NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST MEDICINES POLICY: CODE OF PRACTICE MEDICINES MANAGEMENT WHEN PATIENTS ARE DISCHARGED FROM HOSPITAL Reference CL/MM/024 Approving Body Senior Management Team Date Approved 4 July 207 Implementation Date 4 July 207 Version 6 Summary of Changes from Put into new Trust format; planned review Previous Version Supersedes CL/MM/024 version 5 (June 204) Consultation Undertaken Medicines Management Committee (with Divisional representative input) Clinical pharmacists Date of Completion of st May 207 Equality Impact Assessment Date of Completion of We st May 207 Are Here for You Assessment Date of Environmental st May 207 Impact Assessment (if applicable) Legal and/or Accreditation N/A Implications Target Audience Review Date June 2020 Lead Executive All NUH staff who are involved with prescribing, supplying and issuing discharge medicines for patients. Medical Director Author/Lead Manager Professor Mojgan Sani Head of Pharmacy and Clinical Director for medicines optimisation Ext 699 Further Guidance/Information Sonia Gilmore, pharmacist Medicines Management Committee
secretary Extension 59374 CONTENTS Paragraph Title Page. Introduction 3 2. Executive Summary 3 3. Policy Statement 3 4. Definitions (including Glossary as needed) 3 5. Roles and Responsibilities 4 6. Policy and/or Procedural Requirements 4 7. Training, Implementation and Resources 9 8. Impact Assessments 0 9. Monitoring Matrix 0. Relevant Legislation, National Guidance and 2 Associated NUH Documents Appendix Completion of e-tto discharge prescription 3 Appendix 2 Quick discharges no medicines prescribed 4 Appendix 3 Quick discharges- new medicines prescribed 5 Appendix 4 Equality Impact Assessment 7 Appendix 5 Environmental Impact Assessment 9 Appendix 6 Here For You Assessment 2 Appendix 7 Certification Of Employee Awareness 23 2
.0 Introduction. The aim of this document is to provide a medicines management framework to safely discharge NUH patients on medicines. 2.0 Executive Summary 2. This document outlines which patients require a discharge prescription, and how the medicines should be prescribed. It describes the requirements of pharmacy staff when processing a discharge prescription. It also outlines the process for a nurse to follow once the discharge medicines are available and they are discharging the patient from the ward. 3.0 Policy Statement 3. In order that patients on medicines are safely discharged, all NUH staff involved in the process must follow this policy. Most discharges can be planned in advance and all staff must be proactive in order to ensure that preventable delays in discharge do not occur. Any deviations from the Medicines policy must be covered by a local agreement authorised by the Medicines Management Committee (MMC). All discharge documentation, including electronic prescriptions, must be approved by MMC or Medical Records Committee/ nursing documentation group. 4.0 Definitions 4. etto (electronic TTO treatment to take out / electronic discharge prescription) Homecare drugs (medicines supplied to patients at home via an external provider and not from the GP or hospital or community Pharmacies) OPAT (out-patient antibiotic therapy)- IV antibiotic therapy given in the patient s home (and see 6.6) Paper TTO forms (medicines supplied to patients on hand written NUH prescriptions) 3
5.0 Roles and Responsibilities 5. Committees 5.. Medicines Management Committee (MMC) are responsible for approving all discharge documentation and for authorising any deviations from this policy by approving a local agreement for that area. 5.2 Individual Officers 5.2. Individual practitioners involved in the discharge process of patients are responsible for adhering to this policy and other local procedures in place where appropriate 6.0 Policy and/or Procedural Requirements 6. Authorisation to prescribe discharge medication All prescribing of discharge medication must be performed by an authorised prescriber. Transcription by a nurse or pharmacist for subsequent signature by a doctor is not permitted unless there is a local agreement in place approved by the MMC. An Independent (non-medical) prescriber may complete the TTO discharge prescription providing all medicines are included on their individual approved list, and providing they have the relevant NOTIS permissions. Refer to CL/MM/026 (Medicines Policy, non-medical prescribing) for further details. The prescriber must review all medicines that are currently prescribed on the in-patient chart, and medicines known to be taken at home, to ensure they are appropriate for ongoing treatment, and to ensure a full list of medicines the patient is taking is maintained. 6.2 Patients who require a discharge prescription from NUH All patients must have an electronic discharge prescription (etto) prepared on discharge from NUH. The only areas that may have a handwritten NUH prescription are patients being discharged from: Adult Critical Care 4
