Inefficiencies in the Irish Health Service: The "First Dose".

Posted by Dr. Jane Doe

The ongoing campaign against NCHDs in the Irish health service has recently accused us of "inefficient work practices". Over the next few posts I am going to illustrate some major ineffiencies in the way the health service runs in relation to our job, and the effect this has on patient care. These inefficiencies are not of our making, and are usually stupid, irritating and inefficient ways of doing things that make our job difficult, the nurses job difficult, and the patient's life difficult.

So today, boys and girls, I'm going to talk about a very inefficient and stupid work practice that occurs in every hospital in Ireland, and as far as I am aware, nowhere else in the world.

The First Dose:

In Ireland, for some reason that no-one knows, the first dose of any intravenous medication is required to be given by a doctor. Usually this falls to the intern, or occasionally the SHO. There is no evidence base for this practice. Nowhere else in the Western world has this practice. I have no idea why it exists, nor does anyone else. People stumblingly explain when asked by the frustrated patient waiting for hours that this is "in case you have a reaction" but this is bollocks, as I'll explain in a little bit.

Now, the "first dose" is not limited to antibiotics. Oh no. It can mean first dose intravenous corticosteroids, IV vitamins (such as Pabrinex to treat alcohol withdrawal), IV vitamin K, first dose IV morphine, anything.

And get this. This'll really crack you up. This is just beautiful. Even if the patient has had IV Augmentin 1000 times before on previous admissions, if they get readmitted, the "first dose" principle applies all over again, and only a medic can administer it!

Ah. The flawless logic of our health system astounds me yet again.

So deconstructing this tower of imbecility, I will explain why the "In case you have a reaction" explanation is bogus in extremis. If a patient has an honest to God anaphylactic reaction when I give them an IV medication, what the hell am I going to do? I'm going to put out an emergency call so that the anaesthetist will come and be ready to intubate, and I'm going to give IV antihistamines, IV hydrocortisone, and administer subcutaneous epinephrine,which should be done first, readily available in the form of an EpiPen, or whichever one the hospital has in stock.

Now nurses are allowed to administer subcutaneous meds, and they usually know how to put out the emergency/arrest call faster than the intern/SHO would as they are the ones that usually do it. So the two first, and most important steps, namely 1)calling for help and 2)administering subcut epinephrine do not necessitate a medic at all. Now, if someone other than a doctor was able to administer the IV hydrocortisone and IV antihistamines, say, one of the ward nurses on receipt of a verbal order, then before the emergency team ever got to the patient, most of the treatment would have been instigated and the anaesthetist could then assess the airway etc. and the medic can manage as appropriate thereafter. So the patient would actually get FASTER treatment, and faster is usually better in emergencies.

If a reaction occurs that is NOT anaphylaxis, then the doctor can be bleeped and review the patient as appropriate.

The whole concept of the first dose is mind-bogglingly stupid anyway. The first dose will likely sensitise you to the drug. The next dose might be the one that gets you, if it is going to, in all probability. Or maybe the third. Or fourth. In fact, you have as much chance of having a reaction every time.
Also, the number of cases of reactions to IV medications on the first administration is exceedingly rare. I have never seen one. Nor has any other doc I know. We have occasionally seen angioedema, and very, very rarely anaphylactic shock, but never after a first dose IV med.

In addition, medics are required to make up the first dose IV med before they give it. Now this is where it starts getting dangerous. You see, as it's not really a doctor's job to do this, we obviously don't receive any kind of instruction on it ever. Some drugs are incompatible with normal saline, some are incompatible with dextrose. Some have to be diluted a certain way, some made up under aseptic technique, some vials have to shaken after the solvent is added, some cannot be shaken or the compound will be ineffective.
Some have to be diluted to a certain volume, so that a certain amount can be administered over a certain time. Nurses receive ample training on this. We are not even shown how to put the connecting tube into the bag, or put it through the infusing machine, let alone set it. Occasionally a kind hearted nurse will show you, but the machines change all the time, are different in different hospitals, and in different wards.

Pharmacists know all this stuff. Nurses know all this stuff. Doctors don't have a frigging clue. The majority of this stuff is usually done by the interns, who, having completed 5-6 years of training to know how to prescribe these meds, the indications for doing so, the intended effects, the potential side effects, and long term complications of therapy, now get to use none of that taxpayer funded training as they instead do a job that they were never trained to do and are unfamiliar with.

You tax dollars at good work, people. Once,as an intern, I was called to do anti-TNF alpha infusions. I had never done one before. There was no-one around to show me, so I made it up with the water for injections which the nurse had thoughtfully left out for me. It wasn't dissolving, so I gave it a good firm shaking. As I was doing so, the nurse came in, and turned pale. "STOP SHAKING IT! NEVER shake it! That's about 800euro worth of Remicade gone!"
Shite.

Also, doctors are not based on one ward. Or even one floor. We have to go everywhere, all the time. Routine administration of IV medications is a bit down the list most of the time, as it is relatively non-urgent. So patients are waiting. Waiting for antibiotics to start to treat their pneumonia. Waiting for IV frusemide to ease their breathing and decrease the swelling in their legs. Waiting for IV hydrocortisone to stop their wheezing. Waiting for IV antiemetics to stop their nausea and vomiting.
They wait, and get uncomfortable and frustrated. So do their families. They get mad, usually at the nurses, whose hands are tied, and they in turn get mad at us for not being there-but we have to be eight other places and what can we do? Nurses hate the first dose malarkey as much as we do, they will, after all, be giving all the other doses, and it does not say much for confidence in their professional training either.

So the above practice has the following implications:

1) Causes unneccessary waiting for patients and resultant discomfort, frustration and suffering.
2) Is a completely inefficient use of a trained doctors' time and contributes to further delays in other patients' treatment. The reason the docs aren't reviewing your new onset pain may well be because they are tied up giving 15 first doses.
3)Is potentially dangerous as the person reconstituting and administering the intravenous medication is not formally trained to do so and is often unfamiliar with the ward equipment.
4)Is not based on logic or evidence, and thus is a completely useless and inefficient hindrance to patient care that should be eliminated without delay.

But will it? Is efficiency and good value for money in the public sector really what we're aiming for? It never seems like it.......