Recording Weights and Paracetamol Use on Care of the Elderly Wards

1. Problem/Background • Paracetamol is a potentially hepatotoxic drugand is one of the most commonly prescribed in hospital. • - The dose given needs to be adjusted when given via the intravenous route for patients weighing less than 50kg. Some evidence suggests it should be adjusted when given orally in underweight patients as well1, 2. • - Patients’ weights are often not written on there drug charts. As a result, it is difficult for doctors to prescribe weight-dependant drugs, including paracetamol, safely. Baseline Measurement I. Weights: 15% of patients had their weight recorded on their drug chart II. Paracetamol prescribing in patients <50kg: 25% of patients (4 of 16) on oral paracetamol had an adjusted dose Only 2 patients were on iv paracetamol – both on an adjusted dose • Project Design/Strategy • I. Baseline data collection: • Drug charts were analysed once a week for four weeks in October 2013 to establish baseline measures • The charts for all patients on three care of the elderly wards at the Royal Devon and Exeter hospital were included (except those receiving end-of-life-care) • All analysed charts were marked and excluded the following weeks • 209 charts were analysed in total • II. Intervention • Presentation of baseline measurements with discussion at care of the elderly doctors’ educational meeting • Discussion with ward matrons and members of nursing staff • Posters of baseline measurements with educational material on all three wards • III. Outcome data collection • The drug charts were re-analysed once a week for four weeks in March/April 2014 following the intervention period • The charts for all patients on the same three care of the elderly wards at the Royal Devon and Exeter hospital were included (except those receiving end-of-life-care) • All analysed charts were marked and excluded the following weeks • 198 charts were analysed in total Recording Weights and Paracetamol Use on Care of the Elderly Wards Figure 1. Recording of weights Stephanie Wilsona, James Kearneya and Ray Sheridanb a. Foundation Year 1 Doctors, Royal Devon and Exeter Hospital. b. Health Care for the Elderly Consultant, Royal Devon and Exeter Hospital. Contact: stephanie.wilson11@nhs.net. Figure 2. Oral paracetamol prescriptions in patients <50kg Results I. Weights 30% of patients had their weight recorded on their drug chart II. Paracetamol prescribing in patients <50kg: 27% of patients (3 of 11) on oral paracetamol had an adjusted dose Only 2 patients were on iv paracetamol – only one on an adjusted dose Lessons Learnt - Our intervention made a small difference in the recording of weights on the drug chart. No improvement in paracetamol dosing was achieved. - The intervention we conducted was not sufficient enough to change practice. Further intervention is required to improve these outcomes - Mandatory training for doctors and pharmacists would help to ensure that paracetamol doses are adjusted correctly - More prominent positioning of the weight box (perhaps alongside the allergies box) would help improve recording on drug charts. - Ultimately, electronic prescribing would be the gold standard for ensuring that doses adjusted to weights are always used. • References: • Claridge, Eksteen, Smith, Shah and Holt (2010). Acute liver failure after administration of paracetamol at the maximum recommended daily dose in adults. BMJ, Vol. 341, pp. 1269-70 • Pearce and Grant (2008). Acute liver failure following therapeutic paracetamol administration in patients with muscular dystrophies. Anaesthesia, 63, pp. 89-91