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

ts

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

ge o

f pa

tien

ts

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

44

3

70

0

48

5

70

0

43

5

85

15

84

38

0

10

20

30

40

50

60

70

80

90

100

perc

enta

ge o

f ca

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