Emergency Overdose Management in a Working age Adult Inpatient Psychiatric Hospital

Introduction

Dr Amber Broekhuizen

Methodology

Drug overdoses occur frequently among psychiatric inpatients, however the incidence of this across the country is not known. NICE guidelines (1) recommend TOXBASE advice pages (2) for common overdoses, which provide algorithms for optimal management. This project focused on paracetamol overdoses as these are common overdoses seen in this hospital and one of the most common overdoses presenting to emergency care services in the UK (3). TOXBASE guidelines recommend the following parameters with regards to paracetamol overdoses: ü Patients should be referred for medical assessment if they have ingested over 75mg/kg of paracetamol, or if they are symptomatic ü Activated charcoal may be of benefit if given within an hour of ingestion of 150mg/kg of paracetamol causative

From observation of the treatment overdoses at one inpatient psychiatric hospital, it was noted that management does not often align with these guidelines due to multiple factors such as delayed A&E presentation for multiple reasons, and lack of stock of recommended medications, namely activated charcoal.

This project aims to ensure that the vulnerable and often marginalised population of psychiatric inpatients have equal and timely access to potentially life-saving treatment, working within the constraints of A&E pressures and complex mental health inpatient dynamics.

Project Aim: by October 2023 increase the number of eligible cases of patients with paracetamol overdose in working age inpatient psychiatry offered activated charcoal treatment as per NICE guidelines by 50%.

Results

Common themes surrounding this issue were drawn from observation of clinical practice in hospital. Discussion with key stakeholders and members of the healthcare team with an expertise in overdose management revealed various causative factors, which were explored with the use of a fishbone diagram (Figure 1).

A case note review of overdoses in the last 3 months was completed to assess alignment with optimal management, using the TOXBASE guidelines (2) for paracetamol overdose as per NICE recommendation. (1) Each case was assessed for whether activated charcoal was appropriate using the following criteria: ü Paracetamol ingestion over 150mg/kg ü Staff informed within an hour of overdose

Criteria such as documented delay in A&E attendance and reasons for this were also noted to inform recommendations. Findings were presented to the Physical Health Group for Gloucestershire Health and Care, and recommendations were made to improve care. Each action will be monitored using a PDSA cycle model to check for improvement in the following areas: ü Was activated charcoal discussed with the patient if appropriate? ü Was outcome/refusal documented? ü How many times has activated charcoal been used in hospital since stocking?

Systematic factors

- Short staffing – delays in A&E attendance

- Long wait times to be seen by doctor in A&E

- Unclear how many overdoses occur in hospital

- Patient dislike of the A&E environment

- Refusal of treatment

- Misunderstanding and lack of Awareness of risks of overdose

Pharmacy and stock

- Activated charcoal not stocked in hospital

- Location of medicine for availability across wards

- No TOXBASE login for trust

- Understanding of use of activated charcoal

- Urgency of overdose management

- Importance of documentation

- Awareness of OD guidelines

Patient centred factors

Case note review was completed and yielded 8 cases of overdose over 4 months. In all cases there was a documented delay in A&E attendance. In 50% of cases, staff were informed within an hour of an overdose which would have warranted considering activated charcoal.

On examination of these case notes, it became clear that delay in A&E attendance was due to two main factors:

Firstly, patient refusal to attend A&E contributed to most delays. This could be further subdivided into two groups; patients who disliked the A&E environment and did not wish to attend due to the busy nature of the department or the long wait times, and patients who were refusing treatment altogether regardless of the setting. In the former situation it was not possible to start recommended treatment in the psychiatric ward environment because activated charcoal was not stocked in the hospital.

Secondly, delays were also caused either by short staffing in the psychiatric hospital, or long wait times in A&E. Short-staffing results in lack of staff availability to accompany patients to A&E, causing delays where patient was consenting to attend A&E but staff could not compromise safe staffing levels on the inpatient unit. Furthermore, there was one case where the time period for activated charcoal lapsed due to wait times in A&E.

Staff Awareness/Education

Recommendations

These findings were collated and presented to the inpatient Physical Health Group, where the multidisciplinary team generated recommendations as follows:

- Activated Charcoal to be stocked in hospital for a 6 month trial.

- Partnership with the local A&E to develop a Standard Operating Procedure which will assist clinical decision making.

- Ward staff education sessions to raise awareness of overdose management and ensure prompt action and documentation where appropriate

These action points will be assessed for effectiveness using a PDSA cycle process. The assessment will centre around the criteria described in the methods section, and further recommendations developed from repetitive cycles of improvement.

Learning Points

This process provided an opportunity to better understand the process of changing hospital policy as a member of the healthcare team. It was a new and exciting experience to become involved in the process of improving care and it also revealed the challenges associated with interventions that require approval from multiple departments and healthcare teams. In fact this obstacle highlighted the need for a multidisciplinary approach to intervention, in order to maintain a safe and cohesive healthcare environment.