AUDIT ON PARACETAMOL OVERDOSE

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AUDIT ON PARACETAMOL OVERDOSE

• BY
• DR Chinedu Anosike
• Supervised by Dr Najeeb Rahman

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AIMS AND OBJECTIVES

• This is a retrospective audit on the management
  of patients who were admitted through the AE
  department with Paracetamol overdose between
  August and November 2006. The aims of the audit
  were as follows
• To assess the compliance of AE doctors with BAEM
  Guidelines set by the clinical effectiveness
  committee for the management of Patients
  presenting with Paracetamol overdose.
• To determine the extent to which AE patients
  risk stratify patients presenting to the
  department with Paracetamol overdose.
• To compare results obtained with previous audits
  carried out in the trust.

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BACKGROUND

• Paracetamol Poisoning is a very common
  presentation to the AE department. Studies
  carried in 2003 out by J.Turvill et al and
  published in the lancet revealed that Paracetamol
  overdose is the most common cause of deliberate
  self-harm in the UK with an incidence of 70,000
  cases per year.
• Several studies have shown that Hepatotoxicity
  from Paracetamol Overdose has surpassed Viral and
  seronegative hepatitis as the commonest cause of
  acute liver failure in the UK.

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• The Health care Commission in the UK, while
  evaluating 200 AE departments in 2005, used the
  Management of patients presenting with
  Paracetamol overdose as one of the yardsticks for
  monitoring quality of care and clinical
  effectiveness
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•  

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STANDARD

• Current Guidelines for Management of Paracetamol
  overdose are based on consensus recommendations
  developed by the National Poisons Information
  Services published in 2003
• This was adopted by the Royal College of
  Paediatrics and Child Health and the British
  Association of Emergency Medicine.
• Current practice was examined against standards
  established by the BAEM clinical effectiveness
  committee last ratified in January 2006.
•  
•  
•  

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EVIDENCE BASED FLOW CHART FOR THE MANAGEMENT OF
PARACETAMOL OVERDOSE
From EMJ 200219202
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METHOD

• A list of all patients who were admitted through
  AE with Paracetamol overdose between August and
  November 2006 was obtained from clinical coding.
• Those that took a mixed overdose of tablets
  including Paracetamol and those who presented 24
  hours post overdose were excluded from the audit,
  leaving 41 patients.
• The management of these patients was then
  compared to the standard described above.
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•  

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Estimated Dose taken

lt 12g or 150mg/Kg
 
gt12g or 150mg/kg
Missing 2.4
48.8
48.8
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Time of Ingestion to arrival

lt 1hr 19.5
1-8hrs 58.5
gt8hrs 2.4
Staggered 17.1
Missing 2.4
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Timing of Blood test
At 4hrs-53.7
gt4hrs-24.4
Staggered-14.6
Missing-7..3
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Time of starting treatment
 

Rx within 60mins 5
Rx after 60min 20
No Rx 75
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Assessment of High risk Factors
 

RF Assessed
RF Not assessed
Missing
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Overall Compliance with guidelines
 

Well Treated 34.1
Some omissions 41.5
Serious omissions 17.1
Missing 7.3
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DISCUSSION 1

• A large number of the patients presenting with
  Paracetamol overdose did so within 8hrs following
  the ingestion. This is significant because one of
  the aims of management is to treat those with
  levels above12g or 150mg/ kg within an 8hr window
  post ingestion to prevent hepatotoxicity.
• 19. 5 of the patients presented within the first
  hour of taking the overdose. All of these
  patients received activated Charcoal at
  assessment.
• A substantial percentage (17.1) presented with
  staggered overdose.Most of the patients (53.7)
  had blood tests at 4 hours of ingestion .

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DISCUSSION 2

• A high percentage had bloods done after 4 hours,
  though some of this can be attributed to late
  presentation. A few of the cases were also due to
  time taken from arrival in AE to assessment
• Only 5 of patient requiring treatment received
  it within 60mins of arrival. This may also be
  attributed to the time taken to get assessed.
• A large number of the patient that presented with
  estimated ingestion of Paracetamol greater that
  12g or150mg/kg (75) were not treated.

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DISCUSSION 3

• Majority of the patients were assessed for risk
  factors of hepatotoxicity such as past medical
  and drug history and full social history
  including alcohol and drug use.
• In general there were some omissions in the
  management of 41.5 of the patients seen, while
  34.1 of them were fully managed according to
  guidelines.

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RECOMENDATIONS

• There is need for continuing education of
  doctors and nurses on the guidelines for
  management of Paracetamol overdose,and the high
  risk of hepatotoxicity arising from poor
  treatment of poisoning
• It may be useful to introduce a proforma for
  clerking in patients with Paracetamol overdose in
  order to ensure that important aspects of the
  management are addressed.
• There is need to treat patients with reasonable
  history of large overdose before blood levels
  become available.

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Thank you!!!
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