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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
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
mb
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pa
tie
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pre
sc
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pe
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Indication A
Indication B
Indication C Plus Plus commentarycommentary