1. 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

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

3. 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

4. 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)

5. Subjects & Methods (1)
Snap shot of Paracetamol Proforma

6. 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

7. 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 ed 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

8. 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 (%)

9. 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

10. 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%

11. 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%

12. 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%

13. 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%

14. 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%

15. 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

16. 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

17. 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

18. 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!