MEG Notes 11th October 2017
Attendees:
Chair - Andy Curran (AC – Assistant Medical Director), Mike Jackson (MJ – Chief Consultant
Paramedic), Mary Peters (MP – Clinical Quality), Joanne Hammond (JH – Clinical Quality), Adam
Fleming (AF – Clinical Quality), Nerea Asiain (NA – Acting Pharmaceutical Advisor), Matthew House
(MH – CL Consultant Paramedic), Duncan Robertson (DRo – Corporate Consultant Paramedic),
Matthew Dunn (MD – CM Consultant Paramedic), Tim Byrom (TB – HART Advanced Paramedic) ,
Paul Brennan (PB – CM Advanced Paramedic), Brent Kenny (BK – CL SPTL), Natalie Amriding (NAm -
GM SPTL), Frank Aldred (FA – GM SPTL), David Rawling (CL Acting Operations Manager).
Apologies received from:
Dan Smith, Colin Whiley, David Ratcliffe, Paddy Ennis, Dave Blowers, Brian Buck.
Quorum: Achieved
Minutes
Minutes from the MEG held on the Sept were circulated for acceptance. No further comments on
the content of the minutes. Minutes formally accepted.
It is noted that the October MEG notes will not be classified as minutes as there is no formal admin
support available for this meeting.
Risks
JH informed the group the risk register will not be circulated into this meeting for review due to it
only being 3 weeks since the last MEG where the current medicine risks were reviewed. Risk
updates from the last MEG remain outstanding.
Action: MP to update the current medicines risks for approval by DRo.
Action: JH to circulate updates risks to the MEG via email when completed.
MP raised a new risk concerning a current supply problem with morphine sulphate 10mg/1ml
ampoules. JH confirmed they will receive an update from Lloyds on the extent of the supply issue in
the next couple of days. AF had contacted all current Lloyds suppliers to receive an in branch stock
update and there seems to be sufficient stock in situ for supplied to NWAS for approximately 1
week. An indicative date of resupply to wholesalers is the 27th October. AF confirmed that orders
are currently being prioritised to vehicles with a stock level of 7 or below.AC queried if the risk is
required to go to Exec via DR. MP confirmed that at this time there isn’t sufficient information yet to
confirm this level of risk being raised. BK asked if current stocks in the Trust could be mobilised and
redistributed to those vehicles which may be running low on morphine supplies. MP confirmed this
is not an action that we could take at this time. DRo asked if the introduction of paracetamol IV
could be accelerated to provide an alternative analgesic if morphine supplies are limited. AC stated
this would probably take longer than the morphine restock date of the 27th October.
Action: MP to add new risk to risk register.
1
Action: JH to inform DR when update received and provide information to service delivery as to the
impact of the supply issues they may experience.
Terms Of Reference
Content of the draft ToR for the MEG discussed. AC raised concern over the Medical representative
being present for all meetings which would require his attendance. AC requested this be extended
to include other NWAS doctors if he is not available to attend. MJ stated there must be a doctor
present at all MEGs to provide medical insight into formulary decision making. The group accepted a
nominated NWAS doctor could attend if AC was not available. AC stipulated that no approved
clinical decisions regarding formulary changes i.e. new drugs, changes to dosing/ indications could
be made if a doctor and pharmacist was not present at the MEG in which they would be discussed.
The group accepted this decision. MJ requested more Advanced or Senior Paramedics should be
members of the MEG. A discussion took place to review how this would practically work. FA
suggested a rotational SPTL/AP presence from an area cohort of staff to keep those attending a
small group i.e. 3 of each grade that would be informed on the purpose and content of the MEG. PB
agreed this could be the best way to achieve representation at every MEG rather than named
individuals.
Action: MP/MJ to amend the ToR to incorporate changes to membership, expectations of input and
attendance.
Action: PB to co-ordinate who the SPTL / AP representatives will be for the CM area.
Action: FA to co-ordinate who the SPTL / AP representatives will be for the GM area.
Action: BK to co-ordinate who the SPTL / AP representatives will be for the CL area.
Action: MP to submit final ToR to CGMG scheduled week commencing 16/10/17.
JRCALC Update
MJ introduced the recent updates to JRCALC drug protocols. That will be presented to Clinical
Leadership Board later in the day. MJ confirmed the next full JRCALC version will be available in
2020. It was agreed that any changes to JRCALC drug protocols should be reviewed as part of the
agenda in the MEG.
JH provided an analysis of the differences between current NWAS drug protocol and JRCALC updated
protocols. JH noted the misoprostol dose has increased from 600mg orally to 800mg orally but this
does not feature in the update analysis provided by JRCALC. AC confirmed the dose of 800mg to be
correct as a treatment dose.
TB asked how the changes to drug protocols would be communicated to clinicians. MJ confirmed no
new pocket books would be issued but copies of the A4 JRCALC supplement have been ordered for
all clinical staff. MJ confirmed communication would be via a series of Clinical Bulletins when the
changes are ready for implementation.
