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Standard Operating Procedure:

Delivering Bulk Prescribing of Paracetamol in Care Homes, April 2020

For use during the current Covid-19 pandemic only

This standard operating procedure (SOP) covers the process for CCG pharmacists, pharmacy technicians, GP Practice/PCN Pharmacists, GP prescription clerks (under the supervision of a pharmacist or GP) in East and North Hertfordshire CCG to implement bulk prescribing in care homes. The overall aims of this SOP are to:

• Provide timely access to provision of paracetamol (for relief of pain and fever) in light of the current COVID-19 pandemic.

• To streamline current process for care homes to obtain paracetamol and minimise GP time.

• To maximise the use of currently available stocks of paracetamol.

It is important that the practice and the care home are involved in the initial discussion about setting up bulk prescribing for paracetamol. The practice should be asked for permission to carry out the work on their behalf. The bulk prescription will also need to be signed by the prescriber.

What is a bulk prescription?

A bulk prescription is an order for two or more patients; bearing the name of a school or institution e.g. a

care home, in which at least twenty persons normally reside, and the practice is responsible for at least 10 of

those patients.

A bulk prescription allows care home staff to use the same supply of a medication for all residents who are

clinically identified as suitable for the prescribed medication.

Inclusion and exclusion criteria:

Inclusions:

At least 20 residents residing in the care home

At least 10 residents to be under the care of a single GP practice

All residents currently prescribed ‘when required’ (PRN) paracetamol

All residents currently eligible to receive PRN paracetamol as homely remedy

Exclusions:

All residents currently prescribed regular paracetamol or paracetamol-containing products (e.g. co-codamol,

co-dydramol, tramacet, etc.)

Any resident with an allergy/hypersensitivity to paracetamol

Any residents taking warfarin

Cautions:

Residents taking warfarin – discuss with GP or practice pharmacist

If unsure refer to BNF

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Process (GP Practice):

1. Run a search on the practice system to identify care home residents.

This could be by using the care home name/residential code or postcode

2. For CCG Pharmacists - where required utilise the in-practice pharmacist (IPP) SOPs for SystmOne and Emis Web

access.

3. Complete a data collection form (see Appendix 1) manually/electronically and use the medical records to

document the following:

Patient identifier

Allergies checked to paracetamol/paracetamol-containing products

If paracetamol is already prescribed as PRN or regular medication

Exclusions (see above)

Contraindications/cautions

4. Identify patients who require exclusion and those considered suitable for bulk prescribing of paracetamol. If a

patient is excluded, add a consultation note listing reasons why they are unsuitable.

5. Identify patients who can be initiated on bulk prescribing.

6. If PRN paracetamol is NOT already on the repeat template, add to repeat template with quantity of 1. Include

‘Bulk Prescription’ on the directions

Choose appropriate dosage form e.g. 500mg tablets/ 250mg in 5ml suspension (use judgement

depending on other repeat templates).

7. Suggested directions:

Paracetamol 500mg tablets: 1 or 2 to be taken up to four times a day WHEN REQUIRED.

Paracetamol 250mg/5ml suspension: 10ml to 20ml to be taken up to four times a day WHEN REQUIRED.

8. Ensure appropriate documentation is recorded in the resident’s notes/journal: ‘resident suitable for bulk

prescribing paracetamol’.

9. Write and issue a bulk prescription in the name of the care home, using the ‘care home’ patient record. A

prescriber must sign the prescription. Refer to Appendix 2 on how to set up bulk prescribing.

NB: a maximum of 96 tablets can be prescribed on a prescription. For quantities greater than 96, multiple

prescriptions need to be written.

10. Send to the care homes’ usual pharmacy for dispensing.

References:

1. PrescQIPP Bulletin 66: Care Homes – Bulk Prescribing, May 2014 2. NHS Herts Valleys CCG: Guidance on Bulk Prescribing for Care Home Residents V2, February 2018 3. NHS Herts Valleys CCG: When Required’ Medication (PRN) Good Practice Guidance for Care Homes V1, February 2020

Version 1.0

Developed by Care Home Pharmacy Team, Pharmacy and Medicines Optimisation Team, ENHCCG

Date Published Reviewed remotely by Primary Care Medicines Management Group (PCMMG) membership, ENHCCG; April 2020 To be ratified at next opportunity

Review date October 2020

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Appendix 1 – data collection form

Care Home____________________________

Form completed by_________________________ Date_______________

Date bulk prescribing set up__________________

Patient ID Allergies Checked

Prescribed Paracetamol?

Exclusion Criteria? Suitable for bulk prescribing? Y/N

PRN Regular

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Appendix 2 – Setting Up Bulk Prescribing

A bulk prescription can be written or printed on an ordinary FP10 prescription.

It is not possible to transmit bulk prescriptions electronically

No prescription charge is payable when a bulk prescription is dispensed If bulk prescriptions are handwritten there must be an alternative method of recording. A record of the bulk prescription must be logged at the practice either via:

entry on the care home’s ‘inactive patient’ record

entering details onto each resident’s computer record Ensure the order form is retained by the practice for audit purposes e.g. practice may choose to scan this order into the care home record. A new prescription must be generated for the individual service user if there is any change to the dose of the bulk prescribed medication. Subsequent prescriptions can be requested on bulk prescription.

The bulk prescription must include:

The wording “for patients under my care at {the name of the care home}” (instead of the individual

name of the patient)

The date

The words ‘bulk prescription’ – to identify the type of prescription

The medicine that is being bulk prescribed

The total quantity required for all service users on this medication

The directions may state - “to be given in accordance with GP instruction on the MAR chart”. Due to

variation in doses for each patient, the patients MAR chart will need to provide the dose to be

administered.

For patients under my care at ‘xxxx care

home’

Add ‘Bulk Prescription’

Add Directions e.g. 96 Paracetamol 500mg

tablets; to be given in accordance with GP

instruction on MAR chart

Add GP signature AND date

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Bulk Prescribing on SystmOne – how to guide

1) Register an inactive patient

Register the care home as an inactive/test patient. This is so the care home name will show on the prescription (see

guidance).

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2) Prescribe for each individual resident

The medication must be prescribed initially for the individual resident. This will ensure the medication and specific

directions appear on the resident’s subsequent MAR charts, and evidences that the resident has been clinically

assessed for the medication. Subsequent prescriptions for the medication can then be requested by the care home

as a bulk order. Quantity to be added as ‘one’ tablet or ‘10ml’ solution. See process above (no 6)

Before generating a bulk prescription, an entry must be made on the patient’s repeat screen to ensure there is a record of bulk prescribing. On the selected medication, include the words ‘bulk prescription’ to the dosage instructions to identify the medication which is to be supplied as part of a bulk prescription (e.g. Paracetamol 1-2 tablets FOUR times a day when required- bulk prescription). Add ‘on bulk prescribing system’ to the script notes.

Untick patient can initiate issues. Tick irregularly issued template and repeat template can be reauthorized.

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Read code as ‘Other medication management (XaJr2)’. Include the words ‘bulk prescription’ in the notes section. It will then be possible for the practice to run a report for all patients on this system. 3) Bulk Prescribe

To issue a bulk prescription, access the ‘care home’ record. On the selected medication, include ‘as directed on MAR chart’ in the dosage instructions.

Untick ‘patient can initiate issues’ and tick ‘irregularly issued template’.

The ‘care home’ record should be used to issue all bulk prescriptions for that care home. This will ensure a chronological record of items issued.

Any bulk prescribing order forms sent by the care home should be retained by the practice for audit purposes e.g. scanning into the care home record.