This article was co-written by Sejal Parekh, Denise Farmer and Carry Triggs-Hodge.
During the initial part of the COVID-19 pandemic there was a need for clear guidance on infection prevention and control (IPC) practice for handling prescription charts and patients’ own medication by pharmacy teams, as no guidance was available at that time and there were concerns of fomite transmission. Several approaches were being taken across NHS organisations, however many were not evidence based and there was limited published evidence available.
In response, recommendations for handling drug charts and patients’ own medication during the pandemic were developed by a multidisciplinary group consisting of several organisations such as Public Health England (now the UK Health Security Agency), the Department of Health and Social Care, the Advisory Committee on Antimicrobial Prescribing, Resistance and Healthcare Associated Infection (ARPHAI), and the UKCPA Infection Committee.
This guidance was published on the Special Pharmacy Services (SPS) website in May 2020 and updated in November 2020. Initially, awareness and implementation of the guidance was relatively high amongst surveyed NHS Acute Trusts. However, access to the guidance has dropped considerably since the end of 2020.
The principles for infection prevention and control recommended in the guidance are still valid and applicable to multiple sectors. The original guidance is replicated below.
Infection prevention and control recommendations
In all settings, healthcare staff should practice prudent hand hygiene and avoid touching their own face after handling drug charts or patient’s medicines until hand hygiene is performed (the lipid envelope of the virus can be emulsified by surfactants such as those found in simple soap, which kills the virus, or hand sanitiser containing at least 60% alcohol).
Gloves are not required for handling such items outside of direct patient care or in cohort settings and inappropriate use is associated with a risk of cross-contamination and may give users a false sense of security. Healthcare staff should follow Trust or organisation policies on wearing appropriate personal protective equipment in all settings and where staff are less than two metres from patients as part of their clinical activities, appropriate personal protective equipment should be worn.
hand hygiene and regular disinfecting of surfaces are key measures that should be practiced
The results from recent experiments suggest that the severe acute respiratory syndrome coronavirus 2 (abbreviated to SARS-CoV-2) can be detected up to 24 hours on cardboard, 48 hours on stainless steel, 72 hours on plastic.However, it is important to note that this was under experimental testing conditions, with deliberate smearing of SARS-CoV-2 to surfaces.
The current evidence indicates that the virus spreads primarily through respiratory droplets produced when an infected person coughs or sneezes, dispersing droplets into the atmosphere as far as 1 metre or further if wind is present. However, it could also be spread if people touch an object or surface with virus present from an infected person, and then touch mucosal surfaces such as their mouth, nose or eyes.
Key infection prevention and control measures which are also applicable to all other infective organisms and should already be in practice, including hand hygiene, environmental cleaning and disinfection and appropriate use of personal protective equipment (in the case of COVID when within two metres of patients).
For the handling of medicines packages to pose a risk, surface contamination would need to occur by droplets being expelled from patients coughing and/or sneezing and landing on medicines packages. An alternative route of transmission would occur because of indirect transfer from hands contaminated with excreted virus. Due to the nature of where drug charts and medicines are kept on the wards (such as outside rooms when patients are being barrier nursed) or in people’s homes (for medicines brought into hospital), the likelihood of direct landing of droplets expelled during patient coughing and sneezing and hence risk of contamination is limited.
There is currently no evidence to suggest that additional precautions other than good hand hygiene and surface decontamination are required to reduce the risk of transmission from medicine packages and drug charts.
In all settings there should be increased frequency of cleaning of surfaces, such as dispensing trays, at regular intervals using Trust or organisation approved disinfectant solution, ensuring a contact time of 60 seconds or as recommended by the product’s manufacturer. The contact time is defined as the length of time the surface being disinfected must remain wet for the disinfectant to work.
There is currently no published evidence to support isolation (quarantining) of medications or routine decontamination of medicine packages. As highlighted earlier, hand hygiene and regular disinfecting of surfaces are key measures that should be practiced.
This guidance focuses on medications that have been in clinical areas or brought into hospital by patients (commonly referred to as patients’ own drugs or PODs) with suspected or confirmed COVID-19 infection. All other medications, such as ward and/or pharmacy stock, can be treated as non-contaminated medication and follow usual practice in place prior to COVID-19.
Drug charts and PODs
It is advisable that drug charts and PODs of patients with possible or confirmed COVID-19 remain in clinical areas where feasible. PODs should be kept in the patients’ locker and administered to the patient in accordance with usual Trust or organisation practice. In most cases this would mean they are assessed for suitability of use within the hospital.
Controlled drugs (CDs)
When storing CD PODs, they should be placed into a bag before placing in the CD POD cupboard followed by hand hygiene measures. As per Trust or organisation standard operating procedure, nursing professionals should be reminded of recording the CD PODs in the relevant CD register where the entry should include name, strength and quantity. The CD cupboard where PODs are stored should be cleaned regularly, and lanyards (if used) for CD keys should also be cleaned or changed regularly.
