1. “Just in Case” Boxes Hywel Dda Local Health Board August 2012
Elizabeth Lewis Lead Palliative Care Pharmacist
Dr Ray Majer Palliative Care Consultant
Hywel Dda Local Health Board
August 2012

2. The Just in Case Box Scheme
JIC Box scheme has been launched across Wales to improve access to end of life medication
Ensures health professionals can respond rapidly to worsening symptoms and avoid unnecessary suffering
Aims to avoid inappropriate hospital admissions

3. What is a JIC Box?
Orange plastic box containing end of life drugs, symptom control guidelines, a patient information leaflet and an administration sheet for audit purposes
The box is sealed when supplied by the pharmacy and re-sealed after use, before returning to the pharmacy. Both seal numbers are recorded for security purposes
Prescribed for patients whose death is expected within a period of less than six months

4. Supplied by pharmacists participating in the scheme
Pharmacist dispenses JIC box within 48 hours of receiving prescription – not for emergency supply
JIC Box kept in patients home until needed
The box has a minimum expiry date of six months
Once the JIC box is used the re-sealed box is returned to issuing pharmacy where the use of the medication is matched to the administration sheet

5. Hywel Dda Health Board
Just in case box scheme launched on 11th December 2011
Training delivered to community pharmacists, GPs, DN & ART teams and palliative care CNSs across Health Board both before and after launch
Up-date letters sent to GP practices and community pharmacies at regular intervals
Participating pharmacies visited when signed up to scheme and given on-site training

6. Population Data
Hywel Dda has a population of 372,100 – 13% of Welsh total
Carmarthenshire 183,800 (49%)
Pembrokeshire 122,400 (32%)
Ceredigion 75,900 (20%)
Covers a quarter of land mass of Wales – 2nd most sparsely populated Health Board
Has a dramatically increasing elderly population (>65 expected to increase by 50% by 2026)
55 GP practices
99 Community Pharmacies -66 participating in JIC box scheme

7. What do we want to know? Is the scheme effective?
How many boxes are being prescribed?
Are boxes prescribed for suitable patients ?
Are the boxes prescribed in a timely manner?
Do the boxes contain the right drugs & quantities?
Is there an effective audit trail?
Are we preventing admissions ?
Are there any problems?

8. Methodology
Data collected from returned claim forms for payment from community pharmacies for claims made in the first six months of the scheme
Feedback from comments from Community Pharmacists (CPs) on claim form
Unstructured interviews with Acute Response Team (ART)
Data from NHS Wales Shared Services Partnership

9. Sample 88 JIC boxes issued in first 6 months
since launch of scheme December 2011
69 claims made by community pharmacists for boxes returned (used & unused)

10. Hywel Dda Just in Case Box Pharmacy Claim & Audit Form
Box No.
Date of issue
Date of return
Reason for return (A,B,C or D)
Box sealed? Y / N
Admin sheet completed? Y / N
Did contents match Admin Sheet? Y/ N
No. of 10mg Diamorphine amps used
No. of 30mg Diamorphine amps used
No. of Hyoscine amps used
No. of Cyclizine amps used
No. of Midazolam amps used
Reason for return:
A – Contents used (replacement issued)
B – Contents used (further box not required)
C – Contents not used (no longer required)
D – Contents expired
Comments:

11. JIC Boxes Issued
In the first 6 months of the scheme a total of 88 boxes were issued with a return of 69 (78%)
Boxes are returned when used or out of date (at least six month expiry from issue)
Some boxes will now be out of date & have not yet been returned

12. JIC Box with Patient (Length of time in days)
Number of boxes 15 14 13 12 9 6
Days
N=69

13. Outcome
Compared first and second quarters to see if any difference after:-
Further training
Increased awareness
Experience of using the scheme

14. JIC Box with Patient Comparison of quarters (Length of time in days)
Number of boxes 9 7 10 8 4 7 5 4 4 5 3 3
Days
N=69

15. Reason For Return of JIC Box1 33 35
N=69

16. Reason for Return of JIC Box Comparison of quarters15 23 12 18 1
N=69

17. JIC box sealed when returned to pharmacy19 29 13 8
N=69

18. Administration sheet
Document to record the use of each of the medications in the box and provide an audit trail for the controlled drugs (NB this is in addition to recording administration on a drug chart)
To be completed each time a drug is administered by a doctor or nurse
To be returned with the box to the pharmacy where matched to the remaining contents
Discrepancies should be investigated

