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Implementation ofhospital programs
Beatriz Rosón HernándezServei de Medicina Interna
Hospital Universitari de Bellvitge
ObjectiveTo describe the methods used on the implementation of a BIRT program in a University Hospital, the barriers encountered and the solutions applied
o Why to perform hospital programs?o How should hospital programs idealistically
be developed?o Publicizing the programo Screening (who, when and how)o Intervetion and Treatment optionso Current structure of the programo Future directions
Why to perform hospital programs?
√ Alcohol related harm is observed in all levels of health assistance: primary care, specialized and hospitalary.
√ Unhealthy alcohol use is highly prevalent among hospitalized patients
√ There are some patients in whom the hospital is the first contact with the health system.
√ There is evidence of cost-effectiveness of hospital-based intervention programs
Prevalence of unhealthy alcohol use amonghospitalized patients.Hospital Universitari de Bellvitge.
5136
8 5
58
30
94
72
21
4 40
102030405060708090
100
perc
enta
ge o
f pa
tien
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2005 2006 2007
AbstainersLow riskRisky drinkersDependence
N=435N=473 N=463
Alcohol-related disease in hospitalizedpatients drinking risky aumounts
83
95
74
0
10
20
30
40
50
60
70
80
90
100
perc
enta
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f pa
tien
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alcohol related disease
Overalldependencerisky drinkers
How should hospital programs idealistically be developed?
√ universal
√ opportunistic
√ routinely offered
√ multidisciplinary approach
√ referral to treatment
√ Adaptable/flexible
√ Autofeedback/self-monitorization
Publicizing the program
Methods: general sessions CME course.
Barriers: small assistancelack of motivationtimid support of the hospital managers
What can be done?Solutions: target departments
to inform about activities ‘in situ’ small groupsinstruct new residents
Evalulation of alcohol consumption in medical records in an University hospital
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3
70
0
48
5
70
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43
5
85
15
84
38
0
10
20
30
40
50
60
70
80
90
100
perc
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ses
2005 2006 2007 2008Any evaluation QuantifiedTarget department: any evaluation Target department: Quantified
CME course
General sessionVoluntaryinitial coursefor residents
Formal classin initialcourse forresidents
Screening (who, when and how)
Screening (who, when and how): the patients were included initially by consultation.Problems found were the small number of consultations and mainly of dependent patientswith social problems. The solution applied was to perform the screening in all patientsadmitted to target departments during the first 48 h of hospitalization with the AUDIT andMALT tests and by consultation in other departments. New problems encountered werelonger interview, short hospital stays, limited number of departments could be covered, anddetection mainly of dependence. Solutions engaged were full-time program workers,validation of the use of AUDIT-C, to encourage departments already on the program toperform screening autonomously in order to include new departments
Inclusion by consultation
to screen all patients admitted to target departments
use of standardized screening tests
small number of consultations dependent patients with social problems
More barriers to overcome...
New problems:√ longer interview
√ limited number of departments could be covered
√ short hospital stays
√detection mainly of dependence
Adapt or Diefull-time program workersreduce the time for initial interview: use of AUDIT-Cdelayed intervention in patients with stays shorter than 48 hincorporating departments according to known prevalence validation of AUDIT-C as initial screening test
Comparison of the use of AUDIT-C for screening and intervention in alcohol
consumption in a hospital-based programControls
AUDIT-C positive97 (20%)
Intervention75 patients (15%)
AUDIT-10 Positive82 patients (16.5%)
56% male61 yr
490 screened patients
No differences were statistically significant
AUDIT-10 positive82 patients (15.5%)
Intervention78 patients (15%)
AUDIT-C positive87 (16%)
55% male62 yr
530 screened patients
Cases
Treatment optionsMethods: simple advice and referral to treatmentBarriers:
difficulties in transmitting alcohol-related harminappropriate setting lack of knowledge of the program lack of follow upwaiting list for the specialized visit
More Solutions√elaboration of handout-materials
√ incorporating motivation interview
√publicizing the program continuously
√ inform the authorities about waiting list delays
What are we doing now?
Screening
Drinking patternAlcohol related diseaseSimple adviceDrinking patternPsychiatric comorbiditiesMotivational interviewOver 900 patientsOver 5700 patients
Future directionsTo include quantification of alcohol consumption in computerized medical history. Obligatory vs optional field
Increase the number of case-detection and recording in medical records
Increase the number of new consultations
Widespread the program: to encourage departments already on the program to perform screening autonomously in order to include new departments
Improve links with primary and specialized care
FlexibleAdaptableFeasibleSuccesful
Conclusions
• Flexible• Adaptable
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