ࡱ> twqrs Objbj hhF,AWkkk$Pkzt7:q k " kk4((( kk( ((-{@#O4">ՁH J0z2%22kH ( &r z 2  :  PRIMARY CARE DEVELOPMENT 4.3.4 ENHANCED SERVICE SPECIFICATION FOR NEAR PATIENT TESTING SERVICE SERVICE OUTLINE 1.1 The treatment of several diseases within the fields of medicine, particularly in rheumatology, is increasingly reliant on drugs that, while clinically effective, need regular blood monitoring. This is due to the potentially serious side-effects that these drugs can occasionally cause. It has been shown that the incidence of side-effects can be reduced significantly if this monitoring is carried out in a well-organised way, close to the patients home. 1.2 Each different drug has different monitoring and safety requirements to ensure that the patient takes the medication safely and effectively. Please see Appendix1 to this specification for the individual drug monitoring requirements. Providers should be working to the shared care protocols of the secondary care provider. 2 SERVICE AIMS 2.1 The Near Patient Testing Service is designed to be one in which: therapy is only started for recognised indications and for specified lengths of time maintenance of patients is first stabilised in the secondary care setting and is properly controlled before discharge into this service the service to the patient is convenient the need for continuation of therapy is reviewed regularly the therapy is discontinued when appropriate, including discussing any reported side-effects with the relevant secondary care department (e.g. rheumatology) if necessary any necessary monitoring is undertaken as recommended by the secondary care consultant, and the use of resources by the National Health Service is efficient. 2.2 The Near Patient Testing Service shall include the provision of a shared care drug monitoring service in respect of the following specified drugs: Sulphasalazine Azathioprine Auranofin Penicillamine Leflunomide Oral Methotrexate Sodium Aurothiomalate Services not included in specification Monitoring of drugs not listed above such as chlorambucil, ciclosporin, etanercept and infliximab. 3 SERVICE REQUIREMENTS 3.1 The Provider shall ensure that the Near Patient Testing Service includes but is not limited to: Service specification and criteria ensuring that all newly diagnosed patients (and/or their carers and support staff when appropriate) receive appropriate education and advice on management of, and prevention of, secondary complications of their condition including the provision of written information ensuring that the systematic call and recall of patients using the Near Patient Testing Service is taking place in primary medical services setting ensuring that all patients (and/or their carers and support staff when appropriate) are informed of how to access appropriate and relevant information preparing an individual management plan with the patient, which gives the diagnosis, planned duration, the monitoring timetable and, if appropriate, the therapeutic range to be obtained referring patients promptly to other necessary services and to the relevant support agencies, when clinically appropriate, using locally agreed shared care guidelines where these exist and in line with any Summary of Product Characteristics datasheets available at  HYPERLINK "http://www.medicines.org.uk" www.medicines.org.uk working with other professionals when appropriate developing and maintaining an up-to-date register of all patients using the Near Patient Testing Service, indicating patient name, date of birth, the indication for treatment, duration of treatment and last hospital appointment maintaining adequate records of the performance and result of the Near Patient Testing Service provided, incorporating appropriate known information, as appropriate. This shall include all known information relating to any significant events e.g. hospital admissions and death of which the provider has been notified. Quality Assurance 3.2 The Provider acknowledges that: quality assurance must be carried out in accordance with relevant local and national guidance and protocols all significant events relating to the shared care drug monitoring service must be adequately identified, recorded and investigated both by the Provider in accordance with Section 8 of this specification all significant events resulting in death must be reported to the Primary Care Trust within 72 hours, as specified in Section 8.4 HEALTH RECORD The Provider should ensure that all clinical information related to this service is recorded in the patients own General Practitioner (GP) held lifelong record. 