle exchange facilities.
While in many jurisdictions public intoxication is a criminal offense, the provision of sobering
up services shifts the focus to one of health. This is explicit in the North American 1971
Uniform Alcoholism and Intoxication Treatment Act: “that because alcoholism is an illness, a
homeless alcoholic could not avoid being drunk in public and therefore could not be
punished for his public intoxication”. The Uniform Alcoholism and Intoxication Treatment Act
motivated the development of detoxification centres that accepted clients exhibiting AAI,
diverting them from police custody to an healthcare setting. An evaluation of these
detoxification centres [29] found evidence for an increase in recidivism and fewer accepting
referral to treatment services. Moreover, an overall increase in the number of those
exhibiting AAI was noted, suggesting that the additional capacity had also increased demand
[29]. The North American detoxification centres also process those who have consumed
illicit substances and analyses of presentations found that the characteristics of clients
changed from 1984 to 1996. The mean age at admission declined, those who were
unemployed increased and there was a 25% decline in those presenting with alcohol
intoxication which was coupled with a twofold increase in cocaine use and a fourfold
increase in heroin use [30].
In Australia, as in the USA, a series of “sobering-up centres” were established following the
publication of the 1991 Royal Commission into Aboriginal Deaths in Custody. The primary
motivation was to alleviate the harms due to the then custodial response to public
drunkenness, which they accomplished [31]. There are aspects of Australian sobering-up
centres that suggest the models developed there may not map directly onto UK needs. In
particular, the Australian sobering-up centres are focused on diverting the Aboriginal
community away from police custody and are mostly located in rural areas; whereas the
Cardiff ATC is focussed on diverting patients away from the ED and is located in a city
centre location. However, there is very little available literature on sobering-up centres in the
UK [32] and it is worth therefore considering what is regarded as best practice in the
Australian context. In a study of 25 projects Strempel, Saggers, Gray and Stearne [33] found
key aspects of success included “clearly defined and effective management structures and
procedures; trained staff and on-going staff development programs; good multi-strategy and
collaborative approaches; strong leadership; and adequate and continuing funding.”
Although facilities to divert AAIs away from police custody and hospital ED have been trialled
across the UK, the Cardiff ATC is unique in that it is led by nurse practitioners, clinical
decision makers (CDM) who are able to assess and discharge patients if necessary. One
other long-running project is found in Soho, London by the London Ambulance Service NHS
Trust. A “Booze Bus”, an ambulance that can hold up to five patients, was originally used to
gather and care for the severely intoxicated. The London Alcohol Recovery Centre (LARC)
in Westminster, funded by Westminster PCT, began in 2010, initially operating just in
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December. From April 2012 to March 2013 the LARC received support to operate on Fridays
and Saturdays and from January 2013 Thursdays were also included in routine operation.
The motivation was that the severely intoxicated were too vulnerable to be left on their own
yet the best treatment was time, allowing them to sober up. Most patients did not therefore
require treatment in the ED and would likely disrupt services in ED should they be taken
there. LARC was originally developed by the London Ambulance Service and is therefore
staffed by paramedics with support from Ambulance Technicians. In addition, Turning Point,
a charity providing support for substance misusers and others, supplied an alcohol liaison
officer. LARC accepted 180 patients across the ten nights of Christmas 2011 and an
additional 41 patients on New Year’s Eve 2011. Patients were referred to the centre by
paramedics, police officers and Police Community Support Officers (PCSO). LARC is
housed in a NHS Walk-in Centre. Walk-in Centres are designed to complement GP and ED
services, providing convenient access to health services for those with minor injuries and
illnesses. They also provide advice, for example on matters such as tobacco cessation and
sexual health. No formal documentation relating to or evaluation of LARC is available at this
time.
Figure 2 – Out-take from the original document presented to Cardiff and Vale Health Board
(January 2012) that eventually motivated the partnership commitment to the Alcohol
Treatment Centre
Similar to LARC, the ATC was set up as a response to AAI affecting multiple statutory
services across Cardiff and further afield. Figure 2 presents an out-take from the original
document presented by Claire Bevan to UHD that began the journey of commitment to the
ATC. The ATC was championed by nurse Nici Evans. One of Nici Evans’ roles was, and still
is, to ensure UHB meets partnership priorities one of which is alcohol-related harm (“Cardiff,
What Matters, 2010:2020 – The 10 Year Strategy”2). A series of general themed meetings
were held culminating in the Proud Capital Conference in Cardiff, a conference that
facilitated partnership approaches through making available small pots of money for 30
minute “brainstorming” workshops. This event brought together key partners including
2
http://www.webcitation.org/6Eap0GZWn
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opportunities for financial support from Conrad Eydmann, UHB substance misuse lead, Greg
Lloyd from the Welsh Ambulance Trust, James Brewster-Liddle and Wayne Parsons nurse
practitioners from UHW ED. It was through these meetings that the primary goals of the ATC
were set out. The ATC was developed in part from an earlier project, a collaboration
between ED Emergency Nurse Practitioners (ENP) and WAST to establish a triage
ambulance. ENPs in Cardiff had, for some time, worked to reduce the impact of AAI on ED
and had considerable experience of extending the ED footprint more fully into the NTE.
ENPs accompanied paramedics on the triage ambulance and were therefore able to triage
those requesting an ambulance, provide minor treatment and discharge where appropriate.
The Triage Ambulance brought the ED more into the NTE and provided opportunities for
CDMs to determine need, the goal being to reduce some of the unnecessary attendances at
ED.
Figure 3 – Overview of the interrelationships between services in managing acute alcohol
intoxication in the Night Time Economy
Referring to Figure 3., those exhibiting AAI and who are judged as requiring unscheduled
care can come into contact with a range of agencies. The Street Pastors3 are an interdenominational church-led voluntary organisation that engages with people on the streets to
provide support. They are prominent in the NTE and through their patrols can assist those in
need. Their intervention can result in a call for an ambulance to escort someone to ED.
Similarly, police patrols can either refer AAIs to Street Pastors, freeing police time to manage
the NTE, or call an ambulance. Ambulance assistance may be requested directly by
members of the public, staff in licensed premises and other affiliated organisations. A 999
call to an ambulance obligates WAST to provide an ambulance and escort the person
requiring assistance to a CDM for assessment, unless there is a paramedic practitioner onboard who is able to assess and discharge, if warranted. AAIs can also transit to ED directly
using taxis and other private transportation.
While Street Pastors have become common sights in towns and cities across England and
Wales, they are a voluntary service and therefore have no statutory obligation to provide
support. In Cardiff, Street Pastors typically patrol the NTE from 10pm to 4am on Fridays and
Saturdays and have been doing so for four years. There are approximately 70 volunteers in
Cardiff. The Street Pastor is an inter-denominational response to urban problems (violence
and crime), pioneered in 2003 by Rev Les Isaac (Director of the Ascension Trust).
Volunteers engage with people on the streets to care, listen and engage in dialogue. Costs
are covered by public donations. There are now 250 Street Pastor initiatives across the UK,
3
www.streetpastors.co.uk
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overseeing 10,000 trained individuals who provide over 600,000 volunteer patrol hours every
year. Street Pastors in Cardiff co-operate with premises’ Door Security Staff, Taxi Marshalls
and the police. They carry radios and can access CCTV operatives to request surveillance
and/or assistance. Radios are further fitted with panic buttons.
Street Pastors’ role in the city centre is to seek out the vulnerable and to protect them.
Young men and women place themselves at risk through becoming excessively intoxicated,
under-dressing in winter, walking barefoot, losing their belongings, friends and sense of
direction. They collect broken glass from the street and dispose of it responsibly, hand out
flip-flops (some patrons of the NTE will find their choice of footwear becomes uncomfortable
and therefore decide to walk barefoot), bottles of water and confectionary. Street Pastors
look for those at risk and seek to prevent harm. Volunteers receive training typically over
twelve sessions. The topics covered include sociology, education, knowing your community,
the police, counselling, drugs awareness, alcohol awareness, solvent awareness, probation,
children’s services, youth culture, mentoring and mental health.
Police guidance suggests that police officers are experts in who is and who is not drunk.
ACPO and NPIA [21] define “drunk” according to the Collins English Dictionary “[i]ntoxicated
with alcohol to the extent of losing control over normal physical and mental functions” and
“[h]aving drunk intoxicating liquor to an extent which affects steady self-control”. As such,
officers can choose to arrest those deemed Drunk and Incapable which “means that an
individual has consumed alcohol to the point of being unable to either walk unaided, stand
unaided, or is unaware of their own actions, or unable to fully understand what is said to
them.” South Wales Police are the lead authority for managing the NTE in Cardiff. Typically,
Friday and Saturday evenings will involve approximately 14 officers patrolling the NTE.
Officers work in pairs and on the discovery of AAI officers will stay with that person until they
can be handed over to another responsible party. Depending on perceived severity this can
include Street Pastors and ambulance paramedics. On occasion, officers can also be
required to escort patients to ED if there are no ambulances available or if an offender
requires clinical attention. Officer presence in the NTE can reduce the likelihood that
fractious encounters escalate to assault [34]. Therefore reducing police capacity in the NTE
may also affect the prevalence of assault-related injury.
Police and Street Pastors have little or no clinical expertise and police officers are guided to
place the welfare of people first (see Section 6.1, page 7). Without CDMs and given a
degree of risk aversion in those deciding whether to refer to ED or not, a proportion of ED
attendances for AAI are likely to be unnecessary.
As already noted (see Section 6.1, page 7), AAI can mask underlying injuries, cause
dehydration and increase the risk of hyperthermia and one treatment option is to therefore
allow the patient time in a safe environment to regain some sobriety in order that a better
assessment can be made or they are sufficiently clear minded to find their way home. While
CDMs are expected to triage and refer to ED those with suspected underlying injuries
irrespective of CDMs’ judgement there will be a proportion of patients who do require a safe
environment and can receive expert clinical attention but are unlikely to require anything
more than a blanket. If they do transit to the ED then they will either take up clinical space or
sit in the waiting room until seen. As AAI can lead to a loss of control over bodily function
patients can become covered in their own vomit and faeces. Further, given the known
relationship between alcohol and aggression [35-40] and the reduced capacity to
comprehend their predicament the delay in receiving clinical attention, while clinically
appropriate, can lead to frustration and aggression. The presence of AAI in ED therefore
causes a deterioration of the clinical environment and therefore affects all users of this
space. In addition, their presence stretches resources causing knock-on effects to the
provision of services and ambulance handover times.
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While the triage ambulance offers the opportunity to divert a proportion of AAIs from ED the
requirement of a safe environment means a proportion still transit to ED unnecessarily.
