Standard Operating Procedure for accessing Controlled Drugs for ...

SOP 16PurposeStandard Operating Procedure for accessingControlled Drugs for Palliative Care by the Selby and YorkOut-of-Hours Service of Unscheduled CareVersion 4, issued June 2007 To ensure confidence and satisfaction with access to controlled drugs in theout-of-hours period To ensure timely access to controlled drugs in the out-of-hours period To meet all legal requirements governing the prescribing, issue and receipt ofcontrolled drugs To ensure safe systems of working for service staff1. ScopeThis SOP defines the process for accessing controlled drugs (CDs), namelyinjectable diamorphine or morphine for use in syringe drivers, by the out-of-hoursservice of unscheduled care.2. ProcessStepwise approach to accessing CDs (see appendix 1 for a diagrammaticsummary)2.1 The prescriber should write/print a prescription for the drugs in the usualmanner.2.2 An assessment should be made as to the urgency of the situation, which mayguide the clinician to the most appropriate place to access the CDs. Thisassessment should take into account:• The clinical need of the patient• The time when the drug is required (e.g. now, or several hours fromnow)• The time of day• The location of the patient• The availability of a carer/OOH service to travel to get the prescriptiondispensed• The drug and quantity of CD required – in rare cases YHT pharmacymay be the only means of obtaining large quantitiesThe gold standard, where possible and reasonable, is for the prescription tobe dispensed from a pharmacy. However, based on clinical judgement, it maybe appropriate to move straight to step 3, but the reasons for this must bedocumented and will be scrutinised by the PCT.2.3 STEP 1: The prescription should be presented to a local pharmacy, if open. Ifno local pharmacy is open, the prescriber or nominated healthcareprofessional should seek to get the prescription dispensed at anotherpharmacy that is open within the Selby & York locality, if practical. It would beusual to expect a pharmacy to be open until 6pm on a Saturday and betweenSOP for accessing CDs, NYYPCT – York and Selby USC, Version 4 June 2007 1

SOP 1611am and 5pm on a Sunday in York but only for an hour at lunchtime in Selby.Bank holiday opening hours may vary and may be restricted to one hourduring the morning in some pharmacies but Sunday hours might apply atMonks Cross, Clifton Moor and York City Centre pharmacies (e.g. BootsConey Street). See Appendix 5 for a list of community pharmacies within thelocality and their usual opening hours.2.4 STEP 2: If there are no pharmacies open then the prescriber or nominatedhealthcare professional should consult the list of pharmacies participating inthe palliative care pharmacy scheme – this list is kept by unscheduled careproviders and is located within the PCT palliative care resource pack (seeAppendix 3). Please note that this scheme is voluntary and it is possible thatthere may be no pharmacist available to dispense the prescription. DO NOTgive out home telephone numbers of pharmacists to patients or carers. SeeAppendix 2 for the list of drugs that participating pharmacists should have.2.5 STEP 3: The prescription can be issued from the palliative care out-of-hoursCD stock at the USC in York Hospital Trust A&E – primary care drugsupply - or Selby Hospital. See Appendix 4 for the list of CDs stocked. Theprescription should be assembled and labelled by 2 healthcare professionals,to include at least one doctor, according to a separate SOP for issuing andlabelling CDs. The CD register should be completed appropriately asdocumented in the SOP. NB keys to the CD cupboard will usually be held bythe nurse-in-charge.2.6 STEP 4: If there are no pharmacies available to dispense the prescription andthere is not an adequate supply of the necessary CD at York or Selby USC tolast until the following morning, then the on-call pharmacist at York Hospitalshould be contacted via the hospital switchboard. This service is available outof-hoursevery day of the year and will always be the final option for sourcing asupply of CDs if community routes are not available. The on-call pharmacistwill verify the identity of the prescriber by calling the USC switchboard beforedispensing the prescription. The prescription must be transferred and drugscollected from YHT pharmacy by a member of OOH staff and not acarer/patient.If Step 4 is deemed the necessary route for follow-up supplies, e.g. over abank holiday weekend, the on-call pharmacist should be contacted as early aspossible, after 9am, the following morning.Please note:• Healthcare professionals should always be mindful of their professional code ofconduct when handling controlled drugs.• Ensuring that CDs are obtained and transported remains the ultimateresponsibility of the OOH provider.• Please note that GPs can use their own personal CD stock or their practice’s CDstock for palliative care purposes if necessary. It would be good practice in suchcircumstances for the GP practice register to be countersigned by another OOHworker. Under no circumstances should GPs access CDs from any other source(e.g. ward stock).SOP for accessing CDs, NYYPCT – York and Selby USC, Version 4 June 2007 2

