COST BENEFIT ANALYSIS OF INTRAVENOUS (IV) TO ORAL (PO) SWITCH OF PARACETAMOL IN A TERTIARY CARE HOSPITAL
Senior Clinical Pharmacist, Dept. of pharmacy, Shaukat Khanum Memorial Cancer Hospital & Research Center
Associate Director Pharmaceutical & Ambulatory Care Services, Dept. of pharmacy, Shaukat Khanum Memorial Cancer Hospital & Research Center. Resident Pharmacist, Dept. of pharmacy, Shaukat Khanum Memorial Cancer Hospital & Research Center. Staff Pharmacist, Dept. of pharmacy, Shaukat Khanum Memorial Cancer Hospital & Research Center
Keywords: Intravenous, Oral, Paracetamol
Background: Intravenous to oral switch of medication in clinically stable patients is a part of appropriate medication reconciliation process, which ensures lower cost and reduced hospital stay. Paracetamol injection use has been very frequent in hospital setting especially during emergency care.At Shaukat Khanum Memorial Cancer Hospital 7 Research Center (SKMCH&RC), an online restriction for paracetamol injection prescribing was introduced in Jun, 2014 to ensure parenteral use only in indicated cases.
Aim: In this retrospective study, it was intended to evaluate the impact of online IV paracetamol restriction on consumption of parenteral paracetamol in the institute.
Method:It was a retrospective cross-sectional study. Paracetamol injection consumption was observed for the year 2014 month-wise using hospital information system (HIS).
Results:The number of paracetamol injections used before implementation of restriction was 11429 from Jan to Jun, 2014. After implementation of restriction, the number was reduced to 8219 in total from Jun, 2014 to Dec, 2014. There was a 28.1% decrease in the use of paracetamol injectable dosage form after implementation of the restriction. Rs. 321,000/- approx. were saved as a result of reduced consumption.
Conclusion: Restriction of intravenous paracetamol prescribing is associated with reduced parenteral paracetamol prescribing and lower cost of therapy.
to oral switch in clinically stable patients is associated with lower costs and
reduced duration of hospital stay. For many drugs, bioavailability for
intravenous and oral route is comparable. Oral Route is associated with better
compliance, lower administration and patient related cost in most of the cases1.
Use of intravenous paracetamol is quite common in tertiary care hospitals
across the country. It is primarily used for short term treatment of moderate
to severe pain after surgery or in case of fever. However oral paracetamol is
as effective as the IV preparation, and is a cost effective choice.2
paracetamol provides onset of pain relief in 5-10 minutes. Due to 100%
bioavailability, chances of toxicity are higher as well. Oral paracetamol is
absorbed completely and achieves peak plasma concentration 30-60miuntes after
Indications for the use of IV
·Obvious impairment/ inability to absorb
orally administered paracetamol
· Significant/ prolonged vomiting
(and/or nausea) secondary to e.g. post-operative nausea and vomiting /
postoperative ileus/ bowel obstruction/ short bowel syndrome
· Moderate-severe obstructive sleep
Neutropenia (Absolute neutrophil count <500)
Cautions for the use of IV paracetamol4
·Severe renal insufficiency (creatinine
clearance = 15ml/min).
·Chronic malnutrition (low reserves of
· Concomitant use of paracetamol (4 g
per day for at least 4 days) with oral anticoagulants may lead to slight
variations of INR values. In this case, increased monitoring of INR values
should be conducted during the period of concomitant use as well as for 1 week
after paracetamol treatment has been discontinued.
issued an alert in 2010 regarding accidental over-dose of paracetamol and
chances of life threatening hepatotoxicity. 5
paracetamol orders are being intervened by pharmacists at SKMCH&RC wherever
appropriate for switching to oral route. In this context an online restriction
for IV paracetamol orders was implemented in Jun, 2014. Physicians need to
identify the reason for choosing intravenous root for paracetamol
administration for continuing the order. This restriction, in addition to
interventions by the pharmacists, is expected to improve IV to PO switch
culture at the institute. In order to evaluate the impact of restriction and
online interventions on the trend of injection use, we conducted a retrospective
analysis of IV paracetamol orders for the year 2014. Consumption ofparacetamol
injections month wise as well as quarter wise was compared against guidelines
devised for IV paracetamol use.
