Limited awareness of UK changes in the assessment and management of paracetamol overdose by Emergency Physicians one week after MHRA guidance that required immediate implementation.

DM Wood1,2, PI Dargan1,2. 1Clinical Toxicology, Guy\'s and St Thomas NHS Foundation Trust and King\'s Health Partners, London, UK, 2King\'s College London, London, UK

Background

Previously in the UK, “risk stratification” was used to determine whether an individual with paracetamol overdose was at higher risk of paracetamol-related hepatoxicity, with lower treatment thresholds for those deemed to be at higher risk. Following a recent review by the Commission on Human Medicines (CHM), the Medicines and Healthcare Products Regulatory Agency (MHRA) issued new guidance on the management of paracetamol overdose. This removed the risk stratification process and recommended treatment according to a single treatment nomogram line starting at 100mg/L at 4 hours falling to 15mg/L at 15 hours. These changes were announced for immediate implementation on 3rd September 2012. They were disseminated to UK clinicians by the following means: i) communication by MHRA to all UK hospital Chief Executives; ii) e-mail communication from the College of Emergency Medicine (CEM) to all fellows and members; iii) updated information on TOXBASE; and iv) a safety warning and alert on the MHRA website. We investigated the knowledge of these changes in a cohort of UK emergency physicians one week following its intended immediate implementation.

Methods

A single page questionnaire was designed to capture data from Emergency Department (ED) physicians attending a CEM one day clinical toxicology course on their awareness of these changes in paracetamol overdose management. Data collected included: i) grade of doctor; ii) hospital of primary practice; and iii) awareness of the changes in paracetamol overdose management. For those who indicated that they were aware of the changes, they were asked where they had heard of the changes and whether they had changed their clinical practice.

Results

Forty-four (89.8% of those attending) individuals (30 consultants, 5 associate specialists and 9 specialist trainees) completed the questionnaire; they worked in a total of 28 different UK Emergency Departments. Only 24 (54.5%) stated that they were aware of the changes in UK assessment and management of paracetamol poisoning. Of those who were aware of the changes, this was predominately through the CEM e-mail alert (14 respondents (58.3% of those who were aware); other sources of awareness were: MHRA website (6, 25.0%); internal alert following MHRA communication to Chief Executives (5, 20.8%); and updated TOXBASE pages (1, 4.2%). Management of paracetamol poisoning had been modified following the MHRA guidance by only 16 physicians (36.4% of all respondents, 66.7% of those who were aware of the guidelines).

Conclusion

Despite the significant implications of the change in practice following the CHM review and the MHRA dissemination of new guidance for immediate implementation, there appeared to be limited awareness of this amongst ED physicians. It appears that CEM e-mail alert had greatest impact in raising awareness in this cohort. Greater understanding of the most appropriate methods of disseminating information alerts which could have significant impact on patient safety is required, as the many of the current methods do not appear to be robust.