SELF-ADMINISTRATION OF MEDICINES PROGRAMME WITHIN THE TRANSPLANT UNIT, ROYAL INFIRMARY OF EDINBURGH
Rationale
Within the Transplant Unit part of the nursing philosophy is the promotion of independence by allowing patients to participate in the planning of their own care and thereby make informed choices. Many of the patients have suffered chronic liver or renal disease for a number of years, and have adopted the sick role.
Following transplantation patients will have to take anti-rejection drugs for life and it is imperative that they have a full understanding of their drug therapy. The procedure whereby nurses administering drugs to patients whilst they are in hospital promotes dependence on nursing staff and encourages patients to remain in the sick role. It was not felt that these patients were appropriately prepared for discharge into the community. In conjunction with the Clinical Pharmacist, it was decided to investigate the possibility of a self-administration of medication programme (self-medication) within the Transplant Unit was established in 1994.
The self-medication programme is restricted to post transplant patients including readmissions.
Procedure
These guidelines detail each step of the programme, flow charts are available for a quick reminder.
A) The concept of self-medication is briefly raised with the patients during the assessment for transplantation.
B) Post-transplant the patient is given the self-medication information leaflet when they move to the ward area, or are felt to be ready to commence the programme. The programme is explained fully to the patient and the following points are stressed:
- the programme is optional , nurse administration will continue if they decline to participate, although the patients are strongly recommended to participate.
- the key and medication will be the patient’s responsibility.
- Patient’s who have taken a previous overdose cannot proceed past stage three.
C) The patient is given the relevant drug information leaflets to support the information discussed by the nurses and pharmacist.
D) Having given the patient time to look at the information leaflets the patient’s informed consent should then be obtained. The self-medication consent form is signed by the patient and witnessed by the nurse/ pharmacist.
E) The assessment form is completed taking note of the exclusion criteria -
- Encephalopathy
- Confusion
- Continuous IV controlled drug therapy
Patients commence at stage III. Patient’s being readmitted may commence on stage II depending on their level of knowledge. No patient can commence the programme at stage I.
F) The documentation is filed in the yellow self-medication folder and stored at the foot of the patient’s bed.
G) The pharmacist is contacted to facilitate the ordering of medication from pharmacy.
H) The patient’s individualised medication guide will be prepared by the pharmacist. This details the medication action, strengths available, dose, frequency and any special instructions. Blank spaces will be left to allow new medication to be added. When full the pharmacist will produce a new printed chart. (This will happen routinely, they should not be bleeped to do this.)
I) The medication is counted into the patient’s personal locker by the nurse and witnessed by the patient, the number of tablets noted on the compliance chart in red.
Pre-printed compliance charts, with the protocol medication, and blank spaces for other drugs are available. Blank charts are also available.
J) The patient is shown how to use the kardex.
Points to note:
- The patient signs the kardex in red to indicate they are self-medicating. Nursing staff continue to sign in black.
- The kardex must be easy to read, therefore the doctors must print the drug name.
- The date of commencing each stage should be noted on the compliance chart.
K) Stages
Stage III
Commencing at 0800, the patient receives all the documentation and their own supply of medication.
When the medication is due the patient asks the nurse for the key.
The nurse observes the patient’s selection and administration technique providing as much support and guidance as the patient requires.
The patient continues on stage III for a minimum of 48 hours or until they can safely administer their medication and record it accurately.
Patients who have taken previous drug overdoses must remain on stage III throughout their admission.
Stage II
Commencing at 0800, the patient is given the key to their medication locker and reminded to keep it safe at all times.
The patient self-medicates.
A compliance check is carried out at 1400.
The number of tablets remaining should be recorded for each drug. Any discrepancies should be noted in the comments box.
The patient must remain on stage II for a minimum of 72 hours.
Note: Any errors at this check should be discussed with the patient but they need not go back to stage III.
Stage I
The patient self-medicates.
Compliance checks are carried out weekly.
No patient may commence the programme at stage I
L) It is important to stress to the medical staff the need to print the prescription clearly.
The pharmacist’s routinely check the prescriptions on a daily basis. However, the charts should be checked by the nursing staff after the ward rounds and at the weekend to ensure no changes have been made.
Medication should continue to be dispensed from the drug trolley if, at any time, the patients own supply is not available.
M) Prior to discharge the patient is given a Personal Medication Record Booklet.
This booklet is transcribed from the kardex by either a nurse or the pharmacist.
The dose is written as mg/mcg not number of tablets ( i.e. 75 mg not 50 mg one tab, 25 mg one tab)
The Tacrolimus/ Ciclosporin doses & blood levels are written in the centre of the book.
The patient is reminded to bring the “green book” to out-patient appointments and use it when visiting their GP and pharmacist.
N) Top-up/ Newly prescribed drugs
Order via one stop pharmacy
O) The tablets should be counted in to the locker and the number written in red on the compliance chart. New medication should be noted in the corresponding date column, as with the drug kardex.
P) On discharge the patient must have a 7 day supply of medication. A compliance check is carried out to assess the number of drugs the patient requires. The doctor completes an immediate discharge letter. Inform the pharmacist who will arrange the supply of the medication.
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