title standard operating procedure for the … · 4.4 standard operating procedure ... out the...

NHS FIFE COMMUNITY HEALTH PARTNERSHIPS

of 21 Just in Case SOP13 March 2012

Title SOP no: 13

STANDARD OPERATING PROCEDURE FOR

THE SUPPLY AND USE OF JUST IN CASE BOXES TO COMMUNITY PATIENTS IN FIFE BY GENERAL

PRACTITIONERS, NURSING STAFF AND COMMUNITY PHARMACIES

Author Margaret Vass Andrea Smith

Review /Copy No

Reviewer David Binyon/Aeltsje Oosterhof /Allan Shields/Niall Dewar

Implementation Date July 2010

Status Approved Last Review Date April 2012

Approved By : Evelyn McPhail, Director of Pharmacy, NHS Fife

Signed By:

Karen Nolan Head of Palliative Care Service

Next Review Date April 2014

1 Purpose To ensure the safe, secure and appropriate supply of Just in Case Boxes (JIC boxes), and the medicines contained within, to community patients in Fife.

2 Scope

2.1 NHS Fife supports the supply of JIC boxes to patients in the community via the Network of Palliative Care Community Pharmacies. JIC relies on appropriate anticipatory prescribing and forms part of wider anticipatory care planning processes, see references below.

2.2 Patients with a terminal illness often experience new or worsening symptoms. A JIC

box can be provided in advance where a need for medication is anticipated, but before the patient has reached the stage where they require intensive input. This process must be followed by all professionals in line with NHS Fife Code of Practice Medicines (COPM).

2.3 The only medicines that can be made available through a JIC box are:

• Morphine Sulphate or Oxynorm Injection: analgesic/breathlessness

• Levomepromazine 25mg in 1ml x 1ml amp or Cyclizine 50mg in 1ml x 1ml amp: anti-emetic

• Midazolam 5mg per ml x 2ml amp: terminal agitation/restlessness

• Hyoscine Butylbromide 20mg per ml x 1ml amp : to reduce respiratory secretions

All medicines in JIC are for subcutaneous administration 2.4 Community Nurse/Specialist Palliative Care Nurse/General Practitioner will identify

patients suitable for anticipatory prescribing, and discuss the principle of medication use with patient and family. A risk assessment must be carried out as part of the decision- making to ensure that placing a JIC box in the patient’s home does not introduce an unacceptable risk.

2.5 Prescribers must complete the appropriate prescriptions and Kardex and must ensure

that an Out-of-Hours (OOH) Palliative Care Special Notes/Patient Alert form has been completed using electronic Palliative Care Summary (ePCS) (appendix 11).



2.6 When initiating a syringe driver the JIC box must no longer be used and must be returned to the issuing Pharmacy (see section 9.10 below).

3 References 3.1 NHS Fife CHP Code of Practice – Medicines

3.2 Living and Dying Well 3.3 Liverpool Care Pathway 3.4 NHS Fife Action Plan

4 Definitions

4.1 Pharmacy Team An employee of the Community Pharmacy deemed competent by the Responsible Pharmacist to carry out this procedure.

4.2 Pharmacist Registered Pharmacist with responsibility for carrying out this procedure.

4.3 Registered Practitioner A doctor or nurse working with patients in the community in Fife.

4.4 Standard Operating Procedure A work instruction detailing a specified method for carrying out a particular activity or group of activities. Standard Operating Procedures are controlled documents.

4.5 Author

The person(s) responsible for writing and developing the document.

4.6 Review Authority NHS Fife Pharmacy Services is responsible for reviewing this procedure.

4.7 Approval Authority NHS Fife Pharmacy Services and NHS Fife Palliative Care Service have overall responsibility for ensuring the appropriateness of this Standard Operating Procedure.

5 Safety Requirements

Any member of pharmacy, medical or nursing staff carrying out this procedure must be aware of their own personal safety at all times.

6 Responsibilities For Carrying Out The Standard Operating Procedure For The Supply

And Use Of Just In Case Boxes In NHS Fife 6.1 Pharmacists must ensure that they, and any pharmacy staff, using this SOP have the

required skills and competencies.

6.2 Registered nurses and medical staff using this SOP must ensure they have the required skills and competencies to do so.



8. Community Pharmacy - Procedure

8.1 On receipt of GP10 and completed JIC prescription Kardex, an appropriate member of the pharmacy team must dispense and label the prescribed medication and add any required sundries (appendix 3) into a JIC box.

8.2 Paperwork must be completed as follows and placed in a VERY CLEARLY MARKED

envelope for the attention of Community Nursing staff:

• Running Balance form (appendix 4) with all details completed including entry of each drug and opening balance

• Audit form with section A completed (appendix 5)

• GP Kardex

• ‘Guide for Staff Administering ‘JIC’ Medicines’ (appendix 7).

