Homely Remedy Policy 1 - Family Nursing & Home Care · Microlax® and Relaxit® Micro enemas ......

Homely Remedy Policy and

Protocols

March 2015

Document Profile

Type i.e. Strategy, Policy, Procedure, Guideline, Protocol

Policy & Protocol

Title

Homely Remedy Policy

Category i.e. organisational, clinical, finance

Clinical

Version

1.1

Author

Clinical Effectiveness Facilitator

Approval Route, i.e. Policy & Procedure Group, Operational Governance Group

Operational Governance Group

Approved by

Chief Executive Officer – Julie Gafoor

Date approved

30/03/15

Review date

30/03/17

Contents Purpose of Policy ........................................................................................................ 3 Consent ....................................................................................................................... 3 Contra-indications and Hypersensitivities ................................................................... 3 Record Keeping .......................................................................................................... 3 Treatment Length ........................................................................................................ 4 Authorisation and Responsibilities .............................................................................. 4 Delegation ................................................................................................................... 4 List of Approved Medicinal Products ........................................................................... 5 Monitoring ................................................................................................................... 6 Glycerin Suppositories ................................................................................................ 8

Clinical condition/indication for use ...................................................................... 8 Side Effects .......................................................................................................... 8 Patients eligible for inclusion in the protocol ........................................................ 8 Patients excluded from treatment under the protocol .......................................... 8 Action for patients excluded from treatment under the protocol .......................... 8 Notes.................................................................................................................... 8

Microlax® and Relaxit® Micro enemas ....................................................................... 9 Clinical condition/indication for use ...................................................................... 9 Side effects .......................................................................................................... 9 Caution................................................................................................................. 9 Patients eligible for inclusion in the protocol ........................................................ 9 Patients excluded from treatment under the protocol .......................................... 9 Action for patients excluded from treatment under the protocol .......................... 9 Notes.................................................................................................................... 9

Instillagel® ................................................................................................................ 10 Clinical condition/indication for use .................................................................... 10 Side effects: ....................................................................................................... 10 Patients eligible for inclusion in the protocol ...................................................... 10 Patients excluded from treatment under the protocol ........................................ 10 Action for patients excluded from treatment under the protocol ........................ 10 Notes.................................................................................................................. 10

Paracetamol (for adult use) ....................................................................................... 11 Clinical condition/indication for use .................................................................... 11 Side effects: ....................................................................................................... 11 Patients eligible for inclusion in the protocol ...................................................... 11 Patients excluded from treatment under the protocol ........................................ 11 Action for patients excluded from treatment under the protocol ........................ 11 Notes.................................................................................................................. 11

Non – Proprietary Emollient Preparations ................................................................. 12 Clinical condition/indication for use .................................................................... 12 Side effects: ....................................................................................................... 12 Patients eligible for inclusion in the protocol ...................................................... 12 Patients excluded from treatment under the protocol ........................................ 12 Action for patients excluded from treatment under the protocol ........................ 12 Notes.................................................................................................................. 12 Clinical condition/indication for use .................................................................... 13 Side effects: ....................................................................................................... 13 Patients eligible for inclusion in the protocol ...................................................... 13 Patients excluded from treatment under the protocol ........................................ 13 Action for patients excluded from treatment under the protocol ........................ 13 Notes.................................................................................................................. 13

Emollient Preparations Containing Urea ................................................................... 14 Clinical condition/indication for use .................................................................... 14 Side effects: ....................................................................................................... 14

Patients eligible for inclusion in the protocol ...................................................... 14 Patients excluded from treatment under the protocol ........................................ 14 Action for patients excluded from treatment under the protocol ........................ 14 Notes.................................................................................................................. 14

Emollient Preparations with Antimicrobials ............................................................... 15 Clinical condition/indication for use .................................................................... 15 Side effects: ....................................................................................................... 15 Patients eligible for inclusion in the protocol ...................................................... 15 Patients excluded from treatment under the protocol ........................................ 15 Action for patients excluded from treatment under the protocol ........................ 15 Notes.................................................................................................................. 15

Iodine Preparations ................................................................................................... 16 Clinical condition/indication for use .................................................................... 16 Side effects: ....................................................................................................... 16 Patients eligible for inclusion in the protocol ...................................................... 16 Patients excluded from treatment under the protocol ........................................ 16 Action for patients excluded from treatment under the protocol ........................ 16 Notes.................................................................................................................. 16