Neonatal Units Labour Suite Patients going home for weekend leave Some areas undertaking nurse dispensing of prepacks (some areas are using etto) In instances when the electronic discharge system is off line and unavailable. Patients transferred to Lings Bar and Highbury Hospitals and those patients who qualify for a quick discharge as defined by the etto NOTIS system (see 6.3) do not need an electronic or hand-written TTO prescription. In exceptional circumstances a prescriber may issue an OP prescription to an in-patient as an alternative to an etto. Short stay wards wishing to do this must have the process approved by MMC or a senior pharmacist. In this situation the prescriber will need to write the appropriate wording on the electronic discharge prescription to inform the GP of changes. If a medication list is written onto the etto this goes to a 2 and the etto will require processing via Pharmacy. It is not expected that multiple drugs would be prescribed on the OP prescription. These prescriptions may only be dispensed at NUH Trust Pharmacy, or may be used by nurses approved to issue pre-labelled packs of medicines. FP0HP prescriptions would rarely be used in this situation: they are issued to approved prescribers only. 6.3 Patients discharged as a quick discharge (as defined by NOTIS etto system) For the following groups of patients: Acute medical patients (admitted for less than 24 hours) Adult short stay elective surgical patients (admitted for less than 48 hours) All Paediatric patients admitted for less than 48 hours As long as the patient has sufficient supplies of their own medicines at home and there have been no changes to their regular medication whilst in hospital then the prescriber may issue on the TTO discharge prescription No change in medication and complete a Quick Discharge (see Appendix 2). If newly started items are required and the 5
patient has been in for less than 24-48hours then these items must be dispensed and a Quick Discharge as defined on NOTIS is not possible. A complete list of discharge medicines is not necessary for these patients. If medicines are stopped the details should be clearly communicated to the GP on the front of page of the etto. 6.4 Delayed discharges Whenever possible, discharge prescriptions should be written at least 24 hours in advance in order to prevent delayed discharges. If a patient s discharge is delayed and their prescription changes, the relevant changes must be made to the etto. The pharmacist must be informed that the etto has moved from a 7 to a 2 and that a new pharmacy professional screen is required. Prescribing of medicines onto the etto discharge prescription or paper TTO must comply with the guidance for all prescriptions in section CL/MM/006 of this Medicines Code of Practice. 6.5 Prescribing a discharge prescription All medicines that are to be continued after discharge (including those which are not supplied by the GP, such as Homecare drugs, OPAT drugs, hospital only drugs, and drugs which have already been supplied e.g. defined chemotherapy regimes) must be prescribed on the TTO discharge prescription in addition to any medicines that the patient was taking before admission which are to be continued. 6.5. For completing the electronic discharge TTO (etto) See Appendix 6.5.2 Handwritten discharge prescriptions As a minimum requirement to identify the patient the following must be written onto all copies of the TTO discharge prescription before the rest of the form is completed: the patient s name date of birth NHS or K number or other unique identifying number If a patient addressograph sticker is used for the patient name, one 6
sticker must be placed onto each coloured sheet of the TTO discharge prescription. The prescriber must check that the correct patient addressographs have been used and that they match the in-patient prescription card. If more than one form is used this must be indicated i.e. of 2, 2 of 2 etc. Handwritten discharge prescriptions will be in multiple copies with the one copy for the GP, one copy for the Patients Medical Records and one copy to be given to the patient. 6.6 Prescribing of high risk medicines on discharge prescriptions 6.6. Anticoagulants: This must be prescribed onto the TTO discharge prescription stating the name and strength of tablets required e.g. Warfarin 3mg tablets with the dosage directions as directed. Refer to anticoagulant guidelines. 