Improving Analgesia in Emergency Departments:

Optimising Use of PethidineA Multi-centre DUE Project

Coordinated by NSW Therapeutic Assessment Group

Funded by National Institute for Clinical Studies

Is there a problem?

We know: Australia’s consumption of pethidine ranks Australia’s consumption of pethidine ranks higher than other countries higher than other countries (Berbatis et al, MJA 2000;524-527)(Berbatis et al, MJA 2000;524-527)

Prescribing of pethidine by GPs is of concern to Prescribing of pethidine by GPs is of concern to NSW Health NSW Health TAG pain guidelines for migraine, TAG pain guidelines for migraine, low back pain and other chronic or recurrent non-low back pain and other chronic or recurrent non-malignant pain malignant pain (revised 2002)(revised 2002)

What about prescribing of pethidine in Emergency What about prescribing of pethidine in Emergency Departments?Departments?

PracticePractice

Hospital Pethidine units issued to ED

Pethidine units issued overall

Percentage ED/total

A 950 5,813 16.3%B 0 320 0.0%C 121 2,149 5.6%D 140 445 31.5%E 3,304 8,660 38.2%F 290 2,933 10.0%G 340 2,693 12.6%H 460 3,260 14.0%I 400 2,641 15.1%J 640 2,690 24.0%K 255 2,865 8.9%L 502 4,330 11.6%M 370 1,080 34.0%N 137 2,764 5.0%O 105 1,345 7.8%P 115 905 12.7%Q 200 2,190 9.0%R 389 2,224 17.5%

Average 15.2%

Pethidine prescribing in NSW hospitals: July–September 2001Pethidine prescribing in NSW hospitals: July–September 2001

EvidenceEvidence

Why pethidine is not recommendedWhy pethidine is not recommended1

Pethidine Has a shorter duration of action than morphine and no additional analgesic benefit Has similar side-effects, including increased biliary pressure Is metabolised to norpethidine, which has potential toxic effects (eg convulsions) especially in patients with renal dysfunction Is associated with potentially serious interactions in combination with other drugs (eg anti-depressants, tramadol) Is the drug most commonly requested by patients seeking opioids Is the drug most commonly abused by health professionals11 National Health and Medical Research Council. Acute pain management: scientific evidence, Commonwealth of Australia, 1999 National Health and Medical Research Council. Acute pain management: scientific evidence, Commonwealth of Australia, 1999

The Pethidine in ED Project

Using drug use evaluation to improve practice:

Audit prescribing of pethidine in a range of Emergency Departments

Compare prescribing with recognised evidence-based guidelines

Identify and implement interventions to close the gap between evidence and practice

Collaborate and share experience to help spread practice improvement

The DUE Cycle

Implementing best practiceImplementing best practice

Act Plan Act Plan

Study Do Study Do

Clinical Reference Committee

A/Prof Milton Cohen A/Prof Milton Cohen - Pain Physician, Darlinghurst Pain Clinic - Pain Physician, Darlinghurst Pain Clinic Dr Jan DaviesDr Jan Davies - Project Officer, NICS- Project Officer, NICSProf Ric Day Prof Ric Day - Clinical Pharmacologist, SVH / - Clinical Pharmacologist, SVH / NSWTAGNSWTAGMr Stuart DorkinMr Stuart Dorkin - ED Nurse, Westmead Hospital- ED Nurse, Westmead HospitalDr Robert Dowsett Dr Robert Dowsett - Emergency Physician, Westmead - Emergency Physician, Westmead HospitalHospitalMs Kanan Gandecha Ms Kanan Gandecha - Pharmaceutical Services, NSW Health- Pharmaceutical Services, NSW HealthDr Andis Graudins Dr Andis Graudins - Emergency Physician, Westmead - Emergency Physician, Westmead HospitalHospitalMs Karen KayeMs Karen Kaye - Executive Officer, NSW TAG- Executive Officer, NSW TAGMs Margaret KnightMs Margaret Knight - Consumer- ConsumerMs Kathleen RyanMs Kathleen Ryan - Quality Manager, St Vincents Hospital- Quality Manager, St Vincents HospitalMs Susie WelchMs Susie Welch - ED Pharmacist, Project Officer, NSW TAG- ED Pharmacist, Project Officer, NSW TAGDr Alex WodakDr Alex Wodak - Alcohol and Drug Specialist SVH - Alcohol and Drug Specialist SVH

Participating hospitals

Auburn HospitalAuburn Hospital Murwillumbah HospitalMurwillumbah Hospital

Bankstown HospitalBankstown Hospital Prince of Wales HospitalPrince of Wales Hospital

Blacktown HospitalBlacktown Hospital Royal North Shore HospitalRoyal North Shore Hospital

Mt Druitt HospitalMt Druitt Hospital Royal Prince Alfred HospitalRoyal Prince Alfred Hospital

Grafton Base HospitalGrafton Base Hospital Southern Area Health ServiceSouthern Area Health Service

John Hunter HospitalJohn Hunter Hospital Sydney / Sydney Eye HospitalSydney / Sydney Eye Hospital

Lismore Base HospitalLismore Base Hospital Westmead HospitalWestmead Hospital

Mullumbimby HospitalMullumbimby Hospital Wollongong HospitalWollongong Hospital

Data collection forms

Pharmacy stock distribution reports

Data collection forms

ED prescribing

Please provide as much detail as possible about indication for usePlease provide as much detail as possible about indication for use

Feedback reportsEXAMPLE OF FEEDBACK TO ED STAFF

Indication A Indication B Indication CIntern 4 4 3RMO1 5 2 1RMO2 5 3 2Reg 3 2 3Staff specialist 2 3 4

Pethidine prescribing by designation

0123456

Designation

Nu

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pre

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Indication A

Indication B

Indication C Plus Plus commentarycommentary

When do we start?

First audit period starts:20 January 2003

Feedback: Available in February for review and discussion

by ED staff

For further information or clarification contact: