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Multi-compartment compliance aids to original packs of medication: the transition
COVID-19: Medicines Optimisation in Care Homes
North West London Care Home Pharmacy Group, April 2020
Current challenges The current COVID-19 pandemic poses one of the biggest challenges that
community pharmacy has ever faced
Community pharmacies are facing increasing pressures due to various reasons, including:
1. Staff shortages as a result of self-isolation or parental/carer responsibilities
2. Increasing workload (e.g. due to patients anxiously over-ordering medication during pandemic)
3. Increased demands for medication supplies, including over the counter and anticipatory medicines
Background & Reason for Change As multi-compartment compliance aids (MCAs) can be a highly labour-intensive task and with the current situation and increasing pressures on the pharmacy workforce in mind, the Pharmaceutical Services Negotiating Committee (PSNC) has advised community pharmacies to review the services they provide to care homes and assess the level of risk that may be posed by switching to original pack dispensing.
This could help to ensure that the whole medicines supply chain is protected.
The care home and community pharmacy should undertake a risk assessment to determine whether the change will be safe and appropriate. An open and honest discussion with the home management should take place to understand the complexity this may bring.
The measure is being taken in extreme circumstances to protect all patients who access services from the respective pharmacy.
Important note
The Care Quality Commission (CQC) have identified several reports and studies which indicate that there is no clear evidence that MCAs reduce administration errors
Pros of using original packs • Maintain resident dignity and independence
• May reduce medication waste
• Staff and resident can see original pack of medicine – identification and safety purposes
• Easier to deal with medication changes e.g. if medicine is stopped
• Beneficial for patients who go on short term leave/utilise day services
• Lower risk of microbial contamination
• Takes up less space than MCAs
Cons of using MDS • Many medicines cannot be dispensed into these devices e.g. light-sensitive medicines, moisture-sensitive medicines, cytotoxic medication
• Stability issues for medicines removed from their original packaging
• Carers/nurses less likely to identify dispensing errors
• Homes will most likely have other medicines dispensed in original packs already e.g. PRN medicines, so staff would need be trained and competent to administer from original packs (even prior to the transition)
• Two parallel administration systems i.e. from original packs and MCAs would make the process more complex and the risk of omitted doses may increase
• Over-reliance on MCAs may de-skill staff and induce complacency
Impact on staff and residents • Improves job satisfaction
• Enables staff to develop knowledge on medicines
• Builds a stronger team
• Gives more flexibility for the care home through having more versatile staffing
• Improves care for residents
• Residents able to see their medication in the original packaging (this may also prompt them to be more involved with their medicines)
Legislation & CQC Guidance – Reasonable adjustments
GPs and other healthcare professionals must make reasonable adjustments to help people take their medicines. The Equality Act 2010 requires such adjustments and MCAs may form part of these.
This is something to bear in mind particularly for residents who may be self-administering their medicines
Top tip
Success stories A care home in Lanarkshire switched from MCAs to original pack dispensing. Below is the feedback provided by the deputy manager:
“It has worked out really well for us. Using MDSs [MCAs] de-skilled our staff. Using original packs is so much better for them, it helps with better stock management and it reduces medicines waste.”
“One of my concerns had been the new process would take more time…
…Overall, we have found the time to be comparable and it’s so much better for residents from a dignity point of view.”
You may wish to link in with colleagues from other local care homes who have undergone the transition in case they would like to share some advice and tips
Top tip
Ref: https://www.pharmaceutical-journal.com/opinion/correspondence/switching-between-monitored-dosage-systems-and-patient-pack-dispensing/20206259.article
Ensuring a safe transition…
…what do adult social care providers need to consider?
General standards for safe medicine administration – a refresher Ensure that the prescription is valid, legible, unambiguous and complete
Be aware of the client’s care plan
Check whether the client has any allergies, sensitivities or intolerances
After administration, check whether client has actually taken the medicine
Ensure that the Medicines Administration Record (MAR) is updated
Ensure medicines reconciliation processes are carried out accurately and in a timely manner
Ensure that infection control policies are followed
Ensure staff protect themselves from unwanted drug exposure
Please note: this list is not exhaustive and you will need to carry out additional relevant checks/processes as appropriate
Receiving medication Check medicines upon delivery
• Medicines in their original packs/containers should be clearly marked with the supplying
pharmacy being identifiable
• Check quantity and description
• Check any new MAR charts against the previous MAR charts and latest prescriptions – resolve any discrepancies immediately by contacting the relevant healthcare professionals
• Ensure the quantity of each medicine received is documented in the appropriate section of the MAR chart for each client
Administering medicines from original packs • Check identity of client
• Check the client is ready for the medication; be aware of the right to refuse
• Obtain consent from client
• Check whether the client has any allergies, sensitivities or intolerances
• Check expiry date of medicine – please refer to Care Home Good Practice Guidance 1: Repeat Prescription Ordering for some guidance on expiry dates (Appendix 4). Link on slide 26
• Refer to the Patient Information Leaflet as and when necessary
• Record stock levels and running balances for all medicines, on the appropriate section of the MAR chart (this will also ensure that there is an audit trail of medicines coming into the home)
• Ensure you make the necessary documentation on the MAR chart
Please note: this list is not exhaustive and you will need to carry out additional relevant checks/processes as appropriate
Administering medicines from original packs – questions to consider • Right patient?