2
JH raised paracetamol dose changes for children under the age of 12 years in the new updated
protocols. Dosing tables are specific to having 2 strengths in stock; the 120mg/5ml for under 6 year
olds and the 250mg/5ml for the over 6 year olds. JH raised potential for error if the dose volume
tables are followed without performing a calculation to the current 120mg/5ml stocked within
NWAS. MJ asked what other Trusts use and how they manage the risk. BK and DRo suggested the 2
strengths could be split in the pouches with the stronger one stored in the Therapeutic drug pouch
(TP) and the lower strength packed in the basic drug pouch (BP). AC suggested purchasing different
brands so they visually appear different. FA stated that ibuprofen and paracetamol suspension are
currently stored in the same pouch side by side and because they are visually different they don’t
get mixed up when administering. JH raised a potential for a 4th medicine pouch to be created for
pain medications. AC concerned this would delay the implementation of the new drugs but could be
looked into for future planning.
The group agreed to introduce the 250mg/5ml strength into the NWAS formulary.
Action: AF to source paracetamol 250mg/5ml suspension from suppliers.
Action: AF to review how paracetamol 250mg/5ml can be introduced into the current drug pouches.
Action: JH to review option of a 4th pain pouch.
Action: MJ to plan series of clinical bulletins to communicate the drug protocol changes.
Action: JH / MP to produce report for EMT for any formulary changes requiring financial approval.
AC confirmed Tranexamic Acid has a new indication to be written into the PGD for use in post-
partum haemorrhage. BK asked if TXA could be used for haemorrhage of medical origin. AC
confirmed this indication is still currently under trial and awaiting further evidence before any
changes could be introduced for paramedics.
Action: JH to update TXA PGD for inclusion of PPH as a new indication.
DRo provided an update to the fluid regime for sepsis and was unsure of the evidence base behind
the changes proposed. AC confirmed clinicians would need to look at the clinical response gained
from the initial bolus of sodium chloride given rather than try and infuse the full volume indicated in
JRCALC. DRo had discussed the updated guidance with Advanced Paramedic Danny Butterworth to
decide if NWAS should adopt this new Sepsis fluid guideline or remain with the current NWAS
protocol which is an evidence based regimen. MD confirmed 1 litre over 30 minutes for Sepsis
seemed excessive. AC surmised the regime could be based on mass care of potentially septic
patients as opposed to individual care of a potentially septic patient. TB stated any changes from
the JRCALC guidance issued to clinicians would cause the potential for confusion. BK stated that
NWAS currently utilises its own sepsis screening tool and protocols and does not currently use
JRCALC operationally for this condition and as such confusion could be minimal. AC stated that
patient harm would be minimal by infusion 500ml as opposed to the current 250ml in NWAS
protocol. MJ suggested the use of the clinical leadership structure to aid clinicians who were unsure
of how much to give. This would be based on the initial clinical response by the patient and that
they could turn off the infusion after 250ml if a good response was observed. Make it known to
paramedics that advice is available if required.
3
DRo presented Advanced Paramedic Chris Preston’s paper on the risks of fluid overload in
paediatrics presenting with DKA. AC raised concerns over the sources used for the information in
the paper. DRo confirmed it was taken from guidance produced by the British Society for Paediatric
Endocrinology and Diabetes (BSPED). AC stated that in an ambulance pre-hospital he would
advocate the JRCALC fluid guidance to be given as a single dose and ensure that on handover at
hospital the total infused was relayed. This would allow the receiving hospital to calculate the
infusion rates and volumes for any subsequent fluid regimes accordingly. AC considered it to be a
safe dose. MJ would confer the concerns raised by Chris Preston to JRCALC for discussion.
Action: MJ to relay to JRCALC concerns over fluid regimes for Sepsis and DKA in paediatrics.
Action: Area CPs to co-ordinate advice given by clinical leaders regarding the fluid bolus for sepsis
based on clinical response.
JRCALC Formulary vs NWAS Formulary
MJ and JH presented the additional drugs with a JRCALC protocol in place for discussion as to
whether or not they should be introduced into NWAS.
JH had provided a breakdown of the drugs for discussion including their indications, indicative
pricing and comments for consideration.
Clopidogrel; MJ stated it had previously been agreed with the cardiac network not to include this
pre hospital on the grounds of cost and if needed can be given by hospital. There was also no
agreement in place between the Acute Trusts in the North West which antiplatelet drug is first line
therapy. MJ stated that 4 out of 14 UK ambulance trusts currently include it in their formulary. The
group discussed whether there was reason to include it within NWAS based on the facts provided by
MJ and the decision was to reject clopidogrel from the NWAS drug formulary.
Dexamethasone; MJ confirmed that 5 out of 14 ambulance trusts currently include dexamethasone
in formulary. AC stated that croup is not an emergency but does provide relief for patients but for
patients with severe croup the preference would be to nebulise adrenaline as a pre hospital
intervention. The group could not provide rationale to introduce dexamethasone but could see the
benefit for nebulising adrenaline. Dexamethasone was rejected. Further discussions regarding the
nebulising of adrenaline took place. JH confirmed the stock and equipment required is already
available on all ambulances with medicine stocks. JH confirmed a PGD would be required as it would
be an ‘off label’ use for the drug. AC suggested it could be used for other severe upper airway
restrictions. AC tasked Advanced Paramedic Colin Whiley to review other airway indications in
addition to severe croup as the AP with most knowledge in this area. BK asked if it could be
extended to EMT2 level as they can currently administer adrenaline 1:1000 and are permitted to
nebulise patients. The group agreed to include EMT2 staff into this new protocol.
