Saturday, 14 March 2009

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!"

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.......


  1. I used to have to do this in one hospital where I worked in Scotland. But it was in the middle of nowhere, and was a real bumkin hospital. I kind of expected it in a place like that.
    But in, say, a tertiary hospital in Dublin.
    I can't believe that still goes on.

    And yet they give non-doctors other parts of our job to take over.....bits that we ARE trained to do!!!!

    The mind does indeed boggle.

    Dr Thunder.

  2. Jane

    You given a brilliant outline of this ridiculous practice which explains so much about why patients face long delays in getting an IV set-up and running. I guess this 'rule' is also contributing to the back-up of patients in A&E departments?

    Who sets these rules? Are NCHDs and nurses campaigning to get this one changed?

    You always come up with well-informed suggestions to make our health service work safely more efficiently but I have to ask, who's listening? You should be getting a consultancy fee to advise that shower in the HSE!

  3. I prefer giving the 1st dose Iv antibiotic- They are usually given in emergency setting, or if the patient's gut can't absorb the oral equivalent-you know the dose is given, contrast with leaving instructions to administer say PO medicine, come back an hour later and it is still not given, or the stock excuse of there being none on the ward even though the pharmacy is only 100metres away.

  4. How about prescribing Oxygen? Think of all the years you have been going around the place inhaling all that oxygen, none of it prescribed. Good job the cops don't pursue this drug abuse, the DPP would be a busy man...

  5. Anon,
    That made me laugh out loud, which when I'm post call is a hard thing to do.

  6. Youre welcome, thanks for your blog, it's very articulate and well written. Lets hope we get a big NCHD turnout at the IMO AGM this weekend to make our voice as strong as possible.

    No surrender.

  7. Hi jane

    Ruairi Hanley here - very good post on the first dose madness. Was tipped off about this post at the IMO conference

    However the blame here does not rest with the HSE or the "health service"

    No I'm afraid this piece of idiocy is entirely the fault of the nurses. Yes the nurses. They hide behind rules that their predecessors created but, ultimately, it is they who refuse to change their work practices, because deep down many of them like sticking it to the NCHDs!

    The hse could not care less who gives a first dose. I say again - they don't care! The only people who do are the nurses who would have to give it if we did not.

    Their ability to avoid responsibility is worthy of a thesis. Nurse- average working week = 35 hours (and striking for less) NCHD - 72 hours - never should they be let forget that.

    Your piece was excellent but you avoided identifying who was truly responsible!

    Could that be because no one likes anyone who says anything bold about the angels of mercy eh jane?! Say it ain't so!

    Kind Regards

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  9. hi Ruairi!

    I used to think like that-but in the course of working in a few different hospitals, I found a lot of experienced really good nurses who were utterly sick to the teeth of it all, thought it was a cretinous joke, and made up the IV meds that had been prescibed, hung them, and told me to sign for it when I got there as they didn't want to see the patients waiting and suffering and being in pain/vomiting/short of breath/having treatment delays.

    Yes, there are a large cohort in Ireland who definitely love to stick it to NCHDs in any way possible, but I am not talking about them as I do not consider them nurses. Nurses are healthcare professionals who want the best for the patients, and who are mature enough and have enough self respect to try and work together with all other healthcare professionals to ensure that good care is given.
    In my posts I only ever consider scenarios involving these people. The others are not nurses.

  10. Hi jane

    Appreciate your diplomatic comments re nurses - in 9 years as an Irish NCHD, I too have met many good nurses who would share your views on the first dose issue.

    However Jane - what you have done here is identify a problem eloquently and correctly , but you have not identfied why this problem exists or what needs to happen for it to change.

    The "first dose" protocol is nurse invented, nurse led and nurse driven. They deserve to be criticised for it but you have avoided that!

    It is a not a HSE issue - it is not an issue for Mary Harney, it is not a consultant issue - it is not being driven by NCHDs

    This is a piece of hysterical nurse claptrap. The fact that some nurses recognise this does not alter the reality that it is their colleagues who are insisting on it.