• Right drug?
• Right strength? Be aware that medication may exist in different strengths
• Right form?
• Right dose?
• Right route?
• Right time?
• Right directions? Do the directions match the latest MAR chart and prescription?
• Are there any special instructions/precautions on the label e.g. with or after food?
Please note: this list is not exhaustive and you will need to carry out additional relevant checks/processes as appropriate
Medicine labels – information to be included • Name of patient • Name, address and telephone number of supplying pharmacy • Date of dispensing • Name of medicine • Form • Strength • Quantity • Directions for use • Precautions relating to the use of the medicine • Warning labels • The words ‘Keep out of reach and sight of children’ • The words ‘Use this medicine only on your skin’ where applicable
Storage • Some medication trolleys are made particularly to aid the storing of MCAs. If you require a new medication trolley after the transition, please liaise with your community pharmacy
• Ensure that each resident’s medicines are kept segregated from other residents’ medicines to avoid any mix-up or incidents
• Review and update your policies to reflect the new storage arrangements
Perhaps consider video calling your Care Homes Pharmacist/Pharmacy Technician for advice with storage arrangements in your medication rooms or drug trolleys
Top tip
Some extra tips to help with the transition • Review medication policies and procedures and ensure staff have read + understood these
• Review and update staff training. Ensure that staff are trained and assessed as competent to administer medicines safely
• Appoint a ‘Medicines Champion’ on each unit to oversee the process and help with certain medicines-related issues that may be encountered
• For residents who are self-administering their medicines, undertake an individual patient assessment (which is also person-centred) and liaise with the patient’s GP, community pharmacy and care home pharmacist for advice
Administration of some medicine formulations not stored within MCAs…
…some additional tips and guidance for adult social care providers
Administering medicines from original packs – topical (external) formulations • Only to be used as often as directed by the prescriber
• To be applied only to the area(s) for which it has been prescribed – refer to care/management plan
• Ensure that you refer to the Patient Information Leaflet (PIL) for instructions on use
• Use only for as long as instructed – return any excess/partly used supplies to the community pharmacy for safe disposal at the end of the treatment period
• Apply steroid-based preparations thinly
• Follow your local infection control procedures and policies
• Seek specialist advice e.g. from Tissue Viability Nurse (TVN) or prescriber, if necessary
Administering medicines from original packs – topical (external) formulations
Drug Safety Alert
Warnings released re: the risk of severe and fatal burns with all paraffin-based emollients regardless of paraffin concentration. Data suggest there is also a risk for paraffin-free emollients. Advise patients who use these products not to smoke or go near naked flames, and warn about the easy ignition of clothing, bedding, dressings, and other fabric that have dried residue of an emollient product on them.
Additional guidance:
• ensure that risk assessments are undertaken and updated to reflect the use and storage of emollients
• ensure all emollients are stored safely and securely
Ref: https://www.gov.uk/drug-safety-update/emollients-new-information-about-risk-of-severe-and-fatal-burns-with-paraffin-containing-and-paraffin-free-emollients
Administering medicines from original packs – topical (external) formulations
Topical steroids
• Topical corticosteroids are a type of steroid medicine applied directly to the skin to reduce inflammation and irritation
• They're available in 4 different potencies: mild, moderate, potent, very potent
• The frequency and duration of use should be checked with the prescriber if not specified
• The medicine should only be applied to affected areas of skin. Gently smooth a thin layer onto the skin in the direction the hair grows
• If you're using both topical corticosteroids and emollients you should apply the emollient first. Then wait about 30 minutes before applying the topical corticosteroid.
• The length of cream or ointment expelled from a tube may be used to specify the quantity to be applied to a given area of skin. This length can be measured in terms of a fingertip unit (the distance from the tip of the adult index finger to the first crease). One fingertip unit (from a tube with a standard 5 mm diameter nozzle) is sufficient to cover an area that is twice that of the flat adult handprint (palm and fingers)
Administering medicines from original packs – eye drops • Eye drops are generally instilled into the pocket formed by gently pulling down the lower eyelid and keeping the eye closed for as long as possible after application
• Instillation of more than one drop should usually be discouraged as it may increase systemic side-effects
• When two different preparations are used at the same time of day, leave an interval of at least 5 minutes between the two preparations – the interval should be extended when eye drops with a prolonged contact time, such as gels and suspensions, are used
• Pressure on the lacrimal punctum for at least a minute after applying eye drops decreases systemic absorption from the nasal mucosa and hence reduces risk of side-effects
• After using eye drops or eye ointments, patients should be warned not to drive or perform other skilled tasks until vision is clear
Administering medicines from original packs – eye ointments • If the client is using eye drops as well as eye ointment, the ointment should be applied after drops
• Refer to Patient Information Leaflet for information on how much to apply
• Blinking helps to spread the ointment
• If the ointment causes blurred vision, this may also increase falls risk
• Check the expiry of the eye product(s)
