P71
PARADIGM SHIFT TO ORAL PARACETAMOL AND IBUPROFEN AS PREMEDICATIONS TO REDUCE CARBON FOOTPRINT AND IMPROVE COST EFFECTIVENESS IN PAEDIATRIC THEATRES
M. S. Bakir, Royal London Hospital, UK
Introduction
For paediatric surgical procedures in our department, the predominant practice has been to administer intravenous paracetamol and diclofenac intraoperatively. Paracetamol has similar efficacy and safety profile when given orally or intravenously, as do intravenous diclofenac and oral ibuprofen. However there are significant differences between intravenous and oral preparations in terms of cost-effectiveness and environmental impact. This project aimed to develop a pathway and system to move from intraoperative administration of intravenous paracetamol and diclofenac, towards patient-centred nurse-led administration of oral paracetamol and ibuprofen as premedication.
Methods
The project represented a shift in practice and required consideration of potential risks and challenges. The proposed system relied on nurses having the confidence and competence to prescribe and administer analgesia on admission, requiring education on dose calculations and contra-indications, and electronic prescribing training. A decision-making flowsheet was created to facilitate nurse-led weight-adjusted dose calculations and prescriptions on admission. Patient Group Directives (PGDs) were created that included doses, indications and contra-indications. The support of the anaesthetic clinical team was crucial to implementation, including troubleshooting nurses’ queries. The risk of repeat analgesic administration intraoperatively was addressed by ensuring handover of administered premeditations once patient transferred to theatre; incorporating record of administration in preoperative checklist; signing administration electronically; checking administration in theatre sign-in; including premedication in WHO checklist.
Results
The proposed changes were well received by nursing staff, management, pharmacists and anaesthetists. The explanation of the problem highlighted the issue, and the suggested solutions were seen to be realistic and achievable. The clarity of the decision making flow-chart and PGDs helped enhance the safety of the changes and the empowerment of nurses. The anaesthetic department was on board and actively supported the ward in premedication prescription queries. Handover in theatre was effective and adjustments to sign-in sheets and WHO checklist introduced.
Discussion
Cost-effectiveness and environmental impact are crucial factors in the current financial and environmental climate. When considering packaging, administration supplies, transport and waste disposal processes, the carbon-footprint of intravenous paracetamol is twelve-times that of oral tablets, and twice that of oral liquid preparations. Similarly, the cost of intravenous paracetamol is thirteen-times that of oral tablets, and twice that of oral liquid preparations. This is compounded in children, where weight-adjusted doses are extracted from bottles and the remainder discarded for infection control, posing an additional financial and environmental burden. Oral liquid preparations enable administration of doses to different patients from the same bottle, without risking cross-infection. The shift towards a strategy for administering oral analgesia as premeditation worked towards reducing theatre costs and carbon-footprint, and increased theatre utilisation and efficiency. Furthermore, it was seen to improve patient care, as the oral preparations had time to be effective for the start of the procedure.
Reference:
Davies J McAlister S, Eckelman M, McGain F, Seglenieks R, Gutman E, Groome J Palipane, Latoff K, Nielsen D, Sherman J. Environmental and financial impacts of perioperative paracetamol use: a multicentre international life-cycle analysis, British Journal of Anaesthesia, 2024