ENPs on the ATC project team had had experience of field hospitals and the innovation
proposed was for a temporary treatment centre that provided a safe environment and staffed
with at least one ENP. Furthermore, alcohol-related harm varies considerably and is usually
clustered around significant social events and certain days. Accordingly, the ATC was
planned to operate on those evening when the prevalence of AAI was expected to be
greatest.
In sum, the origins of the ATC were motivated by the multiple effects of AAI on partners and
brought together expertise to put in place a solution that, if successful, would reduce AAIrelated attendance at ED. A space adjacent to Cardiff city centre was identified. This space
was a church hall donated to the Archdiocese of Cardiff. The hall had been recently
purchased and required significant work to allow the ATC to operate in there. Probation
services provided manpower under the Community Payback Scheme, a scheme that allows
members of the community a say in how offenders pay back the community. In addition, the
ATC benefited from donations of time and materials from local builders and merchants
suggesting that the ATC is best described as a community response to the problem of AAI in
Cardiff.
As a clinical space the ATC was subject to scrutiny from Health and Safety, the City Centre
Fire Officer, WAST and UHB Risk Assessment Staff and accordingly the ATC fell within UHB
governance framework. As the ATC was expected to produce clinical waste it was bound by
legislation to ensure that waste was safely disposed of. Finally, ED and WAST collaborated
on drafting an operational policy that was subsequently signed-off accordance with UHB
policy and procedure. As these aspects of the ATC have received scrutiny they are not
discussed further in this report.
6.2 Acute Alcohol intoxication and NHS Targets
There are no generally accepted definitions of AAI that describes variation in levels of care
provided by health services [26]. Furthermore, the position of severe alcohol intoxication is
one that lacks clarity, both in treatment and aftercare. For example, patients who need to
wait in ED for test results before a decision is made on a subsequent course of action can be
excluded from ED episode duration statistics. Despite AAI requiring time for patients to sober
up, no similar opportunity is available in ED reporting and they are therefore included in
returns. Furthermore, there is a known under-reporting of alcohol intoxication in ED. Alcohol
is only recorded if it is the only major symptom motivating attendance, otherwise, the
presenting symptoms are recorded irrespective of alcohol use [41], despite alcohol probably
being accountable for as much as 19% to 26% of all ED attendances [42].
Providers of NHS services are required to submit Quarterly Monitoring Accident and
Emergency Central Returns (QMAE) to the Department of Health. These returns cover
attendances at accident and emergency departments, minor injury units and NHS walk in
centres. The Information Standards Board (ISB) approves information standards for the NHS
and adult social care in England and accordingly provides guidance on what aspects of ED
service delivery are to be recorded [43]. Within the guidance notes the process of recording
and reporting attendance statistics is specified as follows (many of these measures are
referred to and used in subsequent analyses):

Time of Arrival
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o

The time of arrival should be recorded by the clinician (nurse or doctor)
carrying out initial triage/assessment or A&E reception whichever is earlier.
o For ambulance cases, arrival time is when hand over occurs or 15 minutes
after the ambulance arrives at A&E, whichever is earlier. In other words if the
ambulance crew have been unable to hand over 15 minutes after arrival that
patient is nevertheless deemed to have arrived and the total time clock
started
Time of Departure
o Total time in the Department ends when the patient is admitted, transferred,
or discharged home.
 Admission. Admission is defined as an emergency admission via A&E
under admission code 21. Time of admission is defined as the time
when such a patient leaves the department to go to:
 An operating theatre;
 A bed in a ward (see definition of ward below);
 An x-ray or diagnostic test or other treatment directly en route
to a bed in a ward (as defined below) or operating theatre.
However leaving A&E for a diagnostic test or other treatment
does not count as time of admission if the patient then returns
to A&E to continue waiting for a bed.
o Transferred. Transfer is defined as transfer to the care of another NHS
organisation or other public/private sector agency (for example social
services). Time of transfer is defined as when the patient leaves the
department.
o Discharged home. Time of discharge home is defined as when the patient's
clinical episode is finished, unless they are waiting for hospital arranged
transport or social care / social service support. In the latter case the time of
departure is the time the patient actually leaves the department. Patients
awaiting family or 'private' transport or who wish to make their own
arrangements should be considered discharged once the clinical episode is
complete whether or not they have actually left the department
o Time not recorded: Organisations should not have unknown waits. Any
unknown waits which are reported will be excluded from both the numerator
and denominator in calculation of the percentage within 4 hour calculation.
Within this guidance, exceptions are made for patients who need more than four hours for
observation or assessment. “For a few patients, a period of assessment and/or observation
of greater than 4 hours before a decision to admit or discharge is made will be beneficial.
This group would include some patients awaiting results of investigations, CT, reduction of
fractures/dislocations, clinical observation for improvement, time critical diagnostics etc.”
“Every effort should be made to accommodate these patients, for their comfort, away from
the main A&E in a dedicated observation/assessment ward. If this ward meets the criteria
set out above the patient should be treated as admitted for the period required for
observation. In most cases the admission will be very short - often much less than 24 hours.
However the criteria for deciding if the patient is admitted and the time of admission applies
in the same way it would to any other patient being admitted for a 24 hour or longer stay in
the hospital.” “However where these patients remain in A&E or are accommodated in an
environment that does not meet the criteria set out above to help define a ward they should
remain within the total time count until they are either admitted, transferred or discharged.”
While one motivation for the ATC might be that the increased capacity would help ED
achieve these targets, there are questions on whether they are applicable generally or
whether AAIs should be treated as an exception. This is returned to below.
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7 Defining Success
The primary goal of the ATC was to divert AAIs from ED and reduce load on ambulance
services. Analysis of ED data on days when the ATC were open and when it was closed was
therefore used to determine the impact on ED alcohol-related attendances.
The literature concerning health service provision for unscheduled care highlights the
complex relationship between statutory partners, in particular ambulance and ED [8, 44-46],
and further highlights how patient numbers can affect episode duration and ambulance
handover times. Secondary analyses therefore considered how ED episode duration and
ambulance handover times varied on days when the ATC were open and when it was
closed.
While the literature on services similar to the ATC is limited one consistent theme was that
the provision of diversionary services saw increased demand for healthcare, or net widening.
Secondary analyses therefore considered the total number of attendances for alcoholrelated harm across both ATC and ED for days when the ATC was open and when the ATC
was closed.
Greater ambulance handover times means that the number of available ambulances is
reduced. As ACPO guidelines place welfare as a priority if ambulance capacity is reduced
then this may require officers to escort AAIs to ED directly. Secondary analyses therefore
considered the volume of police escort referrals to ED for days when the ATC was open and
when the ATC was closed.
The ATC is an additional service to the usual provision of unscheduled care in Cardiff and
therefore attracts additional costs. Diverting AAIs from ED to the ATC would represent a
saving to the ED and therefore to explore ATC cost efficiency a breakeven analysis is
conducted.
This evaluation considers ATC function over the initial pilot period (September 2012 to
December 2012). As a pilot, our expectation was that the service would develop across this
period, adapting to unforeseen circumstances to improve provision. A key measures of
success therefore included evidence of adaptation in both quantitative and qualitative data.
In addition to quantitative analyses, an embedded process evaluation was conducted. Data
were used to examine how the ATC is implemented and to facilitate interpretation of
outcome effects [47]. In line with MRC guidelines [48], this process evaluation provides
information on opportunities for ATC refinement through identifying key processes, impacts
and outcomes. Following the framework proposed by Steckler [49] and adopting a critical
realistic approach [50] to elucidate what works and in what context. The process evaluation
covered the following themes:
 A characteristic of AAI is loss of bodily control and disruptive behaviour. Diverting
AAIs away from ED therefore offered the prospect that the environment for other
users of that space would improve. Evidence for any such effect was collected
through observing both ATC and ED environments for days when the ATC was open
and when the ATC was closed.
 Interviews were conducted with key partners in agencies associated with managing
the NTE and the impact of the ATC on their operation was assessed, perceived risks
and benefits of the ATC, barriers to implementation and opportunities for
sustainability. In the case of Street Pastors, this also included analysis of their routine
reports for 2012.
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8 Design and Methods
The project was assessed by the Dental Research Ethics Committee and designated as a
service evaluation. Methods involved the analysis of three data types: quantitative analysis
of routine data from WAST, South Wales Police and UHB, observational data and semistructured interview data. This approach facilitated methodological triangulation and thus a
robust analysis that addressed outcomes discussed in Section 7.
Anonymised ED attendance data was accessed from the Cardiff and Vale UHB Information
Services. Data covered January 2010 up to 1 January 2013 and included all ED attendances
(N = 353,521). Data included the date and time of attendance, time to first clinical contact,
episode duration (the time from arrival to discharge), age and sex, whether attendance was
due to an assault-related injury, source of referral, arrival mode, outcome and initial
complaint. Binary indicators were added into these data to identify key dates. These dates
included university and college term times for colleges local to Cardiff, New Years Eve,
Freshers’ week (the first two weeks of the academic year), Christmas, Christmas Eve,
Boxing Day, Halloween, bank holidays and Black Friday (the last working day before
Christmas). Indicators for Freshers’ week applied to the entire range of dates within the
defined period. For single day events, attendances in ED were denoted as occurring during
that event if they attended between 12noon and midnight on the day of the event or between
midnight and 4am the following day. Attendances were organised as a time series by year,
month, day, hour and minute of arrival.
There is a known under-reporting of alcohol intoxication in ED. Alcohol is only recorded if it is
the only major symptom motivating attendance, otherwise, the presenting symptoms are
recorded irrespective of alcohol use [41], despite alcohol probably being accountable for as
much as 19% to 26% of all ED attendances [42]. This figure rises considerably when
assault-related injury is considered [12]. Not only does alcohol increase the severity of injury
[12, 51] estimates suggest 50% of perpetrators are intoxicated at the time of the offense [52]
and, at peak times, 74% of assault-related attendances are intoxicated [53]. Two indicators
were therefore used to determine ATC impact, assault-related injury and alcohol intoxication.
Assault-related injury is a field completed at ED reception based on patient self-report. AAI
was deduced using the free text portion of ED data where clinicians are able to note
characteristics of the primary attending symptom (“alcohol”).
Anonymised WAST data was accessed from the Ambulance Informatics Team for all UHW
arrivals (N = 103,411), these data were restricted to all attendances at the ATC and UHW
ED (98,753). Data included date and time of arrival at hospital, diagnosis and handover time.