Administering medicines from original packs – ear drops
General guidance on how to use ear drops
1. Wash hands thoroughly
2. Hold the bottle in your hand to warm it. Cold ear drops can make you feel dizzy.
3. Lie on your side with the affected ear facing up to put the drops in (in accordance with prescription directions).
4. Gently pull and push your ear to work the drops in.
5. Stay lying down for 5 minutes so the drops do not come out.
6. Wash hands thoroughly
Administering medicines from original packs – transdermal patches • Wear gloves when handling patches
• Use a ‘transdermal patch application record’ to document when and where patches are being applied
• Check the patch frequently to ensure it is still in place
• Used patches should be folded in on themselves and disposed of appropriately in accordance with the policy for safe medication waste disposal. For controlled drugs, refer to CD policy.
• NB: Heat increases the rate of transdermal drug absorption and can cause toxicity – avoid direct contact with heat (e.g. hot water bottle, heat pad)
• If the client has a fever, liaise with the prescriber as the patch dose may need reviewing
Information sources include… • British National Formulary
• Electronic medicines compendium (EMC): https://www.medicines.org.uk/emc/
• Patient information leaflet
• North West London Good Practice Guidance documents for Care Homes: https://www.healthiernorthwestlondon.nhs.uk/bettercare/medicinesop
• Care home pharmacist
• General practitioner
• Community pharmacist
Additional learning materials ‘Managing medicines for adults receiving social care in the community’: e-Learning made available via PrescQIPP
Please see the following link for further information: https://mcusercontent.com/7e7659db46e568cca5e047f43/files/bcb6e5df-709f-40b1-9ca0-c13607dc99e0/PrescQIPP_Managing_medicines_for_adults_receiving_social_care_in_the_community_e_learning_Course_overview.pdf
Some topics that are covered include: Administration of inhalers Administration of liquid medication Covert administration Supporting people to take their
medicines
Additional resources • CQC COVID-19 guidance – medicines information for adult social care providers: https://www.cqc.org.uk/guidance-providers/adult-social-care/covid-19-medicines-information-adult-social-care-providers#mca
•CQC guidance – Multi-compartment Compliance Aids in Care Homes: https://www.cqc.org.uk/guidance-providers/adult-social-care/multi-compartment-compliance-aids-mcas-care-homes
• NICE guidelines for Managing Medicines in Care Homes: https://www.nice.org.uk/guidance/sc1
• London Medicines Information Service – Summary of Guidance and Evidence for use of Multi-Compartment Compliance Aids: https://www.sps.nhs.uk/wp-content/uploads/2019/05/SPS_MCCA_briefing_May2019_final.pdf
• PrescQIPP Bulletin – Reviewing the use of monitored dosage systems in care homes: https://www.prescqipp.info/media/1235/b174-care-homes-use-of-monitored-dosage-systems-20.pdf
• PrescQIPP Information Apr 2020 – Changing from MDS to OPs in care homes: https://www.prescqipp.info/umbraco/surface/authorisedmediasurface/index?url=%2fmedia%2f4757%2fprescqipp-hot-topics-changing-from-mds-to-original-packs-20.pdf
Contact us We understand that this is a difficult time and would like to assure you that the North West London Care Home Pharmacy Group are very dedicated to help and support their care homes as much as possible. Please see below details for the team specifying the region within NWL they cover:
Shamim Jivraj (Lead Pharmacist for Care Homes across NWL STP): [email protected]
Manisha Bhatt (Care Home Pharmacist – Hillingdon CCG): [email protected]
Swarupa Dawada (Care Home Pharmacist – Brent CCG): [email protected]
Devinder Kalsi (Care Home Pharmacist – Harrow CCG): [email protected]
Jagruti Patel (Care Home Pharmacy Technician – Hounslow CCG): [email protected]
Disclaimers This resource is not to be used for commercial or marketing purposes and has been produced with best available evidence at the time of publication
This resource is no way intended to replace, supplement or augment the policies and procedures effective in each care home/provider organisation. Each registered and non-registered practitioner remains accountable for their actions under the law and, where relevant, their Code of Conduct or Standards of Practice
Every care and effort has been taken in the compilation of this resource, however, neither the Medicines Optimisation in Care Homes Team nor North West London Collaboration of Clinical Commissioning Groups will be held responsible for any problems caused as a result of any inaccuracy or error within this document. North West London Collaboration of Clinical Commissioning Groups team are also not responsible for any content that is on a source mentioned in this document
NB: Please contact us if you feel that any information within this resource is omitted or inaccurate