19. The Administration Sheet
The administration sheet is supplied with the box along with a drug chart
It is for audit purposes and must be returned to the pharmacy
Details will have been completed by the pharmacy before supply

20. Results Administration Sheet Completed15 11 8
Leah to determine the number of cases who died within 40 hours from 36 in 1-15 days column. Awaiting pt details of Lizzie. 1 1

21. Results Contents Match Administration Sheet14 10 9
Leah to determine the number of cases who died within 40 hours from 36 in 1-15 days column. Awaiting pt details of Lizzie. 2 1

22. What’s in the JIC box? Diamorphine 10mg x2 Diamorphine 30mg x2
Midazolam 10mg in 2ml x4
Cyclizine 50mg x3
Hyoscine HBr 400micrograms x4
Water for Injection 10ml x2

23. Results Diamorphine Amps Used (10mg)42
Leah to determine the number of cases who died within 40 hours from 36 in 1-15 days column. Awaiting pt details of Lizzie. 13 14
N=69

24. Results Diamorphine Amps Used (30mg)52
Leah to determine the number of cases who died within 40 hours from 36 in 1-15 days column. Awaiting pt details of Lizzie. 8 9
N=69

25. Results Hyoscine amps used49
Leah to determine the number of cases who died within 40 hours from 36 in 1-15 days column. Awaiting pt details of Lizzie. 4 4 4 8
N=69

26. Results Cyclizine Amps Used44 16
Leah to determine the number of cases who died within 40 hours from 36 in 1-15 days column. Awaiting pt details of Lizzie. 7 2
N=69

27. Results Midazolam amps Used51
Leah to determine the number of cases who died within 40 hours from 36 in 1-15 days column. Awaiting pt details of Lizzie. 6 7 4
N=69

28. Results Use of drug
Leah to determine the number of cases who died within 40 hours from 36 in 1-15 days column. Awaiting pt details of Lizzie.
N=69

29. Summary 1st Quarter 2nd Quarter Total Boxes Issued 52 36 88
Dec 11- Feb 12
2nd Quarter
March 12- May 12
Total
Boxes Issued 52 36 88
Boxes Returned
42 (81%)
27 (75%)
69 (78%)
Contents used
24 (57%)
12 (44%)
36 (52%)
Admin sheets returned
15 (63%)
+ 1 (4% ) - partially
11 (92%)
26 (72%)
1 (4%)
Not matched
14 (58%)
10 (83%)
24 (67%)

30. Who is prescribing JIC boxes?
22 GP practices out of 55 have prescribed a JIC box
In the prescribing practices:-
Range 1 to 8 boxes per practice
Average of 3 boxes per practice

31. Who is prescribing JIC boxes?
County
Number of Boxes
Number of Surgeries
Range
Average
Carmarthenshire 61
13/24
1-7 5
Ceredigion 21
6/16
1-8 3
Pembrokeshire 6
2/15 2

32. How many patients with JIC boxes in the home were admitted to hospital?
Cross referenced with
Myrddin Hospital System
Health Board Mortality Database
As at 14th September 2012
5 patients still alive
JIC boxes issued from 11/04/12 – 18/06/2012
Leah to determine the number of cases who died within 40 hours from 36 in 1-15 days column. Awaiting pt details of Lizzie.
N=69

33. 5 out of 69 patients were admitted to hospital
How many patients with JIC boxes in the home were admitted to hospital?
All deaths in hospital are reviewed by Hospital Director of Clinical Care as part of the weekly mortality audit
5 out of 69 patients were admitted to hospital
Possibly 3 of the 5 patients could have remained at home

34. Weekly Mortality Audit
Hywel Dda Mortality Review database
Concern
Comments
LENGTH OF STAY
Date JIC box issued
Date of Death 1
(NJ)
Moderate
Patient has significant hypercalcaemia that is inadequately and inappropriately treated.
died same day of admission
16/12/2011
18/02/2012 2
(JC)
No concerns
Should have had palliative care at home
27/01/2012
14/02/2012 3
(ML)
Died in Ty Bryngwyn – admitted because of family concerns about terminal haemorrhage
2 days
04/02/2012
11/02/2012 4
(RJ)
Demonstrates the lack of end-of-life care planning
1 day
14/03/2012
16/03/2012 5
(GP)
DNAR order put in-place
8 days
16/04/2012
24/05/2012