was a retrospective cross-sectional study. Paracetamol injection use was
evaluated for the year 2014. Data was collected using hospital information
system (HIS). Data was collected for four respective quarters and compared to
identify the trend of paracetamolinjection use. Restriction on IVparacetamol
use was implemented using HIS restriction form.
Table 1:Month-wise Paracetamol Injection
shows the trend of paracetamol injection use from Jan, 2014 through Dec, 2014.
implementation of restriction, a downward trend in use of paracetamol injection
was observed from Jun, 2014 onwards. However the use has shown a gradual
increase later in 2014 again.
Paracetamol injection month-wise, in 2014
2115 injections used in Jan-2014, use decreased to 962 injections in the month
of July after implementation of restriction in Jun, 2014.
2: Paracetamol Injection Consumption Jan – Jun 2014 vs. Jul-Dec, 2014
Figure 2: Paracetamol injection
use Jan- Jun, 2014 Vs. Jul – Dec, 2014
Total number of injections used
decreased from 11429 in first half of 2014 (Jan – Jun) to 8219 in second half
(Jul – Dec)
Table 3: Paracetamol Injections
consumed vs. Accepted clinical interventions on Paracetamol IV to PO switch
Figure 3: Paracetamol IV to PO switch Vs. Accepted
clinical intervention for IV to PO switch
Highest number of accepted intervention
for paracetamol IV to PO switch was observed in Apr, 2014, while it was
comparable in the months of May, Jun, & Dec respectively.
Figure 4: IV to PO switch Interventions & IV
route is generally recommended for patients where oral route is intolerable.
However, it is a costly alternative to oral route. The aim of monitoring drug
therapy is to minimize the duration of intravenous medication use and switching
to the oral dosage form as soon as clinically feasible. This improves compliance
and reduces cost for the patient as well as the service facility. Furthermore,
intravenous administration is associated with higher risk of infusion reactions
and medical management cost.
develop in-house techniques to improve effective and timely IV to per oral (PO)
switch for medications. Proper medication reconciliation is highly recommended
for this purpose. SKMCH&RC implemented online IV paracetamol restriction in
Jun, 2014 to improve the appropriateness of IV paracetamol use. We carried out
a retrospective coss-sectional analysis for evaluating the impact of
restriction. It was observed that the number of paracetamol injections used
before implementation of restriction was 11429 from Jan to May, 2014. After
implementation of restriction, the number reduced to 8219 in total from Jun,
2014 to Dec, 2014. There was 28.1% decrease in the use of paracetamol
injectable dosage form after implementation of the restriction. In the month
wise break-up of injection consumption, it was observed that 2115 injections
were consumed in Jan, 2014, 2042 in Feb, 2107 in Mar, 1375 in Apr, 2374 in May,
1416 in Jun, 962 in Jul, 1210 in Aug, 1747 in Sep, 1592 in Oct, 913 in Nov and
1795 injections in Dec, 2014 respectively. A rapid decline in injection use was
seen during the months of Jun & Jul, 2014, right after the implementation
of restriction. This may represent the impact of restriction on injection use.
Approximately Rs.1, 143,000/- were consumed on IV paracetamol for the first
half (Jan – Jun 2014). The cost reduced to Rs. 822,000/- approx. in the second
half (Jul – Dec, 2014) with a net benefit of Rs. 321,000/- approx. Pharmacist
interventions were evaluated but no correlation could be found between the
number of interventions and number of injections used.
to PO switch of paracetamol through online restrictionis associated with
reduced parenteral paracetamol prescribing and lower cost of therapy.
are grateful to Mr. Shoaib Shammas for technical assistance.
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