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General Medical Practice Doctor’s Bag Audit 2012 Public Health Wales General Medical Practice Doctor’s Bag Audit 2012 Quality improvement toolkit Author: Primary Care Quality and Information Service Date: 7th November 2012 Version: 3 Status: This is an updated version of the Emergency Bag Audit 2010 Review: 2014 Intended audience: Public (Internet) / NHS Wales (Intranet) / PHW (Intranet) Purpose 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 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 Author: Primary Care Quality and Information Service General Medical Practice Doctor’s Bag Audit Version: 3 Date November 2012 -1- Status: Final Intended Audience: Public (Internet)/ NHS (Intranet)/PHW (Intranet)/ PCQIS General Medical Practice Doctor’s Bag Audit 2012 Public Health Wales 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!” Author: Primary Care Quality and Information Service General Medical Practice Doctor’s Bag Audit Version: 3 Date November 2012 -2- Status: Final Intended Audience: Public (Internet)/ NHS (Intranet)/PHW (Intranet)/ PCQIS Public Health Wales General Medical Practice Doctor’s Bag Audit 2012 General Medical Practice Doctor’s Bag Audit 2012 Introduction 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. Author: Primary Care Quality and Information Service General Medical Practice Doctor’s Bag Audit Version: 3 Date November 2012 -3- Status: Final Intended Audience: Public (Internet)/ NHS (Intranet)/PHW (Intranet)/ PCQIS Public Health Wales General Medical Practice Doctor’s Bag Audit 2012 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 Author: Primary Care Quality and Information Service General Medical Practice Doctor’s Bag Audit Version: 3 Date November 2012 -4- Status: Final Intended Audience: Public (Internet)/ NHS (Intranet)/PHW (Intranet)/ PCQIS Public Health Wales General Medical Practice Doctor’s Bag Audit 2012 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. Author: Primary Care Quality and Information Service General Medical Practice Doctor’s Bag Audit Version: 3 Date November 2012 -5- Status: Final Intended Audience: Public (Internet)/ NHS (Intranet)/PHW (Intranet)/ PCQIS General Medical Practice Doctor’s Bag Audit 2012 Public Health Wales Drugs/equipment that may be appropriate in an urban location2,3,4,5,6,7 Analgesia Diamorphine powder Diclofenac injection Opiod overdose Naloxone injection Gastrointestinal Domperidone oral/suppositories Prochlorperazine oral/buccal Cyclizine oral/injection Asthma Salbutamol nebuliser solution Terbutaline MDI and (large volume) suggest compact spacer Ipratropium nebulizer solution Hydrocortisone (powder as sodium succinate for reconstitution with water for injection) Prednisolone oral Infection Benzylpenicillin Cefotaxime vial for reconstitution with water for injection Chloramphenicol vial for reconstitution with water for injection Diabetic Emergencies Glucose as oral gel (Hypostop) Dextrose tablets Glucagon injection Cardiac Emergencies Aspirin oral Glyceryl trinitrate spray/oral Adrenaline/Epinephrine Seizures Diazepam rectal administration Allergy/Anaphylaxis Adrenaline Author: Primary Care Quality and Information Service General Medical Practice Doctor’s Bag Audit Version: 3 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 & complete In date Reason for absence if appropriate Absent CDB DB CDB DB DB Rural/PCDB/DB DB DB DB DB DB DB DB DB DB DB DB DB DB CDB CDB CDB Date November 2012 -6- Status: Final Intended Audience: Public (Internet)/ NHS (Intranet)/PHW (Intranet)/ PCQIS General Medical Practice Doctor’s Bag Audit 2012 Public Health Wales 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 & complete Reason for absence if appropriate In date Absent Rural/DB Chlorphenamine injection Hydrocortisone (powder as sodium succinate for reconstitution) DB Psychiatric emergencies CDB Haloperidol oral/injection CDB Diazepam oral DB Procyclidine 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. PCDB Hyosine Butylbromide injection CDB Diamorphine injection PCDB Cyclizine injection PCDB Dexamethasone Methotrimeprazine/Levomepeomazine injection PCDB PCDB Midazolam injection Drug or other equipment that might be carried Nebuliser & nebules Author: Primary Care Quality and Information Service General Medical Practice Doctor’s Bag Audit Version: 3 Consider if carrying spacer and salbutamol MDI will make this superfluous? Date November 2012 -7- Status: Final Intended Audience: Public (Internet)/ NHS (Intranet)/PHW (Intranet)/ PCQIS General Medical Practice Doctor’s Bag Audit 2012 Public Health Wales Drugs/equipment that may be appropriate in a rural location2,3,4,5,6,7 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 & complete In date Reason for absence if appropriate Absent Emergency bag with resuscitation equipment/oxygen Sodium chloride infusion (0.9% 500mL) Giving set & Venflons (butterfly for paeds) Codeine oral Small supply cocodamol Paracetamol oral Small supply paed suspension possibly DB Ibuprofen oral DB Antacid DB Anti-spasmodic agent (hyoscine butylbromide) oral DB Loperamide DB Dexamethasone 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 Author: Primary Care Quality and Information Service General Medical Practice Doctor’s Bag Audit Version: 3 Date November 2012 -8- Status: Final Intended Audience: Public (Internet)/ NHS (Intranet)/PHW (Intranet)/ PCQIS General Medical Practice Doctor’s Bag Audit 2012 Public Health Wales Upkeep of the bag Date Complied with Not complied with Reason for non 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. Author: Primary Care Quality and Information Service General Medical Practice Doctor’s Bag Audit Version: 3 Date November 2012 -9- Status: Final Intended Audience: Public (Internet)/ NHS (Intranet)/PHW (Intranet)/ PCQIS General Medical Practice Doctor’s Bag Audit 2012 Public Health Wales Other equipment to be carried Present Absent Date if appropriate Reason for absence Identification Mobile phone & charger Personal Alarm Headed note paper – to cover case record, communication/referrals etc. Temporary Resident Claim Forms Phone numbers A-Z Street Maps BNF or equivalent Investigation forms Prescription forms Universal container Examination gloves K – Y jelly Stethoscope Sphygmomanometer (with date tested) Airways (adult and child) and Laerdal pocket mask Tongue depressor Aerochamber (infant, child, adult)4,5 Ophthalmoscope Auriscope/speculae Urine dip-stick Thermometer Tape measure Torch Syringes and needles Tourniquet Sharps Box Peak flow meter Alcohol sterets Scissors Alcohol hand gel Disposal bags Simple dressings Envelopes for dispensing oral medication Water for injection Glucometer & Blood glucose testing sticks Pulse oximeter Micropore tape Author: Primary Care Quality and Information Service General Medical Practice Doctor’s Bag Audit Version: 3 Date November 2012 - 10 - Status: Final Intended Audience: Public (Internet)/ NHS (Intranet)/PHW (Intranet)/ PCQIS General Medical Practice Doctor’s Bag Audit 2012 Public Health Wales 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? Author: Primary Care Quality and Information Service General Medical Practice Doctor’s Bag Audit Version: 3 Date November 2012 - 11 - Status: Final Intended Audience: Public (Internet)/ NHS (Intranet)/PHW (Intranet)/ PCQIS General Medical Practice Doctor’s Bag Audit 2012 Public Health Wales 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 ______________________________________ Author: Primary Care Quality and Information Service General Medical Practice Doctor’s Bag Audit Version: 3 Date November 2012 - 12 - Status: Final Intended Audience: Public (Internet)/ NHS (Intranet)/PHW (Intranet)/ PCQIS General Medical Practice Doctor’s Bag Audit 2012 Public Health Wales 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. accessed August 2012. http://www.ppa.org.uk/edt/August_2012/mindex.htm 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. . Author: Primary Care Quality and Information Service General Medical Practice Doctor’s Bag Audit Version: 3 Date November 2012 - 13 - Status: Final Intended Audience: Public (Internet)/ NHS (Intranet)/PHW (Intranet)/ PCQIS General Medical Practice Doctor’s Bag Audit 2012 Public Health Wales 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, . 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 If No, please comment ___________________________________________________________ 3) Did you find the Part 2 Practice Review template helpful? YES NO If No, please comment ___________________________________________________________ 4) Did you find Part 3 the learning outcomes/reflection template helpful? YES NO If No, please comment ___________________________________________________________ 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] Author: Primary Care Quality and Information Service General Medical Practice Doctor’s Bag Audit Version: 3 Date November 2012 - 14 - Status: Final Intended Audience: Public (Internet)/ NHS (Intranet)/PHW (Intranet)/ PCQIS