    The only people who can change this are the nurses - they are responsible and that needs to be spelled out.

    However it is far easier to blame the "system" rather than the "angels of mercy"

    Think about that.....



  11. hello,

    stumbled among your blog and god bless, you have verbalized the sheer frustration i feel at work nearly everyday. I am a medical SHO in a big waste-of-time-inefficent hospital in dublin. In my first two years (i am now the 2nd year of my scheme) i actually used things like logic to try to persuade the well estalished dinosaurs of the system of why certain things(like 1st doses) didnt make sense at all. All i got in return was grief and a reputation as a trouble maker(with the nurses) . I now dont care one bit....


  12. You commented Pharmacists know all this stuff. Even combat soldiers know all that stuff. It is a job were even if you never see combat you will see death. It happens in training and there are emergencies that you end up at. The part of your training to run to trouble and do all you can pretty much ensures that.

    Unfortunatly Lawyers, Insurance adjusters or administrators write such policies. Those who have a clue are not consulted until it is a firmly established practice

  13. I am an Irish RGN

    I have never come across this in the DATHs hospital.

    I have heard of it.

    But this was a practice of times past!

    Nurses give first (and every) dose of IV meds (excepth those on their exclusion list) in all cases. Abx included.

  14. R

    Seriosuly this is not being nurse driven at all. It was an old policy which has carried over. I have not seen this oractice in quite some time. Even regional HSE hospitals have done away with it.

    Where is this happening?!

  15. I don't know what a DATHS hospital is-to answer your question, in almost every hospital in Dublin, Cork, Limerick, Galway and the midlands, is where it is happening.
    Shockingly, in Tallaght hospital there is a "second dose" policy whereby docs also have to give the second dose.
    This includes antibiotics, morphine, diuretics, antiemetics, anything IV. In at least one hospital that I know of, the nurses made the interns come and mix up TPN and hang it, a la the "first dose" principle. This was in the last 3 years.
    I don't know where you work, but if your hospital does not engage in this foolishness, it is indeed in the minority, if not entirely alone.

  16. the a&e charge nurse1 September 2009 at 09:44

    I haven't laughed so much in ages after reading about this idiotic, and embarrasing policy - do doctors have to give the first 'saline flush' as well?

  17. When I did it in the UK I had to give the saline flush too.

    It's just embarrassing for everyone, to be honest.

    Dr. Thunder.

  18. Hi

    I'm an in tallaght and we give 1st dose abx..been there 2 years and always have..worked in smaller regional hospital for a number of years and nchds were meant to give 1st dose but actually very rarely did(I can actually remember one intern getting really annoyed that we had given first dose so if he was on duty he did it, his choice!)..I don't know any nurse that actually wants to wait around for nchd when they could just do it themselves (same goes for putting in IVC)
    and as a side just seems like everyone within the health services holds all the other professionals in very low regard..(ruairi seems to have a particularly bad view of nurses but he is def not alone)..believe it or not we are all doing the very best we can and we ALL want the best for our patients.
    And also, regards the original blog, agree with all said but there's no harm in NCHDs knowing how to draw up IV meds - monograph for every drug on every ward..its a skill and docs should learn how to do it..never know when it might be needed.


  19. Ok. I think I can explain this.
    You may have noticed that these first dose rules vary from ward to ward nad from hospital to hospital. For example - on certain wards in a large Dublin hospital only Docs give IV frusemide - regardless of what does it is. Well I dug into that a little. Guess what ? It turns out that once upon a time someone had IV frusemide and sometime in the following hours died. It was nothing to do with the frusemide mind you, they were just very sick and died. So the reason that on this ward no nurses give IV frusemide, is that the ward sister decided the dose of IV frusemide was to blame for the death and she dictated the rule. And so here we have the source of the problem. See i once thought that nurses did nurse things and doctors did doctor things. But no, apparently both nurses and doctors both do whatever the ward sister decides they do on her ward, regardless of the evidence base or lack thereof.

    So this first dose policy, whilst it wrecks the heads of doctors and nurses alike, is maintained by the ward sisters. At least that is the most sense I've been able to make of it!!