This document links to the following QAF standards:

1. Care and welfare of people who use services 3. Management of medicines 8. Co-operating with other providers 14 Consent to care and treatment 15 Records 16. Supporting workers

Policy and Protocols Update

Date of Update Changes Made

November 2014 Index added

QAF standards added

Non-Medical Prescribing acknowledged

Dermol® 600 bath emollient and Betadine® added to the protocols

Statement re the use of up to date information added to the ‘Contra-indications and Hypersensitivities’ section

Requirement to inform GP/NMP of medicine administered has been added

Side Effects Updated

Some exclusion criteria clarified/updated

The following protocols were removed

Bisacodyl Suppositories

Fleet® Ready to use Enema

Paracetamol for children

Purpose of Policy This policy and accompanying protocols provide written instruction for the supply and administration of an agreed list of General Sales List (GSL) and Pharmacy (P) medicines to clients by registered nurses competent in the administration of medication employed by Family Nursing and Home Care (FNHC).

The Nursing and Midwifery Council (NMC 2007) states that:

“Registrants must only supply and administer medicinal products in accordance with one or more of the following processes:

Patient Specific Direction (PSD)

Patient Medicines Administration Chart (may be called a Medicines Administration Record MAR)

Patient Group Direction (PGD)

Medicines Act Exemption (where they apply to nurses)

Standing order

Homely Remedy Protocol

Prescription Form”

By using this policy and attached protocols, qualified Nurses can, where applicable, administer the listed medicinal products without written authorisation from a Registered Prescriber. The Homely Remedy Policy and Protocols facilitate the administration of medicines in accordance with the Standards for Medicines Management (NMC 2007) and ‘The Code’ (NMC 2008). Please note however, wherever possible all medication for administration by FNHC staff should have signed authorisation by a Registered Prescriber. Use of this policy and protocols should be reserved for times when it is not practicable to achieve this.

Prescription only medicines (POM) may only be administered following a Patient Group Direction (PGD) or a written direction from a Registered Prescriber.

Consent Prior to the first time the medicinal product is administered/used verbal consent from the patient must be obtained and documented. Thereafter nurses must reaffirm with the patient continued agreement for its use.

Contra-indications and Hypersensitivities The allergy status of the patient MUST be recorded in the patient’s nursing records. Nurses must ensure that there are no contra-indications or exclusions or no hypersensitivity reactions to any of the constituents of the product prior to its administration/use. Examples of where such information can be found include the British National Formulary, the Summary of Product Characteristics (SPC) for the particular medicine and the Patient Information Leaflet (PIL) supplied by the manufacturer of the medicine.

Up to date information regarding the medicines covered by this policy and protocols must be used by staff as the information contained in the protocols may change before this document is updated.

Record Keeping Any medicinal product administered must be clearly recorded in the patient’s nursing records. The following details should be recorded:

Reason for administration

Date and time given

Dose

Route

Signature

For adult patients with Community Adult Client Held Records (CACHR) the medicinal product must be recorded on the ‘Medication Record’ sheet.

If applicable, patients should be informed when the next dose is due.

Treatment Length The maximum time period for administration of most of the medicinal products approved by this policy, unless stated otherwise under the individual product, is 2 days or in the case of weekends and public holidays until the next working day. Thereafter, written authorisation from a Registered Prescriber must be obtained if there is an ongoing requirement for FNHC staff to administer the medicinal product(s) in question. However, clinical judgement should be exercised and if, within the time period, there are any concerns, the patient’s General Practitioner (GP) or an appropriate Non-medical Prescriber (NMP) must be contacted. Before any further doses can be administered there must be discussion with the GP or appropriate NMP regarding re-assessment of the patient’s condition and treatment. If any concerns remain written authorisation from the GP/NMP for continued administration of the medicinal product will be required.

The patient’s GP/NMP must be informed of any medicines administered using this policy/protocols.

NB. The administration/use of FNHC approved topical emollients and barrier preparations may continue without written authorisation from the GP/NMP if clear benefit is attained.

