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Care Homes News

Medicines Management Team

Edition: 7 | April 2019

In This Issue:

Homely Remedies Toolkit – minor amendments
Controlled Drugs Prescriptions – now electronic
Pregabalin andGabapentin – controlled drugs status
Resource ® Thickenup Clear – new mixing instructions
Original pack dispensing
Right Time (Medicines Administration)

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Homely Remedies Toolkit - minor amendments

Please note there have been some minor amendments to our Homely Remedies Toolkit. This is following a review in response to some guidance issued by the Regional Medicines Optimisation Committee. The following changes have been made:

Page 3, paragraph 3, now reads as:
‘Residents or relatives may bring in their own over-the-counter (OTC) medicines for self- administration or for care home staff to administer. These must be approved for use by their own GP. These are not for general use in the home and must remain specific to that resident. They should be counted into the home and recorded as for other medication and should be stored securely in a lockable cupboard or trolley. It must be communicated to the relatives that it is their responsibility for obtaining supplies of these products. The GP surgery should be notified of any changes e.g. if the OTC medicine has been stopped.’
Our previous toolkit referred to ‘homely remedies’ being purchased but this has changed to ‘over-the-counter medicines’ to prevent confusion.

Addition of Appendix 3 – ‘Homely Remedies Staff Signature Sheet’
This signature sheet is to list the staff who can administer homely remedies in the home. Care home staff would need to confirm that they understand the Homely Remedy Toolkit, are competent to administer homely remedies, and to acknowledge that they will be accountable for their actions.

The updated Homely Remedies Toolkit is attached with this newsletter for reference, but can also be accessed via our Care Home Team (BCCG Medicines Management Team) folder on GP Ref: http://www.gpref.bedfordshire.nhs.uk/referrals/care-home-team-(bccg-medicines-management).aspx

Please contact us if you have any questions or concerns regarding the above or if you would like any guidance or support with the implementation of homely remedies in your care home. Our contact details can be found at the end of this newsletter.

Controlled Drug (CD) prescriptions - now Electronic

All GP practices across Bedfordshire are now able to prescribe controlled drugs electronically using the Electronic Prescription Service (EPS). If your care home has arranged for your monthly prescriptions to be transferred to your nominated pharmacy electronically, this will mean any prescriptions for controlled drugs will also be sent in this manner and you will no longer receive a green paper FP10 prescription.

This system will be beneficial as all prescriptions can be sent electronically, leading to a reduction in administration burden on GPs and pharmacies, prescriptions will be sent securely so cannot be lost or misplaced, and safety is increased as errors are less likely.
Reference used: Controlled Drugs in the Electronic Prescription Service, NHS Digital

Controlled Drug (CD) prescriptions - now Electronic

All GP practices across Bedfordshire are now able to prescribe controlled drugs electronically using the Electronic Prescription Service (EPS). If your care home has arranged for your monthly prescriptions to be transferred to your nominated pharmacy electronically, this will mean any prescriptions for controlled drugs will also be sent in this manner and you will no longer receive a green paper FP10 prescription.

This system will be beneficial as all prescriptions can be sent electronically, leading to a reduction in administration burden on GPs and pharmacies, prescriptions will be sent securely so cannot be lost or misplaced, and safety is increased as errors are less likely.
Reference used: Controlled Drugs in the Electronic Prescription Service, NHS Digital

Pregabalin and Gabapentin - Controlled Drug (CD) status

Pregabalin and Gabapentin are medicines used to treat conditions such as nerve pain, epilepsy and anxiety. In 2016, the Advisory Council on the Misuse of Drugs raised concerns over the misuse, illegal diversion and addiction of these medicines. As a result, from the 1st April 2019, both Pregabalin and Gabapentin became reclassified as Schedule 3 Controlled Drugs.

This means that in addition to the normal prescription requirements for prescription only medicines, prescriptions for Pregabalin and Gabapentin must also contain the following (as outlined in the Misuse of Drugs Regulations 2001):

  • Dose (which must be clearly defined; ‘as directed’ is not acceptable)
  • Date on which it was signed
  • Address of the prescriber
  • Formulation (e.g. tablet, capsule etc.)
  • Strength (where appropriate)
  • Total quantity or dosage units of the preparation in both words and figures
  • An appropriate date: prescriptions are valid for 28 days after the appropriate date on the prescription. The appropriate date is either the signature date or any other date indicated on the prescription (by the prescriber) as a date before which the drug should not be supplied – whichever is the later.

There is no legal requirement to keep a record of supplies of Pregabalin and Gabapentin in the CD register and they do not require storage in the CD cupboard. However, if care homes choose to treat Pregabalin and Gabapentin as other controlled drugs then this would be considered good practice.

It is recommended that the maximum quantity of Schedule 3 controlled drugs must not exceed 30 days supply. Emergency supplies are not permitted, so there must be a valid controlled drug prescription to obtain a supply.

As mentioned above, GP practices across Bedfordshire are now using the functionality which allows them to issue controlled drugs prescriptions electronically via the EPS system, this will now include both Pregabalin and Gabapentin .

