Australian Capital Territory
New South Wales
Australian Capital Territory
New South Wales
Improving the quality of care for older people living in (RACS) in Australia requires a better understanding of how, why, where and when residents die. This information contributes to reducing the risk of injury deaths in RACS by developing evidence-based information essential to prevention strategies and the allocation of adequate financial and human resources. Substantive changes are required to improve aged care in Australia. A major aspect of this should be to address the barriers contributing to failure to respect older persons’ autonomy, rights, choices and freedom.
This report is the culmination of an in-depth analysis of injury-related deaths of residents living in accredited Australian RACS. The seven topics of focus comprised: choking; medication; physical restraint; resident-to-resident aggression (RRA); respite; suicide; and unexplained absence.
Following the discussion on patient-controlled-analgesia (PCA) in our June issue of the Clinical Communiqué, we present a supplementary expert commentary with pertinent clinical advice for our readers on the use of oral opioids with PCAs.
Professor Pam Macintyre
BMedSc MBBS MHA FANZCA FFPMANZCA
Director, Acute Pain Service
Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine
Royal Adelaide Hospital and University of Adelaide, Adelaide
One of the key safety features of intravenous (IV) patient-controlled analgesia (PCA), is that when a patient is over-sedated from an excessive dose of opioid – sedation being the earliest clinical sign of opioid-induced ventilatory impairment (OIVI) – the patient will not usually be able to press the demand button to obtain further doses.
When a background (continuous) infusion is included as part of the PCA prescription, opioid will continue to be delivered regardless of the patent’s level of sedation. Routine use of these infusions is known to significantly increase the risk of OIVI (George et al, 2010) and for this reason, background infusions with PCA are used very infrequently.
However, it is not uncommon in many centres for an opioid-naïve patient given IV PCA to also be prescribed oral opioids concurrently – for example slow-release (SR) or immediate-release (IR) oxycodone – even when the institutional practice is to avoid PCA background infusions. Not surprisingly, this practice has also led to OIVI (or respiratory depression) and patient harm.
Administration of SR or IR oral opioids in addition to PCA, other than an opioid that the patient has been taking on a long-term basis prior to admission (where the drug(s) and dose(s) have been independently confirmed) is essentially the same as adding a background infusion. Therefore, the same care must be taken as the same risks exist (Macintyre & Schug, 2015). If sedation occurs as a result of a combination of background SR opioids in addition to PCA bolus doses, then the sedation is likely to be more sustained than it would have been if the background opioid was delivered via PCA.
While initial use of a background infusion or addition of oral opioids to a PCA regimen (other than a patient’s usual long-term opioids) is generally not safe, relative safety may be increased if they are introduced only once a patient’s PCA opioid requirements are known. The rate of the infusion, or the dose of oral opioid, can then be prescribed according to these requirements.
One approach is to ensure that the oral opioid dose or PCA background infusion or provides no more than 50% of a patient’s total opioid requirements (Macintyre & Schug, 2015) – and usually even less (25-30%). As daily opioid requirements may decrease rapidly in the acute pain setting, the rate of a background infusion or the dose of oral opioid, should be reassessed frequently and reduced appropriately, so that these doses remain a similar proportion of the patient’s overall daily opioid requirement.
In patients who are opioid-tolerant, background infusions may sometimes be used in place of the patient’s normal (preadmission) maintenance opioids. But in this setting, the patient’s baseline opioid requirements at least are already known.
Anaesthetists and other doctors who prescribe oral opioid analgesia concurrently with PCA need to consider these issues as they would when prescribing a PCA background infusion and take appropriate steps to minimise the risk of OIVI. In some patients with low PCA opioid requirements, such concurrent prescriptions may be best avoided.
George JA, Lin EE, Hanna MN et al (2010) The effect of intravenous opioid patient-controlled analgesia with and without background infusion on respiratory depression: a meta-analysis. J Opioid Manag 6(1): 47-54.
Macintyre PE & Schug SA (2015) Acute Pain Management a Practical Guide. Boca Raton, CRC Press, Taylor and Francis Group.
The British Geriatrics Society have published an article about the recent landmark Australian study published in Age and Ageing, examining deaths due to physical restraint of people living in nursing homes.
“When will the proper doctor see me? You know, the one who wears the suit.”
