Dispensing of Tuberculosis Medication

Policy

Category: Control of Infectious Diseases
Subject: Dispensing of Tuberculosis Medication
Division: Health Protection
Policy Number: CA.82.01.202
Effective Date: October 1, 2015

POLICY STATEMENT

It is the policy of Wellington-Dufferin-Guelph Public Health (WDGPH) that the Public Health Nurse (PHN) will dispense tuberculosis medications to individuals on receipt of a prescription from a referring Ontario physician. These individuals will be monitored for compliance to prevent further spread of disease and development of drug resistance. Registered Nurses will comply with the Medication practice standard from the College of Nurses when dispensing medication.

SCOPE

This policy applies to all Control of Infectious Diseases (CID) Public Health Nurses (PHNs) who are required to dispense medications for the treatment of tuberculosis disease or infection.

DEFINITIONS

Compliance – The client’s agreement and willingness to take medication as prescribed for the entire length of treatment.

Drug resistance – The ineffectiveness of one or more first line drugs (Isoniazid, Rifampin, Ethambutol, and Pyrazinamide) to kill the mycobacterium tuberculosis germ.

Dispensing – To select, prepare, and transfer stock medication for one or more prescribed medication doses to a client or the client’s representative.

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Procedure: CA.82.02.202 Dispensing of Tuberculosis Medication
CA.50.01.101 and CA.50.02.101 Documentation Practices
Health Protection and Promotion Act, 1990
Ontario Public Health Standards, 2008|
Infectious Diseases Protocol (as current)
Canadian Tuberculosis Standards (as current, online edition)
Canadian immunization Guide (as current, online edition)
College of Nurses of Ontario Practice Standard (2015): Medication
Excelicare CID Desktop Reference

CONTACT FOR INQUIRIES

Manager, Control of Infectious Diseases

APPROVED BY

Director, Health Protection 


Procedure

Category: Control of Infectious Diseases
Subject: Dispensing of Tuberculosis Medication
Division: Health Protection
Procedure Number: CA.82.02.202
Effective Date: October 1, 2015

PROCEDURE

1. When a prescription is received from an Ontario physician for a client, the Public Health Nurse (PHN) will complete the Drug Dispensing Record form (HPDTB(F)4) with prescription information and add it to the client’s file. The PHN will record when the medication is dispensed and when the medication is next due. The prescription will be scanned into the client’s Excelicare chart.

2. Tuberculosis (TB) medications will be stored in a locked cabinet in each office.

3. When filling the prescription, the PHN will check bottles of medication three times for: name of medication, dosage, and date of expiry. The medication will not be dispensed in quantities greater than three months, except in unusual circumstances when approved by the Manager. A second PHN will verify the completed medication order matches the physician’s prescription.

4. The PHN will complete the appropriate medication instruction label which includes the client’s name, date, name of medication, and the quantity dispensed. The label will also include the reason for the medication, dose, frequency, duration, expiry date, medication lot number, prescribing doctor’s name, and drug identification number (DIN). The PHN will apply this label and the Wellington-Dufferin-Guelph Public Health (WDGPH) label to the bottle. Any appropriate warning labels should also be added to the bottle. 

5. The PHN will meet with the client in a private room to dispense medication and to provide health teaching regarding the prescribed tuberculosis medications. The health teaching will include the following:

  • How medication is to be taken (pill dosette may be offered to client);
  • Possible side effects of medication;
  • Regular monitoring of liver function tests;
  • Importance of compliance with treatment for the full length of time the medication is prescribed; and
  • Contact information for PHN.

An episode note will be completed in the client’s Excelicare file.

The PHN will provide the client with the drug fact sheets for medication(s) prescribed:

  • Isoniazid (HPDTB(FS)16);
  • Rifampin (HPDTB(FS)19); 
  • Pyrazinamide (HPDTB(FS)18); and
  • Ethambutol (HPDTB(FS)17).

6. The PHN will record on the Drug Dispensing Record form (HPDTB(F)4 or HPDTB(F)16) the date, dosage of tablet/capsule, number of tablets/capsules given, lot number, expiry date, and each PHN’s initials every time the medication is dispensed.

7. The PHN will submit the required information via iPHIS to the Ministry of Health and Long-Term Care/Public Health Ontario.

8. If the client has active disease, he/she will be assessed for Directly Observed Therapy (DOT).  Refer to CA.82.01.207 and CA.82.02.207 Directly Observed Therapy.

