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Public Health Wales General Medical Practice Doctor’s Bag Audit 2012

General Medical Practice Doctor’s Bag Audit 2012

Quality improvement toolkitAuthor: Primary Care Quality and Information Service

Date: 7th November 2012 Version: 3Status: This is an updated version of the Emergency Bag Audit 2010 Review: 2014

Intended audience: Public (Internet) / NHS Wales (Intranet) / PHW (Intranet)

The former Public Health Wales Primary Care Quality Team, now incorporated within the Primary and Community Care Development and Innovation Hub, developed a series of quality improvement toolkits to assist practices in collating and reviewing information. From information received, practices still find these toolkits useful, therefore they will remain on this webpage for your ease of reference. Please note, however, that the date of publication is clearly stated in the toolkit and that the evidence within may have changed since publicationPurpose and summary of document:This document is for use by General Practice to ensure that the doctor’s bag contains equipment and drugs to enable the GP to deal appropriately with unplanned clinical situations in General Practice outside the clinical base, whether in an urban or rural location.

Included is a practice review section designed to encourage a whole practice response to the audit findings and an evaluation of the quality and usefulness of the audit itself.

Improvements in practice will be optimised by multidisciplinary involvement in the audit and team discussion of the results. We recommend that action plans following audits

Author: Primary Care Quality and Information Service

DateNovember 2012

Status: Final

General Medical Practice Doctor’s Bag Audit

Version: 3- 1 -

Intended Audience: Public (Internet)/ NHS (Intranet)/PHW (Intranet)/ PCQIS


are reviewed at the discretion of the practice, but would recommend not leaving the changes and re-audit too long. This would depend on what you find from the audit results and what systems you have in place.

Publication/distribution: Publication in PHW Document Database (Primary Care Quality & Information Service)

Link from PHW e-Bulletin


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Status: Final


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Contents

Page

Introduction and Background 3

Audit Aim 5

Methodology 5

Part 1 - Audit 5

Part 2 - Practice Review Proforma 11

Part 3 - Reflection 12

References 13

Evaluation Form 14

A GUIDE TO A HEALTHY GENERAL MEDICAL PRACTICE DOCTOR’S BAG

“Although we know it’s such a drag,It’s time again to check your bag,

So do it now, don’t let it wait,Ensure your drugs are all in date!”


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Status: Final


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General Medical Practice Doctor’s Bag Audit 2012Introduction and Background

It is hoped that practices may find the following list helpful when setting up or reviewing the contents of "doctors’ bags". The Primary Care Quality Information Service would stress throughout that all of the following information is advisory only and that the listing provides suggestions that practices may find helpful. What is carried is a matter of personal choice and judgement and there is no requirement for GPs to carry specific items of equipment or drugs, however it may be considered good practice to do so when actively "on duty". With those provisos it makes good sense for practices to organise an "emergency" or "home visiting" bag that is maintained and serviced within the practice for use by GPs when visiting patients at home.

It may be helpful to consider the intended use of such bags and the environments in which they are likely to be used since this will significantly influence the choice of items that will be most appropriate to carry. The principal issues that will affect the range and extent of what is carried are likely to be; the speed of availability of emergency care, such as ambulance response times, and access to community pharmacies and other retail facilities which stock over-the-counter (OTC) medication.

The Primary Care Quality Information Service approach has been that of "what is the minimum extent and range of items that are likely to be of genuine value in providing emergency or urgent care outside the practice". The weight and bulk of the collection are a significant consideration if the finished bag is to be practical to use. Practices will want to consider the quantities of individual items, including documentation and consumables and keep this to a minimum but have a robust process in place to ensure that checking and restocking is carried out after every deployment. Ideally there will be an inventory and means for practitioners to record what has been used on each occasion to simplify this process.

The type of application considered is where the bag is in use during the in-hours period for GPs operating in typical day-to-day GP settings. The requirements for out-of-hours services, GPs providing immediate care, pre-hospital, trauma, obstetric* or other cover are likely to be somewhat different and are not considered here.