6.6.2 Low Molecular Weight Heparin (LMWH) Prescribers must ensure that a complete course of prophylactic LMWH is prescribed where appropriate. Nurses discharging patients on prophylactic SC LMWH injections must ensure that the full supply provided from Pharmacy is given to the patient. It may be supplied in more than bag. They must also ensure the patient is competent to administer it themselves or provisions are in place for somebody to administer it for them. Sharps bins should also be provided to the patient from the ward. 6.6.3 Insulin Prescribers must remember to prescribe patients insulin on the etto giving details of brand name and device. Nurses discharging patients on insulin must ensure they have checked the fridge for all patient insulin, must check it corresponds to the etto, and must check that the patient is expecting that particular insulin. 6.6.4 Alcohol withdrawal regimen Refer to policy Detox regimes for inpatient use cannot be continued on discharge without the agreement of the drug and alcohol liaison nurses. 7
6.6.5 Cytotoxic medicines (refer to cytotoxic chapter CL/MM/03) 6.6.6 Palliative Care medications: Prescribe pre-emptive medications including water for injections for syringe drivers (Refer to discharge planning in End of life care). 6.6.7 Methadone: Usually not supplied on discharge unless in exceptional circumstances a maximum of one day can be provided (up to 3 days on a bank holiday weekend). This will usually need prior approval from the patient s keyworker, if they have one, or the prescriber responsible for continuing therapy in the community setting. 6.6.8 Strong Opioids (oral): Oramorph, Sevredol and Oxynorm should be prescribed ideally at a minimum interval of four hourly, but may be two hourly for discharge. Exceptions to this are: Patients in a specialist palliative care setting ( i.e. Hayward House) or on the advice of the Palliative Care Team Patients on the LCP (End of Life Pathway) Oncology & Haematology (see local procedures) Patient s Own CDs may be returned to the patient if still appropriate for them to use in line the NUH CD Policy- see CL/MM/02 for more information. 6.6.9 Weak Opioids (oral) Nurses discharging patients on weak oral opioids, e.g. dihydrocodeine, codeine, or tramadol must ensure that the number of tablets in the box tallies with the number on the Pharmacy label.. If there is any discrepancy noted, the nurse must investigate. 6.6.0 Lithium: Patients on lithium must have had a 3 monthly lithium blood level and 6 monthly egfr and thyroid function tests recorded in their Lithium Record book. 6.6. Patients post STEMI/ NSTEMI: Must have GTN spray (or tablets) prescribed for discharge. 6.6.2 Outpatient Antimicrobial Therapy (OPAT) patients: Appropriate supplies (antibiotics, diluents, flushes, locks) to last until the 8
next appropriate OPAT clinic appointment need to be prescribed as advised by the OPAT team (see TTO Dispensing and Ward pharmacist s Information Sheet for OPAT, on the antibiotic website for more information). 6.7 Ordering and Supply of discharge medications Pharmacy will provide a supply of medicines to the patient, which will usually be a minimum of 0-4days supply. Refer to prescribing agreement (available from Pharmacy). A reduced supply will usually be made for medicines which have a specific course length or no supply will be made if Pharmacy have confirmed supplies at home or that it is not wanted by the patient. The relevant code will be added onto the etto. For quick discharges (see 6.3) no medication supplies will be made. 6.8 Nurse issuing of TTO to patient Follow appendix 3 of this procedure when issuing medicines to patient or carer. Ensure that any other referrals or follow up care have been sent as per discharge policy. 6.9 Provision of TTOs out of hours At NUH wards are permitted to have discharge medicines dispensed by pharmacy until 2300h. The nurse must contact the on-call pharmacist to process the etto. If a TTO is being requested from City campus, the pharmacist will discuss with the nurse the suitability of returning existing medicines to the patient, confirm further supplies at the patient s home and the subsequent process for the ward to follow. Pharmacy will process the etto to a 7, and inform the ward as appropriate. 6.0 Processing of etto discharge prescriptions- flowcharts Refer to standard operating procedures for details Refer to the following appendices: Appendix 2 Quick discharges no medicines prescribed (prescribers and nurses) Appendix 3 Completing the discharge process- nurses 9
