Just in Case Anticipatory Prescribing DOCUMENTATION PACK

Transcription

1 1 Just in Case Anticipatory Prescribing DOCUMENTATION PACK

2 2 Introduction to Just in Case Anticipatory Prescribing for end-of-life care at home. Quote from QIS standards Patients being cared for at home at the end of life often experience distressing symptoms such as pain, nausea, agitation and secretions. The provision of a Just in Case box in the home ensures that drugs commonly required to alleviate symptoms at the end of life are available in a patient s home before symptoms arise, thus avoiding the distress caused by delayed access to medication. By anticipating need rather than responding to it as it occurs, end-of-life care can be markedly improved. Just in Case is now in place in many health board areas in Britain and has been shown to reduce anxiety, relieve symptoms more quickly, prevent unplanned and crisis hospital admissions, and maximise the expertise of both Marie Curie and community nursing staff, particularly out of hours Just in Case also fits well with other end-of-life care initiatives already adopted by NHS Highland such as: the Gold Standards Framework and Liverpool Care Pathway. Process (see Just in Case flowsheet) Just in Case prescribing is agreed as appropriate by the community health care team, patient and family Recommended as required medications (usually Diamorphine, Midazolam, Hyoscine Butylbromide and Levomepromazine) are prescribed for the patient as well as diluents e.g. water for injection Just in Case is placed in patient s house and GP, nursing staff and NHS 24 informed Syringes etc are supplied by community nursing staff Medications are administered by community nurses/ Marie Curie nurses/ medical staff as and when required Medications are reviewed after any symptomatic phase History A Just in Case prescribing pilot, undertaken by the Palliative Care Network and NHS Highland was conducted in Beauly, Inverness and Isle of Skye during The resulting audit, based on 20 episodes of care for patients at the end of life showed the following benefits to patients and their carers: Just in case saved an admission to hospital or an out of hours call for a doctor in 44% of situations Symptoms were relieved within one hour in 60% of situations Just in case made a difference to care in 94% of cases. A follow up audit was repeated in 2011 where 60 returns were analysed when the corresponding figures were: Just in case saved an admission to hospital in 77% of cases or an out of hours call for a doctor in 60 % of situations Symptoms were relieved within one hour averaged across symptoms in 87% of situations (75% for nausea & vomiting to 100% for breathlessness) Just in case made a difference to care in 85% of cases.

3 On the basis of these audit results, the Palliative Care Network now recommends that all NHS primary care providers adopt Just in Case prescribing when caring for patients at the end of life in their own homes (including residential and nursing care homes). Cost The core palliative care drugs advised for anticipatory prescribing are Diamorphine, Midazolam, Hyoscine and Levomepromazine. The parenteral preparations of these drugs are inexpensive, particularly when compared to the cost of a call to the out-of-hours service or a crisis hospital admission. If a patient requires hospital admission, and where use of patients own medications in hospital is in place, they can take their Just in Case medications with them, as they are prescribed on a named patient basis. Risk management Any situation where controlled drugs are kept in a patient s home should be carefully considered. A chaotic home or one where drug abuse is suspected may not be suitable for Just in Case prescribing and alternative arrangements may be required. If additional security is required in a particular home, the Just in Case should be secured with a combination padlock. It is suggested that a Highland-wide combination of 243 should be used and that this number should be recorded on the patient s special alert with NHS 24. Guidelines Full guidelines and recommendations accompany this brief outline, and should be referred to if undertaking anticipatory prescribing. Highland Hospice also provide a 24 hour advice service for palliative and end of life care issues. Highland Hospice 24 Hour Telephone Helpline:

4 4 JUST IN CASE ANTICIPATORY PRESCRIBING CORE CONTENTS (these are put in the box by the community nurse) Syringes & Needles: 5 x 1ml 5 x 2ml Syringes 5 x 10ml 10 x 21 gauge green needles for drawing up 10 x 25 gauge orange needles subcutaneous 10 x filter needles 3 x 25g Butterfly needles with short tubing Water for Injection (must be prescribed for individual patient) 5 x 10ml Mediswabs Clear film adhesive dressing x 3 Sharps Box Stationery Pack (in clear folder): Introduction Just in case flow sheet Just in case medicines information leaflet Just in case patient/ carer information leaflet NHS Community nurse medicines stock record (for further supplies phone or Stores at Raigmore Hospital, no requisition or product code required) NHS Prescription kardex (NHS Order Supply Code: HWZS113 (short version) and HWZS114 (long version))

5 5 Process for anticipatory prescribing for patients with a terminal illness Patients with a terminal illness often experience new or worsening symptoms. Just In Case can be provided in advance where a need for medication is anticipated. This process should be followed by all professionals in line with the best practice guidelines as contained in the Palliative Care Information Pack. Community Nurse identifies patient, and discusses medications with GP, patient and family. Ensure an OOH Palliative Care Special Patient Alert form been completed? If all parties agree, GP completes prescription sheet and GP10 Patient s carer takes GP10 to pharmacy or dispensing GP Drugs dispensed patient s carer collects drugs (in exceptional circumstances community nurse may collect drugs and deliver to patient). Community Nurse visits patient with Just in Case (collected from the Community Nurse base), stocked with core contents (see list in the case), labeled with community nurse base contact number/address Patient/carer given information leaflet and discussions held regarding use, storage etc Community Nurse packs medications in case and stores in an agreed safe place in the home. Location of case noted in patient s medical and nursing notes Community Nurse inserts prescription sheet and stock sheet into patients notes, and informs others (GP, Out of Hours HUB, carer) that a Just In Case is in the home (giving location of case and combination number of padlock if being used). When items used: record administration on prescription sheet, Controlled drugs entered on drug stock sheet and information included in relevant care plan Community Nurse informs GP discuss future management in view of symptomatic phase. Any new medications to be instructed, prescribed, signed and recorded as before. When episode of care finishes: Patient s carer/relative returns case and contents to pharmacy or dispensing GP practice for destruction of medications. Pharmacist/dispensing GP destroys all medications as appropriate. Just In Case box returned to Community Nurse team. Box cleaned and restocked with core contents

6 6 JUST IN CASE ANTICIPATORY PRESCRIBING Frequently Asked Questions 1. Why do this? Makes patients and carers feel more secure and worry less about having medicines available when they need them. Saves time for healthcare professionals in obtaining medicines especially out of hours 2. Isn't there a lot of waste? Not if the quantities of medicines prescribed are appropriate and the stock is managed well. The medicines identified are relatively cheap except for high dose opioids (approx 42 for 10 amps each of midazolam ( 7.26), hyoscine butylbromide ( 2.23), levomepromazine ( 20.13) and 5 amps of Diamorphine 10mg (12.76)). 3. Can we use the medicines for someone else if they haven't been used? No. The medicines are prescribed for individual patients and are their property or the property of their estate. As with any dispensed medicines, it must be destroyed if it is not used. 4. What about all these medicines in the patient's house? The patient is likely to be already on a number of medicines. These ones will be closely monitored. If it is thought that there may be an issue with leaving these additional medicines in the house, the team can assess whether the medicines should be left and the box locked or whether this is not a suitable situation for 'Just in Case' and alternative arrangements are needed. The quantity of medicines in the Just in Case box will be for hours. This is probably less than the quantities of medicines already prescribed in the house. Where a risk is identified, the boxes can be padlocked. It is suggested to use a combination padlock so that keys are not necessary. A Highland Healthboard-wide code should be used for the lock of '243'. The combination number should be included in the out-of-hours palliative care alert form along with the information that a Just in Case box is in the home so that Marie Curie, Community Nurses etc are able to access the contents. 5. How will we know who has been prescribed 'Just in Case' medicines? The team make this decision It will be clearly identified in the nursing/ medical notes that there is a Just in Case box in the home The Palliative Care Special Alert Form to the Hub, epcs (electronic palliative care summary) or KIS (Key Information Summary) whichever is in use will also indicate this. 6. What about prescribing? The drug kardex can be used to prescribe drugs for a Just in Case. (example charts and instructions for use are enclosed in the training pack and on the intranet site). Bolus subcutaneous doses can be prescribed in the 'as required' section of the chart with the symptom clearly identified and a maximum frequency. These prescriptions will require regular review against background medication requirements. 7. What about removing Controlled Drugs from a patient s house when they are no longer needed? The legal position is that the drugs remain the property of the patient after death, but are not part of the patient s estate i.e. they cannot be willed or left to anyone else, or indeed used or owned by anyone else other than the person to whom they were prescribed. As such, following the death of the patient, the control of Controlled Drugs is via the Crown under formal statute, and they are therefore subject to the law under the Misuse of Drugs Regulations. The nature of how this is to be implemented is still under discussion at national level and at present advice is as follows: Controlled Drugs should be returned to the Community Pharmacy (or dispensing practice) by the next of kin or patient s family where it is assessed that this would be acceptable/safe. Ask the family member to agree the quantity of stocks of CDs to be returned and complete the stock record sheet including the details of the person(name and address), relationship to deceased and that they have accepted stock for return to pharmacy/dispensing practice for disposal. Ask for their signature.

