By Nathan Burley
Background
Up to seven drugs are provided for an early medical abortion, similar to the amount provided after a heart attack. Abortives, pain relievers, antiemetic, contraception and antibiotic could be provided, with each participation resulting in at least four packs being given. Clinics providing this service may stock a variety of different medicines, with staff time spent ordering, receiving, stocking, rotating stock and storing packaging. Requirement of services for abortion care has increased sharply following the Covid-19 pandemic in Scotland. Our team proposed consolidating the most commonly used packages into one bag, delivered to the clinic pre-assembled and labeled, greatly simplifying the process.
Create the package
A strict limit in the number of medicines that can be relabelled or repackaged by end users exists in the UK. Individual administration and labeling for a patient can be done under the supervision of a pharmacist. However, special units have licenses that allow the “packaging” and over-labeling of drugs in large quantities. We commissioned NHS Scotland’s Pharmaceutical Specials Service to provide Early Medical Abortion at Home (EMAH) packs containing the following four medicines (see figure 1):
Cyclizine 50mg x 3 tablets
Dihydrocodeine 30 mg x 5 tablets
Mifepristone 200mg x 1 tablet
Misoprostol 200 micrograms x 6 tablets
In addition to the medicines, the pack also contains a curated leaflet/information sheet with additional instructions and contact details for the clinic. Leaflets/information leaflets can be adapted to each abortion clinic as this pack is now used in many health systems in Scotland.
Picture 1. The contents of the assigned EMAH package are shown (no leaflet).
What were the benefits?
The main benefits were the simplification of drug handling procedures and the saving of staff time. We appreciate it The time saved by senior doctors is approximately 97.5 hours or 2.6 working weeks over a 9 month period. The time saved per consultation is approximately 5 minutes. This resulted in a total of 149 hours of clinical nursing and medical time saved, equivalent to approximately 4 working weeks for one member of staff. A single line item in the prescription system used also saves medical staff documentation time.
In addition, because the pack is standardized, a supply of cyclizine (antiemetic) and dihydrocodeine (moderate pain reliever) is available for patients on whom the pack is used. Historically councils would provide a myriad of options with some abortion clinics in Scotland not providing antiemetics or painkillers.
Finally, there is a saving in the accumulation of pharmaceutical waste or residues in patients’ residences. The disposal of pharmaceutical waste is expensive, poses a risk to the environmentand can lead to patients using drugs to self-medicate where they are not appropriate.
What are the disadvantages?
The contents of the package, for this iteration, have been regulated and agreed by a small working group and for production purposes the component drugs have been locked in place without any variation. However, a second edition with wider stakeholders is planned based on patient feedback and clinical experience with the EMAH package as is.
Negotiating a package assignment of this nature can be complex and the early involvement of a specialist pharmacist was key to success.
The boxes are all white, which could be difficult for patients to differentiate. Additionally, dihydrocodeine may not be appropriate for all patients, so the pack is only used in about 70-80% of all visits. This requires having single component components in the abortion clinic with all the usual drug handling operations around this storage.
A package is an item supplied by a supplier. The supplier is regularly updated with expected demand so that packaging can be manufactured accordingly. However, in the event of miscommunication regarding order volumes and quantities, supply may be interrupted resulting in a return to manual preparation of packages.
Summary
The introduction of the bundle brought significant time savings to clinic staff and offered a degree of fairness to patients accessing an appropriate antiemetic and analgesic for abortion across the country (where used). Accurate amounts are given to patients to reduce pharmaceutical waste. There are considerations that need to be taken into account before adopting such an approach, but if adequately mitigated, there are benefits for both staff and patients.
About the author
Nathan currently works as an advanced pharmacist in public and sexual health at NHS Greater Glasgow and Clyde. This includes providing pharmaceutical knowledge and advice in the areas of public health protection, genitourinary medicine, sexual and reproductive health, gender care and abortion services. With experience in hospital pharmacy, he provides clinical information on complex patient cases and is responsible for ensuring the services run smoothly and efficiently in terms of medication use. He is a visiting lecturer at the University of Strathclyde and past president of the Guild of Healthcare Pharmacists.
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