Standard Operating Procedure 2 (SOP 2) The Prescribing, Monitoring and Administration of Depot / Long Acting IM Medication within Community Mental Health Services Why we have a procedure? Black Country Partnership NHS Foundation Trust is committed to managing medicines safely, efficiently and effectively as a key component for the delivery of high quality patient centred care. Medicines play a significant role in the care of the people who use our services and creating an effective system for managing medicines in an appropriate and timely manner is key to giving patients the best possible care, positive outcomes and reducing incidents of harm. Administering medicines to people should not to be regarded as just a mechanical task to be carried out in line with the instructions of the prescriber, it requires thought, application and the exercise of professional judgement; it is a core component of medicines management and encompasses many areas for potential error. This standard operating procedure describes the procedures and best practice that should be used when providing IM Depot medication to a patient in the community, whether by prescribing, supplying or administering a product. It includes the professional standards that are expected of different staff groups and the personal responsibility and accountability involved. It covers all aspects of the process from accurate prescription writing to safe administration of the Depot medication. The purpose of this policy is to ensure that all staff dealing with medicines follow safe practice in the prescribing, requisition, storage, administration and control of medicinal products. It applies to all individuals employed or contracted by Black Country Partnership NHS Foundation NHS Trust including all locum and agency staff and to all activities relating to medicines use within in-patient, out-patient, community and any residential facilities. The objectives of this SOP are as follows: To comply with Care Quality Commission s essential standards for quality and safety that requires NHS providers to establish, document and maintain an effective system to ensure that medicines are handled in a safe and secure manner. To comply with nationally agreed standards set out in the Duthie Report, Crown Report, relevant medicines legislation and guidance from the UK Nursing and Midwifery Council and the General Medical Council. To define the process and procedures to be followed within Black Country Partnership Foundation NHS Trust for the prescribing, monitoring and Depot Medication within Community MH Services Page 1 of 16 Version 1.0 July 2017
administration of Depot medication within the Community and to ensure the highest standards of medicines management and minimise risks associated with the use of Depot medication. To promote a consistent and best practice approach to the safe administration of Depot medication, aligning practices over Wolverhampton and Sandwell community teams. What overarching policy the procedure links to? Medicines - Administration Policy Please note this policy should also be read in conjunction with: Medicines Prescribing Policy Medication Errors Policy Infection Control Policy Polar Speed SOP BNF General Medical Council Good practice in prescribed medicines (2008) September 2008 Nursing and Midwifery Council of Great Britain (2008). Standards for Medicines Management. Trust Policies can be found on the Trust Intranet site: http://luna.smhsct.local/documents/operational-policies. If you cannot find the Policy you are looking for then please contact the relevant service manager. Which services of the trust does this apply to? Where is it in operation? Group Inpatients Community Locations Mental Health Services all Learning Disabilities Services all Children and Young People Services all Who does the procedure apply to? Medical Director (Executive Lead) Lead responsibility for the implementation of this Standard Operating Procedure. Allocation of resources to support the implementation of this Standard Operating Procedure Chair of the Trust s Medicines Management Committee The Medical Director is responsible for ensuring: The Trust s overall duty for medicines management is discharged appropriately A systematic and consistent approach for the safe and secure handling of medicines Chief Executive (Accountable) The Chief Executive is responsible for assuring that this Standard Operating Procedure is implemented within the Trust. Operational responsibility has been delegated. Depot Medication within Community MH Services Page 2 of 16 Version 1.0 July 2017
Chief Pharmacist (Lead) The Chief Pharmacist is responsible to the Medical Director for all aspects of the safe and secure handling of medicines within the Trust. Matrons/Service / Team Managers/ Trust Pharmacy Team (Day to Day Monitoring) To support the implementation and monitoring of this Standard Operating Procedure. To provide support and advice to all staff involved in the administration of medicines as necessary all incidents, complaints and claims relating to this area of practice and Standard Operating Procedure are reported. Clinical Directors, Divisional Directors, Divisional Managers (Operational Leadership) Responsible for implementing the specific clinical requirements of this Standard Operating Procedure. These specific responsibilities relate to professional conduct, clinical competence, training needs analysis, competence assessment and clinical decision making. In addition this group will be responsible for the day-to-day implementation of the Standard Operating Procedure ensuring that: All staff are aware of their role under the Standard Operating Procedure Staff have received sufficient training and/or are competent to implement the Standard Operating Procedure Appropriate SOP distribution, implementation and compliance throughout relevant teams and services within their group professional standards of record keeping are maintained Lead discussions around this topic area and SOP at Group Quality and Safety Group meetings Oversee the completion of audits in respect of this topic area and SOP Provide updates on this SOP within their Group to the Quality and Safety Steering Group Registered Clinical practitioners Clinical staff are familiar with the SOP and be responsible for adhering to the procedures referred to within the document: They are expected to also follow their own professional codes of practice in relation to medicines. These include: Medical: General Medical Council guidance on good medical practice. Nursing: NMC guidelines for the administration of medicines 2008 Pharmacy: General Pharmaceutical Council, Royal Pharmaceutical Society and the Medicines, Ethics and Practice. Medicines Management Committee (Scrutiny and Performance) Are responsible for: overseeing the governance of medicines management across the Trust receiving specific issues in relation to the delivery, development and monitoring of medicines management reviewing all policies, guidelines and procedures including PGD s, SOP s and prescribing documentation affecting drug use or medicines management Depot Medication within Community MH Services Page 3 of 16 Version 1.0 July 2017
When should the procedure be applied? This SOP should be adhered to and followed for the prescribing, monitoring and administration of Intra muscular Depot / Long Acting IM Medication for all Patients across all Planned Care community services within the mental health Division. How to carry out this procedure Processes The Prescribing of Depot / Long Acting IM medication The prescription for IM Depot medication for a Patient in the Community must be written on the Community Depot / Long Acting Injection Prescription and Administration Card that was approved by the Trust s Medicines Management Committee. Guidance on prescription writing provided in the BNF should be followed at all times. The Depot / Long Acting IM Medication Prescription must: Be appropriate, complete, unambiguous, legible and in capitals Be in black ink. Be signed and dated appropriately. Each prescription item must be validated by the full signature of a registered medical practitioner or authorised prescriber. The signature should be legible and the printed name of the prescriber should be written next to the signature. Initials or abbreviated signatures are not an adequate means of identification of a prescriber or serve as authorisation of a prescription. It is the responsibility of medical staffing to send specimen signatures of all authorised prescribers in the Trust, including Locums, on appointment, to the Pharmacy department and Community team managers. It is the responsibility of the Non-Medical Prescribing Lead to collate and send specimen signatures of all authorised Non-Medical Prescribers in the Trust, on appointment, to the Pharmacy department and Community team managers. Adhere to legal, formulary and Trust policy requirements Bear the full name, address, Date of Birth and NHS number of the patient (Patient information sticker can be used) Only use Trust approved abbreviations:- I.M for Intramuscular The prescriber to ensure that arrangements are in place for all test doses of Depot / Long Acting injections to be administered on Trust premises that have access to emergency life support equipment. It is the administering nurse s responsibility to challenge any queries / concerns relating to the prescription and raise with the Prescriber or a member of the Consultant medical team. This should be escalated as soon as possible to avoid any unnecessary delays in Patient care. The Depot / Long Acting IM Medication Prescription must include: Name of the Medicine The full generic form e.g. zuclopenthixol decanoate. The interval expressed using the word every (e.g. every 3 weeks; this can be abbreviated to every 3/52). The prescription dose should include appropriate use of decimal points. Depot Medication within Community MH Services Page 4 of 16 Version 1.0 July 2017
