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Minimising pethidine prescribing in EDs |
Consumption of pethidine in Australia ranks higher than in other countries of similar economic profile1. NSW Health authorities are also concerned with the amount of pethidine prescribed by GPs2.
In 2002 the NSW Therapeutic Assessment Group arranged to co-ordinate the “Improving Analgesia in Emergency Departments: optimising use of pethidine” project, funded by the National Institute for Clinical Studies. More than 20 hospitals took part, including three from the NRAHS.
Project
The project aimed to minimise the use of pethidine within the emergency department. It was anticipated that this would have a roll on effect to other wards/departments within the participating hospitals. Whole of hospital use of pethidine compared with morphine in the eight months before the project was determined for seven hospitals in the NRAHS. Two hospitals with a high use of pethidine (60% & 80%) and one referral hospital (30%) were nominated for the project.
Rationale
- Pethidine has a shorter duration of action than morphine and no additional analgesic benefits.
- Pethidine has similar side effects including increased biliary pressure.
- Pethidine is metabolised to nor-pethidine which has potential toxic effects, including convulsions, especially in patients with altered renal function.
- Pethidine is associated with potential serious reactions in combination with other drugs such as antidepressants and tramadol.
- Pethidine is the drug most commonly requested by patients seeking opioids.
Pethidine is the drug most commonly abused by health professionals.
The project, built around the Drug Use Evaluation (DUE) cycle, incorporated an audit of the pethidine prescribed in the ED; a comparison of the pethidine prescribed with evidence based guidelines; and the identification and implementation of intervention to close the gap between evidence and practice.
The audit phase was repeated three times within the project timeframe. A formal education session was delivered subsequent to the first audit. This session to doctors and nurses working in the EDs was concerned with evidence-based practice. Particular reference was made to renal and biliary colic, migraine, back and abdominal pain. An educational focus was maintained throughout the project by way of project report, practice guidelines, posters, bookmarks and an ED waiting room poster ‘Treating Your Pain’.
Large downturn in pethidine prescriptions
Overall, pethidine prescriptions for patients presenting to the ED decreased by 70% during the project period. Similarly pethidine units issued to the project EDs decreased by 82% reduction over the 12 month period. One hospital elected to remove pethidine from the ED during the project while another hospital did so at the end of the project.
The ‘roll-on’ effect was also achieved with improvements in whole hospital use of pethidine. At the same time other NRAHS sites invited the project education material and other resources to be introduced to their site. This has resulted in an 82% reduction in pethidine use across NRAHS hospitals over a 24-month period
Awareness raised
The project raised the awareness of evidence-based prescribing practice within the ED. There was an important decrease in pethidine use at the project sites and throughout the NRAHS in general. One other important point is that the DUE process of audit, education and evaluation is effective in bringing about change in prescribing practice. The use of pethidine throughout the NRAHS will continue to be monitored.
References
1. Berbatis et al, MJA 2000; 524-527
2. TAG pain guidelines for migraine, low back pain and other chronic or recurrent non-malignant pain (revised 2002). www.nswtag.org.au
3. Latta, KS., Ginsberg, B. and Barkin, RL. 2002. Meperidine: A Critical Review. American Journal of Therapeutics. Vol 9: pp53-68.
Jenni Prince, NRAHS CNC in pain management for the region, directed the NRAHS involvement in the project.
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