Authorisation and Responsibilities Staff will only be authorised to use the medicinal products detailed in this policy and attached protocols if they sign the declaration on the approved form (appendix 1). It is the responsibility of Line Managers to ensure that any of their staff required to use this policy and protocols sign this form. They are also responsible for ensuring that any appropriate ‘new starters’ are given a copy of this document and sign up to it. Line Managers must also sign to confirm that the staff member is eligible to use the policy/protocols. Completed forms should be sent to the Information Governance Officer for retention. Any changes made to this policy and protocols will require staff to sign the appropriate paperwork again. The Homely Remedy Policy and Protocols will be reviewed every three years or more often if changes are required. Staff will be informed of any changes via the ‘Policy and Procedures Group’

Delegation Registered Nurses may, where appropriate, delegate the administration/use of the medicinal products in this policy to Health Care Assistants (HCAs). However, they must first ensure that the HCA is competent to administer/use the product and provide appropriate supervision and support with this task. Clear instruction in the use of the medicinal product must be written in a care plan which is regularly reviewed by the Registrant and, as previously stated, the medicinal product must be detailed in the patient’s ‘Medication Record’. The HCA must comply with all the requirements of the Association’s Medication Policy to ensure safe administration/use of the product in question.

5

List of Approved Medicinal Products

Medicinal Product Page Number

Enemas and Suppositories

Glycerin Suppositories 7

Micralax and Relaxit Micro - Enemas 8

Catheter Products

Instilagel 9

Analgesia

Paracetamol (for adults) 10

Emollients

Non proprietary emollients

Aqueous Cream, BP

Emulsifying Ointment, BP

Liquid and White Soft Paraffin Ointment, NPF

White Soft Paraffin, BP

11

Proprietary emollients

Diprobase®

Doublebase®

E45®

Epaderm®

Hydromol®

Oilatum®

Unguentum M®

12

Emollients containing urea Calmurid® 13

Emollients with antimicrobials

Dermol® Dermol® 500 lotion

Dermol® 200 shower emollient

Dermol® 600 bath emollient

14

Iodine Preparations

Providone-Iodine Betadine®

15

6

Monitoring It will be the responsibility of all relevant Line Managers or delegated other to monitor adherence with the Homely Remedy Policy and Protocols using the audit tool in Appendix 2. Audit will take place during the first quarter of the year using the data as it stands on the 31st December of the preceding year.

Using the audit results for all clinical areas where the HRP is used, an organisational wide report will be produced by the Governance and Performance Division.

7

Protocols

For the following protocols, the template used by Wyre Forest NHS Trust, in their 2005 Homely Remedy Policy, has been used. Details re all the medication is from the British National Formulary and for some medications, the relevant Summary of Product Characteristics.

8

Glycerin Suppositories Drug Approved Name

Dose Route Frequency Maximum Administration

Glycerol 1 suppository

adults large (4g mould)

Per rectum

Daily 1 suppository per day

Glycerin suppositories act as a rectal stimulant by virtue of the mildly irritant action of glycerol and should be moistened with water before use

Clinical condition/indication for use Constipation

Side Effects Abdominal cramp Irritation in or around the rectum

Patients eligible for inclusion in the protocol Patients who are constipated and the constipation is not secondary to an underlying complaint.

Patients excluded from treatment under the protocol Intestinal obstruction Children Pregnancy Known hypersensitivity to glycerol

Action for patients excluded from treatment under the protocol Consider use of another more suitable laxative or refer to GP or appropriate non-medical prescriber (NMP)

Notes Prior to the administration of this medicine:

a digital rectal examination (DRE) must be carried out as part of the assessment process

the GP/appropriate NMP must be consulted

Where appropriate advice should be given regarding the prevention of constipation

9

Microlax® and Relaxit® Micro enemas

Name Dose Route FrequencyMaximum

Administration Sodium Citrate (rectal)

Adult 5ml single dose disposable pack

per rectum

Daily one per day

Sodium citrate preparations are osmotic laxatives and work by increasing the amount of water in the large bowel either by drawing fluid from the body into the bowel or by retaining the fluid they were administered with.

Clinical condition/indication for use Constipation

Side effects Local irritation

Caution Maintain adequate hydration

Patients eligible for inclusion in the protocol Adults with constipation and the constipation not secondary to an underlying

complaint.