The date prescribed and the next due date if appropriate. Use of the phrase as directed is not acceptable. Explicit dosage instructions, including route and site of administration should be stated. Abbreviations of units should always be written in the singular, e.g. 10mg, not 10mgs. Validity of Community Prescriptions for Depot / Long Acting IM medication: The Depot / Long Acting IM medication prescription will remain valid for a maximum of 6 months. After this 6 month period, the prescription will be invalid. Verbal orders/prescriptions cannot be accepted for Depot / Long Acting IM medication for community Patients where the Community Depot / Long Acting Injection Prescription and Administration Card has not been written. Prior to the rewriting of the Community Depot / Long Acting Injection Prescription and Administration Card, the relevant Consultant medical secretary will check the date of the Patient s last outpatient appointment and communicate this to the Prescriber. The prescriber must ensure that the patient has had a face to face medical review within a maximum period of no more than 12 months. When a community Patient is admitted to an inpatient ward, the ward staff should notify the community team of the Patient s admission as soon as possible. A copy of the Community Depot / Long Acting Injection Prescription and Administration Card should be scanned and emailed / faxed to the inpatient unit to confirm the last and due date of the Patient s Depot / LAI medication. The Community Depot / Long Acting Injection Prescription and Administration Card should then be discontinued and filed in the notes. The Community Depot / LAI Prescription and Administration Card should be completed on discharge by inpatient medical team and forwarded to the relevant community team. Each inpatient ward will have a stock of the Community Depot / LAI Prescription and Administration Cards that will be supplied by the relevant community team. Documentation of Allergies/Hypersensitivities All prescription forms must specify whether or not the patient has any allergies / hypersensitivities information (i.e. allergy details or No known drug allergy NKDA) on the prescription sheet, along with the source of information identified. Prescribing Incidents Prescribing incidents are defined as prescribing: The wrong medicine The wrong dose of medicine The wrong frequency The wrong route The wrong due date of administration outside of the acceptable window as agreed by the prescriber Failure to sign the prescription / patient allergies / Hypersensitivities. All prescribing incidents must be reported via the Trust Datix Incident Reporting System. The Divisional Risk team will ensure that the responsible consultant is informed of the incident and that this is formally addressed in accordance with the Trust medication error policy. Furthermore, Patient Duty of Candour notification and processes will be applied where appropriate. Depot Medication within Community MH Services Page 5 of 16 Version 1.0 July 2017
Initiation of Depot / LAI Medication Care should be taken to ensure that a test dose of Depot medication is prescribed where appropriate. This is not a requirement for LAI medication. Monitoring of Depot / Long Acting IM Medication Any noted deterioration in a Patient s mental or physical health should be escalated to the Responsible Clinician and, where deemed appropriate, medically reviewed at the earliest possibility by the relevant Consultant medical team. All Patients who are receiving Depot / Long Acting IM medication will receive an annual physical health check from the Planned Care Monitoring side-effects Prescribers must fully inform patients of possible side-effects / adverse drug reactions that could be caused by the medication prior to prescribing it (Choice & Medication leaflet). At each review prescribers must ask patients about and document any sideeffects they are experiencing. During every contact, the Registered Mental Health nurse, Medical Officer or a Nurse in training must actively ask patients about side-effects / adverse drug reactions that the patient may be experiencing. Registered Mental Health nurse, Medical Officer or a Nurse in training must record these in the patient s notes and ensure the prescribers are informed. Medical Reviews of Patients on Depot / Long Acting IM medication Prior to the completion or rewriting of a community Depot / Long Acting IM medication prescription, the prescriber must ensure that the patient has had a face to face medical review within a maximum period of no more than 12 months. Prescribers must fully inform patients of possible side-effects / adverse drug reactions that could be caused by the medication prior to prescribing it (Choice & Medication leaflet). The face to face medical review of the patient should include an assessment of the presence of any side-effects / adverse drug reactions that the patient may be experiencing. Details of any adverse effects relating to or suspected to relate to the administration of Depot / Long acting IM medication should