4.2 Where a patient ceases to take drugs that are relevant to this service then the patient record should be duly updated. 5 TRAINING AND ACCREDITATION 5.1 The Provider shall ensure that: all staff involved in providing any aspect of care under this Near Patient Testing Service have the necessary training and skills to do so the expertise of other professionals can be drawn on where necessary all staff involved in this service should be providing care in accordance to the shared care protocols developed by the secondary care provider. Please complete and return the form in Appendix 2 to the Primary Care Trust. 6 INFECTION CONTROL 6.1 Providers must have infection control policies that are compliant with national guidelines, which include: disposal of clinical waste needle stick incidents environmental cleanliness, and standard precautions, including hand washing. 7 Review and audit 7.1 The Provider shall perform an annual review, which includes: details of training and education relevant to the drug monitoring service; details of the standards used for the control of the relevant condition; and assurance that any staff member responsible for prescribing must have developed the necessary skills to prescribe safely. 8 SIGNIFICANT/ADVERSE EVENTS 8.1 The Department of Health emphasizes the importance of collected incidents nationally to ensure that lessons are learned across the NHS. A proactive approach to the prevention of recurrence is fundamental to making improvements in patient safety. 8.2 The Provider should be aware of the various reporting systems such as: the National Patient Safety Agency National Reporting and Learning System the Medicines and Healthcare products Regulatory Agency reporting systems for adverse reactions to medication (yellow card system), and accidents involving medical devices, and the legal obligation to report certain incidents to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). 8.3 In addition to any regulatory requirements the Primary Care Trust wishes the Provider to use a Significant Event Audit system (agreed with the Primary Care Trust) to facilitate the dissemination of learning, minimising risk and improving patient care and safety. 8.4 In addition to their statutory obligations, the Provider will give notification, within 72 hours of the information becoming known to him/her, of all emergency admissions or deaths of any patient treated by the Provider under this enhanced service, where such admission or death is or may be due to the Providers treatment of the relevant underlying medical condition covered by this specification. Notifications are to be sent to the Director of Nursing and Patient Safety with a copy to the Senior Primary Care Commissioning Manager for the specific locality. 9 PRICING 9.1 In 2008/09 each practice contracted to provide this service will receive: Level 3 Provider-funded phlebotomist, provider sample, laboratory test, provider dosing 93.11 9.2 Where a patient is receiving combinations of two or more drugs covered by this specification, only one payment per patient will be made. 9.3 In addition to the above fees, where sampling requires a domiciliary visit to a housebound patient on or behalf of the provider and not by a member of staff employed by an NHS body to provide community health services, an additional fee would be paid for each separate address visited on that day, 3.10. 9.4 Community nursing services staff are only able to take samples for those housebound patients already on their caseload. 10 PAYMENT 10.1 Payment will be made on a monthly basis, pro rata for the number of patients monitored in the previous year. 10.2 Payments will be reconciled after the year end and will be made on the basis of the number of patients monitored each quarter. 11 CONSENT 11.1 In each case the patient should be fully informed of the treatment options, risks and the treatment proposed. 11.2 National guidelines suggest that written consent should be obtained from patients. The Primary Care Trust wishes the Providers to note that their interpretation of written consent in this context is the recording of consent by Read Code where appropriate. Where the Provider Read Codes consent given, the Primary Care Trust will take this to mean that the patient has been fully informed of the treatment options and risks, has been offered written information and has given consent. 