Patients excluded from treatment under the protocol Children Pregnancy Elderly and debilitated Inflammatory bowel disease Acute gastro - intestinal conditions Patients with:

o Electrolyte disturbances o Renal impairment o Congestive heart failure o Ascites o Uncontrolled hypertension o Inadequate hydration

Action for patients excluded from treatment under the protocol Refer to GP or appropriate non-medical prescriber (NMP).

Notes Prior to the administration of a micro - enema:

a digital rectal examination (DRE) must be carried out as part of the assessment process

the GP/appropriate NMP must be consulted

10

Instillagel® Drug Approved Name Dose Route Frequency Maximum

AdministrationLidocaine Hydrochloride 2%, Chlorhexidine Gluconate solution 0.25%

Adults 6ml - 11ml

Per urethra

Once prior to catheterisation

One per day

Instillagel is Lidocaine Hydrochloride 2%, Chlorhexidine Gluconate solution 0.25% in a sterile lubricant. It is presented in a 6ml or 11ml pre-filled syringe for use as a local anaesthetic prior to urethral catheterisation.

Clinical condition/indication for use Local anaesthesia prior to urinary catheterisation

Side effects: Single application of a topical lidocaine preparation does not generally cause systemic side effects. Skin irritation

Patients eligible for inclusion in the protocol Adults prior to urinary catheterisation

Patients excluded from treatment under the protocol Children Pregnancy Hypersensitivity to active ingredients or excipients Damaged or bleeding mucous membranes Impaired cardiac conditions Hepatic insufficiency Epileptics On antiarrhythmic drugs

Action for patients excluded from treatment under the protocol Discuss with GP or appropriate non-medical prescriber (NMP).

Notes Allow sufficient time for Instillagel® to work before inserting the urinary catheter.

Instillagel may slightly impair an individual’s ability to drive or operate machinery. If affected, they should be advised to avoid these activities.

11

Paracetamol (for adult use) Drug Approved Name

Dose Route Frequency Maximum Administration

Paracetamol Adult dosage 500mgs -1g

Oral 4-6 hourly Maximum 4g in 24 hours

Paracetamol is a non-opioid analgesic which has no demonstrable anti-inflammatory activity.

Clinical condition/indication for use Patients with generalised symptoms of mild to moderate pain. Symptomatic pyrexia.

Side effects: Side effects are rare but:

rashes blood disorders IMPORTANT – liver damage (and less frequently renal damage) following

over dosage.

Patients eligible for inclusion in the protocol Adult patient requiring relief from mild to moderate pain

Patients excluded from treatment under the protocol Hepatic impairment or any investigation of the liver. Renal impairment Alcohol dependence Prescription of any other drug containing paracetamol Children Pregnancy

N.B. Also check prior intake of over the counter paracetamol and products containing paracetamol.

Action for patients excluded from treatment under the protocol Should be reviewed by medical staff or appropriate non-medical prescriber (NMP) and alternative medication prescribed.

Notes

12

Non – Proprietary Emollient Preparations

Name Dose Route Frequency Maximum

Administration Aqueous Cream, BP Emulsifying ointment, BP Liquid and White Soft Paraffin

Ointment, NPF (50/50) White Soft Paraffin, BP

Apply liberally

To skin When required (see below)

This is not exhaustive but is a list of common preparations that patients access either over the counter or from a Registered Prescriber to manage dry skin conditions.

Emollients soothe, smooth and hydrate the skin and are indicated for all dry or scaling disorders.

The products vary in levels of ‘greasiness’ which may guide product choice. Ointments tend to hydrate very dry skin more than other less greasy preparations such as Aqueous Cream and are, therefore, considered more effective. However their greasiness may make them less acceptable to patients.

The effects of emollients are short-lived and they should be applied frequently even after improvement occurs. The severity of the condition, patient preference and site of application will often guide the choice of emollient.

Aqueous Cream, BP and Emulsifying Ointment, BP may also be used as soap substitutes where it is rubbed onto the skin before rinsing off completely.

Clinical condition/indication for use Dry or scaling disorders of the skin

Side effects: Rare but may cause sensitisation – this should be suspected if an eczematous reaction occurs The use of aqueous cream as a leave-on emollient may increase the risk of skin reactions particularly in eczema.

