Management of Paracetamol Overdose - Closing the loop in the audit cycle part of the National Audit coordinated by the College of Emergency Medicine Drs Amjed Eljaili Elfaki & James Rigby August 2015 – October 2015 Emergency Department, Ysbyty Gwynedd

Overview Aims of the audit College Emergency Medicine (CEM) standards Subjects & Methods New proforma/guidance sheet Results Compliance with guidelines Conclusions

Aims Gain an insight into extent of Paracetamol OD at Ysbyty Emergency Department Educate ED doctors and nurses (via teaching sessions and at induction) on management of paracetamol OD and promote use of new proforma Re-audit compliance of our department (after the above interventions) at following RCEM standards and compare with results from last audit in 2013

CEM Standards Plasma levels should not be measured earlier than 4 hours after the estimated ingestion time Staggered overdoses - treatment started within one hour of arrival Patients arriving < 8 hours after ingestion - treatment given as per the 2012 MHRA guideline Patients arriving 8 to 24 hours after ingestion – treatment started before blood results available if there is a clear history of > 6 g ingestion (or 75 mg/kg whichever is the smaller)

Subjects & Methods (1) Snap shot of Paracetamol Proforma

Subjects & Methods (2) Based on the ED’s audit performance in 2013 the following areas were identified as key areas for improvement: Recording OD size Not testing paracetamol levels too early Giving NAC within 1h for presentations >8h and staggered overdoses

Subjects & Methods (3) Following plan was actioned throughout July 2015 before data collection commenced on 10th August 2015: Nursing involvement – identify lead nurse or interested nurse – consider guide for triage; printing off proforma and highlighting patients who need immediate NAC All nurses in ED were emailed details of new proforma Deliver SHO teaching session on Management of Paracetamol OD Promote use of new proforma at ED SHO induction 6th August 2015

Subjects & Methods (4) Retrospective audit 30 patients 10th August – 29th October 2015 Following data were recorded: Case Mix: Number of patients audited: Who presented within 1 hour of ingestion (%) Who presented within 8 hours of ingestion (%) Who presented within 24 hours of ingestion (%) Who took a staggered overdose (%)

Subjects & Methods (5) Assessment and Treatment (%): Overdose size recorded Overdose size more than 6g or 75mg/kg Declined treatment (% of all cases), of which had capacity to consent (%) Received plasma level test in ED (% of all cases) of which plasma level tested earlier than 4 hours after ingestion (excludes staggered doses) Where tested within 8 hours of ingestion and plasma concentration above treatment level (% of all cases) of which received N-acetylcysteine (NAC) within 8 hours of ingestion Where dose >6g (or 75mg/kg) and over 8 hours since ingestion of which received N-acetylcysteine (NAC) within 1 hour of arrival Staggered overdoses receiving NAC within 1 hour of arrival

Results; Case Mix 2015 2013 Number of patients audited 30 47 Who presented within 1 hour of ingestion (%) 7% 13% Who presented within 8 hours of ingestion (%) 53% 66% Who presented within 24 hours of ingestion (%) 70% Who took a staggered overdose (%) 17% 19%

Results; Assessment & Treatment (1) 2015 2013 OD size recorded (% all cases) 100% 77% Overdose size more than 6g or 75mg/kg (% of all cases) 80% 66% Declined treatment/lacked capacity (% of all cases) 3% 0%

Results; Assessment & Treatment (2) 2015 2013 Received plasma level test in ED (% of all cases) 93% (1 patient declined test, 1 not tested) 98% …..of which plasma level tested earlier than 4 hours after ingestion (excludes staggered doses) % 0% 7% Where tested within 8 hours of ingestion and plasma concentration above treatment level (% of all cases) 10% 28% …..of which received N-acetylcysteine (NAC) within 8 hours of ingestion (%) 67% 77%

Results; Assessment & Treatment (3) 2015 2013 Where dose >6g (or 75mg/kg) and over 8 hours since ingestion (% all cases) 27% 6% ….. of which received N-acetylcysteine (NAC) within 1 hour of arrival 40% 0% Staggered overdoses receiving NAC within 1 hour of arrival (% all cases) 7%

Results; Compliance of treatment with MHRA guidelines 2015 2013 Yes - recommended treatment received 77% 85% Yes - recommended Partially in accordance with recommended treatment 23% 15% No - serious omissions in treatment 0%

Partly met recommendations Delay in NAC; 6 patients 5 patients presented between 4-8 hours post-OD and therefore paracetamol levels not known within 8 hours post-OD For these patients NAC should have been started within 1 hour of arrival Main reasons for failure include: Average waiting time 2 hours/failure to prioritise at triage Nursing delay in administering NAC within 1 hour after being prescribed

Partly met recommendations Delay in NAC; 6 patients 1 patient (17 yrs) presented 24 hours post-OD, dose >6g (or 75mg/kg). Blood taken for levels but NAC not started until after transfer to Paeds ward NAC should have been started within 1 hour of arrival before ward transfer

Conclusions (1) Majority of patients continue to present within 8 hours of paracetamol OD Improvement in documentation of OD size; 100% compared to 77% in 2013 Improvement in not testing levels earlier than 4 hours after ingestion (excluding staggered doses); 0% compared to 7% in 2013 Improvement in managing patients presenting >8 hours since of which received N-acetylcysteine (NAC) within 1 hour of arrival; 40% compared to 0% in 2013

Conclusions (2) Improvements are still required in giving NAC to patients presenting within 8 hours post-OD, when levels won’t be available before 8 hours; 67% (down 10% from 77% in 2013)  delay in NAC led to ‘partial recommendations of 23% ‘Serious omission’ rate remains at 0% - compares well with other ED’s back in 2013!