No handover times were available in the ambulance data for arrivals at the ATC. Event data
were added into these data in the same way as the ED data. Interviews were conducted with
members of South Wales Police, ED, ATC, UHB and Street Pastors. Interviews were
conducted by two researchers and their notes compared to elucidate key themes. Key
themes covered in interviews covered the points outlined in Section 7 and were revised after
each interview. In some cases interviewees were interviewed a second time when issues
emerged that had not been covered in the first interview.
Observational work was conducted across three sites. At the ED when the ATC was open, at
the ED when the ATC was not open, in the ATC and observers joined the Street Pastors to
assess their role activity in the NTE generally. Street Pastor reports were accessed and
analysed. These reports are not a part of any formal audit process, but do summarise Street
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Pastor activity, including some information on who they attended, where they took people
and the nature of the complaint.
9
Findings
9.1
Observational and Interview Data
9.1.1
Alcohol Treatment Centre
From September 2012 to early November 2012 the ATC opened Wednesdays and
Saturdays, thereafter it opened on Fridays and Saturdays. The reason for opening on
Wednesdays initially was to capture the effect of students returning to colleges and
universities in the Cardiff area and Wednesdays had typically been a day of the week when
greater than usual AAI had been observed in ED during these periods. The original ATC
proposal was for a physician with support from ENPs and HCAs. This was revised to the
final specification whereby the ATC was staffed by ENPs, HCAs with support from St John’s
Ambulance. Evidence suggests that nurse practitioners are regarded as safe and effective
[28] in the treatment of AAI. Furthermore, it was originally planned that AAIs’ behaviour
would be recorded on video cameras and then, once they were sober, have that footage
played back to them, an intervention with no evidence for effectiveness. The expectation
being that by replaying their state of intoxication to patients when they were sober would
motivate them to consider their behaviour and therefore attenuate their future alcohol
consumption. This intervention was, however, dropped at the request of the funders. The
ATC was housed in a large spacious hall, it was clean, well-lit and comfortable. Privacy
screens separated the hall into bays and in each there was one trolley. Trolley heights were
adjusted so that they were low, in case AAIs fell. There was trolley space for a maximum of
15 patients, although with additional floor mats capacity could be increased if clinically
appropriate.
Figure 4 – A trolley bay in the Alcohol Treatment Centre
When the ATC was open on Fridays and Wednesdays it was staffed by one ENP and one
Healthcare Assistant (HCA). On Saturdays staffing was increased to two ENPs and one
HCA. On exceptional evenings when the volume of AAI was expected to be high, for
example New Year Eve, staffing was increased further to two ENPs and one HCA. Staff
professionalism was impressive, calm yet assertive when needed. All nursing staff worked in
the ATC in addition to their normal hours in ED, resulting in some staff working (by choice) in
excess of 60 hours in one week. In addition, one police officer was on duty in the ATC and
typically St Johns Ambulance provided a further two volunteers. Offenders from probation on
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the Community Payback Scheme provided some additional support, mostly cleaning. ATC
operation evolved over the course of the pilot period. Innovations were in response to
barriers in the referral processes. For example, initially ambulance paramedics were
unaware of the ATC and what criteria should be used to divert AAIs to the ATC. Accordingly,
and referring to Figure 5, the pro-forma was redesigned so that the criteria for referral into
the ATC were clearer and paramedics were encouraged to phone ahead to the ATC if they
had any doubt.
Figure 5 – Patient pro-forma for paramedics
Those who have overdosed or have evidence of a head injury are not received into the ATC.
However, the ATC does receive those who are likely to have taken illicit substances and
suffered minor injuries. Access is further restricted to those over 16 years of age. Further
restrictions were in place for those with alcohol dependency problems, psychiatric patients
and the homeless. The ATC provides a safe environment for AAIs to sober-up, those with
alcohol dependency can experience fitting, cardiovascular disturbances and increased risk
of stroke in withdrawal, risks that the ATC was not designed to accommodate.
The ability to innovate and adapt as barriers became apparent demonstrates the ATC pilot
and the staff involved with it operated successfully. Subsequent sections return to this issue,
in particular the innovation of encouraging paramedics and, to a lessor extent, police officers
to phone ahead to the ATC for advice on any AAIs.
Patients arrived at the ATC by ambulance, escorted by Street Pastors, police officers,
occasionally St John’s Ambulance and through self-referral. In all cases, handovers to
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nursing staff in the ATC occurred in a relaxed fashion and in all cases observed those
delivering patients were free to leave the ATC within 10 minutes. This time was typically
given over to completing necessary paperwork. If clinical need dictated, patients were
referred to ED (e.g. suggested fracture, irregular heartbeat, etc.), although such referrals
were direct to speciality therefore obviating the need for the patient to undergo triage in ED.
This was further facilitated through telephone communication between ATC ENPs and
senior ED staff.
The administration of patients was completely paper-based, meaning that practitioners were
unable to easily refer to patients’ prior history on existing data systems and that an additional
session in ED was required to input patient data onto those systems. This entailed a delay in
data becoming available to UHB for analytic purposes. Further, there are mature data
sharing agreements between UHB and the police whereby assault-related attendance data
is shared so that resources can be targeted at the causes of harm (e.g. risky premises) [1,
54].
There was limited evidence of any behavioural intervention delivered to patients presenting
with AAI. While there is a clear need for such interventions and possibly more robust
processes for referral into secondary care, the emphasis of the initial ATC pilot was focused
on implementing and refining the service. However, patients were given leaflets describing
the effects of alcohol misuse, how to reduce risk and contact information on where they
might find further support if required.
Patients are treated for minor injuries including sutures, glue and tape. Medications used
included paracetamol, ibuprofen and lidocaine for local anaesthesia. For dehydration IV
fluids were administered; sodium chloride 0.9% from either 500ml or 1000ml bags. Patients
presented with the already described symptoms of AAI (vomiting, defecating, loss of
consciousness, etc.). While the majority of patients were brought to the ATC from Cardiff city
centre there were instances where ambulances and police officers brought patients from
across the Cardiff and Vale area. ATC ENPs would seek consultations by telephone from
senior consultants in ED if there was any doubt over patient status.
Type I, and to a lesser extent Type II, diabetes carries the risk of ketoacidosis, a state that
also involves the over-production of acetone. Acetone is expelled through urine and breath
and, in the case of the latter, leads to a distinct breath odour that can be confused with a
state of intoxication. Symptoms of ketoacidosis can be similar to AAI and includes a flushed
face, vomiting, dehydration, confusion and coma. CDMs considered the likelihood of
ketoacidosis in all patients with altered consciousness as routine through a BM (BoehringerMannheim) finger-prick blood test to assess glucose levels.
Clinical judgement determined when a patient could be discharged from the ATC. On
discharge, ATC staff made certain all patients were safe to leave and had somewhere safe
to go to, whether that was in the care of friends, family or in a taxi to a known location with
sufficient funds to pay for it. They made sure that patients had their belongings and house
keys. For some patients who were also students this included collection by campus security.
Time of discharge was determined by clinical judgement not with reference to pre-existing
targets on when patients should be discharged.
All patients are asked about where they had their last alcoholic drink. Only the most severely
intoxicated were unable to provide this information. These data are forwarded to the multipartner Cardiff Violent Crime Task Group to inform partnership activity more generally.
The majority of patients that attend the ATC are all acutely intoxicated or present with minor
injuries. Examples of patients include, on Halloween individuals dressed as Goldilocks,
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Tarzan and Cinderella. A teacher who passed out in a taxi (the taxi driver became
concerned for her welfare who referred her to the police who in turn asked the Street Pastors
to escort her to the ATC) who, once conscious, became aggressive in the ATC. On one
evening an incident required the presence of six police officers and resulted in a French
exchange student sustaining a head injury from a glass bottle. He was escorted to the ATC
and on assessment transferred directly to the Intensive Care Unit. A man in his early 20’s
was escorted at ATC by Police and became irrational and aggressive. He was later arrested
and taken to custody once the CDM determined that it was safe to do so. A 19 year old
student was spotted by Street Pastors unconscious behind the refuse bins at Cardiff Central
Train Station. He was wet and due to the temperature that evening at serious risk of
hypothermia. He was escorted to ATC by ambulance and once his clothes were dry, and he
was sufficiently sober, he took a taxi home. He had no memory of the events of that night.
9.1.2
Emergency Department
UHW ED provides 24 hour unscheduled care and designated accommodation for the
reception of accident and emergency patients [55]. Ambulances arrive at one entrance at the
front of ED which is typically staffed by one nurse who assesses patients and directs them
accordingly (e.g. to minor injuries). Bottlenecks occur at this stage when the assessment
area becomes full and ambulances continue to arrive with patients. ED staff described this
part of ED as “chaotic at times”.
While observational and interview data is not conclusive, they do suggest the ED showed an
improvement in the overall environment when the ATC was open. Observation in ED at
times when the ATC was closed found increased levels of disorder. Incidents included one
intoxicated patient who attended due to a hand injury becoming abusive to staff and other
patients. Hospital security intervened and advised him that if he did not calm down he would
face charges of causing public disorder. Two women were observed arguing loudly with one
another. Compared to days when the ATC was open we observed a quieter and more
orderly ED environment. One nurse commented that the difference on Fridays and
Saturdays when the ATC is open was impressive, she said that Saturdays when the ATC
were open had become much easier. ED staff commented that AAIs “overloaded” ED,
creating long wait times as dealing with AAIs almost always absorbed a lot of “time and
resources”. Not only do clinical staff have to attend to “a blurry intoxicated patient” but also
often have to deal with their friends, who also cause problems relating to security at ED.
In the early weeks of ATC operation, several nurses expressed concern over the risks
associated with treating AAIs in the ATC. As the ATC is physically distant from ED concerns
were raised that those attending with, for example, head injury, diabetes or other conditions
that AAI can mask, might be delayed in reaching ED and therefore specialist care. However,
this was balanced with comments from senior staff that such concerns were unwarranted,
further supported through the development of a detailed operational policy with explicit
exclusion criteria prior to the ATC pilot. Moreover, patients receive potentially more attention
in the ATC compared to a busy evening in ED.
Observations also found some evidence that the ED was receiving patients with little or no
requirement for unscheduled care. One evening a man and a woman came in, she wanted
to have a cervical cancer vaccination and he wanted to show someone his thumb, which he
had apparently hurt three months earlier. However, as ED receptionists are not CDMs they
were unable to turn this couple away and they were registered as usual.
As noted in Section 6, Health Boards are subject to reporting requirements and performance
targets. For ED, this is most evident in the requirement that patients spend no longer than
four hours in the Department before discharge. There are exceptions to this rule, such as
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patients who are waiting for test results that will affect their path through unscheduled care.