• Flow Chart-A & B – (appendix 1 & 2)

8.3 Once this process is complete, a final check must be carried out by the Pharmacist and the box must be secured with a green seal. The JIC box should be placed in an appropriate bag, to maintain confidentiality, ready for delivery/uplift. The envelope containing the nursing documents must be sent with, but not inside, the JIC box. Where possible it should be attached with an elastic band or a hole can be punched in the corner of the envelope and it can be attached to the green seal before it is attached to

7. General Practitioner - Procedure

7.1 Once agreement has been reached with nursing staff, the patient and their carers that the patient would benefit from a JIC box the GP must:

• Select the appropriate medicines, ensuring that the opiate dose is appropriate and the anti-emetic is suitable for the patient.

• Write a GP10 for the medication, ensuring legal requirements are met e.g. for a controlled drug.

• EMIS practices can choose ‘Just in Case’ through synonyms to enable selection of medicines required.

• Ensure appropriate quantities required for the individual patient are prescribed – remember to consider requirements for weekends & public holidays etc.

• Complete a JIC Kardex (appendix 8). Guidance on the use of the Kardex is available on the rear of appendix 8. Prescribing guidance is available on appendix 6).

Practice Managers have been given a supply of these forms electronically.

• Complete an electronic special notes/ patient alert form (ePCS- appendix 11).

NB

• If at any point the patient’s regular analgesic dose is changed the dosage of the subcutaneous analgesic included in the JIC box must also be reviewed.

• Where a new prescription is required, this must be written on a GP10, and the patient’s Kardex must be changed to reflect any change to prescribing. Discontinued medicines must be signed off on the Kardex and any new medicines can be added to the blank section at the bottom.

• When initiating a syringe driver the JIC box must no longer be used and must be returned to the issuing Pharmacy (for full instruction see section 9.10 below).



the box. The box number & patient details should be logged to enable tracking on the JIC Box tracking form (appendix 12).

8.4 Confirm arrangements with the family/carer for uplift/delivery of the JIC box and the envelope containing the paperwork, to the patient. If this is not possible alternative arrangements should be made either by the Pharmacy or with the Community Nursing staff for uplift or delivery of the JIC box. 8.5 A claim form, ‘Running Balance’ form and ‘Audit’ form must be completed and returned to Pharmacy Services, Pentland House, Lynebank Hospital whenever a JIC box, which was dispensed and supplied to a patient, is returned to the Pharmacy. If the box is returned to the Community Pharmacy to be re-filled for the same patient a new claim form can be submitted to Pharmacy Services. 8.6 Where possible a Palliative Care Network Pharmacy should inform the relevant non- network pharmacy if they have issued a JIC box to one of their patients. 8.7 For tracking purposes - it is recommended that on a monthly basis, where JIC is

in place, the Pharmacy contact the GP practice to confirm whether it is still required and to prompt, where appropriate, a review of the contents. In some cases it may be possible to do this via the Community Nurse or relative/carer. This should be logged on the Tracking Form (appendix 12).

8.8 Where a JIC box is no longer required arrangements must be made with relatives/carer or nursing staff for return/uplift. Where possible nursing staff will secure the box with a white seal prior to return. 8.9 On return/uplift of a JIC box (even if contents were unused), a copy of the completed ‘audit’ form and ‘running balance’ paperwork must be returned to Pharmacy Services. Pharmacy staff may add any additional information if relevant at section C of the audit form. 8.10 When JIC is no longer required and the box is not returned to the supplying Pharmacy,

and after efforts made to retrieve it have failed, the Community Pharmacy must inform Pharmacy Services as soon as possible to allow an investigation to be undertaken.

8.11 Should the contents of the JIC box for a patient require to be altered and re-supplied to

the same patient:

• A new GP10 and an updated Kardex signed by the GP is required for the changed item.

• Any item returned that is no longer required must be removed from the box for destruction.

• The remaining box contents must be fully checked against the running balance form and the updated Kardex.

• Sundries and seals must be re-stocked if necessary.

• A new completed running balance form and updated Kardex must be issued to nursing staff.

• Arrangements must be made for the prompt return of the JIC box to the patient

• A claim form with ‘Running Balance Form’ and ‘Audit Form’ should be submitted to Pharmacy Services for payment to be made.



9. Community Nursing/Medical Staff - Procedure

9.1 Advise patient/carer on the rationale for using JIC and safe storage of the box. Give patient/carer a copy of ‘Information for Patients and Carers’ leaflet (Appendix 9). 9.2 Arrangements must be made for the delivery of the JIC box to the patient’s home.

• The relatives/carer should collect the box/ paperwork from the pharmacy if possible.

• The Community Nurse or Pharmacy may be required to deliver the box/paperwork to the patient’s home if the relative/carer cannot uplift it. 9.3 The ‘Running Balance’ form, ‘Audit’ form, ‘Kardex’, ‘Guide for Staff Administering JIC

Medicines’ and ‘Flow Charts A & B’ will be in an envelope and will be delivered/collected with the JIC box .The ‘Running Balance’ form and ‘Kardex’ will form part of the nursing record for the patient. The supply of the JIC should be recorded on a ‘Nursing Record of Care/Evaluation Sheet’ for the patient.

