NHS FIFE COMMUNITY HEALTH PARTNERSHIPS

Title SOP no: 13 NHS FIFE COMMUNITY HEALTH PARTNERSHIPS 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 Review /Copy No Andrea Smith Reviewer David Binyon/Aeltsje Implementation Date July 2010 Oosterhof /Allan Shields/Niall Dewar Status Approved Last Review Date April 2012 Approved By : Evelyn McPhail, Director of Pharmacy, NHS Fife Signed By: Next Review Date April 2014 Karen Nolan Head of Palliative Care Service 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 decisionmaking 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). Page 1 of 21 Just in Case SOP13 March 2012

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. Page 2 of 21 Just in Case SOP13 March 2012

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: NB 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). 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). 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 Page 3 of 21 Just in Case SOP13 March 2012

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 nonnetwork 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. Page 4 of 21 Just in Case SOP13 March 2012

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 Page 5 of 21 Just in Case SOP13 March 2012

- 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. Page 6 of 21 Just in Case SOP13 March 2012

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 Page 7 of 21 Just in Case SOP13 March 2012

Appendix 1 NHS FIFE COMMUNITY HEALTH PARTNERSHIPS FLOW CHART A FOR USE OF JUST IN CASE BOX IN NHS FIFE Pharmacist - Clinically check prescription and kardex and ensure that only agreed drugs are prescribed (appendix. 2). NO YES Contact Prescriber for new prescription Pharmacy- Dispense drugs as per prescription and place in JIC box with sundries as per content list (appendix2) 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 Does patient s regular or PRN medication need reviewed? If yes contact prescriber. 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 Break seal and administer medication as required. Complete audit form / running balance form and Kardex Place audit form into JIC box Reseal box with yellow seal Does patient s regular or PRN medication need reviewed? If yes contact prescriber. Medicines Required 2 nd Time Open box, administer medication as required, and complete all appropriate forms. Reseal box with red seal Medicines Required 3 rd Time 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. Open Box, Administer medication as required, and complete all appropriate forms. Reseal box with red seal Repeat as necessary 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 IF A SYRINGE DRIVER IS REQUIRED SEE SECTION 9.10 of SOP and FLOW CHART B 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 Page 8 of 21 Just in Case SOP13 March 2012

Appendix 2 FLOW CHART - B CHANGING FROM JIC BOX TO SYRINGE DRIVER CHANGING FROM JUST IN CASE BOX TO SYRINGE DRIVER SYRINGE DRIVER INITIATED CAN DRUGS USED IN THE JUST IN CASE BOX BE USED AS ONGOING MEDICATION? NO RETURN ENTIRE BOX TO PHARMACY COMMUNITY STAFF ARE PERMITTED TO TAKE JUST IN CASE BOXES & DRUGS TO PHARMACY IF FAMILY OR CARERS ARE UNABLE YES AS - AS REQUIRED MEDICATION 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 YES IN SYRINGE DRIVER 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 Page 9 of 21 Just in Case SOP13 March 2012

Appendix 3 SUNDRIES: CONTENTS OF THE JUST IN CASE (JIC) BOXES 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 Page 10 of 21 Just in Case SOP13 March 2012

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 1. Drug Enter 1 Drug Per Number Batch Number Expiry Date Dose Given Amount Discarded Route Given & Site Date Time Opening Quantity & Running Balance Signature 2. 3. 4. Page 11 of 21 Just in Case SOP13 March 2012

Appendix 5 NHS FIFE COMMUNITY HEALTH PARTNERSHIPS 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. 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 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 Date Box Returned: Additional information that may be useful for audit, i.e. if the box wasn t used do you know why not?: Community Pharmacy: Please send completed forms to: Sheila Dall, Pharmacy Services, Pentland House Lynebank Hospital, Halbeath Road, Dunfermline, KY11 4UW Page 12 of 21 Just in Case SOP13 March 2012

Appendix 6 NHS FIFE COMMUNITY HEALTH PARTNERSHIPS 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. PAIN Morphine: 1 st 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 / 6 th 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 / 6 th 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. TERMINAL RESTLESSNESS & AGITATION RESPIRATORY TRACT SECRETIONS 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. 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 NAUSEA &/ VOMITING 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. 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. DYSPNOEA Use the same dose and choice of opioid as for pain. 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. Page 13 of 21 Just in Case SOP13 March 2012

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. Patient develops symptoms that require (crisis) management 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. If no response after second dose refer to doctor TERMINAL RESTLESSNESS & AGITATION 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 RESPIRATORY TRACT SECRETIONS 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 NAUSEA &/ VOMITING Give Levomepromazine 5mg subcutaneously Review at 2 hours for effectiveness. If no response give second dose If no response after a further 2 hours refer to doctor Give Cyclizine 50mg subcutaneously Review at 2 hours for effectiveness. Consider further dose after 8 hours if effective. If not refer to doctor BREATHLESSNESS (DYSPNOEA) 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. Assess response after 1 hour. If no response administer a further dose. If no response after a further hour refer to doctor Page 14 of 21 Just in Case SOP13 March 2012

Appendix 8 NHS FIFE COMMUNITY HEALTH PARTNERSHIPS 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 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 Route Signed Date Discontinued Date OxyNorm subcutaneous Page 15 of 21 Just in Case SOP13 March 2012

Appendix 8 - continued NHS FIFE COMMUNITY HEALTH PARTNERSHIPS 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/ Page 16 of 21 Just in Case SOP13 March 2012