However, no exception is made for AAIs, despite the typical treatment being to leave AAIs in
a safe environment until they are sufficiently sober for a proper assessment. The reason
being that AAI can mask other symptoms (e.g. symptoms associated with head injury).
However, AAIs fall outside of the reporting standards detailed above and are therefore
included in returns made for quarterly monitoring.
While reporting standards could be reassessed so that AAIs can be removed from returns,
doing so is complicated by failings to accurately describe alcohol symptoms in routine ED
data. Improving how alcohol is recorded in patients presenting to ED and revising reporting
standards would provide a clearer picture of the role alcohol plays in health services, would
lessen the likelihood that episode duration targets are missed due to appropriately allowing
time for patients to sober up and would further provide opportunities for referral for those
patients attending with AAI symptoms.
This approach to AAIs has two implications. First, the clinical environment may suffer in
consequence of AAIs being left to wait. Second, diverting AAIs to the ATC will, by definition,
shift patients who would usually wait longer in ED away from the ED and therefore mask any
impact of the ATC on patients wait times in the ED more generally. This latter issue is
returned to in subsequent sections in respect of analyses concerning episode duration in
ED.
9.1.3
Ambulance Service
Observational data suggested ambulance resources were being misused by the public,
including one example where an ambulance was dispatched to collect a young male adult
who, upon arrival at ED, thanked the paramedics for the “lift” and ran off [56]. Otherwise,
ambulance handover at the ATC was orderly and the only significant delay was attributable
to administrative requirements associated with handing over patients, something that is
common to both the ATC and ED.
In ED we observed an initial reluctance (September and October 2012) to take patients to
ATC by paramedics and some had no knowledge that the ATC was operational. Given that
ambulance control was routinely informed when the ATC was open, this might suggest
communication barriers in WAST influence paramedic use of the ATC. This reluctance
continued through the pilot although declined towards December. One paramedic cited their
mortgage payments as one reason to escort patients to ED rather than the ATC, further
indicating that the benefits of the ATC had not been communicated across the service and
further reinforcing the view that the ATC was perceived as risky by both nurses and
paramedics. Furthermore, ambulance crews were critical of “last minute” decisions to
change ATC opening hours. This refers to the decision to change ATC opening from
Wednesdays and Saturdays to Fridays and Saturdays. However, towards the end of the
pilot, paramedics were phoning CDMs at the ATC routinely and if they had any doubt on
where their patient should be taken. This innovation in ATC function has precedent and is
known to reduce ED attendances more generally [28].
9.1.4
Street Pastors
There was very positive regard for the Cardiff Street Pastors across those who expressed an
opinion, particularly in their support of police officers patrolling the NTE. Usually, Street
Pastors supported those who were vulnerable until they were deemed safe. Safety here
could be that they were reunited with friends, sufficiently sober to find their way home or
appropriately referred in the health service. In terms of referrals, there was some uncertainty
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over who Street Pastors should refer to the ATC. Initially there was a general lack of
awareness in Street Pastors over ATC function. This changed over time with the
recommendation from clinical practitioners that Street Pastors refer to the ATC all those who
might be eligible, rather than Street Pastors stay with those who were vulnerable. Street
Pastors viewed having the ATC open would allow them to refer a greater number of patrons
there so that they could receive expert clinical attention suggesting the ATC would increase
Street Pastor capacity in the NTE and provide the opportunity to attain a rapid clinical
decision and therefore reduce risk in the NTE. However, this suggests that Street Pastors
decisions to refer into the ATC is not only determined by clinical need but is also informed by
their relationship with the ATC.
Evidence suggests that the Street Pastors have a positive impact on welfare in the NTE.
Those who are vulnerable receive attention and guidance that would not otherwise be
available. For example, a 20 year old male student was found by Street Pastors behind the
bins at the train station, half dressed, soaking wet and at risk of hyperthermia. However, as
noted, AAI can mask complications and there is evidence to support Street Pastors
conjecture that the ATC would allow them to refer more into health services than they do at
times when the ATC is not open. For example, Street Pastors do not have the requisite
clinical skills to reliably determine whether someone requires clinical assistance, they do not
routinely test blood glucose levels for example. The ATC facilitates referral and, by
implication, reduces the risks associated with AAI and therefore Street Pastor activity.
Our view is that Street Pastor activity is an important component in ATC success, if Street
Pastors refer as many as they can then this means ATC resources will be potentially wasted.
However, if Street Pastors are encouraged to refer only the most vulnerable then this will
increase risk in the NTE. It is therefore essential that the referral pathway is structured and
agreed. With this in mind opportunities for closer partnership working between Street
Pastors and clinical staff should be explored.
Street Pastors, police and other agencies involved with managing the NTE, including taxi
marshals, paramedics, St John’s Ambulance and door security staff, liaise closely. In
amongst this ad hoc network Street Pastors have become central in providing a link between
agencies and health services. Other than paramedics, none have formal clinical training. The
ATC therefore provides an opportunity for those exhibiting AAI to be rapidly assessed,
monitored, treated and discharged and therefore it is essential that the criteria for referral is
communicated and reinforced.
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9.2 Descriptive Statistics
Figure 6 – Distribution of Emergency Department recorded assault related injury and severe
alcohol intoxication attendances by arrival time
From 1 January 2010 to 1 January 2013 there were 351,918 attendances at ED. On
average, there are 32.47 (SD = 7.77) ambulance trips to ED each evening period (8pm to
4am). Overall we identified 4,884 alcohol-related attendances and 8,844 assault-related
attendances in the available data. Average episode duration for alcohol-related attendances
was 258.79 minutes (SD = 248.13) and assault-related attendances was 196.31 minutes
(SD = 174.74). Yielding a combined average of 218.64 minutes (SD = 206.31). When the
ATC is open it is open from 8pm to 4am. In this evening period, excluding attendances when
the ATC is open, the ED receives, on average 83.76 (SD = 21.71) patients. There are, on
average, 3.17 (SD = 2.78) attendances where alcohol is reported as a primary symptom,
3.97 (SD = 3.51) attendances designated as being due to an assault-related injury and 0.08
(SD = 0.30) attendances where alcohol is reported as a primary symptom and designated as
being due to an assault. Referring to Figure 6 and Figure 7, these attendances are strongly
clustered in the evenings of Friday and Saturday. 65.16% of all alcohol- and assault-related
attendances arrive by ambulance and 27.5% via private arrangements (e.g. taxi).
10
Saturday
Friday
Thursday
Wednesday
Tuesday
Monday
Sunday
0
5
Percent
15
Evening Attandances Alcohol and Assault-Related by Day
Time of Day
Assault
Alcohol
Source: Violence & Society Research Group, Cardiff University
Figure 7 – Proportion of total attendances, between 8pm and 4am, designated as assaultrelated or presenting with alcohol intoxication as the primary symptom by day of week
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Figure 8 shows the relationship between episode duration and the total number of patients
admitted to ED. Regressing number of patients in ED onto episode duration yields a
significant linear association (B = 0.17, t = 14.41, p < 0.001, n = 376,989) that further
suggests the target 240 minute episode duration is exceeded one the number in ED exceeds
148 patients.
Extended episode durations are more characteristic of the evening period. Consistent with
earlier discussion, those attending where alcohol intoxication was a primary symptom and
did wait to be seen by clinical staff had longer episode durations (mean = 307.41 minutes,
SD = 270.47, n = 3453) compared to all other patients (mean = 237.41 minutes, SD =
371.75, n = 355,082; t(358,533) = 15.06, p < 0.001). Moreover, 75.5% of all those attending
with alcohol as a primary symptom were more likely to attend between the hours of 8pm and
4am (z = 66.93, p < 0.001). Thus the increase in episode duration seen in the evening period
is partly attributable to a greater number of AAIs arriving in ED affecting all patients.
However, this difference between evening and daytime episode durations could also be
attributable to other bottlenecks, such as delays in getting results from diagnostic tests and
accessing other services that patients might require.
To determine whether the presence of AAIs impacted on other patients’ episode duration the
number of AAIs in ED were calculated to the arrival time of all non-AAI patients. A significant
and positive relationship was observed controlling for day/evening period (B = 4.64, t =
15.94, p < 0.001) suggesting the increase in episode duration found in the evening period
may reflect a general increase across all patients and that is not simply due to AAIs being
required to wait longer.
Figure 8 – Episode duration for patients attending the Emergency Department by patients
already in attendance at the Emergency Department at time of arrival
9.3 Analyses
9.3.1
ED Attendances
ED data were restricted to those times when the ATC operates and when assault-related
injury and severe alcohol intoxication are most likely (8pm to 4am). Table 1 presents
summary statistics, including the average daily attendances between 8pm and 4am by
patient type (alcohol- and assault-related) for ED only and for the ED and ATC combined
and the number of days (N) for which data were available).
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Table 1 – Daily descriptive statistics for attendances during evening periods (8pm to 4am)
from 31 December 2009 to 1 January 2013
Variable
N4
Description
Alcohol & Assault UHW
Alcohol & Assault
Ambulance UHW
Total attendances at the Emergency Department
designated assault- or alcohol-related
Total attendances designated assault- or alcoholrelated (ED & ATC combined)
Total attendances at the Emergency Department by
ambulance
Mean
SD
Min
Max
1098
7.337
5.456
0
46
1098
7.566
5.736
0
46
1098
32.230
9.717
10
98
From 2010 onwards, ED saw a linear increase in total attendances (n = 122,819 in 2010, n =
124,007 in 2011 and n = 127,974 in 2012). This also corresponded with a linear increase in
episode duration over the same period (average = 213 mins in 2010, 235 mins in 2011 and
237 mins in 2012). A simple “before and after” analysis of ED data to determine ATC impact
is thus complicated by these underlying changes. Time series regression models were
therefore specified.
Table 2 provides results from four time-series regression models. The data used in these
models was constrained to evening periods when the ATC would usually operate (8pm to
4am), and 31 December 2009 to 31 December 2012 (events on 1 January 2013 from
midnight to 4am were included in the 31 December totals). Durbin's alternative test
suggested moderate serial correlation (χ² > 3.5 and p < 0.05 for each test) and the
Cochrane-Orcutt (1949) transformed regression estimator was therefore used to correct for
first-order serially-correlated residuals.