9.4 If the JIC box is required to be used:

• Break the seal

• Administer the appropriate medication as prescribed on the kardex and complete the running balance form and record the use of the box in the ‘Nursing Record of Care/Evaluation sheet’

• If this is the first time that the box has been used, place the completed audit form immediately inside the JIC box to ensure that it is returned at the appropriate time to the Pharmacy with the box.

9.5 After the first and any subsequent use of the JIC box a review of patient’s current

medication requirements should be considered. 9.6 If at any point the patient’s regular analgesic dose is changed the dosage of the

subcutaneous analgesic included in the JIC box must also be reviewed. 9.7 After each use, replace any unused medication and sundries back into the JIC box and reseal with the appropriately coloured seal (Appendix 1-flowchart A). 9.8 Prescribing for a patient must be reviewed where an individual JIC box has been accessed 3 times. However, while prescribing is being reviewed or where new prescriptions are awaited it may be necessary to continue to use the box to meet patient needs. 9.9 Where prescribing has been reviewed and regular medication changed, but JIC box is still required:

• It may be appropriate to leave the JIC box unchanged in the patient’s home should new symptoms occur and all items in JIC box still meet patient need. or

• If new prescriptions are required, e.g. if the patient’s regular analgesic dose has increased:

- The ‘Running Balance’ form must be completed, showing those drugs contained within the box being returned to pharmacy.

NB The patient’s agreement is required before any drugs belonging to them are returned to pharmacy



- The JIC box must be returned to the pharmacy for re-issue with the Pharmacy (bottom) copy of the ’Running Balance’ form and the completed ‘Audit’ form. The

Nurse (top) copy of the ‘Running Balance’ form must be short ruled and filed in the patient’s notes. - The new prescription/s and altered Kardex, signed by the prescriber must be

given to the Pharmacy along with the JIC box and paperwork. The Pharmacy will re-fill the JIC box, ensure all sundries are topped-up, and a new ‘Running Balance’ form, and the altered Kardex will be issued with the box.

9.10 When initiating a syringe driver the JIC box must no longer be used and must be returned to the issuing Pharmacy (as detailed below and in appendix 2 - Flow Chart B).

The medication contained in the JIC box may either be:

A. Used as regular medication for the syringe driver

• Any drugs that are in the JIC box that match those drugs used in the syringe driver must be transferred to the ‘Syringe Driver- Monitoring and Stock Review Chart for Patients at Home’ form.

• Complete the JIC box running balance form, clearly stating those drugs that are to be used for the syringe driver and have been transferred to the ‘Syringe Driver- Monitoring and Stock Review Chart for Patients at Home’ chart. Short rule any blank lines under each entry.

• All remaining drugs should usually be held for ‘as required use’.

B. Held for ‘as required’ use

• Complete the JIC box running balance form clearly stating those drugs that are to be used as ‘as required’ medication and transfer these medicines to the ‘Prescription of Medications/Referral to Community Nursing Services’ form.

C. Drugs no longer required should be returned with the JIC box and paperwork to the pharmacy for destruction following 9.11

9.11. When a JIC box is no longer required:

• Complete the JIC box running balance form and retain the top copy for nursing records

• Ensure the JIC box audit form has been completed - even if the box has not been used

• Ensure the Pharmacy (bottom) copy of the running balance form and the audit form are placed inside the box for return to the supplying network pharmacy.

• Secure the box with the white seal

• Whenever possible inform the supplying network pharmacy that use of the box is complete

• Arrange with the relative/carer to return the box to the network pharmacy. If this is not practical the box can be returned in accordance with NHS Fife COPM Policy for the Management of Controlled Drugs by any healthcare

• professional or the network pharmacy can be contacted to uplift it

• It is essential that the box is returned to the network pharmacy, if there is concern about its whereabouts contact the supplying pharmacy or Pharmacy Services, Pentland House, Lynebank Hospital, 01383 565351.



10. Pharmacy Process for Reissuing JIC Box to a New Patient

10.1 On return/uplift of a JIC box, an appropriate member of the pharmacy team will remove and check the contents of the box. Unused medicines will be destroyed in accordance with GPhC guidance.

10.2 For Infection Control purposes, JIC boxes require to be cleaned with a solution of Hypochlorite (Acticlor Tablets), rinsed and dried. Staff carrying out this procedure must ensure they comply with COSHH requirements – copies can be requested from Pharmacy services.

10.3 In preparation for next use, refill the box with any additional sundries required (Supplied through Pharmacy Services).

