Berkshire Healthcare NHS Foundation Trust Becky White CHS Pharmacist April 2013

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1 Berkshire Healthcare NHS Foundation Trust Becky White CHS Pharmacist April 2013

2 Access to palliative care drugs out of hours Agreement set up with local community pharmacy s to hold stock of commonly prescribed drugs which are on the agreed list set up by the PCT. During normal working hours it is expected that in the first instance, prescriptions would be presented at a local community pharmacy. The service has been running for over 5 years now. Main issues are around items going out of stock and access to pharmacy's for the community nurses i.e. parking.

3 List of palliative care drugs stocked by community pharmacy palliative care providers Cyclizine injection 50mg/1ml 2 x 5 Ondansetron injection 8mg/4ml 1 x 5 Dexamethasone injection 8mg/2ml 1 x 5 Oramorph solution 10mg/5ml 3 x 100ml Diazepam rectal tubes 10mg 1 x 5 Oramorph Conc solution 100mg/5ml 1 x 120ml Diclofenac injection 75mg/3ml 1 x 5 Oxycodone injection 10mg/1ml 4 x 5 Diclofenac supps 100mg 1 x 10 Oxycodone injection 20mg/2ml 4 x 5 Fentanyl Matrix patches 12mcg/hr 1 x 5 Oxycontin tablets 5mg 1 x 28 Fentanyl Matrix patches 25mcg/hr 1 x 5 Oxycontin tablets 20mg 1 x 56 Fentanyl Matrix patches 50mcg/hr 1 x 5 Oxynorm liquid 5mg/5ml 1 x 250ml Haloperidol injection 5mg/1ml 1 x 5 Phenobarbitone injection 200mg/1ml 1 x 10 Hyoscine butylbromide injection 20mg/1ml 2 x 10 Sodium chloride 0.9% injection 10ml 20amps Levomepromazine injection 25mg/1ml 1 x 10 Tranexamic acid tablets 500mg 1 x 60 Levomepromazine tablets 25mg 1 x 84 Water for injection 10ml 20 amps Lorazepam tablets 1mg 1 x 20 Zomorph capsules 10mg 1 x 60 Metoclopramide injection 10mg/2ml 2 x 10 Zomorph capsules 30mg 1 x 60 Midazolam injection 10mg/2ml 2 x 10 Zomorph 60mg 1 x 60 Morphine sulphate injection 10mg/1ml 4 x 5 Zomorph 100mg 1 x 60 Morphine sulphate injection 15mg/1ml 4 x 5 Morphine sulphate injection 60mg/2ml 2 x 5 MST tablets 5mg 1 x 60

4 Prescribing of anticipatory medicines Where possible all anticipatory medication should be in place already. Medication written up on FP10 by GP/ palliative care service and accessed through local community pharmacy or a pharmacy within the palliative care scheme. Ideally the family would be asked to obtain the medication from community pharmacy although the community nurse would collect this and take it to the patients home if necessary. Anticipatory drugs are stored in the patients home. Out of Hours GP service hold some stock.

5 New development Sub Cut sodium chloride for the treatment of dehydration Palliative Care Consultant along with the IV Nurse Specialist, Community Nurses and a Pharmacist have developed the Guideline/SOP. Due to the relative ease of setting up and administering subcutaneous fluids, the procedure can be carried out in the home by district nurses and community matrons (Marsden 2004). Patients will be treated in their own homes in order to avoid unnecessary hospital admissions.

6 Subcutaneous sodium chloride Ethical issues around the use of subcutaneous sodium chloride in palliative care patients. Not first line choice. Training required for NMP s within the service. Sub cut fluids are useful in the small number of patients where their disease prevents drinking before the dying process has started i.e. oesophageal tumours.

7 Questions and issues to be addressed when setting up the service Sub cut sodium chloride is on off-license indication. Who will prescribe the fluid and what paperwork will be used? Can NMP s prescribe off-licence meds? Who will supply the stock? Issues around supply via community pharmacy. Time delays around stock supply.

8 Questions and issues to be addressed when setting up the service Who will pay for it? Is the service commissioned? How often will it be required? Where will the stock be stored? Access out of hours? Will we need to supply stock to both the East and West of the area, therefore multiple sites. Transport of stock to the sites.

9 Questions and issues to be addressed when setting up the service Will the stock need to be pre-labelled? Are dose calculations necessary and are these double checked? Correct selection of the stock. Who will monitor stocks and request more supplies when needed? Disposal of out of date stocks. Pharmacy involvement photocopy prescriptions and send to pharmacy retrospectively.

10 Questions and issues to be addressed when setting up the service How to ensure stock is not removed without a valid prescription? Hardware issues giving sets and drip stands also required. Can these be held in the same place? In line with NPSA 20 Injectable Medicines - a risk assessment will need to be completed. Separation of prescribing and administering for NMP s out of hours. Getting the model right for the future.

11 Also in the pipeline: Extension of the existing IV cellulitis pathway allowing community nurses to give the first dose of antibiotics in the patients home instead of the acute setting. IV UTI pathway. British Heart Foundation IV Furosemide project. Watch this space....

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