This is what junior doctors hear from patients and their families every week.
Who do you trust to provide the medical care you need when you are unwell in hospital? There is the person who sees you every day, orders the x-rays, chases up the blood results, prescribes the medicines you need onto the hospital medication chart and writes the discharge letter. That’s the junior doctor. Or perhaps you prefer the medical specialist who arrives occasionally, stays briefly and is followed by an entourage of other doctors and nurses.
Junior doctor is a term used to describe recent medical graduates, usually in their first three postgraduate years. They are also called interns, resident medical officers or basic trainees. They are still learning and honing their clinical and professional skills.
So when things go wrong, it is very easy to blame the junior doctor; criticism of junior doctors is routine, especially in the media. There is also a perception, unsupported by evidence, that successive cohorts of junior doctors are clinically worse or less professional than their predecessors.
Perpetuating this stereotype disempowers junior doctors, encourages colleagues to undervalue their contribution and erodes public confidence in our health system. This is harsh and unfair.
Our society’s aspirational goal for a world-class health system increases the pressure and expectation on junior doctors. High quality, efficient, safe, timely and personalised care is expected for all individual patients and their families.
Although better educated and better prepared than ever before, junior doctors are less equipped now than 20 years ago to meet the demands and expectations in the workplace. The medical landscape has changed profoundly.
Twenty years ago medical practice was simpler. We treated one disease at a time, had very few administrative and regulatory requirements and could make decisions relying on our clinical judgement. The community were also more likely to accept the limitations of health care.
Now, medical practice is much better because of dramatic improvements in how we use information technology, imaging, pathology, more effective medications with fewer side effects and the advent of non-invasive procedures, such as keyhole surgery.
The most profound is the cultural shift that rightly promotes patient-centred care and safer care, that is, eliminating harm due to how health care is provided.
So now, in an ordinary day, a junior doctor must understand and manage a patient with multiple diseases, and comprehend, balance and navigate treatments that could make one disease better but another one worse.
A junior doctor must choose, order and interpret from the huge range of highly specialised and technical blood tests and imaging techniques while remaining calm, empathetic, compassionate and explaining everything to patients in plain language.
This is as well as completing and meeting all the additional administrative and regulatory requirements introduced to improve the health care system.
Junior doctors work in an environment that demands efficiency and fast turnarounds. The average length of stay in hospital is 5.9 days with an emphasis on reducing this. This drives a form of anticipatory and defensive practice.
The pace of work leads to over-ordering tests to avoid the possibility of “missing something”. This perversely leads to not ordering tests that are needed because doctors are so overwhelmed chasing up what does not need to be done.
A profound and desirable shift in practice was the arrival of evidence-based medicine. However, this has created doubt where there was once certainty. Evidence-based medicine requires gathering, consolidating and critically appraising research evidence so we know what to do or, what not to do. It improves consistency in decision-making and reduces doctors doing “their own thing”.
What we now know is there is not always enough evidence to inform practice and it does not always directly apply to a specific patient situation. We now also know what was once a “fact” becomes “fiction”when it is found not to be true. These concepts are confronting and challenging for senior medical specialists, let alone a junior doctor.
We need junior doctors, not only because they are the future leaders for a better health system, but because they – along with the graduate nurses and allied health professionals – contribute substantially to the smooth operation of our hospitals.
We also need junior doctors because they bring new ideas and new skills, better reflect the values of a progressive contemporary society (such as the importance of transparency, patient-centred care) and need for integration of technology into health care.
Reducing the pressures on junior doctors is possible. Showing appreciation for their contribution to the overall health system should be a simple matter. We only need to reflect on the recent experiences in the UK’s National Health Service – where junior doctors marched on the streets to protest their pay and conditions – to be reminded what happens if we fail to do so.
Another step is to think of a better title, one that recognises junior doctors’ potential as future leaders, to listen to their ideas and ask them to engage their peers to improve patient safety.
The terms “young”, “junior”, “beginner” and “novice” fail to recognise the skills the person who recently graduated bring to the work place.
Perhaps the most challenging is to stop comparing and recognise junior doctors have strengths and that senior doctors have their limitations. A world class health system requires working together. Wearing a suit is a personal choice, not a marker of medical competency.