On that basis the Primary Care Quality Information Service has offered suggestions based on whether a practice provides services in predominantly urban or rural areas. Clearly all of these concepts and distinctions are essentially arbitrary and it will be for practices to make a judgement as to what is most applicable to them. The basic list is what we would regard as reasonable in an "urban" setting, meaning one in which emergency ambulance response times are short (minutes rather than hours) and there is ready access to pharmacies and shops. The Primary Care Quality Information Service has added "rural" suggestions that may be of value in more remote areas. In addition some practices may feel that it is appropriate to include a selection of commonly used palliative care drugs and this may be more of a priority where local specialist palliative care teams are less easily accessed or don't provide peripatetic services. The Primary Care Quality Information Service has also suggested that palliative care drugs may be kept in a separate container within the bag which may not need to be carried if the GP is not going to be seeing such patients on a given occasion.

_________________

* in the case of obstetric emergencies we have included very limited suggestions but clearly this is not intended to be sufficient where obstetric intervention is a foreseeable or regular event in which case consideration would need to be given to carrying a range of medication and equipment that is outside the scope of this document.


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The Primary Care Quality Information Service has divided up the list into broad therapeutic areas to simplify the presentation but to avoid duplication we have not reiterated those items which will have multiple applications.

Controlled Drugs (CDs) in the Doctor’s Bag

Issues around carrying controlled drugs are an area that has become more problematic in recent years with increasingly restrictive and onerous requirements placed on GPs when carrying such medication to ensure safe use and reduce the risk of misuse. Where a GP carries a bag containing CDs for home visits, etc., a separate CD register must be kept for the CD stock held within that bag. Each GP is responsible for the receipt and supply of CDs from their own bag. 1

Restocking of the bag from practice stock should be witnessed by another member of the practice staff, as should the appropriate entries into the practice’s CD register.1

Where a prescription is written by a GP following the administration of a CD to a patient, the GP should endorse the prescription form with the word ‘administered’ and then date it. This aims to avoid unauthorised individuals attempting to reuse such ‘prescriptions’ to obtain CDs illegally. Information should also be entered into the patient’s record as soon as practicable.1

As with any specific item, whether or not a GP or a practice chooses to include CDs in their bags is ultimately a matter of individual discretion.

Destruction of Controlled Drugs

GPs may not destroy any CDs in their possession except in the presence of a person authorised by the Accountable Officer for the Health Board.1

A record must be kept of the date of destruction, the name of the drug, strength and the quantity destroyed. The authorised person must sign the record. It is considered good practice that drugs prescribed and dispensed to a patient but which become surplus to the patient’s needs, are destroyed at the same time as stock CDs and witnessed by the authorised person, (i.e. two signatures, the professional destroying it and the witness). If they are destroyed without an authorised witness, GPs are advised to have a witness from within the practice, preferably another clinician.1


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The Suggested Audit

Audit Aim

To ensure the doctor’s bag contains appropriate equipment and drugs to enable the GP to manage urgent and non urgent situations outside the practice in an urban or rural location. The practice/individual GP should have considered the equipment and drugs required and have a list which they consider as necessary to their particular circumstances.

To ensure drugs carried outside the practice are kept in date and stored appropriately.

Methodology

1. Before commencing the audit you should have already agreed with your practice or as an individual, the choice of drugs and equipment to be included in the doctor’s bag. See Part 1 for a suggested list and audit proforma.

2. The system for monitoring the availability of the equipment and drugs within the doctor’s bag should include the following:-

Checking the expiry date of drugs and replacing where needed. Checking that seals are intact and not broken with “in-date” drugs For all drugs – origin, batch numbers and expiry dates of all the drugs should be recorded Checking that all the drugs and equipment on the agreed list are available. Understanding the system within the practice for availability and monitoring of drugs and

equipment. An action plan for pharmaceutical hazard recalls in case the contents of the bag are the

subject of the recall (refer to the Clinical Governance Practice Self Assessment Tool 2010/138, matrix 14.1, ‘Patient Safety Alerts and Reporting’). Completion of the doctor’s bag audit would be a useful piece of evidence for practices for matrix 14.2 ‘Emergency Drugs and Equipment’. See Part 2 for a proforma to help you consider your practice system.

Ensuring drugs are stored in ideal conditions

3. Reflection - See Part 3 for a proforma to help you reflect on the results of the audit.

Part 1 - Audit

The list of drugs and equipment has been compiled by practicing GPs in the Public Health Wales, Primary Care Quality Service Advisory Group, using the Drugs and Therapeutic Bulletin article Volume 43 no 9 September 20052, the National Association of Sessional GPs (NASP) website at http://www.nasgp.org.uk/handbook/4.htm3, Patient UK – Doctor’s Bag Contents.4 Electronic Drug Tariff August 2012.5 BNF No 63, March 20126 and the Drug and Therapeutic Bulletin volume 43 no 11 November 2005.7

The list can be used to ascertain if the drug or equipment is present or absent and if it is in date. If the drug or equipment were absent, there is a column where a reason can be added. This list should be agreed either with your practice or as an individual and can be added to or adapted as new drugs become available or circumstances change within your working life.