Table 2 – Time-series regression models assessing the association between ATC being
open and control variables on ED attendance outcome measures
Alcohol & Assault UHW
ATC
Alcohol & Assault
Ambulance UHWD
-2.50*
(-2.30)
5.83***
(5.24)
-2.53***
(-3.43)
Black
Friday
3.15
(0.95)
5.77+
(1.71)
-0.28
(-0.13)
24 Dec
-7.79*
(-2.36)
-10.44**
(-3.09)
-4.18+
(-1.87)
25 Dec
-4.38
(-1.32)
-4.54
(-1.34)
-2.20
(-0.98)
26 Dec
1.16
(0.33)
1.11
(0.31)
0.07
(0.03)
24.19***
(7.39)
26.06***
(7.77)
9.79***
(4.41)
University
0.51
(1.26)
0.55
(1.34)
-0.02
(-0.08)
F.Holiday
9.83***
(7.42)
9.94***
(7.32)
4.84***
(5.39)
St Patrick's
-1.51
(-0.46)
-1.70
(-0.51)
-0.47
(-0.21)
Halloween
17.47***
(5.33)
17.70***
(5.27)
6.86**
(3.09)
Varsity
-0.46
(-0.14)
-0.41
(-0.12)
-0.64
(-0.29)
Freshers
2.80*
(2.11)
2.51+
(1.87)
1.92*
(2.14)
Mon
0.79
(1.28)
0.86
(1.35)
0.35
(0.83)
Tue
-1.13+
(-1.73)
-1.10
(-1.64)
-0.20
(-0.46)
Wed
0.95
(1.44)
0.85
(1.26)
0.98*
(2.20)
Thr
0.54
(0.83)
0.55
(0.83)
0.59
(1.35)
Fri
10.53***
(16.03)
10.61***
(15.79)
6.71***
(15.10)
Sat
15.15***
(24.07)
15.61***
(24.13)
9.16***
(21.46)
Constant
7.42***
(14.92)
7.42***
(14.61)
4.25***
(12.65)
NYE
Day of
Week
4
2012 was a leap year, adding an additional day, also included were new year eve 2010 and new
year day 2013
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N
1096
1096
1096
adj. R-sq
0.544
0.568
0.464
C
1.79
1.81
1.89
DW
Coefficient (t statistics)
+ p < 0.10; * p < 0.05; ** p < 0.01; *** p < 0.001
Notes:
A – Days when there were no alcohol and assault related attendances are 03 Jan 2010, 19 Feb
2010, 06 July 2010, 06 Dec 2010, 07 Dec 2010, 06 Jan 2011, 22 Feb 2011, 26 April 2011, 06
Jun 2011, 01 Aug 2011, 05 Jun 2012, 21 Jun 2012, 10 Dec 2012
B – The lead descriptor for Holiday (F.Holiday) is missing for the public holiday on New Years
Day at the end of the time series
C – Durbin-Watson statistic
(transformed)
D – For alcohol & assault related
attendances
The results presented in Table 2 (Alcohol & Assault UHW) suggests that when the ATC is
open there are statistically fewer alcohol and assault-related attendances in ED, suggesting
that the ATC successfully diverts attendances away from ED. However, if the ATC simply
diverted patients away from ED then the coefficient on ATC in the Alcohol & Assault
equation should be zero. Instead it is positive and significant and therefore we would
conclude that the total number of patients (in both ED and ATC) for assault- and alcoholrelated injury increases on days when the ATC is open. This is consistent with the opinion of
Street Pastors and previous evaluations of sobering-up centres (Section 6, page 7)
suggesting that diversionary schemes such as the ATC would lead to an increase in
demand. Consistent with the diversionary success of the ATC, fewer ambulances attended
the ED with patients exhibiting assault- or alcohol-related symptoms.
Also of note are those factors that promote attendance in ED, ATC and require ambulance
services. There were fewer AAIs on Christmas Eve (24 Dec). There were strong increases
on New Year’s Eve, evenings before a public holiday, Halloween and a modest increase
during Freshers’ week. University term time (University), Black Friday and Varsity (an annual
student sporting event) were not systematically associated with increased levels of AAI. A
greater prevalence of AAIs is observed on Friday and Saturday evenings.
9.3.2
Emergency Department Patient Episode Duration
Episode duration is the time patients spend in ED from initial attendance to discharge. In
order to assess any relationship between ATC activity and episode duration individual level
patient data were restricted to those equal to or over 16 years of age to exclude paediatric
attendances (paediatric attendees are separated from adult attendees in UHW ED). Further,
data were restricted to the evening period when the ATC would typically open (8pm to 4am)
and those who did not wait to be seen were excluded. Referring to Figure 9, episode
duration showed a log-normal distribution and was therefore log transformed.
27
0
.001
Density
.002
.003
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0
500
1000
Time in mins from arrival to conclusion
1500
Figure 9 – Density histogram for episode duration for those attending between 8pm and
4am, 16 years of age or older, and excluding patients who did not wait to be seen
Log episode durations were compared on days when the ATC was open to equivalent days
in 2010 and 2011. No significant difference was observed in these values (t < 1). Restricting
tests to New Years Eve, Halloween, Freshers Week and evening periods in ED episode
durations similarly found no significant differences in log episode duration (t < 1). Moreover,
from 2010 to 2012 the ED saw an increase in total attendances (2010 = 244,173, 2011 =
246,277, 2012 = 254,375) and a corresponding increase in episode duration (2010 mean =
231 mins; 2011 mean = 235 mins; 2012 mean 237 mins) suggesting that a steady increase
in attendances might mask any effect of the ATC on daily averages over time in these simple
effect comparisons. OLS regression was therefore specified, controlling for mode of arrival
(emergency ambulance), severity (proxied by whether the patient was subsequently
admitted [57]), age on arrival, and day of week, monthly and primary diagnosis dummies.
While overall, the linear combination of predictor variables explained variance in the
outcome measure (F(72, 39,989) = 83.68, p < 0.001) the overall fit was moderate (adjusted
R² = 0.13). However, this result is broadly consistent with expectations and the more robust
finding that there fewer assault- and alcohol-related attendances at ED when the ATC was
operational.
Table 3 – Regression model assessing the association between ATC being open and
patient episode duration in ED
ATC
-0.12**
(-3.21)
ED present
0.002***
(11.72)
Age on visit
0.01***
(24.14)
Emergency ambulance
0.51***
(41.73)
Admitted
0.26***
(17.08)
Day of week dummies
Yes
Month dummies
Yes
Diagnosis dummy
Yes
Constant
4.37***
N
40,062
adj. R-sq
0.129
(122.89)
t statistics in parentheses
* p < 0.05; ** p < 0.01; *** p < 0.001
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9.3.3
Alcohol Treatment Centre Activity
Data from 268 attendances at ATC were available for analysis. These data identified
whether patients had been assaulted, primary symptom, mode of referral and where they
had their last alcoholic drink: 14% had been assaulted and 57% presented with AAI.
Table 4 – Mode of arrival at the Alcohol Treatment Centre (where referrer noted)
Month
Oct
Nov
Dec
Total
14
33
70
117
St Pastor
1
6
7
14
Police
2
3
19
24
Public
1
0
0
1
Self
0
0
4
4
Total
18
42
100
160
Ambulance
These data indicate that the majority of referrals were from the police, Street Pastors and
ambulance service. Intoxication was mentioned as the reason for attendance in 82.63% of
cases, the remaining were mostly minor injuries except for one allergic reaction, three with
suspected hyperthermia, one convulsion, one overdose and one person experiencing a
panic attack. Overall, 14.8% had been involved in an assault.
Table 5 – Discharge route from the Alcohol Treatment Centre (where discharge route noted)
Month
Discharge
ED
Sept
Oct
Nov
Dec
Total
4
12
8
21
45
Home
23
39
54
104
220
Police
0
0
1
2
3
Total
27
51
63
127
268
Of those who were able to provide a location for their last alcoholic drink (n = 149), data
indicated that 81.21% had consumed their last alcoholic drink in a licensed premises, 6.71%
in a street location, 12.08% had their last alcoholic drink at home.
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Figure 10 – Total number of attending patients in the Alcohol Treatment Centre by day
Figure 10 shows the number of patients admitted to the ATC by day. Consistent with the
numbers presented in Table 4, there appeared to be a bedding-in period across the ATC
such that the use of the Centre increased as processes were refined, communicated and
other partners became more familiar with the ATC. This is further consistent with
observations discussed in Section 9.1 where paramedics were found to have some
uncertainly over ATC referral pathways.
9.3.4
Police Activity
On average there were 0.69 police referrals to the ED each evening for alcohol- or assaultrelated harm (8pm to 4am) over the full ED dataset (min = 0, max = 10). Determining the
effect of the ATC on police activity is complicated in that South Wales Police do not routinely
record the time that officers would spend in ED with a patient. Therefore, only the binary ED
data item denoting whether a patient was referred by the police or not was available for
analysis. This descriptor likely includes a variety of scenarios. There may be occasions
where an offender’s health poses concern and therefore officers are obliged (see Section 6)
to seek advice from a CDM and then may stay with the offender until appropriately treated.
On some occasions officers may escort someone to ED when ambulance capacity is
stretched, but depart shortly after. Furthermore, officers may refer the severely intoxicated to
Street Pastors and paramedics. It is therefore difficult to fully understand the effect of
referrals to ED on police time and capacity from what information is available.
We can state with certainty that officer time to escort patients to the ED will affect officer
capacity in the NTE. Officer capacity varies depending on expected demand but on average
about 14 officers working in pairs are in the NTE on a typical Saturday night. Therefore two
officers escorting a patient to ED represents a reduction in capacity upwards of 15%.
We explored the effect of the ATC on police officer referrals to ED however models (negative
binomial regression model) proved to be poorly specified due to a scarcity of data.
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We also considered SWP arrest data for the offences “drunk and disorderly in a public place”
and “drunk and incapable in public place / highway / licensed premises.” In total, for 2012,
there were 583 arrests for drunk and disorderly and 3 arrests for drunk and incapable. This
reinforces the view that AAI has become normalised, such that the only arrests made are
when AAI is accompanied with disorder and might undermine opportunities to develop
sobriety schemes to target risky alcohol use. These data are discussed further in the
discussion.
9.3.5
Ambulance Activity
Ambulance staff are given a target of 15 minutes to hand patients over to ED staff, plus an
additional five minutes to restock their ambulance (ED episode duration begins at 15
minutes irrespective of whether the patient is in ED or not [55]). The effect of ATC function
on ambulance attendance numbers at ED are presented in Section 9.3.1, page 25). Figure
11 presents the relationship between the number of patients in ED and the effect on
ambulance handover. Table 6 presents the average number of patients in ED at ambulance
time of arrival for the evening period and the average handover time in the evening period.
The average Saturday ambulance referrals (8pm to 4am) to ED for alcohol- or assaultrelated harm when the ATC was not open was 13.57 (SD = 5.73), when the ATC was open it
was 9.93 (SD = 4.74; t = 2.37, p < 0.01). On Fridays, when the ATC was not open the
average was 11.04 (SD = 5.08) and when the ATC was open the average was 8.14 (SD =
4.30; t = 1.48, p = 0.07).
