title: An integrated care pathway improves the management of paracetamol poisoning.
abstract: BACKGROUND
  Paracetamol poisoning remains a major cause of morbidity and mortality. Clinical care of paracetamol poisoning depends on a range of patient variables and typically involves both medical and nursing care. An integrated care pathway (ICP) is a multidisciplinary management plan that incorporates guidelines and best practice to enhance care and documentation for a specific patient group. Paracetamol overdose is thus amenable to an ICP.
  
  
  OBJECTIVE
  To evaluate the introduction of an ICP on process of care of the paracetamol poisoned patient.
  
  
  METHODS
  A retrospective case note review of consecutive patients admitted to the Royal Infirmary of Edinburgh following a paracetamol overdose was conducted. Data were collected for a 3-month period before and after introduction of the ICP to the emergency department and toxicology inpatient unit.
  
  
  RESULTS
  The ICP was used in 77% of cases in the time period studied and was associated with improvements in initial documentation of patient assessment (pre-ICP vs post-ICP: 87/161 (54%) vs 101/113 (89%), p<0.0001) and appropriateness of blood sampling (146/161 (91%) vs 111/113 (98%), p=0.01), but no change in timely blood sampling (pre 124/161 (77%) vs post 93/113 (82%)). All aspects of intravenous acetylcysteine administration also significantly improved: administration of acetylcysteine if indicated (pre-ICP vs post-ICP: 57/71 (80%) vs 71/71 (100%), p<0.0001); acetylcysteine commenced in a timely fashion (33/71 (46%) vs 55/71 (77%), p=0.0002); and acetylcysteine correctly prescribed (44/58 (76%) vs 71/71 (100%), p<0.0001).
  
  
  CONCLUSIONS
  Implementation of an ICP for paracetamol poisoning significantly improved patient management and helped to standardise inter-professional decision making in this challenging patient group. This is likely to improve patient outcome.
authors.affiliation: Clinical Toxicology Unit, Combined Assessment Area, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH 16 4SA, UK. janice.pettie@luht.scot.nhs.uk
authors.forename: Janice M
authors.initials: JM
authors.lastname: Pettie
authors.forename: Margaret A
authors.initials: MA
authors.lastname: Dow
authors.forename: Euan A
authors.initials: EA
authors.lastname: Sandilands
authors.forename: H K Ruben
authors.initials: HK
authors.lastname: Thanacoody
authors.forename: D Nicholas
authors.initials: DN
authors.lastname: Bateman
mesh_terms: D000082:Acetaminophen / Q000506:poisoning*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018712:Analgesics, Non-Narcotic / Q000506:poisoning*; D003422:Critical Care / Q000379:methods*; D019091:Critical Pathways / Q000458:organization & administration*; D003657:Decision Making; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D005260:Female; D006801:Humans; D007400:Interprofessional Relations; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D015397:Program Evaluation; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D018712:Analgesics, Non-Narcotic; D000082:Acetaminophen