patient group direction

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Loraine Ellis
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1 SALBUTAMOL v01 1/12 SALBUTAMOL PGD Details Version 1.0 Legal category Staff grades Approved by POM Paramedic (Non-ECP) Nurse (Non-ECP) Emergency Care Practitioner (Paramedic) Emergency Care Practitioner (Nurse) Medicines Management Group Date issued 01/02/2013 Review date 30/01/2015 Clinical Publication Category Mandatory (RED)- No deviation from document permissible Clinical Requirements Competencies Continuing education Successful completion of a competency assessment in the use of this medicine for the indications stated; Completion of education in both the legal and professional aspects of PGD administration and the supply of medicines; Registered paramedics must have successfully completed a recognised Emergency Care Practitioner course; Registered nurses must be employed as Nurse Practitioners or have successfully completed a recognised Emergency Care Practitioner course. The clinician is responsible for keeping him/herself aware of any changes to the recommendations for the medicine listed. It is the responsibility of the individual to keep up-to-date with continued professional development and to work within the limitations of their own individual scope of practice.

2 SALBUTAMOL v01 2/12 Clinical Situation Clinical situation Inclusion criteria The immediate relief of acute asthma symptoms. Patients with acute asthma must be given oral prednisolone (see prednisolone PGD) but routine use of antibiotics is not indicated for acute asthma. Adults and children aged 2 years and over; Patients with mild to moderate asthma. Moderate asthma defined as: Moderate asthma; Increasing symptoms; PEF > 50-75% best or predicted; No features of acute severe asthma.

3 SALBUTAMOL v01 3/12 Known hypersensitivity to salbutamol or any other excipient; Children under 2 years; Patients requesting an emergency supply of medication when local community pharmacy services are available, and there are no access issues with the patient attending the pharmacy; Patients with acute severe asthma or life threatening asthma defined as: Exclusion criteria Acute severe asthma Any one of following symptoms present: PEF 33-50% best or predicted; Respiratory rate 25/min (adults), > 30/min (children 5-7 yrs), > 40/min (children aged 2-5 yrs); Heart rate 110/min (adults), >125 (children > 5 to 12yrs), >140/min (children aged 2-5 yrs); Inability to complete sentences in one breath (too breathless to talk children); Patients with life threatening asthma. Life threatening asthma (any one of the following); Altered conscious level; Exhaustion; Arrhythmia; Hypotension; Cyanosis; Silent chest; Poor respiratory effort; PEF < 33% best or predicted; SpO 2 < 92%; PaO 2 < 8kPa.

4 SALBUTAMOL v01 4/12 Cautions Hyperthyroidism; Cardiovascular disease (sympathomimetic rare instances of myocardial ischaemia associated with salbutamol use); Arrhythmias; Susceptibility to QT-interval prolongation; Diabetes (monitor blood glucose); Risk of hypokalaemia particularly in more severe asthma when given concomittantly with theophylline and its derivatives, corticosteroids, diuretics and by hypoxia; Pregnancy; Breast feeding. NB: Requests for emergency supply Salbutamol can be used to excess and some patients seek extra supplies from out of hours services. Salbutamol inhalers are also used as a vehicle to deliver drugs of abuse. The patient s GP needs to be aware that their asthma is not adequately controlled. Patients may use false names, addresses etc. Where the facility exists, practitioners should check Adastra (using the patient s D.O.B.) to ensure that there are no special messages which indicate that the patient has requested salbutamol frequently from any available local clinical system. Alternatively, ask the patient to produce a prescription as evidence that they are prescribed salbutamol.

5 SALBUTAMOL v01 5/12 Side effects Action if excluded Action if patient declines Fine tremor (particularly in hands); Nervous tension; Headache; Muscle cramps; Palpitation; Tachycardia; Arrhythmia; Peripheral vasodilation; Myocardial ischaemia; Disturbances of sleep or behaviour; Paradoxical bronchospasm (occasionally severe), urticaria, angioedema, hypotension and collapse have also been reported; High doses are associated with hypokalaemia. If patient meets exclusion criteria, explain reason to patient/carer and record reason. See also referral criteria; Use nebulised salbutamol driven by oxygen when symptoms severe or life threatening and refer to hospital; Patients seeking an emergency supply of their regular medication who are not demonstrating any clinical symptoms should be referred to a community pharmacist who may be able to make an emergency supply (note the patient should be advised that they will be required to pay for their inhaler); Refer to a medical practitioner; Document reasons for exclusion and any action taken in patient clinical record. If patient declines treatment or advice, ensure the patient clinical record details: The advice given by the clinician; Details of any referral made; The intended actions of the patient (including parent or guardian).