be recorded in the patient s record and this information should be related to the prescriber. A yellow card should be filled in and sent to the MHRA. Yellow forms are available in the back of the BNF or at www.yellowcard.gov.uk. Administration of Depot / Long Acting IM Medication Depot / long acting IM medication must only be administered with a valid, a clearly written and unambiguous prescription, using the generic name of the medication, on the Trust approved community Depot / LAI prescription and administration Card. IM Depot / LAI medication must be administered by a Registered Mental Health nurse, Medical Officer or a Nurse in training under the direct supervision of a Registered Nurse The person who administers a medicine is responsible and accountable for his/her action / omission. IM Depot / LAI medication must be administered by a Registered Mental Health nurse, Medical Officer or a Nurse in training under the direct supervision of a Registered Nurse. Depot Medication within Community MH Services Page 6 of 16 Version 1.0 July 2017
The Registered Mental Health nurse, Medical Officer or a nurse in training under the direct supervision of a Registered nurse must ensure the following is in place prior to administering the Depot / LAI medication - Valid prescription - Correct Patient - Correct Depot / Long acting IM medication - Correct date - Correct dose The registered nurse responsible for the administration of the IM injection must ensure that any required calculation is correct. A second practitioner must check the calculation in order to minimise the risk of error. A test dose of Depot / Long Acting IM Medication should only be administered to inpatients or patients under the care of Crisis Home Treatment team (CHTT). Registered nurses responsible for the administration of the IM injection in a patient s own home (or outside of the Depot / LAI clinic) are exempt from the checking requirements due to the nature of the role and the safeguards in place. If there is any doubt about the content or clarity of a prescription the Registered Mental Health nurse, Medical Officer or a Nurse in training under the direct supervision of a Registered Nurse must contact the prescriber or deputy before proceeding to administer the Depot / Long acting IM injection. If there is still uncertainty a pharmacist must be contacted. In an emergency, if the prescriber is unable to attend, the Registered Mental Health nurse, Medical Officer or nurse in training under the direct supervision of a registered nurse may defer the administration of the medication until further clarification is obtained. The Registered Mental Health nurse, Medical Officer or a Nurse in training under the direct supervision of a Registered Nurse must ensure that all prescribed test doses of Depot / LAI medications are administered on Trust premises that have access to emergency life support equipment. Whilst under the care of the CHTT, the Depot / LAI medication for a community Patient will be administered by the Patient s care coordinator / CPN or within the community Depot / LAI clinic unless exceptional circumstance prevails and then the IM medication will be administered by a registered nurse within the CHTT. The administration of Depot / LAI medication for older adults under the care of the CHTT will be undertaken by registered nurses within the CHTT. Any noted deterioration in a Patient s mental or physical health should be escalated to the Responsible Clinician and, where deemed appropriate, medically reviewed at the earliest possibility by the relevant Consultant medical team. If the Registered Mental Health nurse, Medical Officer or a Nurse in training under the direct supervision of a Registered Nurse becomes aware of or observes an adverse drug reaction following the administration of the Depot / Long acting IM medication, he / she should contact the relevant medical team without the delay. Details of any adverse effects relating to or suspected to relate to the administration of Depot / Long acting IM medication should be recorded in the patient s record and this information should be related to the prescriber. A yellow card should be filled in and sent to the MHRA. Yellow forms are available in the back of the BNF or at www.yellowcard.gov.uk. Recording of Depot / Long Acting IM Medication Administration Each written entry should include the standards as outlined within the Trust clinical record keeping policy and NMC record keeping guidelines. Depot Medication within Community MH Services Page 7 of 16 Version 1.0 July 2017