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http://www.nasgp.org.uk/handbook/4.htm


Drugs/equipment that may be appropriate in an urban location2,3,4,5,6,7

Analgesia

Key:DB = Drug box (item to be kept in)CDB = controlled drug box (lockable, probably within main drug box)PCDB = Palliative care drug box

Present &

completeIn

date Absent

Reason for absence

if appropriate

Diamorphine powder CDBDiclofenac injection DBOpiod overdose Naloxone injection CDBGastrointestinal Domperidone oral/suppositories DBProchlorperazine oral/buccal DBCyclizine oral/injection Rural/PCDB/DBAsthma Salbutamol nebuliser solution DBTerbutaline MDI and (large volume) suggest compact spacer DB

Ipratropium nebulizer solution DBHydrocortisone (powder as sodium succinate for reconstitution with water for injection)

DB

Prednisolone oral DBInfection Benzylpenicillin DBCefotaxime vial for reconstitution with water for injection DB

Chloramphenicol vial for reconstitution with water for injection DB

Diabetic Emergencies Glucose as oral gel (Hypostop) DBDextrose tablets DBGlucagon injection DBCardiac EmergenciesAspirin oral DBGlyceryl trinitrate spray/oral DBAdrenaline/Epinephrine CDBSeizures Diazepam rectal administration CDBAllergy/Anaphylaxis Adrenaline CDB


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Present &

completeIn

date Absent

Reason for absence

if appropriate

Chlorphenamine injectionRural/DB

Hydrocortisone (powder as sodium succinate for reconstitution) DB

Psychiatric emergencies

Haloperidol oral/injectionCDB

Diazepam oralCDB

ProcyclidineDB

Palliative care drugs Practices may want to include this option particularly if in rural settings or if local palliative care services do not cover fully.

Hyosine Butylbromide injectionPCDB

Diamorphine injectionCDB

Cyclizine injectionPCDB

DexamethasonePCDB

Methotrimeprazine/Levomepeomazine injection

PCDB

Midazolam injectionPCDB

Drug or other equipment that might be carried

Nebuliser & nebulesConsider if carrying spacer and salbutamol MDI will make this superfluous?


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Drugs/equipment that may be appropriate in a rural location2,3,4,5,6,7


Present &

completeIn

date Absent

Reason for absence

if appropriate

Emergency bag with resuscitation equipment/oxygen Sodium chloride infusion (0.9% 500mL)Giving set & Venflons (butterfly for paeds)Codeine oral Small supply cocodamolParacetamol oral Small supply paed suspension possibly DB

Ibuprofen oral DB

Antacid DBAnti-spasmodic agent (hyoscine butylbromide) oral DB

Loperamide DBDexamethasone oral solution (only for use in Croup) DB

Amoxicillin oral DB

Clarithromycin oral DB

Furosemide injection DB

Syntometrine injection DB

Fluorescein/local anaesthetic eye drops DB


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Upkeep of the bag Date Complied with

Not complied with

Reason fornon compliance

Lockable bag

Temperature between 4oC and 25oC. (max and min thermometer). NB Syntometrine will not stay active for more than 2 months if temp above 8 degrees centigrade

Silver bag (tends to keep temperatures within the desired range more effectively than black bag)

Close when not in use (to prevent light inactivation e.g. injectable prochlorperazine)

Lock the bag out of sight in the boot when not in use.

The origin, batch numbers and expiry dates of all drugs should be recorded when administered.

Drugs checked at least twice a year (more often for Syntometrine)

Discard and replace out of date drugs safely

Adhere to Recording and Destruction of Controlled Drugs legislation

If more than immediate treatment is given, the patient should also be given a patient information leaflet.

If oxygen is carried, the car may be labeled with correct “hazchem” sticker

Possibly good practice. There does not appear to be any formal requirement for this. Some may feel this compromises security and this will be a personal choice dependent on environment/level of risk.