SOP 163. Audit and monitoring arrangements3.1 All FP10s for controlled drugs should be securely retained inside a designatedenvelope within the CD cupboard and brought to the attention of theUnscheduled Care Service manager in-hours by usual communicationchannels.3.2 All such FP10s will be subject to scrutiny by the PCT to ensure that thestepwise plan has been followed and that CDs have been accessedappropriately.3.3 Staff who wish to raise any questions about accessing CDs for palliative careout-of-hours should do so with their line manager or the PCT seniorpharmacist.4. ResponsibilityDoctors working for the out-of-hours service of unscheduled care will undertake thisprocedure.5. ReviewFollowing implementation, this SOP shall be subject to review, in accordance withany change in the law regarding controlled drug prescribing, issue and receipt. Itmay also be reviewed following audit or error-reporting which has identified risk withthe existing procedure.SOP written by: Prescribing and Medicines Management Team, NYYPCTDate: June 2007Approved for use by: Rachel Ainger, Principal PharmacistReview Date: June 2008 or sooner if requiredSOP for accessing CDs, NYYPCT – York and Selby USC, Version 4 June 2007 3

SOP 16Appendix 1: Diagrammatic Summary of Stepwise plan for accessing CDs forPalliative Care Out-of-HoursSTEP 1: Contact local pharmacy if openSTEP 2: Consult Palliative Care Pharmacy Scheme listSTEP 3: Utilise stocks from York A&E Primary Care Supply or Selby USCSTEP 4: Contact YHT on-call pharmacist via switchboardNB The approach taken can vary depending on the circumstancesin question, as referred to in the earlier text.SOP for accessing CDs, NYYPCT – York and Selby USC, Version 4 June 2007 4

SOP 16Appendix 2: Recommended list of drugs to be stocked by pharmacies participating inthe Palliative Care Pharmacy SchemeQuantityDexamethasone injection 4mg/ml (1ml ampoules) x 10Metoclopramide injection 10mg/2ml x 10Cyclizine injection 50mg/ml x 15Haloperidol injection 5mg/ml x 10Levomepromazine injection 25mg/ml x 10Midazolam injection 5mg/ml (2ml ampoules) x 10Hyoscine butylbromide injection 20mg/ml x 10Hyoscine hydrobromide injection 400mcg/ml x 10Diamorphine injection 100mg x 5Diamorphine injection 30mg x 5Diamorphine injection 10mg x 15SOP for accessing CDs, NYYPCT – York and Selby USC, Version 4 June 2007 5

SOP 16Appendix 3: If healthcare professionals require more detailed info aboutwhere to access palliative care drugs in Selby & York locality out ofhours, pharmacy numbers are held at 08450568060N.B. DO NOT give out home telephone numbers of pharmacists topatients or carers.SOP for accessing CDs, NYYPCT – York and Selby USC, Version 4 June 2007 6

SOP 16Appendix 4: List of Palliative Care controlled drugs stocked by the Selby and YorkOut-of-Hours Service of Unscheduled Care at York A&E and Selby HospitalControlled drug:Quantity stockedDiamorphine 5mg injection* 5 ampoulesDiamorphine 10mg injection 5 ampoulesDiamorphine 30mg injection 5 ampoulesDiamorphine 100mg injection 5 ampoules* Larger stocks of diamorphine 5mg are kept at York A&E Primary Care Supply as these are used forre-stocking the cars for use in chest pain.SOP for accessing CDs, NYYPCT – York and Selby USC, Version 4 June 2007 7