Each entry should include: Prescribed medication administered Concordance and compliance Mental health presentation Expressed or observed adverse effects Next due date of administration Any other concerns voiced or noted within the consultation Completion of Community Depot/Long Acting Injection Prescription and Administration Card. All Community Depot/Long Acting Injection Prescription and Administration Cards for Patient s on Community Treatment Orders (CTO) should have the forms CTO 11/12 attached to the treatment card and the form should then be removed if the CTO is discontinued. All Community Depot/LAI Prescription and Administration Cards that are full, should be scored with a single diagonal line through the card. All records and copies of the Community Depot / LAI Prescription and Administration Cards must be permanently filed in the notes. Records should be completed immediately or at the earliest opportunity not exceeding 24 hours after the medication is administered, or if a dose is refused or wasted, this must also be recorded, signed and dated. Patient contact must be recorded electronically on all relevant IT systems within 3 working days as per Trust policy. All Patients on Depot / LAI medication will have a community records file that contains the following minimum standard: Demographic sheet Abbreviation sheet Care record booklet Completed consent to treatment form Any relevant clinical correspondence Any relevant CPA documentation Specimen Signatures / Initials Each Community mental health team should have an up to date nurse specimen signature list that is reviewed on a quarterly basis. A copy of this list should be forwarded to Pharmacy and a copy available within the team clinic / treatment rooms It is the responsibility of the team manager / Deputy to review and update the specimen signature list on a quarterly basis Retention of Trust approved Community Treatment cards All old copies of Community Treatment cards must be permanently filed in the notes, which are retained according to nationally defined minimum periods. Errors in Administration of Medicines In the event of a medication error, refer to the Trust Medications Error Policy Depot Medication within Community MH Services Page 8 of 16 Version 1.0 July 2017
Refusal of Medication In general, Patients have a right to refuse medicines. Reasons for refusal must be documented and escalated to the Patients Consultant medical team immediately and advice sought. Patients who do not attend (DNA) Clear process guidelines should be adhered to in accordance with DNA flowchart and letter (See Appendices) The Management of Depot / LAI Clinics The following guiding principles should be applied for the management of Depot/ LAI Clinics: The Depot / LAI clinic checklist is available for reference The Depot / LAI clinics should be delivered by a minimum of 2 staff. The Clinics should be delivered from a treatment/clinic room within identified central team bases. The treatment / clinic room should include appropriate waiting areas that maintain privacy and dignity and include a waiting ticket system where appropriate. The Treatment / Clinic room should be a safe and clean environment, infection control compliant, accessible with disabled access. The Treatment / Clinic room should contain emergency life support equipment and a panic alarm system. The Treatment / Clinic room should contain adequate supplies of IM medication, medical equipment, with the Patient notes available. Monitoring / Review of this Procedure In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness. Equality Impact Assessment Please refer to overarching policy (Medicines Policy). Data Protection Act and Freedom of Information Act Please refer to overarching policy (Medicines Policy). Depot Medication within Community MH Services Page 9 of 16 Version 1.0 July 2017
Appendix 1 Community Depot/ Long Acting Injection Prescription and Administration Card Surname: First Name: Address: DRUG ALLERGIES AND SENSITIVITIES DO NOT LEAVE THIS SECTION BLANK Date of Birth: NHS Number: Contact Number: M/F: Signature: Print: Date: Source: None Known Community Team/Base: Consultant: Care Co-ordinator: GP: P R E S C R I P T I O N N.B. Unless otherwise directed each prescription must be reviewed and rewritten within six months from the date of prescribing DATE DRUG (GENERIC NAME) DOSE ROUTE FREQUENCY PRESCRIBER S SIGNATURE DURATION NURSING RECORD OF ADMINISTRATION DATE NEXT DUE DATE GIVEN DRUG GIVEN (GENERIC NAME) DOSE ROUTE SIGNATURE SITE/ COMMENTS Depot Medication within Community MH Services Page 10 of 16 Version 1.0 July 2017
Appendix 2 Depot / LAI Clinic Referral Form Please note that a referral form is required for all new Patients to the Depot Clinic Patient contact details Patient Name: Address: DOB: Relevant contacts Consultant: Community Team: Affix Label Ethnicity: Oasis Number: NHS No: Patient Contact Number: Next of kin: Care co-ordinator: Contact number: Contact number: GP: Consent to share information: yes or no Consent to have injection Contact number: Patients signature: Medication details Depot / LAI prescribed: Frequency of depot / LAI : Current dose: Next due: Any other medication: Any known allergies: Is the patient subject to CTO Date of review Any identified or historical risks: Depot Medication within Community MH Services Page 11 of 16 Version 1.0 July 2017
