Transcript Improving Analgesia in Emergency Departments: Optimising

Improving Analgesia:
Farewell to Pethidine
A Multi-centre DUE Project
Susie Welch B.Pharm
Project Officer, NSW TAG
ED Pharmacist, St Vincent’s Hospital, Sydney
Coordinated by NSW Therapeutic Assessment Group
Supported by the National Institute of Clinical Studies Australia's national agency for
closing the gaps between evidence and practice in health care.
Background
Is there a problem?
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Prescribing of pethidine in general practice
Prescribing audit in hospitals 2001
Influence of hospital prescribers
Continuity of care
The Problem
• Pethidine limitations include:
– higher potential for adverse effects and
interactions than other opioids
– no proven advantage
• Widely prescribed in hospital despite lack
of evidence
ADRAC reaction reports
Drug
Pethidine
Morphine
Tramadol
Years of data
collection
1972-2003
1974-2003
1999-2003
Number of
reactions reported
to ADRAC
2321
799
1307
Sole suspected
agent
845
380
838
Evidence-based Guidelines:
Pethidine is not the strong analgesic of
choice in Emergency Departments
Aim
• To increase awareness of limitations of
pethidine
• To encourage use of appropriate alternatives
Approach
• Linking Emergency Department (ED) teams
and pharmacists
• Work together using DUE to achieve aims
• Utilise the resources and experience
available through the TAG network
The DUE Cycle
NSW TAG
= NSW Therapeutic Assessment Group
• NSW TAG = independent, non-profit organisation
• Promotes quality use of medicines through collaboration and
consensus.
• NSW TAG committee = representatives from teaching
hospital Drug Committees in NSW and University
Departments of Clinical Pharmacology.
• The TAG network represents 46 NSW public hospitals
23 Participating Hospitals
Auburn Hospital
Murwillumbah Hospital
Bankstown Hospital
Prince of Wales Hospital
Blacktown Hospital
Royal North Shore Hospital
Mt Druitt Hospital
Royal Prince Alfred Hospital
Grafton Base Hospital
Southern AHS (7 hospitals)
Frankston Hospital (Vic)
Sydney / Sydney Eye Hospital
John Hunter Hospital
Westmead Hospital
Lismore Base Hospital
Wollongong Hospital
Mullumbimby Hospital
Approach
• DUE
– 3 cycles over 12 months, commenced in
September 2002
– Each cycle involved 1 week audit of ED
prescriptions for pethidine.
– Audit results fed back to prescribers
– Audit results directed education and messages
specific to local ED practice
Clinical Reference Committee
Prof Ric Day
Dr Andis Graudins
A/Prof Milton Cohen
Dr Alex Wodak
Dr Robert Dowsett
Ms Kanan Gandecha
Ms Margaret Knight
Mr Stuart Dorkin
Ms Kathleen Ryan
Ms Nolene Smith
Ms Susie Welch
Ms Karen Kaye
- Clinical Pharmacologist, SVH / NSWTAG
- Emergency Physician, Prince of Wales
- Pain Physician, Darlinghurst Pain Clinic
- Alcohol and Drug Specialist SVH
- Emergency Physician, Westmead
- Pharmaceutical Services, NSW Health
- Consumer
- ED Nurse, Westmead Hospital
- Quality Manager, St Vincents Hospital
- Project Officer, NICS
- ED Pharmacist, Project Officer, NSW TAG
- Executive Officer, NSW TAG
NSW TAG’s Role as Facilitator
• Hospital Coordinators
– SUPPORT them in their liaison with ED staff &
hospital committees
– PROVIDE materials to facilitate data collection,
education and feedback
– FACILITATE collaboration and sharing of experience
to help spread practice improvement
– COMMUNICATION strategies - email, monthly
teleconference, website (www.nswtag.org.au )
NSW TAG’s Role as Facilitator
• Coordinate evaluation of project progress.
– Data on volume of parenteral analgesics issued
from pharmacy departments each month
Strategies Audit/ Feedback Process
• Cycle 1
– Focus on educational messages
– Alternative treatment guidelines
 posters
 bookmarks
Audit/ Feedback Process
• Cycle 2
– Ongoing areas of concern
• morphine allergy
• colic
 Answers to Frequently Asked Questions
• patients seeking pethidine,
• feedback from consumer rep
 Patient Waiting Room Poster
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Ab
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Number of episodes
Have We Made a Difference ?
Use of pethidine in EDs: Indications identified to date
90
80
70
60
50
Audit 1
40
Audit 2
30
Audit 3
20
10
0
Have We Made a Difference ?
900
800
700
600
500
400
300
200
100
0
p0
O 2
ct
-0
N 2
ov
-0
D 2
ec
-0
Ja 2
n0
Fe 3
b0
M 3
ar
-0
Ap 3
r-0
M 3
ay
-0
Ju 3
n03
Total All
Number of Units
Pethidine issues to ED by Peer Grouping
Se
p0
O 2
ct
-0
N 2
ov
-0
D 2
ec
-0
Ja 2
n0
Fe 3
b0
M 3
ar
-0
3
Ap
r-0
M 3
ay
-0
Ju 3
n03
1800
1600
1400
1200
1000
800
600
400
200
0
Se
Number of units
Pethidine Issues to EDs
All hospitals
Total A
Total B
Total CD
Have We Made a Difference ?
Total issues of morphine to ED all hospitals
Total issues of Morphine to ED by Peer Grouping
7000
12000
Number of units
8000
Total All
6000
4000
2000
Number of units
6000
10000
5000
Total A
4000
Total B
3000
Total CD
2000
1000
0
0
Sep- Oct02
02
Nov- Dec- Jan02
02
03
Feb- Mar03
03
Apr03
May- Jun03
03
Sep- Oct02
02
Nov- Dec- Jan- Feb- Mar- Apr02
02
03
03
03
03
May- Jun03
03
Have We Made a Difference ?
Total issues of tramadol to EDs
All hospitals
1000
800
Total All
600
400
200
0
Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun02 02 02 02 03 03 03 03 03 03
Number of units
Number of units
Total issues of tramadol to EDs
All hospitals
Total A
600
500
400
300
200
100
0
Total B
Total CD
Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun02 02 02 02 03 03 03 03 03 03
What’s Next ?
Conclusion
• A clear reduction in ED use of pethidine has
occurred.
More importantly:
• Prescribers are thinking about
• alternatives
• most appropriate analgesia
• Promotion of information sharing between
pharmacists, nurses and doctors and ED
staff
 enable prescribers to make appropriate
treatment choices
Hospital Coordinators
Ms Wai-Jen Lee
Ms Charissa Salzmann
Ms Margaret Macarthur
Ms Helen Evans
Ms Paula Doherty
Ms Jenni Prince
Ms Linda Graudins
Ms Roseleen O’Doherty
Ms Vanessa Simpson
Ms Gabrielle Couch
Ms Cathy Vlouhos
Ms Lorraine Koller
Dr Rob Dowsett
Mr Lou Gaetani
Ms Mary Mitchelhill