12 PATIENT AND PUBLIC INVOLVEMENT 12.1 The service will conform to professional and legal requirements especially clinical guidelines and standards of good practice issued by the National Institute for Clinical Excellence (NICE) and professional regulatory bodies, and legislation prohibiting discrimination. It is anticipated that for the majority of enhanced services translated information will be available via the Department of Health. If a patient wishes to communicate via a language that is not covered via these leaflets please let the Primary Care Trust Equality and Diversity Lead know and use the commissioned interpretation and translation service (Applied Language Solutions) to facilitate the consultation and provision of information to the patient. Use of the interpretation/translation service should be recorded in the patients lifelong medical record including confirmation of the first language of the patient. 12.2 Practices should encourage, consider and report any patient feedback (positive and negative) on the service that they provide and use it to improve the care provided to patients, particularly if there are plans to alter the way a service is delivered or accessed. 13 REFERENCES 13.1 Shared Care protocol for oral methotrexate, Drug and Therapeutics Committee November 2007. 13.2 The Health Act 2006: Code of Practice for the Prevention and Control of Healthcare Associated Infections. The Stationary Office, 2006. APPENDIX 1 PROTOCOLS FOR DRUG MONITORING Protocol 1 Sulphasalazine Indication: Rheumatoid Arthritis (long term treatment, two preparations Salazopyrin EN is considered to have less GI side effects) Dosage Regimes: 500mg daily increasing by 500mg weekly increments to a maximum of 1g bd, if tolerated. Some patients may respond to a lower dose. Treatment may be continued indefinitely, the usual reason for stopping being loss of benefit. Sulphasalazine is sometimes co-prescribed with other anti-rheumatic agents. Dose adjustment usually initiated in secondary care. Monitoring: FBC, U&E, LFTs prior to treatment. FBC, LFTs at 3, 6 and 12 weeks, every 3 months thereafter. Urgent FBC if patient complains of intercurrent illness during initiation of treatment. Protocol 2 Oral Methotrexate (injections of methotrexate are not covered by this specification/shared care arrangement) Indication: Rheumatoid Arthritis, Psoriasis (second-line drug immunosuppressant and anti-inflammatory effects) Dosage Regimes: Initially 5mg to 7.5mg orally once weekly, maintenance dose 7.5 to 12.5mg per week. However dosage should be set by a secondary care clinician responsible under shared care for the patient - they may recommend exceptions to these restrictions. To limit the side effects of methotrexate, Folic Acid (5mg) should be taken once a week on the day after methotrexate. Monitoring: FBC, U & E, LFTs prior to treatment Urinalysis prior to treatment FBC weekly for 6 weeks initially then monthly, any dosage increase should be followed by an FBC one week later LFTs 3 monthly CRP, ESR 3 monthly (to assess response to therapy) U & E, creatinine 6 monthly Protocol 3 Azathioprine Indication: Rheumatoid Arthritis (used for the long term treatment, usually prescribed for cases that have not responded to other disease modifying drugs. Patients prescribed AZATHIOPRINE should avoid allopurinol and should avoid live vaccines.) Also used as a steroid sparing drug (e.g. in myaesthenia gravis) initiated in secondary care. Dosage Regimes: Starting dose 50mg daily increasing to a maximum of 2.5mg/kg daily in divided doses. Watch for signs of early toxicity. Nausea, vomiting and diarrhoea may occur, usually starting early during the course of treatment, and may necessitate withdrawal of the drug. Herpes zoster infection may also occur. Lower doses should be used in the elderly or if significant renal or hepatic impairment. Monitoring: FBC, prior to treatment. FBC, WEEKLY for first month, every 4-6 weeks thereafter. Urgent FBC if patient complains of abnormal bruising, oral ulceration or sore throat. WBC < 4.0 x 109/L Withhold and discuss with Rheumatologist Neutrophil count < 2.0 x 109/l Withhold and discuss with Rheumatologist Platelet count <150 x 109/l Withhold and discuss with Rheumatologist MCV > 105 fl Check B12 and Folate Trends should be monitored regularly (ideally quarterly). A downward trend (in addition to a rapid fall) should prompt caution and may require referral. Patients should be warned to report immediately any signs or symptoms of