PODs requiring refrigerated storage should be placed in a clearly demarcated area of the fridge, such as the bottom shelf or tray. Frequently touched areas of the fridge (such as door handles) should be cleaned regularly as per Trust policy.
PODs can be returned to patients if they are still taking this medication in accordance to Trust guidance. If CDs are still required, this should be signed out of the register and returned as per standard operating procedure.
Waste disposal of patients’ own drugs (PODs)
Where PODs are no longer required, they should be discarded on the ward as part of the medicine waste standard operating procedure. If this medicines waste is from patients with possible or confirmed COVID-19 it should be segregated in a bag and clearly identified. It should be disposed of following recommended hand hygiene and surface decontamination principles and as per the waste medicines standard operating procedure.
Destruction of controlled drugs that are not required by the patient should be undertaken in the usual manner as per Trust standard operating procedure. They should also be denatured in the presence of another member of staff as per Trust standard operating procedure. Staff should avoid touching their own face during this process until hand hygiene is performed.
Staff should maintain a system of processing only one item or tray of items at a time, being careful not to touch their faces whilst working on the tray. Once complete and checked, staff should clean their hands (soap and water or alcohol gel for 20 seconds) before moving on to the next item or tray. Trays and dispensary surfaces should be cleaned at regular intervals.
For examples of work flow of how to maintain a clean pathway through Dispensary during COVID-19, please see Appbox.
Specific guidance is available relating to medicines management in care home and/or hospice settings.
Health and justice settings
The information above can be used to develop local processes. In prisons and other prescribed places of detention PODs from transferred and community admitted detainees will be assessed for suitability in line with normal procedures. Whilst in storage within the healthcare areas (including house blocks or wing storage) these PODs should be stored in bags including any CDs usually stored in CD cupboards.
Where POD medicines are no longer required, they should be discarded as part of the medicine waste standard operating procedure. If this medicines waste is from patients with possible or confirmed COVID-19 it should be segregated in a bag and clearly identified. It should be disposed of following recommended hand hygiene and surface decontamination principles and as per the waste medicines standard operating procedure. Destruction of controlled drugs that are not required by the patient should be recorded in the relevant records including: POD name, strength and quantity. All other stock and named patient supplies that have been dispensed by an on-site or external pharmacy can be treated as non-contaminated medication and follow usual procedures.
Individuals from multiple organisations and committees contributed to the development and consensus process of this guideline, including:
- (now UK Health Security Agency): Aoife Hendrick, Anna Sallis, Colin Brown, Susan Hopkins
- ARPHAI): Karen Shaw, Neil Wigglesworth
- Ceri Philips, Nicholas Reid, Mark Gilchrist,Jacqueline Sneddon
This guidance Recommendations for handling drug charts and patients’ own medication during the COVID19 pandemic: Infection prevention and control recommendations was published on the Special Pharmacy Services (SPS) website in May 2020 and updated in November 2020.
- NHS England and Improvement and 4 Nations IPC Cells: 7 May 2020 & 22 May 2020
- Susan Hopkins and Keith Ridge: 11 May 2020
- Updated on 26 October 2020 following discussions through email and meeting with members of the consensus group
- Version 2 of this guidance was updated in November 2020 and reviewed by Diane Ashiru-Oredope, Elizabeth Beech, Wasim Baqir, Rakhee Patel, Scott Hill, Nicola Wake, Mark Gilchrist, Anna Sallis, Kirsty Bennett, Ceri Phillips, Andrew Davies, Denise Farmer, Anne Woolridge, Colin Brown and Lesley Smith.
|1||Those commenting felt that hand hygiene after every item or tray was not feasible and implementation was having significant effects on skin integrity of their dispensary staff.||The Group agreed to include example guidance in Appbox for how to mitigate the risk to staff skin integrity.|
|2||A Trust asked about the recommendation to store CD PODs in clear plastic bags when put into the CD cupboard. They are keen to reduce their plastic burden and, as a Trust, the TTOs they receive from the local secondary care Trust are all in paper bags. Even if in a see through plastic bag, there would be a check of the physical container for quantity so the plastic bag would be opened to facilitate that.||The group agreed to remove the words ‘clear plastic’ in line with the NHS commitment to reduce plastic use.|
|3||Medicines which have been by a COVID patient’s bed space should be quarantined for 72 hours.Medicines which have been in a drug cupboard in a COVID area, do NOT need to be quarantined. Paper/order books in aerosol-generating COVID areas (eg critical care) should be quarantined for 72 hours.||The overall consensus was that quarantine should not be required and important to follow recommended hand hygiene recommendations. The risk from a COVID-19 patient will depend on whether they are symptomatic. If there is a true risk the healthcare worker may choose to quarantine medicines/order books.|
The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.
Competing interest statement:
The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.