6 SALBUTAMOL v01 6/12 Description of Treatment Generic name Presentation Route Salbutamol. CFC-free inhaler, 100mcg per inhalation. Inhalation (via spacer) Children aged < 3 yrs are likely to require a face mask). Method Administration Supply Dose Frequency Duration of treatment Quantity to supply Adults via spacer: Four puffs initially and a further two puffs every two minutes according to response up to a maximum of 10 puffs. If the response to initial treatment is good (symptoms improve, respiration and pulse settling and PEF> 50%) continue or step up to usual treatment and prednisolone; Children over 2 yrs via spacer with or without facemask: Two puffs followed by a further two puffs every two minutes according to response up to a maximum of 10 puffs. If the response to initial treatment is good (symptoms improve, respiration and pulse settling and PEF> 50%), the patient may continue to use the inhaler as needed but not more frequently than four hourly. See dose. Until relief obtained or patient admitted. One inhaler; Ensure that each pack of medicine supplied is labelled with the patient s name, the date and the Trust s contact details.

7 SALBUTAMOL v01 7/12 Follow Up Referral arrangements and safety netting Admit to hospital; If poor response; If any life threatening features; Features of acute severe asthma present after initial treatment; There is a history of previous near fatal asthma. Lower the threshold for admission if: Afternoon or evening attack; Recent nocturnal symptoms or hospital admission; Previous severe attacks; Adult patients are unable to assess own condition or there are concerns about the family s ability to cope at home (children); Concern over social circumstances. If left, patients should be told to seek further medical advice if there is a deterioration in their condition; Patients without their own agreed written action plan and peak flow meter should be referred to their GP; Ensure that there is a communication to the patient s registered GP to inform him/her about the consultation, the outcomes of that consultation and any treatment given using local mechanisms. This information must also be available to other healthcare professionals who may be required to administer care to the patient following the consultation.

8 SALBUTAMOL v01 8/12 Advice to patients Records References Protect canister from frost and direct sunlight; Do not exceed the advised dose; Patients will need to have their inhaler technique checked or be shown how to use the inhaler (and aerochamber if supplied). The manufacturer s diagrams directing correct use should be pointed out to the patient; If a previously dose of inhaled salbutamol fails to provide at least 3 hours of relief, a doctor s advice should be obtained as soon as possible. N.B. As with most inhaled medication in aerosol containers the therapeutic effect may decrease when the canister is cold; Patients with asthma should have an agreed written action plan and their own peak flow meter. They should have their inhaler technique and compliance checked regularly by their GP or practice nurse. Action plans can decrease hospitalisation for, and deaths from asthma. Check that the patient has one; The canister should not be broken, burnt or punctured even when apparently empty; Replace the mouthpiece cover firmly after use. Complete patient clinical record. British National Formulary (BNF) 64, September 2012; Electronic Medicines Compendium uk accessed ; British Guideline for the Management of Asthma accessed at sign101.pdf.

9 SALBUTAMOL v01 9/12 Authorisation Chief Executive Officer Medical Director Pharmaceutical Advisor Name Ken Wenman Signature Date 01/02/2013 Name Dr Andy Smith Signature Date 01/02/2013 Name Sue Oakley Signature Date 01/02/2013 This must be signed by the Chief Executive Officer, Medical Director and Pharmaceutical Advisor to be legally valid.

10 SALBUTAMOL v01 10/12 Individual Authorisation (Staff Copy) Individual Name Signature Date / / Authorising officer Name Signature Date / / I have read and understood the Patient Group Direction and agree to supply this medicine only in accordance with this document. PGDs do not remove inherent professional obligations or accountability. It is the responsibility of each professional to practice only within the bounds of their own competence and in accordance with their own Code of Professional Conduct. This signed page must be retained by the member of staff, together with the full PGD, which must be available in clinical practice.

11 SALBUTAMOL v01 11/12 Individual Authorisation (Trust Copy) Individual Name Signature Date / / Authorising officer Name Signature Date / / I have read and understood the Patient Group Direction and agree to supply this medicine only in accordance with this document. PGDs do not remove inherent professional obligations or accountability. It is the responsibility of each professional to practice only within the bounds of their own competence and in accordance with their own Code of Professional Conduct. This signed page must be retained by the member of staff, together with the full PGD, which must be available in clinical practice.

patient group direction

patient group direction NAPROXEN v01 1/10 NAPROXEN PGD Details Version 1.0 Legal category Staff grades Approved by POM Paramedic (Non-ECP) Nurse (Non-ECP) Emergency Care Practitioner (Paramedic) Emergency Care Practitioner (Nurse)