References used:

  • Rescheduling of Gabapentin and Pregabalin as Schedule 3 Controlled Drugs – Briefing note issued 12th February 2019, NHS England
  • Rescheduling of Gabapentin and Pregabalin as Schedule 3 Controlled Drugs from 1st April 2019 – Support Alert issued 29th March 2019, Royal Pharmaceutical Society

Resource® Thickenup Clear - new mixing instructions

As you may recall from a previous newsletter (Edition 4: July 2018), we highlighted the ‘Patient Safety Alert’ entitled ‘Resources to support safer modification of food and drink’. The International Dysphagia Diet Standardisation Initiative (IDDSI) developed a standard terminology with a colour and numerical index to describe texture modification for food and drink. This is fully supported by the Royal College of Speech and Language Therapists and the British Dietetic Association.

Manufacturers of thickeners are in the process of changing their labelling and instructions accordingly. We have previously informed care homes of the new scoop and mixing instructions for Nutilis® Clear, and now the manufacturers of Resource® Thickenup Clear descriptor have also changed their descriptors from a ‘Stage’ to a ‘Level’, this is in line with the new IDDSI framework.

Please find attached the conversion chart for Resource® Thickenup Clear.

Original Pack (OP) Dispensing

We are aware that some care homes across Bedfordshire (as well as nationally) will be switching over from having their monthly medication dispensed in a Monitored Dosage System (MDS) to Original Pack (OP) dispensing. We understand that making this change might be difficult when staff are already used to a system that may already be working. However, we would like to use this opportunity to inform our care homes of the advantages of OP dispensing.

MDS are no longer regarded as the solution for solving medicines related problems.

The National Institute for Health and Care Excellence produced a comparison between MDSs and original packs in its guideline on managing medicines in care homes (March 2014). For medicines administration, NICE found the advantages of MDSs are that they provide an additional visual safety check for care staff and can help facilitate self- administration. In comparison, the list of advantages for original packs is longer (see below).

This also reflects guidance produced by the Royal Pharmaceutical Society, it states: “The use of original packs of medicines, supported by appropriate pharmaceutical care, should be the preferred intervention for the supply of medicines in the absence of a specific need for a multi-compartment aid in all settings.”

Panel 1: NICE comparison of MDS and original pack size

According to the National Institute for Health and Clinical Excellence, the ad- vantage of the original packs are that they:

  • Maintain resident dignity and independence
  • Enable residents to take medicines as if in their own homes
  • Avoid re-dispensing
  • Take up less space than MDSs
  • Support the provision of patient information leaflets
  • Help residents to identify medicines
  • Are less wasteful
  • May be beneficial for residents who go out on short-term leave
  • Are easier to amend following medication changes
  • Carry a lower risk of infection

NICE did not find any disadvantages for administration in original packs, but lists the following disadvantages for MDSs:

  • They may de-skill care home staff
  • They may result in issues with high-risk medicines
  • They can cause difficulties if medicines are stopped, need to be omitted or otherwise identified
  • They require two systems to be used – MDSs plus original packs for acute and “when required” medicines
  • They require separate arrangements for residents on short-term leave
  • They carry a risk if staff over-rely on MDSs so fail to look at the medicine label or description

The use of MDS can result in medicines administration being a robotic task rather than enabling trained carers to deliver person-centred care, and although the Care Quality Commission does not recommend how medicines should be dispensed (ie, original packs or MDSs), it does put emphasis on person-centred care. Another advantage of changing to OPs would be the opportunity to reduce polypharmacy at medication reviews so residents take fewer medicines.

Switches from MDS to OPs have been done successfully in a number of care homes across the country. This involved adequate training and support from pharmacies, local CCG medicines management teams and the use of ‘care home champions’ to help manage the process.

With the advent of more digitised systems including ‘electronic MAR charts’ many pharmacies and care homes are moving towards OP dispensing as their preferred option.

Please contact us if you would like any further guidance on OP dispensing systems

References used:

  • NICE Managing medicines in care homes. Published: 14 March 2014, Full Guideline, Appendix D
  • The Pharmaceutical Journal – Care Homes: the move away from using monitored dosage systems, 10 April 2014

Right Time (Medicines Administration)

Certain medicines have to be taken at specific times without delay or omission. These are considered to be ‘time critical medicines’. For example, Parkinson’s disease medicines, when a resident with Parkinson’s doesn’t get their medication at the time prescribed for them their symptoms can become uncontrolled, which not only can be distressing for them but can also increase their care needs.

There are also medicines that must not be omitted as they can have a direct result on the resident’s clinical status, for example, antibiotics to treat an infection. Recently a care home brought to our attention a query regarding the administration time of an antibiotic used to treat urinary tract infections (UTIs). The dosage instructions on the prescription and MAR chart were: take two tablets for one dose followed by one tablet every 8 hours.

As per instruction the antibiotic was administered every 8 hours, which led to the resident being woken up in the middle of the night to receive a dose. It is important to balance the needs of the resident whilst ensuring adherence to the treatment course. A practical approach to administering antibiotics in this case would be giving ‘Three times a day’ following the administration of the initial two tablets.

With antibiotics it is important to space the doses out evenly during the day to ensure there is an adequate amount of antibiotic in the body to treat the infection. Doses of antibiotics must not be missed. If a treatment dose is missed, administer the dose as soon as possible and ensure that the following dose is given at least 6 hours afterwards. Never double up to make up for a missed dose.

Reference used: PrescQIPP: Care homes – Refused and missed doses, B179, July 2017, Electronic Medicines Compendium 2019

Contact Us

If you would like to get in touch with us, please contact the Medicines Management Team:
bedccg.bedsmeds@nhs.net or 01525 624 375

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