7.0 Training and Implementation 7. Training This is an update to an existing policy and no further training needs have been identified. 7.2 Implementation This is an update to an existing policy and implementation will take place through the existing procedures. 7.3 Resources No additional resources are required. 8.0 Trust Impact Assessments 8. Equality Impact Assessment An equality impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. 8.2 Environmental Impact Assessment An environmental impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. 8.3 Here For You Assessment A Here For You assessment has been undertaken on this document and has not indicated that any additional considerations are necessary. 0
9.0 Policy / Procedure Monitoring Matrix Minimum requirement to be monitored Incidents Responsible individual/ group/ committee Individual Managers Process for monitoring e.g. audit Monitoring of DATIX incidents Frequency of monitoring Ongoing Responsible individual/ group/ committee for review of results Ward managers Responsible individual/ group/ committee for development of action plan Ward managers Responsible individual/ group/ committee for monitoring of action plan Ward managers 2
0.0 Relevant Legislation, National Guidance and Associated NUH Documents 0. Relevant documents Discharge and Transfer Policy and Procedure (CL/CGP/036) NotIS Electronic Discharge / TTO NUH Standard Operating Process (available on NUH intranet) NUH Doctor Reference Guide (available on NUH intranet) NUH Pharmacist/Technician Reference Guide (available on NUH intranet) NUH Guidance notes for Prescribing via the etto system Information for doctors NUH Guidance notes for endorsing supply details via the etto system Information for ward pharmacists and ward technicians NUH positive patient identification policy Service level agreement/prescribing contract between CCGs and NUH 3
Appendix : Completing the electronic Discharge TTO (etto)- Prescribers (Refer to Guidance notes for prescribing via the etto system Information for doctors) and Standard Operating Procedure. Select relevant patient name on NotIS Ensure patient name corresponds with correct patient in-patient chart Complete the following MANDATORY fields: Name of drug (Only one medicine may be prescribed per line of the form) Status of drug: New ( MUST include indication in the comments section) Amended ( MUST include reasons for changes and requirement for monitoring in the instructions section) Unchanged Dose Route Frequency Treatment duration Medications stopped o State if none stopped or o If intentionally stopped then: Give reason for stopping Restarting instructions (if relevant) Any specific dosage details and duration of medicines on a variable dose. Prescribing Controlled Drugs on e-tto Prescriptions must comply with the CD legal requirements (see section CL/MM/02 of the Medicines Code of Practice. Prescriptions must be printed out on the ward and signed by the prescriber and attached securely to the inpatient chart on each side where a CD appears. The electronic form will be submitted and the signed paper copy sent to pharmacy for dispensing. 4
Appendix 2: Quick discharges no medicines prescribed- Prescribers and nurses Refer to NotIS E-discharge/TTO SOP for details of doctors and nurses responsibilities for each stage of the process Select relevant patient name on NotIS Discharging doctor/nurse to confirm the patient has sufficient supplies of regular medicines in the hospital or at home Refer to Section 6.3 for inclusion criteria of quick discharge If the patient does not have sufficient supplies of their regular medicines and cannot obtain from GP, these should be prescribed and the prescription submitted to a number 2 for a Pharmacist Professional screen and dispensing- see Appendix To process the Discharge Summary to a number 7: Ensure all mandatory sections of the Discharge summary have been completed Ensure the no change to regular medicines box is ticked Ensure the no medications stopped intentionally box is ticked (if applicable) Ensure the discharging prescription is submitted, this will automatically send the prescription to a number 7 Generate patient copy of etto and issue to patient/carer: Discharging nurse to print out etto Give a copy of the etto discharge prescription to the patient or carer, Place copy of the etto in the patients notes. An etto discharge prescription is transmitted to the GP electronically or printed and sent by post. Ensure the etto is now processed and is now number 9 5