10.4 Continue as from section 7.1.

11. Attachments

11.1 Appendix 1 - Flow Chart A for JIC Box

11.2 Appendix 2 – Flow Chart B changing from JIC box to Syringe Driver 11.3 Appendix 3- Contents List 11.4 Appendix 4 - Running Balance Form 11.5 Appendix 5 - Audit Form

11.6 Appendix 6 - Guide for Prescribing JIC Medicines 11.7 Appendix 7 - Guide for Administering JIC Medicines 11.8 Appendix 8 - Prescription Kardex for JIC medicines (with brief prescribing notes on reverse) 11.9 Appendix 9 - Information for Patients and Carers 11.10 Appendix 10 - Fife Network of Palliative Care Community Pharmacies 11.12 Appendix 11 - Special Notes/Patient Alert 11.12 Appendix 12 - JIC box Tracking Form



Appendix 1 FLOW CHART A FOR USE OF JUST IN CASE BOX IN NHS FIFE

NO YES

IF A SYRINGE DRIVER IS REQUIRED SEE SECTION 9.10 of SOP and FLOW CHART B

Medicines Required 2nd Time

Medicines Required

Pharmacy - Complete running balance form (appendix 3) put box number on running balance form and audit form. Final check box and seal with green seal.

Place patient label on box label tag. Arrange for JIC box to be delivered to patient along with the envelope containing kardex, audit form, running balance form, guide

for staff administering JIC Medicines and Flow Chart A

Nurse - Ensure you have a JIC Kardex and running balance form for this patient and their notes

Break seal and administer medication as required. Complete audit form / running

balance form and Kardex

Does patient’s regular or PRN medication need reviewed?

If yes contact prescriber.

Contact Prescriber for new prescription

Pharmacist - Clinically check prescription and kardex and ensure that only agreed drugs are prescribed (appendix. 2).

Pharmacy- Dispense drugs as per prescription and place in JIC box with sundries as per content list (appendix2)

Place audit form into JIC box Reseal box with yellow seal

Open box, administer medication as required, and complete all appropriate forms.

Reseal box with red seal

Does patient’s regular or PRN medication need reviewed?

If yes contact prescriber.

Open Box, Administer medication as required, and complete all appropriate forms.

Reseal box with red seal Repeat as necessary

Patient’s Regular Medicine must be reviewed after box has been used 3 times. As

appropriate contact prescriber or NHS 24 for review, meanwhile box can continue to be

used.

Return Box to Pharmacy when no longer required. Ensure a copy of running balance form and audit form

are returned in box to the Community Pharmacy. Follow SOP if changes to prescribing are made

Pharmacy – return completed running balance and audit form to Pharmacy

Services. Prepare box as described in SOP for next patient or for re-use by

Nurse - ensure box is stored in a secure manner in patient’s home and that patient/carer understands what it is for. Ensure patient/carer has

information leaflet

Medicines Required 3rd Time

If changes to medicines in JIC box are required arrange for new GP10 and updated Kardex along with JIC box to be delivered to pharmacy for

re-filling in accordance with SOP



Appendix 2 FLOW CHART - B CHANGING FROM JIC BOX TO SYRINGE DRIVER

SYRINGE DRIVER INITIATED

CAN DRUGS USED IN THE JUST IN CASE BOX BE USED AS ONGOING MEDICATION?

NO YES

IN SYRINGE DRIVER

YES AS - AS

REQUIRED MEDICATION

RETURN ENTIRE BOX TO PHARMACY

COMMUNITY STAFF ARE PERMITTED TO TAKE JUST IN

CASE BOXES & DRUGS TO PHARMACY IF FAMILY OR

CARERS ARE UNABLE

IF DRUGS ARE TO BE USED, BUT NOT VIA SYRINGE DRIVER,

THEY MUST ALSO BE PRESCRIBED ON THE

‘PRESCRIPTION OF MEDICATIONS/REFERRAL TO

COMMUNITY NURSING SERVICES’ SHEET AS A

GENERAL PRESCRIPTION.

IF THESE DRUGS ARE CONTROLLED DRUGS, A

RUNNING BALANCE MUST BE KEPT IN THE 5

TH COLUMN

ENTITLED ‘CD STOCK RUNNING BALANCE’

A COPY OF THE ‘RUNNING

BALANCE FORM FROM THE JUST IN CASE BOX’ MUST BE RETAINED IN THE CARE PLAN

AS A RECORD OF STOCK TRANSFERRED.

RETURN JUST in CASE BOX TO

PHARMACY

ANY DRUGS TO BE USED IN THE SYRINGE DRIVER MUST

BE ENTERED ON THE ‘SYRINGE DRIVER –

MONITORING AND STOCK REVIEW CHART FOR PATIENTS

AT HOME’ AS INCOMING STOCK

A COPY OF THE ‘RUNNING

BALANCE FORM FROM THE JUST IN CASE BOX’ MUST BE RETAINED IN THE CARE PLAN

AS A RECORD OF STOCK TRANSFERRED.

RETURN JUST in CASE BOX TO

PHARMACY

CHANGING FROM JUST IN CASE BOX TO SYRINGE DRIVER



Appendix 3

CONTENTS OF THE JUST IN CASE (JIC) BOXES

SUNDRIES:

ITEM QUANTITY PER

BOX

1ml Leur Slip Syringes 10

2ml Leur Slip Syringes 10

21 Gauge Needles 10

25 Gauge Needles 10

Blunt Fill Filter needles 10

70% isopropyl alcohol swabs 10

Tags

I green on box – 1 yellow and 3 red , 1 white inside

box

5

Sundries will be supplied by Pharmacy Services Tel: 01383 565351.

