Patience, persistence and Pabrinex – a junior doctor’s experience of overcoming obstacles to change hospital policy

Aims

To develop and establish an evidence-based policy for the treatment and prevention of Wernicke's encephalopathy in patients undergoing alcohol detoxification in an alcohol and substance misuse unit.

Methods

1. The administrative route of thiamine replacement (Pabrinex) was audited for patients admitted during April 2015 (n = 20).

2. A literature review was undertaken to determine the gold standard of care.

3. Guidelines were developed using the up-to-date recommendations.

4. Consultations with the multidisciplinary team identified practical implications and concerns of providing such care.

Results

Only 15% of the patients were treated in concordance with the gold standard treatment (intravenous Pabrinex). 85% received the second-line intervention, intramuscular thiamine, with subsequent subtherapeutic dosage. The obstacles to introducing intravenous administration included historical practice, lack of intravenous drug training for mental health nurses, misconceptions of peripheral venous cannulation-associated infection and equipment deficits. Additionally, the risk factors and symptomatology of Wernicke's encephalopathy were poorly understood.

Conclusions

The main barrier to change was challenging nursing staff perceptions of best practice as a junior member of medical staff, following over a decade of undisputed intramuscular administration. Open channels of communication with nursing colleagues and the support of medical consultants were of utmost importance to ensure successful implementation of the new guideline. Following interdisciplinary teaching and determined championing of the policy change, the updated guidelines are now in place. Mental health nurses received training to administer intravenous medications and funds for intravenous pumps were granted. The unit is a hospital leader for clinical innovation and ultimately patient care has been optimised. Junior doctors are in an ideal position to lead improvements in service provision but time, patience and persistence are required.