Alcohol Misuse: The PAT System of Working

Research, innovation and implementation

We initiated work in the A&E department at St Mary's in 1988 showing that 46% of patients detected as misusing alcohol - using a combination of the CAGE and modified MAST questionnaires - were motivated to re-attend the department that same week to discuss their drinking (Green et al, 1993).

We developed and validated a simpler methodology. This led to the "1-minute Paddington Alcohol Test” (PAT)(Smith et al, 1996; Alcohol - can the NHS afford it? Royal College of Physicians of London, 2001, Appendix 6E) - a clinical and therapeutic tool for screening hospital patients for alcohol problems such as hazardous drinking and dependency.

The PAT is an evolving pragmatic clinical tool (Patton et al, 2004) that detects alcohol misuse early on in a drinker’s natural history and acts to implant the relationship between A&E attendance and alcohol misuse, thereby combating especially binge drinking by making best use of ‘The Teachable Moment’ (Williams S et al, Drug & Alcohol Dependence 2005).

PAT is non-judgemental, enabling patients to develop insight into their drinking, its cause and effect. Using the PAT, plus referral for specialist alcohol assessment, results in lower alcohol consumption and reduces the likelihood of re-attendance. (Crawford, Patton, Touquet et al, Lancet, 2004) It takes only about 30 seconds to complete the PAT.

View PAT Form July 2005

For further ease of use – selective screening - we refined the PAT to delineate the top 10 categories or groupings of clinical conditions that are associated with alcohol misuse. A four-fold increase in detection rate was recorded compared with the previous PAT test (Huntley et al, 2001).

We defined a protocol for the use of B vitamins to prevent the development of Wernicke’s Encephalopathy in dependent patients (often difficult to handle in A&E; we have made it clear that one must never give up) with poor diet who chronically misuse alcohol (Thomson et al, 2002; Alcohol - can the NHS afford it? Royal College of Physicians of London, 2001, Appendix 3).

Providing brief feedback about the health consequences of their alcohol consumption to A&E patients identified as hazardous drinkers using the PAT, resulted in a significant increase in the proportion of patients that accept an appointment with our Alcohol Health Worker (Patton et al, 2003).

We assessed A&E Senior House Officers’ (SHOs) attitudes towards PAT usage. We found commitment to the principles underlying the PAT, an awareness of the importance of early detection of alcohol misuse, but a high PAT positive drinking rate amongst A&E SHOs: ‘The Doctors’ Paradox’ (Huntley, Patton & Touquet, 2004).

We have demonstrated that the half-life of the Teachable Moment in A&E for acceptance and attendance (or not) at the next clinic, for Brief Intervention with the Alcohol Health Worker (AHW) is between 24 and 48 hours (Williams et al, 2005).

Following our pilot cohort study (Wright et al, 1998), our randomised controlled trial (2001-2003) 'Reducing alcohol misuse in patients attending an accident and emergency department: a randomised controlled trial and economic evaluation’ (REDUCE), funded by the Alcohol Education and Research Council, compared written advise alone, versus written advice and brief intervention (BI) from an Alcohol Health Worker. With 599 patients entered, follow-up assessments were undertaken at 6 months and l2-months to review alcohol consumption, general health (including episodes of accidental or deliberate self harm) and levels of service contact to calculate direct and indirect costs (economic evaluation). Not only did we demonstrate reduced consumption with BI, but also for every 2 referrals to the AHW there was one less reattendance within the next 12 months (Crawford, Patton, Touquet et al, 2004).

The above work has now resulted in Adrian Brown being appointed as f/t Clinical Nurse Specialist (Alcohol) for the whole of St Mary’s NHS Trust, 1.5.05, funded by Westminster PCT, as recommended by the RCP London (see above). The impact for alcohol misusing patients will be audited to evaluate benefits.

Professor Robin Touquet Link to WKS Syndrome page

Recent Publications:

Attitudes towards alcohol of emergency department doctors trained in the detection of alcohol misuse (pdf)

Cost-effectiveness of screening and referral to an alcohol health
worker in alcohol misusing patients attending an accident and
emergency department: A decision-making approach (pdf)

Screening and referral for brief intervention of alcoholmisusing
patients in an emergency department: a pragmatic
randomised controlled trial (pdf)

The half-life of the ‘teachable moment’ for alcohol misusing
patients in the emergency department (pdf)

The development of alcohol services in A&E at St Mary’s is also highlighted in: - (Please note: Imperial College is not responsible for the content of external sites)
- www.nhs.uk/nhsmagazine/feat16a.asp December 2004
- Public Health White Paper, Chapter 6, a health promoting NHS, p.148, 16.11.04, DOH. http://www.dh.gov.uk/assetRoot/04/09/47/64/04094764.pdf
- Hansard, House of Lords, Alcohol Abuse, 12.5.2004: 661(82), 321-361. www.publications.parliament.uk/lordshansard00/40512-x.htm
- Cabinet Office’s Interim Analytical Report, Nov. 2003; Alcohol Harm Reduction Strategy for England, March 2004, http://www.strategy.gov.uk/
- The London agenda for action on alcohol, November 2003, http://www.london.gov.uk/
- Scottish Intercollegiate Guidelines Network No. 74, Sept. 2003, http://www.sign.ac.uk/
- The Royal College Physicians London, Alcohol – Can the NHS Afford it, 2001, http://www.rcplondon.ac.uk/