Table 3 Prescribing and sourcing ICDs in the care home context

Step 1: Contact the GP to prescribe the ICDs.

Out-of-hours GPs are more reluctant than the resident’s GP to prescribe ICDs because they are not familiar with the resident’s medical history.

“if a resident is end of life and we need those medications urgently then it’s very frustrating [because] we need to try in time to quickly get the meds in, so we need to wait for the GP to do the prescription” [Senior carer 1]

“the out of hours GPs, I shouldn’t say they’re afraid, [but] they’re more reluctant to prescribe end of life medications for a person they don’t know. So what they will do, let’s say we call them out for somebody, they might say […] “Well, it’s Sunday today, you can call your GP to come in tomorrow, let’s try some Oramorph liquid, let’s do that”. Which sounds quite appropriate because just think about yourself going in somewhere, seeing someone the first time” [Nurse 4]

Step 2: Order the ICDs through the pharmacy.

There are some caveats which complicate the ordering of ICDs through the pharmacy:

a) only selected pharmacies store ICDs,

b) surgeries cannot fax controlled drugs prescriptions, and

c) not all surgeries have electronic prescription services.

“[Senior carer 5] complained that morphine and midazolam are almost impossible to get out-of-hours (during the weekend or at night) because they are controlled drugs and only a few pharmacies store them.” [Fieldnote extract 13:277]

“we can’t use other pharmacies but our pharmacy that we work with […] and because it’s a controlled drug prescription the surgery can’t fax it to them [pharmacy] so somebody from [pharmacy] have to go and collect it” [Senior carer 1]

Step 3: The pharmacy can take up to 24 h to deliver the ICDs.

Senior staff feel the need to chase the pharmacy when ICDs are needed urgently, even when these were prescribed electronically.

“the doctor will prescribe it electronically, it will go straight to [local] pharmacy [with which the Home works] so after the GP visit we have to inform the [local] pharmacy to […] keep an eye because we need it tonight, will you please deliver it tonight?” [Nurse 6]

“If you don’t have the meds, send somebody over or chase [pharmacy] and see, when are they going to be here because we need them as soon as possible.” [Senior carer 2]

Step 4: Collect the administration authorisation chart from the GP surgery.

ICDs cannot be administered without the chart stating the dosage.

GPs complete the chart at the surgery.

Senior staff need to free a member of staff to collect the Chart from the surgery. This is difficult due to high care workloads.

“the GP does that chart [administration authorisation chart] at the surgery and he will usually leave it there and then it’s up to us to coordinate. […] Sometimes the [district] nurses, kindly, if they’re around the area will go and collect the chart from the surgery but these new nurses don’t really do that so then […] I need to find somebody, a member of staff, a volunteer, anyone, to go to surgery to collect that chart because without that chart, they [district nurses] can’t give the person any medication” [Senior carer 1]

“[Nurse 7] asked me to go the GP practice and collect the Palliative Care Chart [administration authorisation chart] for resident [Ellen] because all carers were busy with residents and he could not leave the floor. The practice was only a 5-minute walk from the nursing home.” [Fieldnote extracts 13:25–26]