Appendix 3 Completing the discharge process- nurses Patient to be discharged within next 24 hours: Check etto has been completed by Pharmacy and is at level 7 Ensure all drugs on the etto correspond to the in-patient prescription and supplementary charts Any discrepancies should be brought to the attention of the prescriber who must amend the prescription and resubmit for a Pharmacy screen 2. Contact your designated Pharmacist immediately for Pharmacist Professional screen and processing. Ensure etto is now a 7 The discharging nurse to check that discharge medicines supplied by pharmacy and patient own supplies in bedside locker correspond with the etto discharge prescription regarding: Patient name Drug name Dose and frequency on the medicine label matches the etto directions Pharmacy has completed supply at home or not required on etto for those medicines which have not been issued to the patient Any discrepancies must be brought to the attention of the ward pharmacist and the drugs should not be supplied to the patient. Empty patient s bedside medicine locker, and check CD cupboard and fridge if necessary. Do not give stock containers, unlabelled medicines or labelled medicines with incorrect directions to the patient. Stock drugs to be returned into ward stock cupboards and should not be left in POD lockers. Drugs which have been labelled for patients for their inpatient stay but are not suitable for discharge should be returned to pharmacy. 6
Generate patient copy of etto and issue medicines to patient/ carer The discharging nurse is to confirm the medication and the etto are for the correct patient. Refer to positive patient identification policy Print out the etto from NOTIS Confirm that the patient or carer understands how to take their medication and its purpose and how to obtain further supplies if necessary Replace the medicines in the pharmacy bag and issue them to the patient or carer Give a copy of the etto discharge prescription to the patient or carer Place copy of the etto in the patients notes An etto discharge prescription is transmitted to the GP electronically or printed and sent by post. Once the medicines have been issued to the patient or their carer, the security of the medicines is the responsibility of the patient or carer Ensure the etto is now processed and is now number 9 If 2 nurses involved in checking of the medicines in the discharge process, one of these should complete the final sign off on NOTIS. 7
APPENDIX4 Equality Impact Assessment (EQIA) Form (Please complete all sections) Q. Date of Assessment: st May 207 Q2. For the policy and its implementation answer the questions a c below against each characteristic (if relevant consider breaking the policy or implementation down into areas) Protected Characteristic a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups experience? i.e. are there any known health inequality or access issues to consider? The area of policy or its implementation being assessed: b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening Race and N/A N/A N/A Ethnicity Gender N/A N/A N/A Age N/A N/A N/A Religion N/A N/A N/A Disability N/A N/A N/A c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality Sexuality N/A N/A N/A 8
Pregnancy and N/A N/A N/A Maternity Gender N/A N/A N/A Reassignment Marriage and N/A N/A N/A Civil Partnership Socio-Economic N/A N/A N/A Factors (i.e. living in a poorer neighbour hood / social deprivation) Area of service/strategy/function Q3. What consultation with protected characteristic groups inc. patient groups have you carried out? None Q4. What data or information did you use in support of this EQIA? n/a Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? none Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups identified or to create confidence that the policy and its implementation is not discriminating against any groups None What By Whom By When Resources required 9
Q7. Review date st May 2020 20
Environmental Impact Assessment APPENDIX 5 The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b) implement mitigating actions. Area of impact Waste and materials Soil/Land Water Air Environmental Risk/Impacts to consider Is the policy encouraging using more materials/supplies? Is the policy likely to increase the waste produced? Does the policy fail to utilise opportunities for introduction/replacement of materials that can be recycled? Is the policy likely to promote the use of substances dangerous to the land if released (e.g. lubricants, liquid chemicals) Does the policy fail to consider the need to provide adequate containment for these substances? (e.g. bunded containers, etc.) Is the policy likely to result in an increase of water usage? (estimate quantities) Is the policy likely to result in water being polluted? (e.g. dangerous chemicals being introduced in the water) Does the policy fail to include a mitigating procedure? (e.g. modify procedure to prevent water from being polluted; polluted water containment for adequate disposal) Is the policy likely to result in the introduction of procedures and equipment with resulting emissions to air? (e.g. use of a Action Taken (where necessary) No n/a No No n/a No No No No 2