Figure 11 – Ambulance handover duration for ambulances attending the Emergency
Department by patients already in attendance at the Emergency Department at time of
arrival
A t-test on handover time, restricting the data to the evening period and significant dates that
the ATC targeted (e.g. New Years Eve, Christmas, Black Friday, public holidays) yielded a
near significant effect (t = 1.18, p = 0.12) for handover time at ED on days when the ATC
was open (mean = 16.12 mins, SD = 11.13) compared to similar days when the ATC was
closed (mean = 17.33 mins, SD = 13.95). However, handover times were log-normally
distributed and showed cyclical variation, therefore times were log transformed for further
analysis. Handover times were restricted to the evening period and regression models
suggest a robust relationship between ATC opening and reduced handover times.
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Table 6 – Daily descriptive statistics for evening periods (8pm to 4am)
Variable
Description
ED present
Average number of patients in ED at ambulance time of
arrival
N
Mean
SD
Min
Max
35,658
99.71
33.66
6
193
Handover
Ambulance handover time (minutes)
33,561
17.24
14.94
0.02
260.92
Table 7 – Association between Alcohol Treatment Centre operation and log ambulance
handover time at ED in the evening period
Patients in ED
0.005***
(29.23)
-0.06*
(-2.14)
Black Friday
0.06
(0.67)
Christmas eve
-0.11
(-1.28)
Christmas day
-0.09
(-1.06)
Boxing day
0.01
(0.10)
NYE
-0.05
(-0.55)
University term time
-0.03**
(-3.26)
F.Holiday
ATC open
-0.11**
(-3.22)
St. Patricks
0.05
(0.55)
Halloween
0.03
(0.31)
Varsity
-0.07
(-0.68)
-0.10**
(-2.91)
Mon
0.02
(1.26)
Tue
0.02
(1.37)
Wed
0.04*
(2.34)
Thr
0.02
(1.15)
Fri
0.03+
(1.91)
Sat
-0.00
(-0.02)
Constant
2.07***
(109.27)
N
33,560
adj. R-sq
0.027
Freshers
Day of Week
t statistics in parentheses
="+ p<0.10, * p<0.05, ** p<0.01
Table 7 presents results from an OLS regression on log handover time and suggests the
number of patients in ED affects handover duration. As the number of patients increases
longer handovers are observed, but handover durations are reduced when the ATC is open.
Care is needed in interpreting these findings, however, given the low adjusted R² value.
9.3.6
Street Pastors
We received reports from Street Pastors covering 154 sessions in total, from 6 January 2012
to 9 February 2013. These reports included information on the number of “drunks” they had
assisted, the number of water bottles given out, the number of flipflops given out, the number
of violent incidents observed, the number that they escorted to an ambulance and the
number taken to the ATC. We combined the ambulance and ATC referrals to provide a
measure of total referrals. This figure was then divided by the number of drunks to control for
activity in the NTE to provide an index of referral activity.
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Table 8 – Descriptive statistics for Street Pastor activity
N
Mean
SD
Min
Max
Water bottles
154
11.44
5.63
0
29
Flipflops
154
5.88
4.65
0
23
Drunks
Violence
154
6.50
3.15
0
16
154
0.58
0.75
0
4
Ambulance referrals
154
0.90
1.06
0
5
Referral to the ATC
37
2.27
1.48
1
6
154
1.54
2.12
0
10
Space blankets
A t-test on referral activity yielded a significantly greater referral activity when the ATC was
open (mean = 0.58, SD = 0.46) compared to when the ATC was closed (mean = 0.13, SD =
0.15; t(149) = 9.11, p < 0.001), consistent with the earlier finding that Street Pastors
themselves suggested they would be more likely to refer patients into healthcare when the
ATC was open.
9.3.7
Referrals
There are numerous agencies into which those exhibiting risky alcohol or substance related
behaviour can referred to receive treatment. While there exists robust evidence that
intervention and referral for alcohol misuse can prevent further harm (see Section 6) there
was little evidence that the ACT had in place any substantive intervention or referral policy.
Noted in Section 6 were pathways that agencies, in particular the police, are able to use to
refer offenders forward to treatment agencies. We therefore accessed the Welsh National
Database for Substance Misuse5 to better where referrals into treatment for 2012 for adults
19 years and over were originating and for two of the main services that provide support to
those with alcohol use problem: the Drug Intervention Programme (DIP) in East South Wales
and the Community Addiction Unit (CAU). Analysis revealed that there were zero referrals
from ED to either service, one referral to CAU by SWP and 233 referrals to DIP by SWP.
9.4
Cost Analysis
The total cost of the ATC across the initial three months was £60,000, funds for 24 sessions
(two each week), yielding an average per-session cost of £2,500. The itemised sessional
costs are presented in Table 9 (the number of Health Care Support Workers and ENPs
varied by session).
Table 9 – Itemised costs for the Alcohol Treatment Centre
Item
Cost
Emergency Nurse Practitioner
£451
WAST Triage Vehicle & Paramedic Cover
£870
St John’s Ambulance
£300
Police Officer
£342
Health Care Support Worker
£150
Consumables (heating & lighting) are covered in the £300 St
John’s Ambulance cost
The salary costs detailed above are at overtime rates of “time-and-a-half” and therefore
inflate the cost of the ATC somewhat, compared to the expected costs should the ATC be
formally implemented.
5
http://wales.gov.uk/splash?orig=/topics/housingandcommunity/safety/substancemisuse/stats/
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The cost of an attendance at ED can be derived from the NHS reference costs (Appendix
14.1, page 47). No reference cost exists for AAI, but the cost for “Accident and Emergency
Services: Not Leading to Admitted” is £108 and “Accident and Emergency Services: Leading
to Admitted” is £157. Of all those assault- or alcohol-related attendances presenting to ED
4.76% are admitted. Weighting these unit costs accordingly gives an approximate unit cost
of £110. For the ATC to therefore breakeven it would need to divert 23 patients away from
ED on average each session. However, in addition there are saved ambulance journeys.
Appendix 14.2 (page 47) provides the unit cost for an “amber” journey as £222. Of all those
assault- or alcohol-related attendances presenting to ED, 44.41% arrive by ambulance.
Reweighting the unit cost accordingly provides £208.59. For the ATC to therefore breakeven
it would need to divert 12 patients away from ED on average each session.
There are also additional savings through reducing ambulance wait time. The unadjusted
coefficient on ambulance handover time for patients in ED suggests that every patient
diverted to the ATC saves 0.031 hours in handover time. There are, on average, 32.48
ambulance trips to ED each evening period, suggesting a total saving per evening of 0.996
hours. Assuming an hourly unit cost of £76 [58] for ambulance waiting times then each
patient in the ATC saves £75.70. However, from ED data, the average episode duration of a
patient in ED is 218 minutes, or 45% of the time that the ATC is open (8pm to 4am). Thus
each patient in the ATC who would have normally gone to the ED cannot be reasonably
expected to influence each ambulance handover. Adjusting the initial sum to account for this
time suggests a saving per patient of £34.07. Including this estimate suggests the ATC
would need to divert 10 patients from ED.
Data available from the initial 24 ATC sessions indicates 236 patients attended the ATC.
However, analyses presented in Table 2 (page 26) suggests demand increased, there are
more patients in the system because of the ATC then there would be otherwise. This is
complicated as the ATC took time to become embedded in routine paramedic practice and
initially opened on Wednesdays and Saturdays but then switched to Fridays and Saturdays.
Thus the average 9.8 patients in the ATC per session will include patients who would not
normally go to the ED but is lower due to the bedding in period. Crude estimates based on
the equations presented in Table 2 would suggest that for every 10 patients diverted there
are at least an additional 20 patients who would not normally be expected to be in the health
system.
There are additional, intangible, savings. Keeping the drunk and incapable away from ED
improves that environment and allows clinical staff to pay more attention to legitimate users.
Further, there are legitimate questions concerning the level of risk presented in the NTE. We
found that Street Pastors welcomed the ATC as it meant they could refer more easily and
further found that there were instances where those in Street Pastor care should have been
referred to a CDM but were not.
There are, however, additional costs due to the increased demand opening the ATC
involves. Table 2 (page 26) provides analyses from which we might reasonably infer that for
every patient diverted away from the ED an additional two patients are treated in the ATC.
This will imply additional costs but are somewhat mitigated by the unmeasured reduction in
risk to those using the NTE.
We cannot definitively state that the ATC is cost-effective, however, the above discussion
strongly suggests that the continuing bedding in and appropriately targeting high risk
evenings when AAI prevalence is expected to be high could yield a cost effective service.
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10
Discussion
The traditional model for unscheduled care is one where the decision to attend is made by
those without formal clinical training. The same is true in the NTE, where typically partners
including police officers, Street Pastors and the public determine whether someone requires
assistance or not and accordingly the decision to refer will be based on contextual factors
not necessarily related to clinical need. ACPO guidelines suggest officers should exercise
caution and refer to CDMs if alcohol use is expected. On the other hand, Street Pastors
were aware that AAIs in ED were impacting on service provision and attempted to stay with
patrons until they were deemed sober or until they could be helped by friends. Extending the
ED footprint into the NTE therefore provides an accessible service that can rapidly triage,
treat and discharge. It effectively minimises non-clinical criteria from healthcare decision in
the NTE. Our view, albeit subjective, has a net effect of reducing risk given the extent of
alcohol-related harm in the NTE. This is an unanticipated benefit of the ATC.
Management of the NTE involves a complex set of relationships between both statutory and
non-statutory services. The impact of acute intoxication and injury that emanates from the
NTE impacts on health, ambulance and police capacity and in turn affects their ability to
respond, not only to events in the NTE but also, through depleting available capacity, to
events in the community more generally. This is most apparent in ambulance handover
delays at ED. There is also reason to believe police capacity in the NTE is affected, which
would be expected to reduce opportunities for officers to intervene early to prevent disorderly
behaviour escalating to violence and serious injury. Further, all patients who attend the ED
are similarly affected: they wait longer to be seen and suffer the ignominity of a shared
space in which the severely intoxicated and disruptive are left to sober up with their friends.
The purpose of this report was to evaluate ATC function and, in particular, what benefits, if
any, the ATC has on service provision in and around the NTE. In Section 7 (page 16) we
defined what we understood would constitute criteria that could be used to asses ATC
function. These criteria are now discussed in light of the earlier presented analyses.