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Other equipment to be carried Present Absent Date if

appropriate Reason for absenceIdentificationMobile phone & chargerPersonal AlarmHeaded note paper – to cover case record, communication/referrals etc.Temporary Resident Claim FormsPhone numbersA-Z Street MapsBNF or equivalentInvestigation formsPrescription formsUniversal containerExamination glovesK – Y jellyStethoscopeSphygmomanometer (with date tested)Airways (adult and child) and Laerdal pocket maskTongue depressorAerochamber (infant, child, adult)4,5

OphthalmoscopeAuriscope/speculaeUrine dip-stickThermometerTape measureTorchSyringes and needlesTourniquetSharps BoxPeak flow meter Alcohol sterets ScissorsAlcohol hand gel Disposal bagsSimple dressings Envelopes for dispensing oral medicationWater for injectionGlucometer & Blood glucose testing sticksPulse oximeterMicropore tape


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Part 2 – Practice Review Proforma

How does the Practice/I as a GP, ensure that I have access to the appropriate drugs and equipment needed to deal with any common emergency in general practice?

What processes have the Practice/I used to agree the contents of the doctor’s bag and equipment?

What process is used for the monitoring of the agreed equipment and drugs?

What is the system for checking the expiry date of drugs in the doctor’s bag?

What system is in place for pharmaceutical hazard recalls if the contents of the doctor’s bag are the subject of the recall?


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Part 3 - Reflection (useful for including in appraisal folder)

A. Learning Outcomes: What lessons did you discover from carrying out this audit?

B. What changes, if any will you implement as a result of this audit?

C. Consider how your learning outcomes and changes made will improve patient care

This audit was compiled by;

Name(s) ___________________________________________________________

Signature(s) ____________________________________________________________

Practice (name and address)

Date ______________________________________


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References

1. National prescribing Centre. A Guide to good practice in the management of controlled drugs in primary care (England). Third edition December 2009, version 3.1 updated 1st October 2010. http://www.npci.org.uk/cd/public/docs/controlled_drugs_third_edition.pdf accessed August 2012.

2. Drugs and Therapeutic Bulletin Volume 43 No 9 September 2005 dtb.bmj.com accessed August 2012.

3. National Association of Sessional GPs. The Doctor’s Bag NASGP National Association of Sessional GPs formerly the National Association of Non-Principals accessed 05/11/09

4. Patient UK. Doctor’s bag contents. www.patient.co.uk accessed 05/11/09

5. Electronic Drug Tariff August 2012. http://www.ppa.org.uk/edt/August_2012/mindex.htm accessed August 2012.

6. BNF No 63 March 2012. http://www.bnf.org/bnf/index.htm accessed August 2012.

7. Drugs and Therapeutic Bulletin vol 43 no 11 November 2005 Drugs for the Doctor’s Bag: 2 -Children http:/dtb.bmj.com/archive/2005.dtb accessed 5/11/09

8. Clinical Governance Practice Self Assessment Toolkit 2010/13. http://howis.wales.nhs.uk/sitesplus/888/page/37945 accessed October 2012.

.


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http://howis.wales.nhs.uk/sitesplus/888/page/37945

http://www.bnf.org/bnf/index.htm

http://www.ppa.org.uk/edt/August_2012/mindex.htm

http://www.patient.co.uk/

http://www.nasgp.org.uk/

http://www.nasgp.org.uk/

http://dtb.bmj.com/

http://www.npci.org.uk/cd/public/docs/controlled_drugs_third_edition.pdf


Quality Improvement Toolkit - EVALUATION FORM

The Primary Care Quality and Information Team would like to ensure that the information and suggested tools help practices to monitor and audit their practice data, therefore please could you take a moment and provide your comments on this General Medical Practice, doctor’s bag, quality improvement toolkit.

1) Did you find the introduction, aims and methodology to be clear and easy to understand?

YES NO

If No, please comment ___________________________________________________________

2) Did you find the Part 1 drug/equipment audit data proforma easy to use?

YES NO


3) Did you find the Part 2 Practice Review template helpful?

YES NO


4) Did you find Part 3 the learning outcomes/reflection template helpful?

YES NO


5) Do you have any suggestions on how we should improve our quality improvement toolkits?_____________________________________________________________________________

_____________________________________________________________________________

Please send to:Laura Jones, PCQIS

Public Health Wales, 1st floor, 36 Orchard Street, Swansea, SA1 5AQ email [email protected]


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