Transcript Palliative Care Emergency Medicine Packs

Palliative Care Emergency
Medicine Packs
“Just In Case”
Jason Carroll
Medicines Management Pharmacist
Powys tLHB
17/07/2015
Background
• Within Primary & Secondary care, Powys LHB has
adopted:
– The Gold Standards Framework for Palliative Care.
– All Wales Integrated Care Pathway for Last Days of Life.
• These frameworks help to develop and implement
an agreed standard of quality palliative care.
• Access to palliative care medicines is one of the
aspects of care included in these guidelines.
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Access to Medicines
• Most people would prefer to be cared for
at home and to die at
• Up to 90% of patient’s palliative care
takes place in the home.
• Despite this, most people with terminal
malignancy die in an inpatient setting.
• Breakthrough symptoms and lack of
anticipatory palliative care are a
contributory factor in patients being
admitted to hospital.
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Recommendation
• The Palliative care Baseline Review
for the South West Wales Region
(inc. Powys) recommended:
– Local arrangements should be
formalised (or existing arrangements
fully implemented) to ensure that
patients receiving palliative care have
access to all necessary medications as
and when required.
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Anticipatory Prescribing
• Easy access to palliative care
medicines out of hours has proved
difficult to implement in Powys.
• The service developed in response to
this problem will provide patients
with a supply of the most commonly
required drugs, before the need for
them has arisen.
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The PCEMP Scheme
• A Palliative Care Emergency Medicine Pack
(PCEMP) will be provided to suitable
patients, following assessment by
members of the primary healthcare team.
• The GP prescribes the individual drugs in
the usual way.
• An accredited pharmacy issues the drugs
in a sealed case.
• The case is retained in the patient’s home
to be opened by a GP or nurse if required.
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Suitable Patients
• Prescribers in conjunction with other members of
the healthcare team will identify appropriate
patients.
• Patients will have a terminal diagnosis and be
eligible for a DS1500 (i.e. a prognosis of 6
months or less).
• Initiating PCEMP supply 2-3 months before
anticipated need is usually appropriate.
• The pack should ideally be supplied well in
advance of the patient commencing the Last
Days of Life Care Pathway.
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Patient Consent
• The PCEMP scheme should be discussed with the
patient and family/carers and participation
agreed before initiating supply.
• Ideally, this should be recorded in the patient’s
notes.
• A patient information leaflet (available bilingually)
should be provided to the patient.
• It is vital that the importance of returning
PCEMPs no longer required (both used and
unused) to the pharmacy is made clear.
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Team Communication
• The patient should be referred to the
community nursing team for
assessment & the introduction of
nursing notes into the patient’s
home.
• The provision of a PCEMP should be
flagged to out of hours teams.
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Outer Case
• A hard, plastic,
reusable outer case.
• Sealed with a tamper
proof, uniquely
numbered strip.
• A clear plastic pocket
on the side of the case
contains important
documentation.
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Inside the Pack
• Six dispensing cartons
containing ampoules
of 4 key drugs and
water for injections.
• Symptom control
guidelines adopted
from the Last Days of
Life Care Pathway.
• A replacement tamper
proof seal.
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Medication
• The following drugs are provided, in quantities
sufficient to last 24 hours:
–
–
–
–
–
–
Diamorphine 10mg x2 (for pain)
Diamorphine 30mg x2 (for pain)
Hyoscine Hydrobromide 600mcg/ml x3 (respiratory secretions)
Cyclizine 50mg/ml x3 (for nausea)
Midazolam 10mg/2ml x4 (for agitation & anxiety)
Water for Injection 10ml x2
• It is anticipated that further supplies of
medication will usually be obtainable via the
traditional route within 24 hours.
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Symptom Control Guidelines
• These are contained
within the case.
• Adapted from Powys
Palliative Integrated
Care Pathway.
• Guidelines only and do
not provide detailed
drug information.
Pain Relief
Is the patient able to swallow medication?


If yes continue oral SR morphine + 1/6th dose for breakthrough pain
If no commence syringe driver.
1. If patient not previously using strong opioid, initial doses should be as
follows:
o Bolus diamorphine 2.5-5mg SC.
o Syringe driver 10-20mg SC diamorphine over 24 hours.
o PRN medication - 2.5-5mg SC diamorphine.
2. If patient previously using oral morphine, calculate dose of diamorphine as
follows:
o Calculate total 24 hour intake of morphine (regular + breakthrough).
o Divide total by 3 to calculate the equivalent dose of diamorphine SC over 24
hours.
e.g. Patient taking 60mg MST bd plus 2 doses of 30mg Oramorph®
Total morphine intake = (2*60mg) + (2*30mg) = 180mg
Equivalent dose of diamorphine = 180mg/3 = 60mg SC over 24 hours
Prescribing for breakthrough pain should be 1/6 of dose in the syringe driver (i.e.
10mg diamorphine for the above example).
3. If patient previously using diamorphine, calculate new dose as follows:
o Calculate total intake of diamorphine (regular + breakthrough) in previous 24
hours.
o Adjust syringe driver dosage accordingly
If pain persists consider other possible causes of distress e.g. bone pain, neuropathic pain,
anxiety, fear, full bladder.
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What’s Not in the Pack?
• The PCEMP does not contain:
– Injection equipment
– Syringe driver equipment
– Care pathway guidance and patient
assessment tools
– Death verification forms
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Prescribing
• WP10s for the contents of the PCEMP are produced in the usual
way.
• The exact drugs & quantities must be prescribed.
• Templates can be used to facilitate production of the scripts.
• CD prescription requirements apply to the diamorphine, including
dosage instructions:
– “10mg to be administered for pain relief as directed” is a suitable
instruction.
– “as directed” or “as required” is not suitable.
• The prescriber is responsible for notifying the chosen pharmacy
(via a notification form) that a PCEMP is required and then
facilitating transfer of the prescription to that pharmacy.
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Notification Forms
• This should be completed
by the patient’s GP.
• Details of the local
palliative care contacts are
particularly important.
• The completed form should
accompany the
prescription to the
community pharmacy.
Palliative Care Emergency Medicine Pack
Pharmacy Notification Form
Please complete all details below
Patient Details
Name
Address
Tel. No.





A PCEMP is required for the above patient.
The patient has been assessed for suitability and has given
their full consent for a pack to be provided.
The purpose of the pack has been explained and a patient
information leaflet has been provided.
The patient has been informed of the importance of the
pack being returned to the pharmacy when it is no longer
required.
The out-of-hours service has been notified that a PCEMP will
be available at the patient’s home.
A prescription for the full contents of the pack is enclosed.
Prescriber Details
Name
Practice
Tel. No.
Palliative Care Contact
Name
Tel. No.
Please inform the practice when the pack has been
supplied to the patient.
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Dispensing
• The drugs are dispensed in white cartons and
labelled in the usual way.
• Patient information leaflets must be provided for
each drug.
• Relevant information is recorded on the front of
an audit sheet. This is placed in the document
wallet together with a PCEMP patient information
leaflet.
• A replacement security tag is placed inside the
pack along with the symptom control guidelines.
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Dispensing
• The pack is sealed, given a unique
identifying number and an expiry date (the
earliest expiry date of the included drugs).
• The PCEMP is collected by the patient or
their representative. Delivery of the pack
by the pharmacy may also be possible.
• The prescriber should be informed that the
PCEMP has been supplied.
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In the Patient’s Home
• The PCEMP should be stored safely in an
appropriate place (with regards to
security, temperature, humidity etc), but
not hidden.
• Healthcare teams should be made aware
of its location, which should be recorded in
the patient’s notes.
• The pack should never be opened by the
patient or their family.
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Using the PCEMP
• The PCEMP should be opened by a GP or
nurse only when the administration of one
or more of the drugs inside is required.
• If the PCEMP has been tampered with (i.e.
its seal broken) or the expiry date has
passed, the drugs inside should not be
used.
• Administration of any drug must be
recorded in the patient notes and on the
PCEMP audit sheet.
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The Audit Sheet
• Each PCEMP will be
supplied with an audit
sheet in its clear pocket.
• This will be partially
completed by the
pharmacy before supply.
• Further details will be
completed by the nurse
or doctor administering
any of the drugs.
Palliative Care Emergency Medicine Pack
Administration Sheet
Patient Details
Name
Address
Prescriber Details
Name
Address
Tel. No
Tel. No
Initial Security Tag Number:
Spare Security Tag Number:
Pack Expiry Date
Date of Dispensing
PLEASE ENSURE THIS PACK IS RETURNED TO THE PHARMACY FOR A
REPLACEMENT OR WHEN NO LONGER REQUIRED
Drug Details
Diamorphine Ampoules
10mg
Administration
Details (1)
Administration
Details (2)
N/A
N/A
N/A
N/A
Date of Administration
Date of Administration
Administered by
Administered by
Date of Administration
Date of Administration
Administered by
Administered by
Administered by
Date of Administration
Date of Administration
Date of Administration
Administered by
Administered by
Administered by
Date of Administration
Date of Administration
Date of Administration
Administered by
Administered by
Administered by
Administered by
Date of Administration
Date of Administration
Date of Administration
Date of Administration
Administered by
Administered by
Date of Administration
Date of Administration
Dose: 30mg to be
administered for pain as
directed
BN
Exp
Hyoscine Hyd. Ampoules
600mcg/ml
Administration
Details (4)
Administered by
Dose: 10mg to be
administered for pain as
directed
BN
Exp
Diamorphine Ampoules
30mg
Administration
Details (3)
Administered by
N/A
Dose: Use ONE as directed
BN
Exp
Cyclizine Ampoules
50mg/ml
N/A
Dose: Use ONE as directed
BN
Exp
Midazolam Ampoules
10mg/2ml
Dose: Use ONE as directed
BN
Exp
Water for Injection BP
Ampoules 10ml
N/A
Dose: Use ONE as directed
BN
Exp
Pharmacist Name:
Pharmacy Address:
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Emergency Contact Details
Shropdoc
Other
Telephone No.
N/A
Following Administration
• Where a drug has been administered from
a PCEMP, the patient’s GP must be
informed as soon as possible.
• This will allow a supply of further
medication to be initiated without delay.
• A replacement PCEMP may be requested if
it is deemed appropriate.
• Where a PCEMP has been used out-ofhours, both the nursing team and the outof-hours service should notify the patient’s
GP.
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No Longer Required
• There are 3 scenarios where a PCEMP may
no longer be required:
– One or more of the drugs inside has been
administered by a suitable professional.
– The PCEMP has been tampered with or has
reached its expiry date.
– The PCEMP is no longer needed (i.e. the
patient has commenced on the last days of life
pathway and sufficient medication has been
supplied, or has died).
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Returning the PCEMP
• Every pack must be returned to the supplying
pharmacy when it is no longer required.
• The pharmacy should be informed by the
palliative care team, GP or nurse that the pack is
no longer required.
• The pack can be returned by the patient’s family
or carers, or a member of the healthcare team if
absolutely necessary.
• Pharmacy staff cannot collect cases from
patients’ homes.
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Back at the Pharmacy
• The back of the audit sheet should
be completed and submitted to the
LHB.
• The medication should be disposed
of in an appropriate manner.
• Any remaining paperwork and seals
should be removed from the PCEMP
and disposed of.
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Infection Control
• The outer plastic case and document
wallet have been designated as low risk
items for the purposes of infection control.
• Washing with hot water and neutral
detergent is suitable to facilitate reuse.
• Where MRSA or CJD is known or
suspected the pharmacy must be informed
as soon as possible to initiate a clinical
disposal process with LHB.
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The Audit Sheet
• The back of the audit sheet
should be completed by the
pharmacy when the PCEMP is
returned.
• The original is retained in the
pharmacy for 5 years.
• A copy (with patient ID
removed) should be submitted
to the LHB for monitoring and
payment.
Palliative Care Emergency Medicine Pack
Audit Sheet
FOR PHARMACY USE ONLY
(To be completed upon return of pack)
Date of Return
Reason for Return
Contents Used
Expiry Date Reached
Pack no longer required
Complete Section A
Complete Section B
Complete Section C
Section A
How many items have been used?
Was the pack sealed with the spare security tag upon return?
Have the appropriate administration details been completed?
Are the remaining contents present and correct?
Is a replacement pack required?
Y
Y
Y
Y
N
N
N
N
Y
Y
Y
N
N
N
Y
Y
N
N
Section B
Was the pack sealed with the appropriate security tag?
Are the full contents present and correct?
Is a replacement pack required?
Section C
Was the pack sealed with the appropriate security tag?
Are the full contents present and correct?
Comments
Complete this audit form and retain in the pharmacy for 5 years.
Send a copy (with patient details removed) to Powys LHB Medicines Management Dept.
17/07/2015
Powys Palliative Care Emergency Medicine Pack (PCEMP) Process Flowchart
Identify patient suitable for
PCEMP (Eligible for DS1500)
The Full Process
Obtain patient consent. Explain
PCEM P & provide leaflet
D. nurse or PC team
w ith GP
Issue WP10 for full contents of
PCEM P
• This flowchart
summarises the
whole PCEMP
process.
Dispense WP10.
Assemble PCEM P with audit
sheet
Community Pharmacy
Supply PCEM P to patient.
Reinforce relevant information
Store PCEM P safely at patient's
home &
inform PC team of location
PCEM P
tampered with
1 or more of PCEM P
contents administered
PCEM P
expiry date
reached
Complete audit sheet
& facilitate return
PCEM P to Pharmacy
Inform GP &
PC Team
Yes
Is Replacement
PCEM P needed?
No
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End of PCEM P Process
May need further encouragement
to return PCEMP
Patient's Home
PCEM P no
longer required
Complete audit sheet
& facilitate return of
PCEM P to Pharmacy