35. Feedback from Community Pharmacists
District nurses not familiar with the All Wales Medication Administration Record
2 boxes issued in lead up to Christmas. Inappropriate use of boxes and they were returned within a day or two. Also District nurse waited at the pharmacy for the box to be made up
Contents of a returned box did not match the Admin Sheet – GP contacted. Unrecorded drugs were administered by an Out of Hours GP
One box returned via district nurse – Admin Sheet missing – could not recover
Boxes tend to be issued too late – relatives turn up at closing time wanting pack urgently. Not enough to last until Monday morning if started on Friday night. GPs in this area usually use hyoscine 600mcg and not the 400mcg in the pack
System does not seem to work well in completing the circle of drug usage
Prescription written incorrectly – referred back to practice. Second attempt also written incorrectly even though details were faxed to practice.

36. Feedback from Community Pharmacists cont.
Box returned with contents not matching Admin Sheet. All Wales Medication Chart blank but amps of Diamorphine, Hyoscine and Cyclizine missing from box
Pharmacist received prescription but no Notification Form – not apparent that it was for a JIC box as strengths listed were not as per the scheme. Patient expected box to be done in 5 mins – as advised by GP and District Nurse. Pharmacist referred matter to GP practice who insisted that JIC box was need and if Boots couldn’t provide in 5 mins – there was another pharmacy that could
System works well, GPs need further info. Fee is not enough to cover the work involved
Admin sheet not being returned in some instances. GPs & Nurses unsure of how JIC works properly
Had to supply JIC box to a patient in New Quay as local pharmacy not participating in service – long distance for Boots to deliver. Not enough PILs supplied with meds to put into box. Having PDFs of the PILs would be useful.

37. Feedback from Acute Response Team (ART)
‘ART - first point of contact out of hours before OOHs GPs – very frustrating if no meds prescribed’
‘Often attend patient with JIC box but no medication written on chart then have to ring OOHs GP and wait for up to an hour for them to arrive to write up drugs- distressing for patients & carers, ‘soul destroying for ART nurses’
‘GPs reluctant to write up PRN medication’
‘ART prompt DNs to ask for drugs to be prescribed but they need to flag up patients when they start to deteriorate and are needing frequent calls’
‘Not sure when to re-seal box’

38. Feedback from Acute Response Team (ART)
‘When executed properly it is an amazing scheme which has helped lots of patients’
‘Could set up syringe driver there and then’
‘Recommend there is more liaison during working hours DN should prompt GP to prescribe drugs’
‘Not enough water for injection in the box’

39. Conclusions
JIC boxes need to be issued earlier in the patients’ journey
13/69 boxes issued in last 3 days of life
22/69 boxes issued in last 7 days of life
Security of JIC scheme compromised by failure to complete & return administration sheet and to re-seal the box after use
More advance planning needed for GPs to prescribe the medication on the drug chart prior to the patient requiring the drugs

40. What did we want to know?
Is the scheme effective? Are we preventing admissions ?
5/69 patients admitted to hospital.
‘When executed properly it is an amazing scheme which has helped lots of patients’
How many boxes are being prescribed?
88 boxes in first 6 months –anticipated 200 per annum from Powys model
Are boxes prescribed for suitable patients ?
Don’t know
Are the boxes prescribed in a timely manner?
The boxes need to be prescribed earlier
Do the boxes contain the right drugs & quantities?
Yes
? More water for injection
Is there an effective audit trail?
Yes but not adhered to

41. Discussion Currently less than 50% of surgeries participating
Advance prescribing is an issue
Audit trail often not completed. Administration sheet not completed and/or not returned
Security seals not always used
All Wales electronic system for claims and audit not yet developed (relying on paper records and no flagging up of out of date boxes)
Electronic system for prescribing being developed locally to solve CD prescribing issues
Introduce PDF versions of PILs

42. Electronic prescribing
GP prescribing template for the JIC box developed in Hywel Dda on a local basis for Vision and is being developed for EMIS
Should there be an All Wales approach?

43. Thank You