MEDICINES

Morphine Sulphate Inj or OxyNorm Inj

Hyoscine Butylbromide 20mg per ml x 1ml amps

Midazolam 5mg per ml x 2ml amps

Levomepromazine 25mg in 1ml x 1ml amp or

Cyclizine 50mg in 1m x 1ml amp

QUANTITY PER BOX IS

DEPENDENT ON

PATIENT NEED



RUNNING BALANCE FORM - RECORD OF CONTENTS OF JUST IN CASE BOX

• Pharmacist must complete the drug, date, batch number, expiry date and running balance columns of this sheet for each drug placed into JIC box, sign it and enclose it in an envelope with

other documents for nursing staff

• Person administering medication must complete the appropriate part of the form for each drug used, complete the dose, route, date, time and running balance and sign the sheet for each administration. Complete an entry line with appropriate balance (which may be zero) showing any drugs that have been left with when box is returned to pharmacy.

JIC Box No: Date Dispensed Patient Name CHI Number

Drug Enter 1 Drug Per Number

Batch Number

Expiry Date

Dose Given

Amount Discarded

Route Given & Site

Date Time Opening Quantity & Running Balance

Signature

1.

2.

3.

4.



Appendix 5 ‘JUST IN CASE’ AUDIT FORM

Section A – to be completed by Community Pharmacy

BOX NUMBER SUPPLYING PHARMACY DATE DISPENSED

Section B- To be completed by first healthcare professional to use the ‘Just in Case Box’ and placed in the box for return to Community Pharmacy

Name of Health Professional:…………………………………………….Signature:……………………………………………………………… Job Title:………………………………………………………………………… Base:………………………………………………….…

1. When was the box first used?

DATE: TIME:

2. Please describe briefly what prompted the first use of this JIC Box.

3.

Did the Just In Case Box Prevent any of the following? Yes No

a An Out of Hours Call to a doctor?

b An admission to hospital?

c An admission to a hospice?

d A call-out to a pharmacist out-of-hours?

e. Did it prevent an extra journey to the GP or Community Pharmacy?

f Did the patient remain in their preferred place of care?

g Were there any problems in collecting, using or returning the Just in Case box?

h Were the medicines included in the JIC box appropriate?

i Should there have been any other medicines included in the JIC box?

If yes, please provide details.

Community Nursing/Medical Staff: Please return this form and a copy of the ‘Running Balance’ form to the supplying Community Pharmacy with the box

along with any unused contents when JIC is no longer required

Section C – To be completed by Community Pharmacy

Community Pharmacy:

Please send completed forms to: Sheila Dall, Pharmacy Services, Pentland House

Lynebank Hospital, Halbeath Road, Dunfermline, KY11 4UW

Date Box Returned:

Additional information that may be useful for audit, i.e. if the box wasn’t used do you know why

not?:

□ Inability to swallow oral meds □ Breathlessness

□ Breakthrough pain □ Secretions □ Agitation or restlessness □ To set-up a syringe driver □ Nausea □ To be used as PRN medication

□ Vomiting □ Other – please specify



Appendix 6

GUIDE FOR PRESCRIBING JIC MEDICINES

The following is a guide to prescribing the medicines contained within the NHS Fife Just in Case Box. They should be prescribed as part of an overall anticipatory care plan for patients with advancing disease resident in their own home or within a residential care setting. They are intended for the management of the patient at times of distress and will allow attending staff to administer appropriate medicines. The medicines have been chosen to reflect guidance contained in the Liverpool Care Pathway.

The patient should be assessed and regular medicines reviewed at the earliest opportunity after the initial event. This may necessitate use of a syringe driver for drug delivery. If 2-3 when required doses have been administered consider use of a syringe driver.

PAIN

Morphine: 1st

choice option; if opioid naïve prescribe a 2.5 or 5mg subcutaneous dose; for patients using regular morphine use a when required dose of

1/6th of

the current 24hour dose. e.g. Zomorph 60mg twice daily = 10mg Morphine Sulphate when required subcutaneously. (To convert from oral morphine to subcutaneous morphine divide by 2) Oxycodone: 2

nd choice for patients intolerant of morphine eg vomiting,

drowsiness, confusion, hallucinations. For patients using regular oxycodone use a when required dose of

1/6th of current 24hr dose. e.g. OxyContin 30mg twice

daily = 5mg OxyNorm injection when required subcutaneously. (To convert from oral oxycodone to subcutaneous oxycodone divide by 2) If numerous when required doses have been used consider using syringe driver.

NAUSEA &/ VOMITING

TERMINAL RESTLESSNESS

& AGITATION

RESPIRATORY TRACT

SECRETIONS

DYSPNOEA

Midazolam 2.5mg subcutaneously repeated hourly up to 3 times Sedative, anticonvulsant and muscle relaxant. If hallucinations and paranoia are a feature Haloperidol 0.5-1.5mgs subcutaneously may be more effective Useful if patient is anxious / frightened or when sedation is necessary.