9. If the client is not put on DOT, or is being prophylaxed for latent TB, the PHN will contact the client or guardian to evaluate compliance within two weeks after commencement of course of medication.

10. On a monthly basis, all client charts due for medications that month will be pulled.  Clients will be contacted to confirm that the medications are being tolerated.  The PHN will address any concerns with the client’s physician (ordering).

11. For renewal of prescriptions, the PHN will prepare medications following the procedures outlined above (3–6).  The PHN will contact the client and advise him/her to come to WDGPH to pick up the medication and to bring all remaining pills. If the PHN has difficulty contacting the client by telephone, the form letter Prescription Pick-up – Dear Client (HPDTB(L)20) may be mailed to the client.

12. To assess for compliance, the PHN will count all pills remaining in the client’s supply and record them on the Monitored Medication Count Sheet (HPDTB(F)7)  before dispensing the next supply.  If compliance is questionable, the PHN will review the importance of compliance and arrange for more frequent visits to pick up medication and to monitor closely.

13. If compliance continues to be a problem, the PHN will discuss with the Manager the use of DOT.  Refer to CA.82.01.207 and CA.82.02.207 Directly Observed Therapy.

14. On completion of medication for the treatment of active or latent disease, the PHN will complete a Record of Treatment for Active Tuberculosis Infection (HPDTB(F)26) or Record of Treatment for Latent Tuberculosis Infection (HPDTB(F)27) and give it to the client.  Update completion of treatment via iPHIS.

15. Occasionally, clients live within our jurisdiction but are receiving their TB medication directly from a physician at another health unit.  In this case, the PHN will:

  • Create a chart including Case Information form (HPDTB(F)1), Progress Notes form (CID(F)3), Drug Dispensing record (HPDTB(F)4), and record pertinent information;
  • Ensure the client has been created in iPHIS and keep the record updated;
  • Contact the client to ensure he/she has obtained TB medication and received instructions for use, side effects, and continued follow-up through prescribing physician;
  • Mail Client Letter – Medications Received to the client;
  • Contact the client at the estimated treatment completion date to ensure treatment is complete; and
  • Mail Client Letter – Medications Complete.

RESPONSIBILITIES

Management will:
  • Ensure employees are oriented and adhere to the policy and procedure;
  • Monitor policy compliance on a regular basis; and
  • Review documentation on a regular basis.
Employees will:
  • Adhere to this policy and procedure;
  • Review this policy and procedure and the College of Nurses Standard on medication dispensing;
  • Always implement and document a 2-PHN check of prescription and dispensed medications;
  • Ensure medications are dispensed according to this procedure and at no cost to the client with active or latent tuberculosis; and
  • Monitor client for side effects as well as compliance to prevent the further spread of disease and development of drug resistance.

DEFINITIONS

Compliance – The client’s agreement and willingness to take medication as prescribed for the entire length of treatment.

Dispensing – To select, prepare, and transfer stock medication for one or more prescribed medication doses to a client or the client’s representative

Drug resistance – The ineffectiveness of one or more first line drugs (isoniazid, rifampin, ethambutol, and pyrazinamide) to kill the mycobacterium tuberculosis germ.

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Procedure: CA.82.02.202 Dispensing of TB Medication
CA.50.01.101 and CA.50.02.101 Documentation Practices
CA.82.01.207 and CA.82.02.207 Directly Observed Therapy.
HPDTB(F)4  Drug Dispensing Record form
HPDTB(FS)16  Isoniazid
HPDTB(FS)19  Rifampin 
HPDTB(FS)18  Pyrazinamide
HPDTB(FS)17  Ethambutol
HPDTB(L)20  Prescription Pick-up – Dear Client
HPDTB(F)7  Monitored Medication Count Sheet 
HPDTB(F)26  Record of Treatment for Active Tuberculosis Infection
HPDTB(F)27  Record of Treatment for Latent Tuberculosis Infection
HPDTB(F)1  Case Information form
CID(F)3  Progress Notes form
Client Letter – Medications Received
Client Letter – Medications Complete

Health Protection and Promotion Act, 1990
Ontario Public Health Standards, 2008
Infectious Diseases Protocol (as current)
Tuberculosis Prevention and Control Guidance Document, 2011 (MOHLTC)
Canadian Tuberculosis Standards (as current, online edition)
Canadian immunization Guide (as current, online edition)
College of Nurses of Ontario Practice Standard (2015): Medication
Excelicare CID Desktop Reference

CONTACT FOR INQUIRIES

Manager, Control of Infectious Diseases

APPROVED BY

Director, Health Protection