Prescribing Practices in Emergency Departments in Ireland

1
Prescribing Practices in Emergency Departments in
Ireland

• Name Mark Foley
• Department Emergency Medicine
• Supervisor Dr S. Cusack

2
Introduction

• Treatment of pain is a key aspect of emergency
  medicine.
• Commonly under treated.
• The use of evidence-based hospital protocols for
  analgesia have been shown to improve the
  provision of analgesia.
• These protocols are derived from the WHO pain
  ladder.
• In the Cork area the guidelines of the BAEM are
  used.

3
Aims

• To explore prescribing practices for pain and
  nausea of doctors working in EDs in Ireland.
• To determine if doctors are aware of hospital
  protocols and if they are following these
  protocols when prescribing.
• To compare these practices with a sample group of
  US emergency medicine doctors.
• To review the literature to determine if recent
  trials suggest new treatment options or if
  current guidelines require review.

4
Methods

• Using convenience sampling, a brief questionnaire
  was administered to doctors working in emergency
  departments at six hospitals around Ireland.
• An identical questionnaire was also administered
  to doctors working in the ED at SJMMC in St Louis
  Missouri.
• These results were analysed using SPSS software.
• A pubmed search was performed looking for
  emergency department based clinical trials
  involving analgesia or anti-emetics and relevant
  articles were then retrieved.

5
Results

• 51 Emergency Department doctors were surveyed (40
  Irish and 11 US).
• Mean level of experience 6.4 years for Irish
  doctors and 16.9 years for US doctors.
• 77.5 of Irish and 45 of US respondents were
  aware of hospital protocols for analgesia.
• When administering a strong narcotic, 50 of
  Irish and 28 of US respondents will always co
  administer an anti-emetic.
• 47.5 of Irish and 72 of US respondents will
  only administer an anti-emetic if patient
  develops nausea.

6
Pain Relief

• 100 of US and 67.5 of Irish doctors cited
  clinical experience as their primary factor in
  choosing particular analgesia.
• 20 of Irish doctors report following hospital
  protocol as their primary factor when prescribing
  (28 of junior staff Vs 6.7 senior staff).
• 90 of Irish and 54 of US doctors were correctly
  following guidelines for all levels of pain.
• Those not following guidelines were more likely
  to over treat pain for each step of the ladder.
• For treating severe pain, the majority of both
  Irish and US doctors use Morphine (87.5 and 82)
  as their analgesic of choice.

7
Analgesic of Choice forModerate Pain
8
Analgesic of Choice forMild Pain
9
Primary Factor in ChoosingAnti-Emetic
10
Anti-Emetic of Choice
11
Review of Literature

• Few trials carried out in Emergency departments
  comparing analgesics or anti-emetics.
• New evidence suggesting the addition of NSAID to
  Paracetamol does not improve analgesia for
  moderate pain in acute musculoskeletal injury.
• 0.1mg/kg of Morphine may not be adequate to
  relieve severe pain.
• Ondansetron has not been proven in a clinical
  trial to be superior than metoclopramide in the
  treatment of nausea in the ED, and it costs over
  20 times as much!!
• There is a low incidence of N/V when using
  opiates in the ED, therefore the literature does
  not support routinely co administering anti
  emetics

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Conclusion

• Current prescribing practices among Irish doctors
  closely follow recommended guidelines.
• Increase in awareness of hospital guidelines
  needed to ensure staff stay abreast of latest
  research.
• The habit of co-administering anti-emetics when
  prescribing strong narcotics should be
  discouraged.
• This study did not explore what treatment
  patients actually receive in the ED, or how
  doctors assess pain. This is an area for further
  research.
• More ED-based clinical trials involving treatment
  of pain and nausea are needed.

13
Thank You!

• Staff at CUH, MUH, SIVH, Mallow General,
  Limerick Regional, UCHG, Beaumont Hospital,
  SJMMC, Dr S Cusack, Ms Charlene Talir