Choose Levomepromazine 5mg subcutaneously for nausea and vomiting associated with conditions other than highlighted above. Effective at low doses without causing undue sedation. Larger doses also used for terminal agitation. Could be repeated after 2 hours. Consider a syringe driver if effective (5-25mg / day) If already taking oral levomepromazine the equivalent subcutaneous dose should be divided by 2.

Choose Cyclizine 50mg subcutaneously for nausea associated with raised intracranial pressure, recent head / neck radiotherapy, brain / meningeal disease, vestibular / movement related. Could be repeated after 8 hours up to 150mg / day Consider syringe driver dose 150mg/24 hours if effective. Consider Levomepromazine if not effective.

Use the same dose and choice of opioid as for pain.

Hyoscine Butylbromide subcutaneously 20mg when required repeated 2 hourly up to 3 times. Used to dry respiratory secretions and relieve colic Hyoscine Butylbromide 60-120mg/24 hrs sc via syringe driver



Appendix 7

GUIDE FOR STAFF ADMINISTERING JIC MEDICINES

The following is a guide to the use of the medicines contained within the NHS Fife Just in Case Box. It is intended for the immediate (or rapid or crisis) management of the patient at times of distress and the assessment of effectiveness of the intervention used. The patient should be assessed and regular (prescribed) medicines reviewed at the earliest opportunity after the initial event/crisis. If 2- 3 when required (PRN) doses have been administered consider use of a syringe driver.

PAIN

If already taking regular opioid the ‘when required’

dose of Morphine / OxyNorm should be

1/6

th

(one sixth) daily dose. Half the dose of oral

Morphine / Oxycodone when converting to the

subcutaneous route.

Assess analgesic response and

respiratory rate after 30-60 minutes. If no

response administer a further dose. If

respiratory rate < 8 refer to doctor.

NAUSEA &/ VOMITING

TERMINAL RESTLESSNESS &

AGITATION

RESPIRATORY TRACT SECRETIONS

BREATHLESSNESS (DYSPNOEA)

Give Midazolam 2.5mg

subcutaneously

Assess after 1 hour, if no relief administer

a second dose. If respiratory rate < 8

refer to doctor.

Assess after a further hour, if no relief

administer a third dose. If no response after 3 doses refer to doctor

If no response after second dose refer to

doctor

Give Hyoscine Butylbromide

20mg subcutaneously

Assess after 1-2 hours. If no response after 2 hours repeat

dose

If no response after a further 2 hours repeat

dose and refer to doctor

Patient develops symptoms that require (crisis) management

Give Levomepromazine

5mg subcutaneously

Give Cyclizine 50mg subcutaneously

Review at 2 hours for effectiveness.

Consider further dose after 8 hours if

effective. If not refer to doctor

If no response after a further 2 hours refer

to doctor

Review at 2 hours for effectiveness. If no response give

second dose

Assess response after 1 hour. If no

response administer a further dose. If no

response after a further hour refer to

doctor

If not already taking an opioid usually 2.5mg Morphine subcutaneously

If already taking regular opioid the ‘when required’ dose of

Morphine / OxyNorm should be

1/6

th (one sixth)

daily dose. Half the dose of oral

Morphine / Oxycodone when converting to the

subcutaneous route.



Appendix 8 PRESCRIPTION KARDEX

‘When Required Medicines’ for patients with anticipated palliative needs Remember to prescribe appropriate analgesia for breakthrough pain on this kardex

Patient Name

Address

CHI

Practice

Medicine Dose Frequency Recommended Guide of Maximum number of doses

before referral to Doctor

Route Signed Date Discontinued Date

For Nausea and Vomiting

Levomepromazine 5mg 2 hourly 2 subcutaneous

Cyclizine 50mg 8 hourly 2 subcutaneous

For anxiety / restlessness

Midazolam 2.5mg hourly 3 subcutaneous

For respiratory secretions

Hyoscine Butylbromide 20mg 2 hourly 3 subcutaneous

For Pain / Breathlessness

Morphine Sulphate subcutaneous

OxyNorm subcutaneous



Appendix 8 - continued Guidance on the use of the pre-printed Prescription Kardex.

This document allows consistent anticipatory prescribing of some of the medicines that may be required by patients with palliative care needs. It complements the use of the ‘Just in Case’ boxes supplied to some patients and reflects the medicines included within these boxes. The medicines chosen are based on the recommendations from the Liverpool Care Pathway as adopted by NHS Fife. The prescription kardex will sit in the patient’s care plan and allow administration of the medicines prescribed should they be needed. It is anticipated that the biggest benefit of the pro-forma will be during the out-of-hours period and should help out-of-hours services facilitate management of a patient’s condition until usual care can be continued. If any of the medicines are identified as being suitable for a patient the prescriber should sign and date the prescription kardex. If any of the medicines are unsuitable for a patient, the prescribing GP should not sign or date the kardex. Only medicines that have been signed and dated by the prescriber can be administered by community nursing staff. If a patient’s condition changes making a previously prescribed medicine no longer suitable for the patient, the prescriber should sign and date the shaded discontinued boxes and place a score line through the order. Because the dose of an analgesic will be dependent both on the previous dose and preparation the patient has been receiving, the prescriber is asked to add this ‘when required - PRN’ dose on the prescription themselves. Suitable PRN schedules are detailed below as a guide. The one sixth (1/6) rule applies in that the PRN dose should be calculated as one sixth of the patients regular dose. If a patient’s regular dose of analgesia changes the breakthrough dose of analgesic should be reviewed and reflect this dose change. When an analgesic prescription is no longer appropriate the prescriber should sign and date the shaded discontinued boxes and place a score line through the order. If the prescription kardex is used for a patient this should be included in the ‘Special Notes’ Alert supplied to NHS24 / PCES or the electronic Palliative Care Summary (ePCS) when available. Quick Guide to Breakthrough Dosing of Analgesia based on a patient’s regular analgesic intake:

Regular Prescription Corresponding Subcutaneous Breakthrough Conversion factors from oral to subcutaneous Zomorph 30mg bd PO Morphine Sulphate Inj SC 5mg Morphine sulphate 10mg PO = Morphine sulphate SC 5mg

OxyContin 30mg bd PO OxyNorm Inj SC 5mg Oxycodone 10mg PO = OxyNorm SC 5mg Fentanyl TTS 25mcg / hr Morphine Sulphate Inj SC 7.5mg or

Diamorphine Inj SC 5mg Morphine sulphate 30mg PO = Diamorphine SC 10mg

For further information on dose equivalence see NHS Fife Guidelines for the Control of Pain in Patients with Cancer at: http://www.fifeadtc.scot.nhs.uk/



Appendix 9

What is the Just-in-Case Medicine Box and What is in it?

Information for Patients and Carers

The Just-in-Case (JIC) box is a box that contains medicines. The medicines are helpful in treating pain

and sickness. They are given into the skin via a needle if you have difficulty swallowing. The box with

the medicines will be there so that if you need control of symptoms your healthcare team can treat you

quickly. Most patients find this helpful. The JIC box is not to be used instead of your usual medicines

but is kept as a back-up. It will be helpful should you need any of the medicines in the evenings or at

weekends and need to contact NHS24. NHS24 will have a record that you have been supplied with a

JIC box and that the medicines are available.

The JIC contains the following medicines:

1. MORPHINE SULPHATE / OXYCODONE: for pain.

2. LEVOMEPROMAZINE / CYCLIZINE: for sickness.

3. MIDAZOLAM: for relaxing muscle.

4. HYOSCINE BUTYLBROMIDE: to dry up chest / mouth secretions.

The JIC box will be provided by a specialist pharmacy (a list of these will be provided by your surgery).

The JIC box will be sealed so that it is only opened by the healthcare staff looking after you. They will

make sure that the medicines are used appropriately. Your healthcare team will discuss the use of the

JIC box with you. The medicines prescribed for you will be provided by the pharmacy using a normal

prescription. Your GP will give you an extra sheet called a ‘Prescription Kardex’. This should be given

to the pharmacy along with the prescription so they know that the medicines should be packed into the

JIC box. If the box is no longer needed then it should be returned to the pharmacy that supplied it

along with the paperwork.



Appendix 9 Cont.

FAQs

1. When will I be given the JIC box?

The JIC box will be prescribed for you when you and your healthcare team feel it may be useful to

have these extra medicines at home.

2. Does the JIC box mean I am going to need these drugs immediately?

No. The JIC box is just back-up and may not be used for many weeks, if at all.

3. Do I take it into hospital with me?

No. Leave the JIC box at home but take your regular oral medicines. If you go to hospital, they will

provide any treatment you require.

4. Who will know when to use the JIC box?

The JIC box will only be opened and used by a member of the healthcare team qualified to do so.

5. Where should I keep the JIC box?

The JIC box should be kept in a safe place and away from children. The seal should not be opened by

anyone except a nurse or doctor.

6. What happens to the JIC box when it is not needed?

The JIC must be returned to the pharmacy that provided it.

7. Who do I talk to if I have any questions about the JIC box?

You can talk to any member of your healthcare team including the Pharmacist supplying the box.



Appendix 10

Fife Network of Palliative Care Community Pharmacies

LOCATION

PHARMACY

OPENING HOURS

LUNCH HOUR

Anstruther Central Pharmacy, 23 Rodger Street, Anstruther.