7 7 Where there is an obvious risk of misuse or public safety and there is a need to remove the drug to a Community Pharmacy or Dispensing Practice (in the absence of a Community Pharmacy) for destruction, the nurse may take the drugs to the community pharmacy/dispensing practice. The community pharmacist/gp can be asked to countersign the record sheet accepting the quantities of drugs for destruction. This is likely only to be a practical option during daytime working hours that the pharmacy/dispensing practice is open. The nurse will not have appropriate storage facilities or processes for CDs. If the Nurse feels that (s)he will be placing her/himself at any risk by removing the drugs from the home, then the Accountable Officer ( ) or police should be informed as soon as practicable and the drugs should not be removed. An alternative is that the patient s drugs can be destroyed in the patient s home by the Community Nurse in the presence of a witness, which may be a family member, or another member of the Nursing team, or another healthcare professional. In each case, the witness and the nurse should sign the nursing record to indicate that the drug has been properly disposed of. It is not normally the responsibility of community nurses to become involved in the disposal of unwanted Controlled Drugs and they should be formally trained in the denaturing and disposal of drugs before this option is followed. Disposal may not be in the waste water system as this contravenes waste disposal legislation. CDs must be appropriately denatured and sent for incineration as special medicines waste. Further information will follow as the position is clarified from the Accountable Officers Group and the Scottish Government on the practicalities which are acceptable to ensure the integrity of the audit trail and meet controlled drug legislative requirements. AMacRobbie & Lis Philips November 2013

8 8 ***FOR GUIDANCE ONLY. PLEASE KEEP IN JUST IN CASE RED FOLDER - PLEASE USE NEW COMMUNITY KARDEX FOR PRESCRIBING. *** Name of Patient: Patient Number: of Birth: AS REQUIRED THERAPY Drug (Approved Name) Diamorphine Injection Dose Route SC Frequency & Instructions If required for relief of pain or breathlessness to a maximum of.. doses in 24 hours then seek advice Start Stop : Given By Signature Name Pharmacy Given By Drug (Approved Name) Levomepromazine Injection 25mg/ml Dose Route SC Start Stop : Given By Frequency & Instructions If required for relief of Signature Name nausea, vomiting or deliriumto a maximum of.. doses in 24 hours then seek advice Pharmacy Given By Drug (Approved Name) Hyoscine Butylbromide Injection 20mg/ml Dose Route SC Start Stop : Given By Frequency & Instructions If required for Signature Name respiratory tract secretions or relief of colic to a maximum of doses in 24 hours then seek advice Pharmacy Given By Drug (Approved Name) Midazolam Injection 10mg/2ml Dose Route SC Start Stop : Given By Frequency & Instructions If required for relief of Signature Name anxiety, acute Pharmacy Given By agitation or restlessness to a maximum of.. doses in 24 hours, then seek advice