The primary criterion for success was for the ATC to successfully divert patients away from
ED to the ATC. It was expected that doing so would reduce the number of ambulance trips
to the ED and therefore improve ambulance function.
Both observational, interview and quantitative data agree that while the ATC is open there
are fewer AAIs in ED and that the environment is generally improved and "less chaotic".
Furthermore, there are fewer patients escorted by ambulance to the ED. The available data
may under-estimate impact due to the bedding period the ATC underwent, whereby
paramedics, in particular, took time to adapt to the additional capacity provided by the ATC
and escort patients there who met the criteria for treatment in the ATC.
Piloting services such as the ATC allows practitioners to assess those processes in place
and make modifications to improve delivery. We therefore sought evidence of this learning
process and looked at how elated agencies reacted to the presence of the ATC.
There was clear evidence that the pilot period saw developments in service provision over
the duration. This was most notable in the increase in ambulances escorting patients to the
ATC and better communication between partners across the police, health and ambulance
services.
It was expected that if the ATC did divert patients away from the ED that this would have
consequences for ambulance handover times, and patient episode durations in ED.
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We observed a strong positive relationship between the number of patients in ED and
ambulance handover times. Accordingly, the reduction in AAIs attending ED also brought
about a small but significant reduction in ambulance handover times. Some evidence further
suggested that this also extended to episode durations in non-AAI patients attending ED.
While there is little empirical evidence from diversionary schemes generally, what was
available suggested that the ATC might cause an increase in demand for health services.
Data strongly indicate that the additional capacity provided by the ATC also increased
demand for health services. However, this was mitigated by the observation that previous
limitations in capacity meant that non-statutory services were not referring patients into the
health services in order to help prevent bottlenecks in ED. This increased demand might
therefore reflect the true extent of the demand for health services and that earlier numbers
were restricted due to limitations in capacity.
In reviewing guidelines for the police it was clear that ACPO places greater weight on
individuals’ welfare, meaning that officers are obliged to ensure the severely intoxicated are
safe, receive clinical attention and that custody is the only suitable place for those who are
deemed no longer at risk. The implication is that AAI is no longer an offense and has been
medicalised and on occasion officers might have to escort those in their custody to ED. With
the ATC we therefore reasoned that fewer officers would be required to visit the ED.
No systematic relationship between police officer activity and ATC function was observed. It
is reasonable to presume, however, that the ATC may, in time, free police officers from the
occasional event where they are required to escort AAIs to ED.
The ATC is an additional service to the usual provision of unscheduled care in Cardiff and
therefore attracts additional costs. Diverting AAIs from ED to the ATC would represent a
saving to the ED and therefore to explore ATC cost efficiency a breakeven analysis is
conducted.
A definitive answer was not available; however estimates suggest that the ATC is capable of
providing a cost-effective service in the NTE.
A characteristic of those patients the ATC seeks to divert from ED is loss of bodily control
and disruptive behaviour. Their effect on the ED environment and other patients is hard to
measure and we therefore sought the opinion of staff in the ED.
There was strong evidence from observational and interview data that the clinical
environment in ED did show marked improvements.
Also considered were the broader implications of the ATC including the perceived risks and
benefits, barriers to implementation and opportunities for sustainability.
There are no obvious policies and procedures in place to refer patients to alcohol health
workers or provide brief alcohol interventions. An attempt was made to video record patients
as they arrive and play back to them evidence of their severe intoxication. This is an
untested intervention and could, without due care, encourage some to drink to the extent
that they can obtain such video footage. If the ATC is adopted then efforts should be made
to formally develop referral and intervention policies and procedures that are consistent with
the considerable evidence based in this area.
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10.1 General Discussion
The police, ambulance and health services are understandably risk averse. Police guidelines
explicitly prioritise welfare, ambulance standard operating procedures require that patients
on a 999 call are delivered to ED. Under usual conditions those determining need for
unscheduled care therefore have little or no clinical expertise. ED therefore passively
receives patients whose need for healthcare has not been assessed, the default “admit to
decide” arrangement. Alcohol misuse is serious and is further associated with injuries and
other conditions that require appropriate clinical expertise to assess and monitor for adverse
events. For a significant proportion, however, the best treatment is time, allowing patients to
process the alcohol in their system in a safe environment; others will require expert medical
attention. Without the ATC the ED is that safe environment, it is where all clinical decisions
are made and therefore it becomes the holding space for those who are vulnerable due to
their misuse of alcohol and irrespective of the extent of that vulnerability.
This is balanced against our finding that Street Pastors would, in the knowledge that AAIs
impact on ED and ambulance capacity, occasionally make decisions where those presenting
with injuries and an altered state of consciousness were allowed to travel home. This is in
context of the Street Pastors’ view that the ATC would allow them to refer more of those they
encounter into health services. So while there is a theme of inclusivity in statutory partners,
whereby all those deemed at risk are referred and treated as required, non-statutory
partners are less risk-averse and are more likely to exclude some who may be at risk.
A peculiarity of ED service provision is the targets against which the ED expected to
perform. Broadly, all those attending ED are expected to have been processed within four
hours with little appreciation of the complexity of AAI. Without the ATC the ED is the only
safe environment for those exhibiting AAI in Cardiff and therefore the only environment in
which many can be left to sober until their welfare is assured. In this case, the strict
application of a maximum episode duration and with no other location for those exhibiting
AAI to be discharged to could increase risk. The validity of targets in respect of AAI is
therefore baseless and lacks understanding of this condition. Of greater concern is the effect
this might have on ED willingness to deliver interventions to those presented while
intoxicated. If patients cannot be discharged until such an intervention is delivered then this
will further increase the proportion of episodes exceeding the prescribed target of four hours.
As there are financial implications involved with exceeding targets it is fair to conclude the
current system as a whole is not adequately designed for the treatment of AAI. One option
would be to create a class of patient, similar to those patients who need to wait for test
results, for those presenting with AAI such that if alcohol is associated with attendance they
can be removed from the QMAE episode duration reporting requirements and be given time
to determine the extent of their alcohol misuse.
Related to the above target anomalies are the mechanisms in place available to record the
involvement of alcohol in ED attendances. If a class of patient were created then this would
require that alcohol is appropriately recorded, so that further down the line analysts could
adjust returns as required. As noted earlier, however, the involvement of alcohol in
attendance notes is poor with only those attending with alcohol as the primary symptom
being adequately captured. Capturing alcohol in ED is a matter returned to below, however,
if reporting standards were revised to account for AAI then this may provide an incentive for
practitioners to more reliably capture these data so that the full extent of alcohol-related
harm can be determined and therefore fed into partnership and allied referral activities.
Although the true extent of AAI in Cardiff cannot be precisely stated from ED data, the
available data, coupled with that data available from the ATC, does suggest there are, on
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occasion, significant numbers presenting. New Years Eve, for example, saw approximately
40 attendances. The Civil Contingencies Act 2004 requires that the UHB plans, prepares
and responds to major emergencies, or major incidents. The Department of Health describes
a major incident as “[a]ny occurrence that presents serious threat to the health of the
community, disruption to the service or causes (or is likely to cause) such numbers or types
of casualties as to require special arrangements to be implemented by hospitals, ambulance
trusts or primary care organisations”6. Accordingly, there is a major incident plan for Cardiff
and Vale University Health Board that specifies how the organisation as a whole should
respond. Responses are broadly aligned according to three categories of incident severity:
major, mass and catastrophic. The number of those who are severely intoxicated and
requiring access to health services is considerable. This report has described how the
severely intoxicated impact on services and other members of the community, impacts that
are clustered on particular times and days. One might, therefore, define the levels of alcoholrelated harm generated in the NTE as a major incident, albeit one that has become
normalised and routine. Consistent with the definition of a major incident, the ATC could
therefore be described as a necessary response.
In his introduction to NHS Wales Annual Quality Framework 2011/2012 Paul Williams, Chief
Executive NHS Wales, stressed the need for “less command and control and centrally driven
targets and more freedom for staff to innovate and improve services,” placing public health
centre stage and replacing competition with “collaboration, joint working, whole systems
thinking and greater emphasis on quality and patient outcomes” [59]. Irrespective of the
ATC’s success, those who collaborated and worked to make the Centre operational did so
knowing that the pilot might fail. It was their continual innovation, motivation and ability to
utilise resources from across the community that brought the ATC to fruition and the ATC is
therefore consistent with Paul Williams’ expectations. Further, the cross-partner project
group behind the ATC brought together knowledge of the complex interrelationships that
propagated the effects of AAI on both health and police services.
Numerous events are likely associated with increased levels of alcohol-related harm. If we
assume that a proportion of those in the NTE are prone to misuse alcohol, then simply
increasing the number in the NTE will have the effect of increasing the numbers
experiencing alcohol-related harm. Moreover, events that encourage excessive alcohol use
may not affect the number of those in the NTE but might increase levels of intoxication and
therefore the number of those experiencing alcohol-related harm. From the data available,
and not having reliable data on the number of those visiting the NTE, it is not possible to
assess whether the effect of events are due to a greater number of those misusing alcohol
or simply a greater number of people exposed to the NTE. Never-the-less, there are
opportunities for some reorganisation of events to reduce harm. Freshers’ Week is an
obvious example: a week where students are afforded freedom from academic
responsibilities and are encouraged to socialise in the NTE. Reassessing how the academic
year begins may provide one opportunity to reduce the impact of alcohol-related harm on the
community.
10.1.1 Follow-up and Intervention
As a pilot, the ATC was focused on service innovation and delivery. It is therefore a logical
precursor that the ATC should meet it’s intended goals in respect of treating and caring for
AAIs’ immediate needs before looking towards how the system might then be adapted to
provide follow-up and interventions. Given that there is little evidence of neither referral nor
intervention activity in ED such innovation would be new to those working in unscheduled
6
www.webcitation.org/6EGJyX6nP
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care and this section therefore considers some of the existing evidence that might steer
future delivery.
AAIs presenting to unscheduled care are at risk of repeat attendance, with ED usage in 12
months as high as 1.7 visits [60], suggesting brief interventions in ED provide an essential
part of the treatment pathway. Currently, there are initiatives that involve training nurses in
secondary care to deliver brief alcohol interventions through a collaboration between the
Welsh Government, Public Health Wales and Cardiff University. However, not all patients
are referred into secondary care, in turn suggesting that interventions in primary care and
the ATC in particular are warranted.
As noted, the original proposal was to record AAIs as they presented to the ATC and then
replay this footage to patients once they were deemed eligible for discharge, a novel
approach that has no evidence to suggest it might be expected to reduce future
consumption. The footage would then be deleted in order to comply with the extant data
protection legislature. This approach was dropped from the ATC pilot.
