Case study:

11 May 2010

Just in Case Boxes in Solihull NHS Care Trust

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Key points

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Solihull NHS Care Trust is offering all patients who die at home access to anticipatory palliative medications through a ‘Just in Case’ box which can be kept close to the patient at all times.

A follow-up audit showed that the new scheme had led to improvements in prescribing anticipatory medications as well as easier access for patients.

There was evidence that patients were receiving community nursing support with administration of anticipatory medications for symptom control problems, both in hours and out of hours

There is also ongoing evidence from electronic Prescribing Analysis and Cost (ePACT) data for Solihull of a consistent increase in prescribing the recommended anticipatory medications for the dying phase.

The decision to introduce Just in Case boxes came after an audit in 2005 showed that while 68% of patients had anticipatory medications prescribed for the dying phase, most only had an analgesic and one other medication prescribed in advance.

A working group was set up to develop algorithms to support anticipatory prescribing in the dying phase. Once approved, laminated copies were given to all GPs, community nurses, out of hours providers and nursing care homes. A copy was also placed in the Just in Case boxes along with a patient/carer leaflet.

A protocol was developed which included a stock list and direction on how to use the boxes. The district nurse teams are responsible for stocking the boxes with syringes and needles, then placing the dispensed medications in the box in the patient’s home. Prescribing of palliative medications is reviewed quarterly through ePACT data.

The trust’s community nursing teams were initially given a total of 40 boxes but this has since been increased to 60 to support the larger community nursing teams and the community children’s team.

One potential challenge was finding enough room to store the boxes in the community nursing bases. For some teams this has been an issue but all teams have managed to create space to store the boxes not in use. All the boxes are stackable.

A follow up audit in December 2007 of 19 patients showed that anticipatory medications were written up for 89% of dying patients compared to 68% previously. Of the 17 who had anticipatory medications prescribed, 11 had them for symptom control problems that developed in the dying phase. Fifty three per cent had all four recommended anticipatory medications written up while 37% had three of the recommended anticipatory medications prescribed (see graph below).

Thirteen of this group of 17 actually had medication administered for symptom control problems. In most cases this was to resolve a symptom control problem before a syringe driver was set up.

An authorisation to administer subcutaneous palliative care medications document has now been developed and implemented to support GPs and non-medical prescribers with authorising the administration of anticipatory medications and community nurses with recording the administration.

All Care Trust palliative care training sessions now include information on the community care pathway and the Just in Case boxes. Information is also available on the Care Trust palliative care intranet site.

The use of the boxes will be audited again as part of the Community Supportive Care Pathway audit in 2009.

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