Checklist: The following paperwork is required for all new Patients to the Depot / LAI Clinic: Current Community Prescription sheet Copy of latest needs assessment and risk assessment All relevant CTO paperwork if applicable (CTO 11/12) Is the relevant treatment team aware of this referral (Circle): YES NO Name of Referrer: Contact Number: Signed referrer: Date: Depot Medication within Community MH Services Page 12 of 16 Version 1.0 July 2017
Appendix 3 Depot / LAI Clinic Letter for Non-Attendance Community Base Address Tel: 0121 543 4295 Fax: 0121 612 3721 Our ref: DNA/ NHS Number: Date: NAME ADDRESS Dear Re: Non-attendance to Depot / Long Acting Injection (LAI) Clinic We note that you did not attend Depot / LAI clinic for your depot injection on <<DATE>>. Could you please attend the next available clinic, which is held as follows: <<Treatment team name and address>> <<Day of week>> <<Time of Day>> If you are having difficulties in attending the Clinic, please contact your CPN / Care Co- Ordinator or the Duty Worker within the team on <<xxxxxxxx>> to discuss other possible ways of supporting you with this. Yours sincerely Depot / LAI Clinic Nurse XXXXXXXX Depot Medication within Community MH Services Page 13 of 16 Version 1.0 July 2017
Appendix 4 Community Depot / LAI Clinic Checklist PRIOR TO DEPOT / LAI CLINIC Ensure Community Treatment Card rewrites have been completed and are ready for Depot / LAI Clinic Prepare and ensure all named Patient IM medications are available Ensure all Patient notes / case record booklets are available Ensure that yellow top sharps bins are available for disposal of sharps during depot / LAI clinic ONGOING ACTIONS Ensure allergies are documented prior to administration of Depot / LAI medications Ensure prescription sheets have attached labels and up to date Patient contact details and demographic details Ensure Risperdal Consta medication reaches room temperature prior to administration (recommended 15 minutes) DNA S Adhere to DNA Flowchart for reference FOLLOWING DEPOT / LAI CLINIC Ensure all sharps bins are disposed of in accordance with Trust policies Prepare the following clinics folder Check for rewrites for the following week Order any Olanzapine/Aripiprazole injections that have been used on the day (via Penn/ Hallam Pharmacy) Order transport for the following week email ref number and copy to phillip.bate@wmas.nhs.uk (where appropriate) E mail clinic list and transport list to whoever is doing clinic the following week (Wolverhampton) Ensure adequate stocks of medical equipment is available / requirement to order stocks communicated to relevant staff member Ensure filing cabinet and folders are left in an alphabetical and orderly manner Ensure adequate IM medication stocks are available / requirement to order stocks communicated to relevant staff member Tidy Clinic Area and leave it the way you d wish to find it Signed Dated. Depot Medication within Community MH Services Page 14 of 16 Version 1.0 July 2017
Appendix 5 Flowchart for Patients that DNA Depot/LAI Clinic Patient DNA Depot/LAI Clinic Clinic nurse to attempt phone contact Document DNA and outcome in nursing notes and on prescription sheet. Email RC and Care coordinator to advise 1 st DNA 2 nd DNA (Week overdue) 3+ DNA (2 weeks + overdue) Failed Telephone Contact with Patient Consider any risks Send DNA letter inviting to following weeks depot/lai clinic Telephone Contact with Patient Ascertain current mental health & reason for DNA If no concerns, Invite in to attend base/alternative clinic If concerns noted, arrange home visit Failed Telephone Contact with Patient Consider any risks Consider contacting NOK Doorstep safe and well check to be arranged by care coordinator or in absence of CC or non CPA then delegated by Team manager/deputy Team Manager Joint visit where appropriate Raise in Zoning/Team meeting Telephone contact with patient Ascertain current mental health & reason for DNA Invite in to attend base/alternative clinic Escalate to RC for discussion and further action No contact with patient Contact NOK Escalate to RC for discussion and further action Consider risks and consider safe and well check by Police if not already completed Prescription to be reviewed medically prior to administration of depot Consider OPA review Depot Medication within Community MH Services Page 15 of 16 Version 1.0 July 2017
Standard Operating Procedure Details Unique Identifier for this SOP is State if SOP is New or Revised BCPFT-MM-SOP-01-2 New Policy Category Executive Director whose portfolio this SOP comes under Policy Lead/Author Job titles only Committee/Group Responsible for Approval of this SOP Month/year consultation process completed Medicines Management Medical Director Community Matron Mental Health Medicines Management Committee July 2017 Month/year SOP was approved July 2017 Next review due July 2020 Disclosure Status B can be disclosed to patients and the public Review and Amendment History Version Date Description of Change 1.0 July 2017 New SOP for BCPFT Depot Medication within Community MH Services Page 16 of 16 Version 1.0 July 2017