Patients eligible for inclusion in the protocol See under clinical condition/indication for use

Patients excluded from treatment under the protocol

Action for patients excluded from treatment under the protocol Any patient excluded should be discussed with their GP or appropriate non-medical prescriber (NMP).

Notes Emollients should be applied in the direction of hair growth.

Fire hazard with paraffin-based emollients Emulsifying ointment and 50% liquid paraffin and 50% white soft paraffin ointment in contact with dressings and clothing are a fire hazard. The greater the amount of these preparations that are used the higher the fire risk.

Patients must be advised to keep away from fire or flames and not to smoke when using these preparations. Patients on oxygen should avoid using paraffin based products on their face and hands. Carers should avoid having paraffin-based emollients on their hands when caring for those on oxygen.

A risk assessment must be undertaken: before using large quantities of paraffin-based emollients if the patient is on oxygen

13

Proprietary Emollient Preparations Proprietary Name Dose Route Frequency

Maximum Administration

Diprobase® Doublebase® E45® Epaderm® Hydromol® Oilatum® Unguentum M®

Apply liberally

To skin When required (see below)

This is not exhaustive but is a list of common preparations that patients access either over the counter or from a Registered Prescriber to manage dry skin conditions.

Emollients soothe, smooth and hydrate the skin and are indicated for all dry or scaling disorders.

The products vary in levels of ‘greasiness’ which may guide product choice. Ointments tend to hydrate very dry skin more than other less greasy preparations such as Aqueous Cream and are, therefore, considered more effective. However, their greasiness may make them less acceptable to patients.

The effects of emollients are short-lived and they should be applied frequently even after improvement occurs. The severity of the condition, patient preference and site of application will often guide the choice of emollient.

Clinical condition/indication for use Dry and scaling disorders of the skin Epaderm® and Hydromol® may also be used as soap substitutes where it is rubbed onto the skin before rinsing off completely Doublebase® - dry, chapped or itchy skin conditions

Side effects: Rare but may cause sensitisation – this should be suspected if an eczematous reaction occurs





Fire hazard with paraffin-based emollients Paraffin based emollients may present a fire hazard. The greater the amount of these preparations that are used the higher the fire risk.

Patients must be advised to keep away from fire or flames and not to smoke when using these preparations. Patients on oxygen should avoid using paraffin based products on their face or hands. Carers should avoid having paraffin-based emollients on their hands when caring for those on oxygen.


14

Emollient Preparations Containing Urea


AdministrationCalmurid® Apply a thick layer

for 3-5 minutes, massage into area and remove excess

To skin Twice daily Twice a day

Urea is a hydrating agent used in the treatment of dry scaling skin disorders. It may be useful in elderly patients. It is occasionally used with other topical agents e.g. corticosteroids to enhance penetration of the skin.

Clinical condition/indication for use Dry and scaling disorders of the skin

Side effects: Rare but may cause sensitisation – this should be suspected if an eczematous

reaction occurs Stinging





If stinging occurs, discuss with GP/Non-medical prescriber.

15

Emollient Preparations with Antimicrobials


Administration Dermol® Dermol® 500 lotion Dermol® 200

shower emollient

Dermol® 600 bath emollient

Apply liberally Up to 30 ml/bath (adults only) Up to 15 ml/bath (infants) – soak in bath for 10-20 minutes

To skin Add to bath

Apply frequently

Clinical condition/indication for use Dry and pruritic disorders of the skin including eczema and dermatitis Dermol®, Dermol® 500 lotion, and Dermol® 200 shower emollient

preparations may be used as a soap substitute, however, Dermol® 600 bath emollient must not be used undiluted.

Side effects: Rare but may cause sensitisation – this should be suspected if an eczematous reaction occurs





Fire hazard with paraffin-based emollients

As the Dermol® range contains liquid paraffin consideration of the risk of fire should be given when large quantities are used.


16

Iodine Preparations


Administration

Betadine® - dry powder spray (Providone iodine 2.5% w/w)

Topical Once a day

Clinical condition/indication for use Skin disinfection – minor wounds and infections

Side effects: Sensitivity is rare; may interfere with thyroid function tests

Patients eligible for inclusion in the protocol Adult patients with small minor wounds including, ulcers, burns and other minor injuries

Patients excluded from treatment under the protocol Children Pregnant Breastfeeding Large wounds Severe burns Patients with thyroid disorders Patients receiving lithium therapy Renal impairment


Notes Shake can well before use. Spray from a distance of 15cm-25cm to deposit a dusting of powder on the required area.

