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An integrated care pathway improves the management of paracetamol poisoning
  1. Janice M Pettie1,
  2. Margaret A Dow1,
  3. Euan A Sandilands1,
  4. H K Ruben Thanacoody2,
  5. D Nicholas Bateman1
  1. 1Clinical Toxicology Unit Royal Infirmary of Edinburgh, Edinburgh, UK
  2. 2Royal Victoria Infirmary, Newcastle upon Tyne, UK
  1. Correspondence to Janice M Pettie, Clinical Toxicology Unit, Combined Assessment Area, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH 16 4SA, UK; janice.pettie{at}


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.

Aim 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.

  • Paracetamol
  • overdose
  • integrated care pathway
  • acetylcysteine
  • mental health
  • overdose
  • poisoning
  • toxicology

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  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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