KY10 3DU Tel: 01333 310354

Mon- Fri: 9.00-18.00

Sat: 9.00-17.00

Auchtermuchty Rowland’s Pharmacy, 42 High Street Auchtermuchty. KY14 7AP Tel: 01337 828345

Mon-Fri: 9.00-17.30 Sat: 9.00-12.30

Burntisland Lloyds Pharmacy, 239 High Street, Burntisland. KY3 9AE Tel 01592 873725

Mon-Fri: 9.00-17.30 Sat: 9.00-17.30

Sat only 1.00 – 2.15

Cowdenbeath Wm Morrison Pharmacy, 1-2 Raith Centre, Cowdenbeath. KY4 8PB

Tel 01383 610164

Mon-Fri: 9.00-17.30 Sat: 9.00-17.00

Cupar Rowlands, Bonnygate, Cupar KY15 4BY

Tel: 01334 654755

Mon-Fri 9.00-17.30

Sat: 9.00-17.00

ASDA, Halbeath, Dunfermline. KY11 4LP

Tel: 01383 843617

Mon-Fri: 9.00-21.00 Sat: 8.30-19.00

Sun: 10.00-18.00

Dunfermline

Co-op Pharmacy, Douglas Street, Dunfermline

Tel: 01383 724772

Mon-Fri: 9.00 – 17.30

Sat: 9.00-13.00

Boots the Chemist 14 Lyon Square, Glenrothes. KY7 5NR

01592 758783

Mon-Fri: 8.45-17.30 Sat: 8.45-17.30

Sun: 12.00-16.00

Glenrothes

Your Local Boots Pharmacy,

Cos Lane, Glenrothes Tel: 01592 752554

Mon-Fri: 8.30-17.30

Sat: 9.00-12.30

ASDA, Carberry Road,

Kirkcaldy. KY1 3NG Tel: 01592 657210

Mon-Fri: 9.00-21.00

Sat: 8.30-19.00 Sun: 9.00-18.00

Boots, Retail Park, Kirkcaldy KY2 6QL

Tel: 01592 644139

Mon-Fri: 9.00-20.00 Sat: 9.00-18.00

Sun: 10.00-17.30

Lloyds, Viceroy Street, Kirkcaldy. KY2 5HT Tel: 01592 260925/ 261367

Mon-Fri: 9.00-17.30 Sat: 9.00-13.00

1.00 – 2.00

Kirkcaldy

Lloyds, Whytemans Brae, Kirkcaldy KY1 2NA Tel: 01592 268784

Mon-Fri: 8.30-18.00

Leven T W Buchanan, 30 Commercial Road,

Leven Ky8 4LD Tel: 01333 423133

Mon-Fri: 9.00-17.30

Sat: 9.00-13.00

Lochgelly Rosewell Pharmacy, Bank St, Lochgelly KY5 9QQ

01592 780598

Mon-Fri: 8.45-17.45 Sat: 9.00-12.00

12.45 – 2.00

Methil C Buchanan, 345 Methilhaven Rd, Methil. KY83HR Tel: 01333 423972

Mon-Fri: 9.00-17.30 Sat: 9.00-12.30

1.00 – 2.00

Newport-on-Tay Rowlands, Tayview Medical Practice, Victoria Street, Newport on Tay DD6 8DJ

Tel: 01382 543179

Mon-Fri: 9.00-17.30 Sat: 9.00-12.30

1.00 – 2.00

Oakley Oakley Pharmacy, Wardlaw Way, Oakley Tel: 01383 850349

Mon-Fri: 8.30-17.45 Sat: 9.00-12.30

1.00 – 2.00

Rosyth Rowlands, Queensferry Road, Rosyth KY11 2RA 01383 413504

Mon-Fri: 9.00-18.00 Sat: 9.00-17.00

St. Andrews Lloyds, St Andrews Community Hospital,

St.Andrews. KY16 8EL Tel: 01334 475395

Mon-Thurs: 9.00-17.30

Fri 9.00 – 18.00 Sat: 9.00-13.00



Appendix 11

Please note that the contents of this document will form part of an NHS 24 patient record

Patient Details (*Mandatory category) *FORENAME (S)

*SURNAME *DATE OF BIRTH GENDER

AGE (if no DOB given) *CHI NO

ADDRESS Line 1

ADDRESS Line 2

ADDRESS Line 3

ADDRESS Line 4

*POST CODE

Practice/Co-op Details

USUAL GP NAME

GP PRACTICE

Special Note/Patient Alert – Info for NHS 24

START DATE END DATE

IMPORTANT DETAILS/ ACTION REQ’D FOR NHS24

CATEGORY OF ALERT

� Terminally Ill Patient � Violent Patient � Mental Health Patient � Other (please specify below) � Frequent Caller ________________________________________

Info for Consulting GP

CONTACT & TEL NO (IF NOT PATIENT, I.E. CARER, ETC)

DIAGNOSIS

ALLERGIES

PRESCRIBED MEDS AVAILABLE IN HOME

RECOMMENDED ACTION FOR CONSULTING OOH GP

(PLEASE FAX TO PCES CENTRAL OFFICE ON 01592 740249 /740243 or e-mail to [email protected])

SPECIAL NOTES/PATIENT ALERT (PLEASE FAX TO PCES CENTRAL OFFICE ON 01592 740249 /740243

or e-mail to [email protected] THIS FORM MUST BE TYPEWRITTEN (Handwritten forms will no longer be acceptable)



Appendix 12 Just in Case Box Tracking Form

Date Issued

Box Number

Patient Name Or CHI

Address Name of Contact i.e. Relative/Nurse/GP

Date Of Monthly Check - If Required

Date Box Returned

title standard operating procedure for the … · 4.4 standard operating procedure ... out the...

Documents