improving analgesia: farewell to pethidine

1. 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.

2. NSW health concerned for some time about pethidine use by GPs and hence commissioned NSW TAG to prepare evidence -based guidelines on the rational use of opioids for primary care physicians. Attempts to implement these guidelines and discourage GP use of pethidine was countered by ongoing use of pethidine in hospitals. This was information obtained from GP divisions as well as from a survey of 18 NSW hospitals which showed that many hospitals still used it with ED use accounting for a significant proportion of this use. So it was important to target ED use of pethidine so that successful implementation of these guidelines could occur as well as promoting best practice in EDs across the state..So this is the second step in the process.NSW health concerned for some time about pethidine use by GPs and hence commissioned NSW TAG to prepare evidence -based guidelines on the rational use of opioids for primary care physicians. Attempts to implement these guidelines and discourage GP use of pethidine was countered by ongoing use of pethidine in hospitals. This was information obtained from GP divisions as well as from a survey of 18 NSW hospitals which showed that many hospitals still used it with ED use accounting for a significant proportion of this use. So it was important to target ED use of pethidine so that successful implementation of these guidelines could occur as well as promoting best practice in EDs across the state..So this is the second step in the process.

3. 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

4. ADRAC reaction reports

5. Evidence-based Guidelines: In this project data was evaluated against recognised evidence - based guidelines and the message from all of these was that pethidine is not the strong analgesic of choice in the Emergency DepartmentIn this project data was evaluated against recognised evidence - based guidelines and the message from all of these was that pethidine is not the strong analgesic of choice in the Emergency Department

6. Aim To increase awareness of limitations of pethidine To encourage use of appropriate alternatives

7. 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

8. The DUE Cycle Drug Use Evaluation is a methodology which has been used for many years by drug and Therapeutics Committees and pharmacists. It uses information about drug use to focus educational strategies. It overlaps with quality improvement cycles such as the IHI methodology. (differences for Qs) Identify and implement interventions to close the gap between evidence and practice Drug Use Evaluation is a methodology which has been used for many years by drug and Therapeutics Committees and pharmacists. It uses information about drug use to focus educational strategies. It overlaps with quality improvement cycles such as the IHI methodology. (differences for Qs) Identify and implement interventions to close the gap between evidence and practice

9. 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 TAG network invited NSW public hospitals 23 hospitals participating TAG network invited NSW public hospitals 23 hospitals participating

10. 23 Participating Hospitals

11. 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

12. Clinical Reference Committee The CRC was comprised of Drs, RNs, pharmacists, quality representatives and consumers. Their role was to: identified the key messages for the educational material and to advise on strategiesto use to impart these key messages to the prescribers advised Hospital CoordinatorsThe CRC was comprised of Drs, RNs, pharmacists, quality representatives and consumers. Their role was to: identified the key messages for the educational material and to advise on strategiesto use to impart these key messages to the prescribers advised Hospital Coordinators

13. 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 )

15. NSW TAG�s Role as Facilitator Coordinate evaluation of project progress. Data on volume of parenteral analgesics issued from pharmacy departments each month Pharmacists collected data on the volume of parenteral analgesics issued from pharmacy departments each month throughout the project to evaluate if the project was making a difference. This data would show if pethidine usage was reducing and if any new problems were being created, such as an increase in the use of less appropriate analgesics replacing pethidine.Pharmacists collected data on the volume of parenteral analgesics issued from pharmacy departments each month throughout the project to evaluate if the project was making a difference. This data would show if pethidine usage was reducing and if any new problems were being created, such as an increase in the use of less appropriate analgesics replacing pethidine.

16. Strategies - Audit/ Feedback Process Cycle 1 Focus on educational messages Alternative treatment guidelines ? posters ? bookmarks

19. 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

21. Have We Made a Difference ?

22. Have We Made a Difference ? There has been an overall reduction in the use of pethidine . This appears to correlate with the timing of audit cycles which were in Jan and April. This trend in reduction occurred in all peer groupings. It was most marked in Peer groupings A and B where there were the most hospitals, where. hospital peer groups are a = principal referral, B= major non-teaching, C= district, D = community hospitalsThere has been an overall reduction in the use of pethidine . This appears to correlate with the timing of audit cycles which were in Jan and April. This trend in reduction occurred in all peer groupings. It was most marked in Peer groupings A and B where there were the most hospitals, where. hospital peer groups are a = principal referral, B= major non-teaching, C= district, D = community hospitals

23. Have We Made a Difference ? As would be expected there was an increase in the use of morphine. This was not a huge increase.As would be expected there was an increase in the use of morphine. This was not a huge increase.

24. Have We Made a Difference ? An area of concern was the marked increase in tramadol use in EDs possibly in response to the reduction in pethidine use.An area of concern was the marked increase in tramadol use in EDs possibly in response to the reduction in pethidine use.

25. What�s Next ?

26. 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

27. 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