Improving Analgesia in Emergency Departments: Optimising Use of Pethidine A Multi-centre DUE Project Coordinated by NSW Therapeutic Assessment Group Funded by National Institute for Clinical Studies

Is there a problem? We know: Australia’s consumption of pethidine ranks higher than other countries (Berbatis et al, MJA 2000; ) Australia’s consumption of pethidine ranks higher than other countries (Berbatis et al, MJA 2000; ) Prescribing of pethidine by GPs is of concern to NSW Health  TAG pain guidelines for migraine, low back pain and other chronic or recurrent non- malignant pain (revised 2002) Prescribing of pethidine by GPs is of concern to NSW Health  TAG pain guidelines for migraine, low back pain and other chronic or recurrent non- malignant pain (revised 2002) What about prescribing of pethidine in Emergency Departments?

Practice Pethidine prescribing in NSW hospitals: July–September 2001

Evidence Why pethidine is not recommended Why pethidine is not recommended 1 1 Pethidine   Has a s horter duration of action than morphine and no additionalanalgesic benefit   Has similar side-effects, including increased biliary pressure   Is metabolised to norpethidine, which has potential toxic effects (eg convulsions) especially in patients with renal dysfunction   Is associated with potentially serious interactions in combination with other drugs (eg anti-depressants, tramadol)   Is the drug most commonly requested by patients seeking opioids   Is the drug most commonly abused by health professionals 1 National Health and Medical Research Council. Acute pain management: scientific evidence, Commonwealth of Australia, 1999

The Pethidine in ED Project Using drug use evaluation to improve practice: Audit prescribing of pethidine in a range of Emergency Departments Compare prescribing with recognised evidence- based guidelines Identify and implement interventions to close the gap between evidence and practice Collaborate and share experience to help spread practice improvement

The DUE Cycle Implementing best practice Act Plan Act Plan Study Do

Clinical Reference Committee A/Prof Milton Cohen - Pain Physician, Darlinghurst Pain Clinic Dr Jan Davies- Project Officer, NICS Prof Ric Day - Clinical Pharmacologist, SVH / NSWTAG Mr Stuart Dorkin- ED Nurse, Westmead Hospital Dr Robert Dowsett - Emergency Physician, Westmead Hospital Ms Kanan Gandecha - Pharmaceutical Services, NSW Health Dr Andis Graudins - Emergency Physician, Westmead Hospital Ms Karen Kaye- Executive Officer, NSW TAG Ms Margaret Knight - Consumer Ms Kathleen Ryan- Quality Manager, St Vincents Hospital Ms Susie Welch- ED Pharmacist, Project Officer, NSW TAG Dr Alex Wodak- Alcohol and Drug Specialist SVH

Participating hospitals Auburn HospitalMurwillumbah Hospital Bankstown HospitalPrince of Wales Hospital Blacktown HospitalRoyal North Shore Hospital Mt Druitt HospitalRoyal Prince Alfred Hospital Grafton Base HospitalSouthern Area Health Service John Hunter HospitalSydney / Sydney Eye Hospital Lismore Base HospitalWestmead Hospital Mullumbimby HospitalWollongong Hospital

Data collection forms Pharmacy stock distribution reports

Data collection forms ED prescribing Please provide as much detail as possible about indication for use

Feedback reports Plus commentary

When do we start? First audit period starts: 20 January 2003 Feedback: Available in February for review and discussion by ED staff For further information or clarification contact: