Transcript Just in Case Boxes - Palliative Care Wales

“Just in Case” Boxes
Elizabeth Lewis Lead Palliative Care Pharmacist
Dr Ray Majer Palliative Care Consultant
Hywel Dda Local Health Board
August 2012
The Just in Case Box Scheme
 JIC Box scheme has been launched across
Wales to improve access to end of life medication
 Ensures health professionals can respond rapidly
to worsening symptoms and avoid unnecessary
suffering
 Aims to avoid inappropriate hospital admissions
What is a JIC Box?
 Orange plastic box containing end of life drugs,
symptom control guidelines, a patient information
leaflet and an administration sheet for audit
purposes
 The box is sealed when supplied by the
pharmacy and re-sealed after use, before
returning to the pharmacy. Both seal numbers
are recorded for security purposes
 Prescribed for patients whose death is expected
within a period of less than six months
 Supplied by pharmacists participating in the scheme
 Pharmacist dispenses JIC box within 48 hours of
receiving prescription – not for emergency supply
 JIC Box kept in patients home until needed
 The box has a minimum expiry date of six months
 Once the JIC box is used the re-sealed box is returned
to issuing pharmacy where the use of the medication is
matched to the administration sheet
Hywel Dda Health Board
 Just in case box scheme launched on 11th December
2011
 Training delivered to community pharmacists, GPs, DN
& ART teams and palliative care CNSs across Health
Board both before and after launch
 Up-date letters sent to GP practices and community
pharmacies at regular intervals
 Participating pharmacies visited when signed up to
scheme and given on-site training
Population Data
 Hywel Dda has a population of 372,100 – 13% of
Welsh total
 Carmarthenshire 183,800 (49%)
 Pembrokeshire 122,400 (32%)
 Ceredigion 75,900 (20%)
 Covers a quarter of land mass of Wales – 2nd most
sparsely populated Health Board
 Has a dramatically increasing elderly population (>65
expected to increase by 50% by 2026)
 55 GP practices
 99 Community Pharmacies -66 participating in JIC
box scheme
What do we want to know?
 Is the scheme effective?
 How many boxes are being prescribed?
 Are boxes prescribed for suitable patients ?
 Are the boxes prescribed in a timely manner?
 Do the boxes contain the right drugs & quantities?
 Is there an effective audit trail?
 Are we preventing admissions ?
 Are there any problems?
Methodology
 Data collected from returned claim forms for payment from
community pharmacies for claims made in the first six
months of the scheme
 Feedback from comments from Community Pharmacists
(CPs) on claim form
 Unstructured interviews with Acute Response Team (ART)
 Data from NHS Wales Shared Services Partnership
Sample
88 JIC boxes issued in first 6 months
since launch of scheme December 2011
69 claims made by community
pharmacists for boxes returned (used &
unused)
Hywel Dda Just in Case Box
Pharmacy Claim & Audit Form
Box No.
Date of issue
Date of return
Reason for return (A,B,C or D)
Box sealed? Y / N
Admin sheet completed? Y / N
Did contents match Admin Sheet? Y/ N
No. of 10mg Diamorphine amps used
No. of 30mg Diamorphine amps used
No. of Hyoscine amps used
No. of Cyclizine amps used
No. of Midazolam amps used
Reason for return:
A – Contents used (replacement issued)
B – Contents used (further box not required)
C – Contents not used (no longer required)
D – Contents expired
Comments:
JIC Boxes Issued
In the first 6 months of the scheme a
total of 88 boxes were issued with a
return of 69 (78%)
Boxes are returned when used or out of
date (at least six month expiry from
issue)
Some boxes will now be out of date &
have not yet been returned
JIC Box with Patient
(Length of time in days)
25%
Number of boxes
20%
19%
17%
15%
10%
22%
20%
13%
13
15
14
12
9
9%
6
5%
0%
0-3
4-7
16-32
8-15
Days
N=69
34-61
64-78
Outcome
Compared first and second quarters to see
if any difference after:Further training
Increased awareness
Experience of using the scheme
JIC Box with Patient Comparison of quarters
(Length of time in days)
30%
Number of boxes
25%
26%
24%
21%
20%
17%18%
15%
15%
9
15%
12%
19%
15%
10%
4
5%
4
5
11%
8 7
10
4
7
5
7%
3
3
0%
0-3
4-7
8-15
16-32
1st Qtr (N=42)
2nd Qrt (N=27)
Days
N=69
34-61
64-78
Reason For Return of JIC Box
1%
1
48%
33
35
A. Contents used (replacement issued)
B. Contents used (further box not req)
C. Contents NOT used (no longer req)
N=69
51%
Reason for Return of JIC Box
Comparison of quarters
55%
60%
50%
56%
44%
43%
40%
30%
23
12
18
15
20%
10%
0%
2%
1
0%
A. Contents used
(replacement issued)
B. Contents used (further C. Contents NOT used (no
box not req)
longer req)
1st Qtr (N=42)
N=69
2nd Qrt (N=27)
JIC box sealed when returned to
pharmacy
70%
69%
70%
60%
50%
40%
30%
31%
19
29
20%
13
8
10%
0%
Yes
1st Qtr (N=42)
N=69
30%
No
2nd Qrt (N=27)
Administration sheet
 Document to record the use of each of the medications in
the box and provide an audit trail for the controlled drugs
(NB this is in addition to recording administration on a drug
chart)
 To be completed each time a drug is administered by a
doctor or nurse
 To be returned with the box to the pharmacy where
matched to the remaining contents
 Discrepancies should be investigated
The Administration Sheet
 The administration sheet
is supplied with the box
along with a drug chart
It is for audit purposes
and must be returned to
the pharmacy
 Details will have been
completed by the
pharmacy before supply
Results
Administration Sheet Completed
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
92%
63%
33%
15
11
8
4%
1
Yes
0
Partially
1st Qtr (N=24)
8%
1
2nd Qrt (N=12)
No
Results
Contents Match Administration Sheet
90%
83%
80%
70%
58%
60%
50%
40%
38%
14
10
30%
17%
20%
9
10%
2
0%
Yes
No
1st Qtr (N=24)
2nd Qrt (N=12)
4%
1
0
Not returned
What’s in the JIC box?
Diamorphine 10mg x2
Diamorphine 30mg x2
Midazolam 10mg in 2ml x4
Cyclizine 50mg x3
Hyoscine HBr 400micrograms x4
Water for Injection 10ml x2
Results
Diamorphine Amps Used (10mg)
70%
61%
60%
50%
40%
42
30%
19%
20%
20%
10%
13
14
1
2
0%
0
N=69
Results
Diamorphine Amps Used (30mg)
80%
75%
70%
60%
50%
40%
52
30%
20%
10%
12%
13%
8
9
1
2
0%
0
N=69
Results
Hyoscine amps used
80%
71%
70%
60%
50%
40%
49
30%
20%
6%
10%
4
6%
4
6%
4
2
3
11%
8
0%
0
N=69
1
4
Results
Cyclizine Amps Used
70%
64%
60%
50%
40%
44
30%
23%
20%
10%
10%
7
3%
2
1
2
0%
0
N=69
16
3
Results
Midazolam amps Used
80%
74%
70%
60%
50%
40%
51
30%
20%
6%
10%
0%
0
N=69
9%
10%
4
6
1%
7
1
2
3
4
Results
Use of drug
40%
39%
36%
28%
30%
26%
24%
20%
10%
0%
Diamorphine
(10mg)
N=69
Diamorphine
(30mg)
Hyoscine
Cyclizine
Midazolam
Summary
1st Quarter
2nd Quarter
Dec 11- Feb 12
March 12- May 12
52
36
88
Boxes Returned
42 (81%)
27 (75%)
69 (78%)
Contents used
24 (57%)
12 (44%)
36 (52%)
15 (63%)
11 (92%)
26 (72%)
Boxes Issued
Admin sheets
returned
+ 1 (4% ) - partially
Not matched
14 (58%)
Total
1 (4%)
10 (83%)
24 (67%)
Who is prescribing JIC boxes?
22 GP practices out of 55 have prescribed
a JIC box
In the prescribing practices:Range 1 to 8 boxes per practice
Average of 3 boxes per practice
Who is prescribing JIC boxes?
Number of
Boxes
Number of
Surgeries
Range
Average
Carmarthenshire
61
13/24
1-7
5
Ceredigion
21
6/16
1-8
3
Pembrokeshire
6
2/15
3
2
County
How many patients with JIC boxes in
the home were admitted to hospital?
 Cross referenced with
Myrddin Hospital System
Health Board Mortality Database
As at 14th September 2012
5 patients still alive
JIC boxes issued from 11/04/12 – 18/06/2012
N=69
How many patients with JIC boxes in the home were
admitted to hospital?
All deaths in hospital are reviewed by Hospital
Director of Clinical Care as part of the weekly
mortality audit
5 out of 69 patients were admitted to hospital
Possibly 3 of the 5 patients could have remained
at home
Weekly Mortality Audit
Hywel Dda Mortality Review database
Concern
Comments
LENGTH OF STAY
Date JIC
box issued
Date of
Death
16/12/2011
18/02/2012
27/01/2012
14/02/2012
2 days
04/02/2012
11/02/2012
1
(NJ)
Moderate
Patient has significant hypercalcaemia
that is inadequately and inappropriately
treated.
0
died same day of
admission
0
died same day of
admission
2
(JC)
No
concerns
Should have had palliative care at
home
3
(ML)
No
concerns
Died in Ty Bryngwyn – admitted
because of family concerns about
terminal haemorrhage
4
(RJ)
No
concerns
Demonstrates the lack of end-of-life
care planning
1 day
14/03/2012
16/03/2012
5
(GP)
No
concerns
DNAR order put in-place
8 days
16/04/2012
24/05/2012
Feedback from Community Pharmacists
 District nurses not familiar with the All Wales Medication Administration Record
 2 boxes issued in lead up to Christmas. Inappropriate use of boxes and they were
returned within a day or two. Also District nurse waited at the pharmacy for the box
to be made up
 Contents of a returned box did not match the Admin Sheet – GP contacted.
Unrecorded drugs were administered by an Out of Hours GP
 One box returned via district nurse – Admin Sheet missing – could not recover
 Boxes tend to be issued too late – relatives turn up at closing time wanting pack
urgently. Not enough to last until Monday morning if started on Friday night. GPs in
this area usually use hyoscine 600mcg and not the 400mcg in the pack
 System does not seem to work well in completing the circle of drug usage
 Prescription written incorrectly – referred back to practice. Second attempt also
written incorrectly even though details were faxed to practice.
Feedback from Community Pharmacists cont.
 Box returned with contents not matching Admin Sheet. All Wales Medication
Chart blank but amps of Diamorphine, Hyoscine and Cyclizine missing from box
 Pharmacist received prescription but no Notification Form – not apparent that it
was for a JIC box as strengths listed were not as per the scheme. Patient
expected box to be done in 5 mins – as advised by GP and District Nurse.
Pharmacist referred matter to GP practice who insisted that JIC box was need and
if Boots couldn’t provide in 5 mins – there was another pharmacy that could
 System works well, GPs need further info. Fee is not enough to cover the work
involved
 Admin sheet not being returned in some instances. GPs & Nurses unsure of how
JIC works properly
 Had to supply JIC box to a patient in New Quay as local pharmacy not
participating in service – long distance for Boots to deliver. Not enough PILs
supplied with meds to put into box. Having PDFs of the PILs would be useful.
Feedback from Acute Response Team (ART)
 ‘ART - first point of contact out of hours before OOHs GPs
– very frustrating if no meds prescribed’
 ‘Often attend patient with JIC box but no medication written
on chart then have to ring OOHs GP and wait for up to an
hour for them to arrive to write up drugs- distressing for
patients & carers, ‘soul destroying for ART nurses’
 ‘GPs reluctant to write up PRN medication’
 ‘ART prompt DNs to ask for drugs to be prescribed but they
need to flag up patients when they start to deteriorate and
are needing frequent calls’
 ‘Not sure when to re-seal box’
Feedback from Acute Response Team (ART)
 ‘When executed properly it is an amazing scheme
which has helped lots of patients’
 ‘Could set up syringe driver there and then’
 ‘Recommend there is more liaison during working
hours DN should prompt GP to prescribe drugs’
 ‘Not enough water for injection in the box’
Conclusions
 JIC boxes need to be issued earlier in the patients’
journey
 13/69 boxes issued in last 3 days of life
 22/69 boxes issued in last 7 days of life
 Security of JIC scheme compromised by failure to
complete & return administration sheet and to re-seal the
box after use
 More advance planning needed for GPs to prescribe the
medication on the drug chart prior to the patient requiring
the drugs
What did we want to know?
 Is the scheme effective? Are we preventing admissions ?
 5/69 patients admitted to hospital.
 ‘When executed properly it is an amazing scheme which has helped lots of
patients’
 How many boxes are being prescribed?
 88 boxes in first 6 months –anticipated 200 per annum from Powys model
 Are boxes prescribed for suitable patients ?
 Don’t know
 Are the boxes prescribed in a timely manner?
 The boxes need to be prescribed earlier
 Do the boxes contain the right drugs & quantities?
 Yes
 ? More water for injection
 Is there an effective audit trail?
 Yes but not adhered to
Discussion
 Currently less than 50% of surgeries participating
 Advance prescribing is an issue
 Audit trail often not completed. Administration sheet not completed
and/or not returned
 Security seals not always used
 All Wales electronic system for claims and audit not yet developed
(relying on paper records and no flagging up of out of date boxes)
 Electronic system for prescribing being developed locally to solve CD
prescribing issues
 Introduce PDF versions of PILs
Electronic prescribing
GP prescribing template for the JIC box
developed in Hywel Dda on a local basis
for Vision and is being developed for EMIS
Should there be an All Wales approach?
Thank You