AAI is not adequately recorded in ED data, a fact that will also have repercussions for the
delivery of any structured intervention and referral pathway. The typical Alcohol Brief
Intervention (ABI) involves initially triaging patients into three categories: no risk, moderate
risk and high risk. Those at high risk should be referred to specialist Alcohol Health Worker
(AHW), those at no risk are not provided with treatment and those at moderate risk are given
an ABI [61]. Trials that have assessed the benefits of such approaches generally find that
they are both effective and cost effective [62]. Further, given the type of patients the ATC
accepts there exists an unique opportunity for practitioners to directly challenge high risk
behaviour generally and alcohol misuse specifically. Particularly as the point where patients
are safe to be discharged they are likely to be in a “teachable moment,” a period when brief
interventions are most effective [63]. It is therefore of concern that the ATC has sought to
implement a brief intervention that involves filming patients and replaying that footage to
them, an intervention that has not been formally evaluated and at the expense of existing
approaches that are supported by evidence [62]. Untested interventions can have
unexpected consequences and it is feasible that AAIs might reinterpret the sight of their
inebriation positively with the net effect of that intervention reinforcing future consumption.
Without formal testing there will be no means of determining whether the planned video
capture exercise is meeting expectations or not.
Of concern is the implication of ACPO guidelines in combination with implementation of the
ATC. Integrated Offender Interventions Service in South Wales is a partnership approach
between the Welsh Government, Wales Probation Trust, NOMS Cymru and South Wales
Police to address the complex treatment and support needs for individuals within the
Criminal Justice System (CJS). There is therefore existing pathways through which those at
risk from substance abuse or alcohol misuse can be appropriately referred. If the ATC
attracts those who might have otherwise entered the criminal justice system then such
opportunities for referral might be lost.
The nature of the ATC suggests that it is a worthwhile venue for alcohol referral and
intervention. We observed that some patients were distressed when they sobered sufficiently
to appreciate their situation. This suggests that patients are in a “teachable moment”, the
time when recipients are naturally reflecting on their use of alcohol and when interventions
are expected to work best [63].
A structured approach to interventions in the ATC is available, likely to be cost effective [61]
and have been evaluated using robust methods [62].
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10.1.2 Measuring Alcohol
Currently there are no mechanisms in place to reliably capture the extent of alcohol misuse
in patient attending ED or the ATC. Broadly, measuring aspects of alcohol use can facilitate
referral, intervention and epidemiological initiatives. For example, standard brief alcohol
interventions [62] are usually most effective when targeted at those who are at moderate risk
because of their level of consumption. It is wasteful to deliver interventions to those at no or
minimal risk and those who are dependent or at high risk benefit most from referral to
alcohol health workers [61].
Furthermore, Noted in the WHO report on alcohol and injury, “[r]esearch from hospital
emergency departments also suggests that patients who consumed alcohol prior to their
injury are more likely to be heavy drinkers and have had prior experience of alcohol-related
problems. Furthermore, these patients are unlikely to access health care services apart from
emergency departments. The collection of accurate data on drinking patterns of these
patients would therefore be useful in determining whether emergency departments can be
used as intervention points for these hard to reach population groups” [64].
The ATC therefore provides a unique opportunity to work with a subset of patients whose
main contact with health services generally is through ED or the ATC.
There are two broad categories of measure. The first relies on self-report and includes
the Alcohol Use Disorders Identification Test (AUDIT) [65, 66] and the Fast Alcohol
Screening Test (FAST) [67]. There are also simpler derivations of these metrics, including
the Single Alcohol Screening Question (SASQ) [68]. The second set are biomarkers and
objective measure that are associated with alcohol use. Blood alcohol concentration is
associated with and a reliable indicator for alcohol dependence in trauma patients [69]. The
bio-markers carbohydrate-deficient transferrin, gamma-glutamyl-transferase, and mean
corpuscular volume, however, add little discriminatory power to AUDIT scores in determining
alcohol problems in patients attending a ED [70]. Blood or breath alcohol concentration at
time of attendance for trauma patients is a good indicator of hazardous drinking when
compared against serum gammaglutamyl transferase, aspartate aminotransferase,
carbohydrate-deficient transferrin and mean corpuscular volume in 16 to 49 year olds [71].
Subjective estimates by clinical staff, such as olfactory sense, over-estimate the presence of
alcohol intoxication in sober patients [72].
There are two reasons why patients should be screened for alcohol in the ATC and ED.
First, to determine the extent of alcohol-related harm. Currently it is grossly under-reported
and with understanding the extent of the problems associated with alcohol misuse resources
are unlikely to be appropriately targeted to challenge these issues. Second, to appropriate
the correct treatment of patient. In particular, to determine whether patients would benefit
from a brief alcohol intervention or referral to an alcohol health worker. In general, self-report
measures (AUDIT, FAST and SASQ) are used to determine the need for intervention or
referral. Bio-markers, however, are the only measure that provides an indication of the
presence of alcohol at time of attendance. Given that blood or breath alcohol concentration
is broadly associated with hazardous drinking and that there already exists ICD-10 [73]
alcohol codes to classify the extent of alcohol toxicity, blood or breath alcohol concentration
is preferred.
Table 10 – ICD-10 codes for blood alcohol level
ICD-10 Code
Y90.0
Description
Blood alcohol level of less than 20 mg/100 ml
Y90.1
Blood alcohol level of 20-39 mg/100 ml
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Y90.2
Blood alcohol level of 40-59 mg/100 ml
Y90.3
Blood alcohol level of 60-79 mg/100 ml
Y90.4
Blood alcohol level of 80-99 mg/100 ml
Y90.5
Blood alcohol level of 100-119 mg/100 ml
Y90.6
Blood alcohol level of 120-199 mg/100 ml
Y90.7
Blood alcohol level of 200-239 mg/100 ml
Y90.8
Blood alcohol level of 240 mg/100 ml or more
Y90.9
Presence of alcohol in blood, level not specified
11 Conclusion
The Alcohol Treatment Centre is of benefit to the Cardiff community, it reduces risk of harm
to those who use the city centre at night, reduces ambulance waiting time at the Emergency
Department and therefore improves ambulance capacity in the community, and it
successfully diverts those exhibiting severe intoxication away from the Emergency
Department. The latter has implications for the clinical environment in the Emergency
Department with evidence suggesting a quieter and more orderly environment for all
patients.
This report concludes that the Alcohol Treatment Centre pilot has successfully demonstrated
it’s value. Further work is required to insure only those patients who are eligible for the
Centre are admitted, to minimise additional attendances that would not usually require
medical assistance. That the Centre staff consider carefully which days the Centre should
operate, so that available resources are maximised.
More generally, consideration should be given to the context in which those exhibiting
alcohol intoxication are recorded in health systems. First, too few of those who are
intoxicated are recorded as such in ED systems. Second, there is a conflict between the
treatment of drunkenness (typically patients are left to sober up) and the reporting standards
that require patients to spend no longer than four hours in the Emergency Department.
All partners should consider how best to intervene and refer patients to secondary care for
the treatment of underlying alcohol misuse problems. The Centre provides an appropriate
context in which patients can be assessed and referred to alcohol health workers as
appropriate. Necessary of the considerable burden that alcohol misuse places on health
services is to me appropriately addressed.
12 Recommendations
That the Alcohol Treatment Centre is adopted, subject to regular evaluation, audit and
clinical governance and that dedicated staff are appointed to insure compliance with
European Working Time Directives.
That more work is completed on existing data to determine which evenings will be the most
helpful for the ATC to be opened.
That the ATC data is shared with partners in the same manner that ED data is shared: to
inform the optimal allocation of resources to target the source of alcohol-related harm.
That the medium and long-term outcome of patients attending the ATC is considered and
monitored.
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That partners consult on what brief alcohol intervention is likely to be successful for patients
at moderate risk due to their use of alcohol and develop robust referral pathways for those
deemed at significant risk. That consideration is given to opportunities to work with the police
service in the development of sobriety schemes, whereby statutory powers are used to
motivate patients in seeking help with their alcohol use.
That ED targets are revised so that those presenting with acute alcohol intoxication can be
removed from the standard four hour see-treat-discharge restriction, recognising that these
patients require greater time because of their condition.
That efforts are made to develop robust methods to accurately record alcohol intoxication
levels in those presenting to the ATC and ED and that these data are used to inform
intervention and referral.
That attention is given to the misuse of unscheduled care resources (either through
inappropriate referral or through patients not requiring unscheduled care) both at the ATC
and ED, the source of those referrals and opportunities to re-educate to reduce waste.
That time is invested with partners, including the police and Street Pastors, to ensure the
ATC only receives appropriate referrals, and that the ATC does not become a general
holding area for those not requiring clinical attention.
That basic data management is improved so that practitioners in the ATC can access patient
files and update systems accordingly and ATC data is inputted into systems in a timely
manner to inform partnership activity.
That partners consider further innovations in the ATC so that a less alcohol-specific remit is
considered. For example, provision might be made to treat those presenting with symptoms
indicative of the recreational use of illicit substances and there may be opportunities to
consider services and advice for those who have engaged in risky sexual intercourse.
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14 Appendices
14.1 NHS Reference Costs
Unit cost is determined by dividing total cost by activity
National Schedule of Reference Costs 2011-12
AandEMSAD
AandEMSNA
AandEMinAD
AandEMinNA
AandEWiCAD
AandEWiCNA
Description
Accident and Emergency Services:
Leading to Admitted
Accident and Emergency Services:
Not Leading to Admitted
Accident and Emergency Services:
Minor Injury Service: Leading to
Admitted
Accident and Emergency Services:
Minor Injury Service: Not Leading
to Admitted
Accident and Emergency Services:
Walk In Centres: Leading to
Admitted
Accident and Emergency Services:
Walk In Centres: Not Leading to
Admitted
Activity
Unit Cost
Total Cost
4,040,760
£157
£635,283,308
10,405,762
£108
£1,126,156,223
199,816
£74
£14,713,583
1,606,657
£60
£97,171,176
92,610
£42
£3,901,387
1,251,374
£42
£52,067,489
14.2 Ambulance Handover Costs
Ambulance costs
TPCTPARA
TPCTPARB
TPCTPARC
TPCTPARETU
TPCTPARO
Paramedic Services: Category A / Red
Paramedic Services: Category B /
Amber
Paramedic Services: Category C / Green
Paramedic Services: Emergency
Transfers / Urgents
Paramedic Services: Other
1,925,679
£238
£458,578,782
2,515,971
983,504
£222
£223
£557,682,962
£219,397,713
882,498
425,037
£246
£70
£216,862,211
£29,774,041
47