Energy Nuisances furnaces; combustion of fuels, emission or particles to the atmosphere, etc.) Does the policy fail to include a procedure to mitigate the effects? Does the policy fail to require compliance with the limits of emission imposed by the relevant regulations? Does the policy result in an increase in energy consumption levels in the Trust? (estimate quantities) Would the policy result in the creation of nuisances such as noise or odour (for staff, patients, visitors, neighbours and other relevant stakeholders)? n/a n/a No no 22
APPENDIX 6 We Are Here For You Policy and Trust-wide Procedure Compliance Toolkit The We Are Here For You service standards have been developed together with more than,000 staff and patients. They can help us to be more consistent in what we do and say to help people to feel cared for, safe and confident in their treatment. The standards apply to how we behave not only with patients and visitors, but with all of our colleagues too. They apply to all of us, every day, in everything that we do. Therefore, their inclusion in Policies and Trust-wide Procedures is essential to embed them in our organization. Please rate each value from 3 ( being not at all, 2 being affected and 3 being very affected) Value Score (- 3). Polite and Respectful Whatever our role we are polite, welcoming and positive in the face of adversity, and are always respectful of people s individuality, privacy and dignity. 2. Communicate and Listen We take the time to listen, asking open questions, to hear what people say; and keep people informed of what s happening; providing smooth handovers. 3. Helpful and Kind All of us keep our eyes open for (and don t avoid ) people who need help; we take ownership of delivering the help and can be relied on. 4. Vigilant (patients are safe) Every one of us is vigilant across all aspects of safety, practices hand hygiene & demonstrates attention to detail for a clean and tidy environment everywhere. 23
5. On Stage (patients feel safe) We imagine anywhere that patients could see or hear us as a stage. Whenever we are on stage we look and behave professionally, acting as an ambassador for the Trust, so patients, families and carers feel safe, and are never unduly worried. 6. Speak Up (patients stay safe) We are confident to speak up if colleagues don t meet these standards, we are appreciative when they do, and are open to positive challenge by colleagues 7. Informative We involve people as partners in their own care, helping them to be clear about their condition, choices, care plan and how they might feel. We answer their questions without jargon. We do the same when delivering services to colleagues. 8. Timely We appreciate that other people s time is valuable, and offer a responsive service, to keep waiting to a minimum, with convenient appointments, helping patients get better quicker and spend only appropriate time in hospital. 9. Compassionate We understand the important role that patients and family s feelings play in helping them feel better. We are considerate of patients pain, and compassionate, gentle and reassuring with patients and colleagues. 0. Accountable Take responsibility for our own actions and results. Best Use of Time and Resources Simplify processes and eliminate waste, while improving quality 2. Improve Our best gets better. Working in teams to innovate and to solve patient frustrations TOTAL 2 24
APPENDIX 7 CERTIFICATION OF EMPLOYEE AWARENESS Document Title Medicines Management When Patients Are Discharged From Hospital Version (number) 6 Version (date) 4 July 207 I hereby certify that I have: Identified (by reference to the document control sheet of the above policy/ procedure) the staff groups within my area of responsibility to whom this policy / procedure applies. Made arrangements to ensure that such members of staff have the opportunity to be aware of the existence of this document and have the means to access, read and understand it. Signature Print name Date Division/ Directorate The manager completing this certification should retain it for audit and/or other purposes for a period of six years (even if subsequent versions of the document are implemented). The suggested level of certification is; Clinical Divisions - Divisional General Manager or nominated deputies Corporate Directorates - deputy director or equivalent. The manager may, at their discretion, also require that subordinate levels of their directorate / department utilize this form in a similar way, but this would always be an additional (not replacement) action. 25