Reducing Paracetamol Co-Prescribing with Strong Opioids on the Sheffield Macmillan Unit for Palliative Care

Project completed as part of the 2023-4 Sheffield Teaching Hospitals Green Team Competition.

Team members

• Dr Kay Stewart Consultant in Palliative Medicine

• Dr Hayley Evans SpR in Palliative Medicine

• Miss Fiona Stephenson, Clinical Pharmacist

Setting / patent group:

Macmillan Unit for Palliative Care (MPCU) - an 18-bedded NHS funded palliative care in-patient unit.

Issue:

Patients have historically been prescribed regular paracetamol, despite evidence supporting that paracetamol is not effective for patients who are already taking strong opioids for pain management. Clinicians are often reluctant to stop paracetamol “in case it makes things worse” but will do so, usually with no change in symptom control, when the patient begins to struggle with their medication burden. Prescription and administration of low value drugs leads to unnecessary medicines use and waste

Intervention:

We aimed to review medications prescribed on admission to MPCU (already part of the admission process) and consider, jointly with the patient, whether moving paracetamol to the “as required” part of the medication prescription would reduce the medication burden to the patient, with no change to pain control, reduce nursing time spent administering an ineffective treatment and reduce waste (time, money and physical waste) on the ward. We ran short education sessions with the nursing and medical team. We produced a poster to put up in clinical areas showing the waste associated with paracetamol administration along with some measurements of time spent/cost to encourage the prescribers and administrators of paracetamol. We initially hoped for a 50% reduction in the usage of paracetamol on MPCU.

Outcomes:

This project ran for 10 weeks, interrupted by industrial action and a covid outbreak on the ward. A snapshot of the patient medications prescribed before the project revealed (10/18, 55%) were prescribed regular paracetamol. By the end of the study period, an average of 3.5/18 (19%) patients had regular paracetamol prescribed. Of the 19 patients that had switched to prn paracetamol on admission, only six doses of paracetamol were administered in a two week period. If the patients had stayed on regular paracetamol on admission to MPCU, each patient could have had 56 doses in 2 weeks, a total of 1,058 doses avoided. No patient that was switched to prn paracetamol had a regular dose reinstated during the project period. A 66% reduction will bring an annual saving of £387 and 282 kgCO2e, equivalent to 833 miles driven in an average car. The project has also saved staff time and will save stock space on the unit. Staff were receptive to the project change. Many had not realised the cumulative time impact of relatively “simple” analgesia but were not surprised when presented with data to show time taken to administer. It was found that paracetamol was often the medication omitted as not being seen as important when patients started to struggle to take their medications. The project therefore has potential to reduce tablet burden to patients.

Key learning point

The project nudged us to make a small change with a relatively big impact which would positively benefit the patients (reduced medication burden compared to perceived effect), the nursing staff (time saved administering paracetamol), the environment (kgCO2 saved), the drug budget (money not spent) with little impact on the medical staff enabling the change (asking if the patient felt the paracetamol helped and would they like to not have it regularly if not).