bone marrow suppression e.g. inexplicable bruising, bleeding or infection. Protocol 4 Penicillamine Indication: Rheumatoid Arthritis (second-line drug) Dosage Regimes: 125mg daily, increasing by 125mg increments every 4 weeks to 500mg daily if tolerated. Some patients respond to a lower dose, occasionally 750mg a day is required. If no response in one year discontinue treatment. Not to be taken within two hours of food. Monitoring: FBC, U&E, LFTs prior to treatment. Urinalysis prior to treatment. FBC, urinalysis every 2 weeks for 8 weeks, 1 week after any dosage increment, monthly thereafter. Protocol 5 Leflunomide Indication: Active Rheumatoid Arthritis (third-line use (after Methotrexate/Sulphasalazine treatment contra-indicated, not tolerated or ineffective). Shared care to commence after patient has been prescribed by a consultant for at least one month and the response to treatment has been assessed. Also used in some other conditions (e.g. Wilsons disease (excessive copper deposition) and autoimmune hepatitis. Dosage: Loading dose of 100mg once daily for three days, recommended maintenance dose is 10-20mg once daily. Loading dose may be ignored at the Rheumatologists discretion. Therapeutic effect usually starts after 4-6 weeks and improvement may continue for a further 4-6 months. Monitoring: FBC, ESR, U&E, BP prior to treatment LFTs (in particular ALT (SGPT)) prior to treatment exclusion of pregnancy prior to treatment FBC, LFTS, BP every two weeks for 6 months, every two months thereafter Protocol 6 Sodium Aurothiomalate (Myocrisin) Indication: Rheumatoid Arthritis (slow-acting drug, improvement can be expected after 2-3 months (400-600 mg total dose), and in the absence of toxicity, gold injections can be continued indefinitely.) Dosage Regimes: 10mg IM test dose, then 50mg one week later, followed by 50mg weekly to a total dose of 500mg. If there is a clinical response, the frequency of injections can be reduced to every two weeks up to a total dose of 1g. In the absence of an improvement continue at 50mg weekly to a total dose of 1g. If after 1g there is clinical improvement, reduce the frequency of injections to every 3-4 weeks. If no response after 1g total dose stop gold. Monitoring: Dose record cards are available from the hospital and must be carefully maintained. FBC, U+E, LFTs prior to treatment Urinalysis prior to treatment FBC, urinalysis prior to each injection (ESR/CRP is useful to assess response to therapy) Patients should be requested to report sore throats, unexplained bruising, breathlessness, unexplained rashes and mouth ulcers. Protocol 7 Auranofin Indication: Rheumatoid Arthritis (less effective, less toxic and slower to induce a remission than intramuscular gold, and clinical benefit may not become apparent for up to 3-6 months) Dosage Regimes: 6mg daily - either 6mg before breakfast, or 3mg bd before meals. Monitoring: FBC, U&E, LFTs prior to treatment Urinalysis prior to treatment FBC, urinalysis every 2 weeks for 3 months then monthly Please note that full shared care protocols for all of the drugs can be sought from the Primary Care Trust intranet site (address as below:)  HYPERLINK "http://nww.somersetpct.nhs.uk/pmm/Shared%20Care%20Documents/Forms/AllItems.aspx" http://nww.somersetpct.nhs.uk/pmm/Shared%20Care%20Documents/Forms/AllItems.aspx APPENDIX 1 LIST OF NAMED PRACTITIONERS Provider Name: The below named general practitioners will be providing services under the Near Patient Testing (DMARD monitoring) Enhanced Service for patients registered with this provider. The practitioners are aware and have copies of the latest shared care protocols. General PractitionerSignatureDateSulphasalazineAzathioprineAuranofinPenicillamineLeflunomideMethotrexateSodium Aurothiomalate(Myocrisin)     Please add more lines if the practice has more than 4 general practitioners. Shared care guidelines can be sourced from the medicines management/shared care section on the Primary Care Trust intranet site (link below)  HYPERLINK "http://nww.somersetpct.nhs.uk/pmm/Shared%20Care%20Documents/Forms/AllItems.aspx" http://nww.somersetpct.nhs.uk/pmm/Shared%20Care%20Documents/Forms/AllItems.aspx  See references 13.1.  See reference 13.2.  Orange book with regard to these services is available at  HYPERLINK "http://www.somersetpct.nhs.uk/how%20we%20do%20things" www.somersetpct.nhs.uk/how we do things PINs for accessing this service have been given to each provider.      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