N.B. not for use in serous cavities

17

References

Actavis UK Ltd (2014) Paracetamol Summary of product Characteristics https://www.medicines.org.uk/emc/medicine/24178 (last accessed 25.11.14)

Ayrton Saunders Ltd. (2006) Summary of Product Characteristics, Betadine Dry Powder Spray, http://www.mhra.gov.uk/Safetyinformation/Medicinesinformation/SPCandPILs (last accessed 25.11.14)

British Medical Association (2012) British National Formulary BNF 58, BMJ Group and RPS Publishing, London

Farco-Pharma GmbH (2014) Instillagel Summary of Product Characteristics, http://www.mhra.gov.uk/home/groups/spcpil/documents/spcpil/con1408342123099.pdf (last accessed 25.11.14)

McNeil Healthcare (Ireland) Ltd (2008) Microlax Summary of Product Characteristics http://www.medicines.ie/medicine/3842/SPC/Microlax/

Nursing and Midwifery Council, (2007) Standards for Medicines Management, Nursing and Midwifery Council, London

Nursing and Midwifery Council, (2008) The code: Standards of conduct, performance and ethics for nurses and midwives, Nursing and Midwifery Council, London

Thornton and Ross Ltd (2014) Glycerin Suppositories BP 4g Adult Size Summary of Product Characteristics, http://www.medicines.org.uk/emc/medicine/24114 (last accessed 25.11.14)

Wyre Forest NHS Primary Care Trust (2005) Homely Remedies Policy for Wyre Forest Community Unit, Wyre Forest NHS Primary Care Trust

Bibliography

Hunt, J and Gemmill, K (date unknown) Homely Remedy Protocols: A solution to the supply and administration of non-prescription medicinal products and dietary supplements by nurses to research participants in non-nhs settings, Bournemouth University

Appendix 1 Named individuals who may supply or administer medicines under the Homely Remedy Policy and Protocols

Line Managers must maintain an accurate record of their staff eligible to administer medication under the Homely Remedy Policy and Protocols. When completed this document is to be held centrally by the Information Governance Officer.

Date of Policy/protocols: ..………………………………………………………………………..

Name of Team: …………………………………………………………………………………...

Declaration of Nurse

I have read the Homely Remedy Policy and Protocols document and agree to use it in accordance with the criteria described.

I am competent to supply &/or administer all the medicinal products that are relevant to my job role.

Declaration of Line Manager

I agree that the staff member is eligible to use the Homely Remedy Policy and Protocols.

Date Name of Nurse Signature of Nurse Name of Line

Manager Signature of

Line Manager

Appendix 1 Named individuals who may supply or administer medicines under the Homely Remedy Policy and Protocols - continued

Line Managers must maintain an accurate record of their staff eligible to administer medication under the Homely Remedy Policy and Protocols. When completed this document is to be held centrally by the Information Governance Officer.

Date Name of Nurse Signature of Nurse Name of Line

Manager Signature of

Line Manager

Appendix 2

Homely Remedy Policy and Protocols Audit

This audit will be undertaken in January using data from the previous year. The data as it stands on the 31st December of the previous year will be used.

All clinical teams/staff groups who are required to use the Homely Remedy Policy and Protocols will be included in the audit’s data collection process.

Standard statement: 100% of staff who are required to use the Homely Remedy Policy and Protocols will be signed up to it.

Name of Team/Staff Group: ……………………………………………………………………………

Name of Line Manager: …………………………………………………………………………………

Date of Audit: ……………………………………………………………………………………………..

Number of Staff on 31st December required to use the Homely Remedy Policy and Protocols

Number of these staff who are signed up to the current Homely Remedy Policy and Protocols

Results:

Of the ……………… staff required to use the Homely Remedy Policy and Protocols

…………….% have signed up it. This is compliant /partially compliant / non compliant with the

standard. Tick as appropriate

75% or below= non-compliant Red

76% - 84% = partially compliant Amber

85% and above = compliant Green

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