9 9 Palliative Care Prescribing Points Background One of the most consistent delays in the supply of controlled drugs to patients are prescriptions which do not fulfil the legal requirements. Practitioners have an ethical duty of care to the patient to act in their best interests and wherever possible deal with this as promptly as possible. Practice Points A sample prescription, adapted from one produced by The Royal Pharmaceutical Society, can be provided to assist prescribers and pharmacists in ensuring that prescriptions meet legal requirements and minimising inconvenience and delays to patients and carers. Practitioners can contact the Palliative Care Network office on or Alison MacRobbie, Macmillan Palliative & Community Care Pharmacist on or alison.macrobbie@nhs.net for a copy. Prescriptions for Schedule 2 and 3 controlled drugs can be amended by the pharmacist if the total quantity is specified in words but not figures or if it contains minor typographical errors When faced with an ethical dilemma regarding supply against an illegal prescription, please remember that pharmacists and prescribers should be able to defend their actions and inactions. It is advisable to keep records of the decision making process Strong Opioids are schedule 2 controlled drugs and Midazolam Injection 10mg in 2ml is a schedule 3 controlled drug. A. MacRobbie 2013

10 JUST IN CASE Anticipatory Prescribing NHS Highland This summary has been produced by NHS Highland as a guide to managing emergency symptoms. For more detailed information, please refer to the current Palliative Care Guidelines, BNF, or contact your local specialist palliative care service. Highland Hospice tel: Pain Consider: Whether due to disease itself, treatment, disease-related debility, concurrent disorder, psychological or social factors Diamorphine If opioid naïve: 2mg to 5mg by subcutaneous bolus or 5mg to 10mg over 24 hours by continuous subcutaneous infusion Breakthrough dose equivalent to 1/6 th or 1/10 th of the 24 hour dose of the patient s regular opioid prescribed Incremental increase for opioids is around 30% of total daily dose. Remember to increase breakthrough dose also Conversion Oral morphine 3mg = s/c diamorphine 1mg Nausea / Vomiting Consider: Gastric stasis, intestinal obstruction, drug induced, biochemical causes Levomepromazine (sc) 2 to 10mg by subcutaneous bolus or 5mg to 25mg over 24 hours by continuous subcutaneous infusion Anxiety/Convulsions/Restlessness Consider: whether restlessness caused by urinary retention, pain, constipation Midazolam 2mg to 10mg by subcutaneous bolus and if required repeated up to once every hour if necessary and review or 5mg to 30mg over 24 hours by continuous subcutaneous infusion Breathlessness Consider: Mechanical causes (pleural effusion, airway or superior vena caval (SVC) obstruction), Biochemical causes (anaemia, hypoxaemia), Psychological causes Diamorphine: if opioid naïve: diamorphine 2mg to 5mg by subcutaneous bolus or give 1/6 th to 1/10 th of the 24 hour dose of the patient s regular opioid Midazolam(if breathless and anxious): 2 mg by subcutaneous bolus Confusion / Agitation at end of life Consider: Infection, Hypoxia, Physical (pain, urinary retention, constipation), Psychological distress, Drugs (opioid toxicity; acute withdrawal of antidepressants, steroids, alcohol, nicotine), Metabolic: (uraemia, hypercalcaemia, low sodium, glucose, liver failure) Levomepromazine 5mg to 50mg by subcutaneous bolus or 10mg - 200mg over 24 hours by continuous subcutaneous infusion; start at low end of dose range and review and increase as required seeking specialist advice if needed Respiratory Secretions Consider: Repositioning patient with explanation and reassurance for family and carers Hyoscine butylbromide 20mg by subcutaneous bolus or 20mg to 60mg over 24 hours by continuous subcutaneous infusion Acute Terminal Event (e.g. bleeding / choking) Midazolam (iv or im) 10mg to 20mg : November 2012 Version 3 (Supersedes May 2008) Approved by: NHSH PPG ADTC of approval: November 2012 Review by: November 2014 Lead reviewer: Alison MacRobbie on behalf of Highland palliative Care Network