Appendix 9 NHS FIFE COMMUNITY HEALTH PARTNERSHIPS 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. Page 17 of 21 Just in Case SOP13 March 2012

Appendix 9 Cont. NHS FIFE COMMUNITY HEALTH PARTNERSHIPS 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. Page 18 of 21 Just in Case SOP13 March 2012

Appendix 10 Fife Network of Palliative Care Community Pharmacies LOCATION PHARMACY OPENING HOURS LUNCH HOUR Anstruther Auchtermuchty Burntisland Cowdenbeath Cupar Dunfermline Glenrothes Kirkcaldy Leven Lochgelly Methil Newport-on-Tay Oakley Rosyth St. Andrews Central Pharmacy, 23 Rodger Street, Anstruther. KY10 3DU Tel: 01333 310354 Rowland s Pharmacy, 42 High Street Auchtermuchty. KY14 7AP Tel: 01337 828345 Lloyds Pharmacy, 239 High Street, Burntisland. KY3 9AE Tel 01592 873725 Wm Morrison Pharmacy, 1-2 Raith Centre, Cowdenbeath. KY4 8PB Tel 01383 610164 Rowlands, Bonnygate, Cupar KY15 4BY Tel: 01334 654755 ASDA, Halbeath, Dunfermline. KY11 4LP Tel: 01383 843617 Co-op Pharmacy, Douglas Street, Dunfermline Tel: 01383 724772 Boots the Chemist 14 Lyon Square, Glenrothes. KY7 5NR 01592 758783 Your Local Boots Pharmacy, Cos Lane, Glenrothes Tel: 01592 752554 ASDA, Carberry Road, Kirkcaldy. KY1 3NG Tel: 01592 657210 Boots, Retail Park, Kirkcaldy KY2 6QL Tel: 01592 644139 Lloyds, Viceroy Street, Kirkcaldy. KY2 5HT Tel: 01592 260925/ 261367 Lloyds, Whytemans Brae, Kirkcaldy KY1 2NA Tel: 01592 268784 T W Buchanan, 30 Commercial Road, Leven Ky8 4LD Tel: 01333 423133 Rosewell Pharmacy, Bank St, Lochgelly KY5 9QQ 01592 780598 C Buchanan, 345 Methilhaven Rd, Methil. KY83HR Tel: 01333 423972 Rowlands, Tayview Medical Practice, Victoria Street, Newport on Tay DD6 8DJ Tel: 01382 543179 Oakley Pharmacy, Wardlaw Way, Oakley Tel: 01383 850349 Rowlands, Queensferry Road, Rosyth KY11 2RA 01383 413504 Lloyds, St Andrews Community Hospital, St.Andrews. KY16 8EL Tel: 01334 475395 Mon- Fri: 9.00-18.00 Sat: 9.00-17.00 Mon-Fri: 9.00-17.30 Sat: 9.00-12.30 Mon-Fri: 9.00-17.30 Sat: 9.00-17.30 Mon-Fri: 9.00-17.30 Sat: 9.00-17.00 Mon-Fri 9.00-17.30 Sat: 9.00-17.00 Mon-Fri: 9.00-21.00 Sat: 8.30-19.00 Sun: 10.00-18.00 Mon-Fri: 9.00 17.30 Sat: 9.00-13.00 Mon-Fri: 8.45-17.30 Sat: 8.45-17.30 Sun: 12.00-16.00 Mon-Fri: 8.30-17.30 Sat: 9.00-12.30 Mon-Fri: 9.00-21.00 Sat: 8.30-19.00 Sun: 9.00-18.00 Mon-Fri: 9.00-20.00 Sat: 9.00-18.00 Sun: 10.00-17.30 Mon-Fri: 9.00-17.30 Sat: 9.00-13.00 Mon-Fri: 8.30-18.00 Mon-Fri: 9.00-17.30 Sat: 9.00-13.00 Mon-Fri: 8.45-17.45 Sat: 9.00-12.00 Mon-Fri: 9.00-17.30 Sat: 9.00-12.30 Mon-Fri: 9.00-17.30 Sat: 9.00-12.30 Mon-Fri: 8.30-17.45 Sat: 9.00-12.30 Mon-Fri: 9.00-18.00 Sat: 9.00-17.00 Mon-Thurs: 9.00-17.30 Fri 9.00 18.00 Sat: 9.00-13.00 Sat only 1.00 2.15 1.00 2.00 12.45 2.00 1.00 2.00 1.00 2.00 1.00 2.00 Page 19 of 21 Just in Case SOP13 March 2012

Appendix 11 NHS FIFE COMMUNITY HEALTH PARTNERSHIPS SPECIAL NOTES/PATIENT ALERT (PLEASE FAX TO PCES CENTRAL OFFICE ON 01592 740249 /740243 or e-mail to Fife-UHB.pces@nhs.net THIS FORM MUST BE TYPEWRITTEN (Handwritten forms will no longer be acceptable) 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 AGE (if no DOB given) ADDRESS Line 1 ADDRESS Line 2 ADDRESS Line 3 ADDRESS Line 4 *POST CODE Practice/Co-op Details USUAL GP NAME GP PRACTICE GENDER *CHI NO Special Note/Patient Alert Info for NHS 24 START DATE IMPORTANT DETAILS/ ACTION REQ D FOR NHS24 CATEGORY OF ALERT Terminally Ill Patient Mental Health Patient Frequent Caller END DATE Violent Patient Other (please specify below) 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 Fife-UHB.pces@nhs.net) Page 20 of 21 Just in Case SOP13 March 2012

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 Page 21 of 21 Just in Case SOP13 March 2012