Action: CW to review nebulised adrenaline protocol for other upper respiratory conditions in addition
to severe croup.
Action: CW/JH to develop PGD for nebulised adrenaline.
4
Furosemide; MJ confirmed that 12 out of 14 UK ambulance trusts currently include furosemide in
their formulary. AC stated that the latest evidence is indicating furosemide as first line for LVF and
nitrates as the second line option. JRCALC updated guidance indicates GTN as first line drug
followed by furosemide for patients with longer transfer to hospital. NA said that it was the most
requested drug from paramedics. JH provided the pricing and wholesale packs are in boxes of 10
ampoules. AF to source pricing for a pack down option containing just 2 ampoules as it would not be
anticipated to be a high use drug.
Action: AF to source supplier and pack down for furosemide injection in 2 ampoule pack.
Midazolam; MJ confirmed no other UK ambulance trust currently has midazolam within their
formulary. NWAS currently stocks midazolam for Advanced Paramedics for use with Ketamine and is
included in the chemical restraint protocol. BK asked if it was considered to allow SPTLs to have
midazolam. MJ stated they hadn’t reviewed its use with APs yet and this would be required to be
completed before any decisions to give to other paramedic grades was made. MH confirmed they
would still be looking to cascade midazolam to SPTL level and possibly to paramedics in due course.
Oramorph; MJ confirmed 8 other UK ambulance trusts currently have oramorph in their formulary.
JH explained to add oramorph to formulary the medicine supply hub would require a Homme Office
licence to possess and supply controlled drugs. Lloyd Pharmacy group (current suppliers to NWAS of
controlled drugs) cannot currently supply NWAS with the 10ml pack down bottles that NWAS would
want to procure. AC asked why we don’t use the 100ml wholesale bottle size. JH confirmed they
have a 1month expiry after opening and other ambulance trusts previously experienced high
volumes of waste to deal with when using the 100ml bottle size. The 10ml pack down size is an
unlicensed product and Lloyds would not be permitted on their wholesale dealers licence to supply
unlicensed products. MP concluded NWAS would be required to directly the procure the 10ml size
which would require a Home Office licence to hold the stock on the site. MP confirmed this
potential area is going to be explored. Oramorph negated for time being due to agreement to
include IV Paracetamol in formulary.
Reteplase; MJ explained that NWAS no longer performs thrombolysis in any regions of NWAS. MH
confirmed arrangements
are in place in the Furness area for Tenectaplase to be stocked at Furness
General for any patients whose thrombolysis would be delayed beyond the time limit by attempting
a transfer to the nearest PPCI centre. The group rejected Reteplase as an addition to the NWAS
formulary.
Sodium Lactate; JH confirmed this fluid is only indicated in JRCALC when sodium chloride 0.9% is not
available. JH confirmed sodium chloride 0.9% is readily available across NWAS. The group rejected
sodium lactate as an addition to the NWAS formulary.
Tetracaine gel; MJ confirmed only 1 UK ambulance trust had tetracaine in its formulary. AC
confirmed it is not effective pre hospital due to it taking 30 minutes to provide analgesic effect. The
group rejected tetracaine as an addition to the NWAS formulary.
Ciprofloxacin / Dicobalt /Doxycycline / Obidoxime / Potassium iodate are all drugs used for CBRNE
purposes. JH explained there is a Department of Health protocol in place for the deployment of
these drugs. There is an NWAS protocol in place within the CBRNE section of resilience to activate
5
requests for these via EOC. The group were satisfied with the national arrangement and agreed they
would not be required to be stocked as an addition to the NWAS formulary.
JRCALC drugs previously removed from NWAS Formulary
Heparin and Tenectaplase; JH confirmed both drugs were removed from the NWAS formulary due
pre hospital thrombolysis no longer being performed within the NWAS regions.
Syntometrine; JH confirmed syntometrine was removed due to lack of evidenced use by paramedics
and its 8 week expiry date once it was issued out of the suppliers fridges to the ambulances.
Misoprostol was agreed to be its replacement and is listed in NICE guidance and now features in
JRCALC. MJ confirmed Tranexamic acid is now indicated for post-partum haemorrhage (PPH). AC
stated both drugs would be required simultaneously to be effective in controlling PPH.
The group agreed all 3 drugs removed from NWAS formulary that feature in JRCALC did not require
re-introduction to the NWAS formulary.
PGD Reviews
Midazolam - MH presented the updated Midazolam PGD to include indications and dosing for
chemical restraint and for administration as apart of end of life care (EoLC). MD raised concern over
the inclusion of end of life care within the midazolam PGD. MD would prefer clinical advice is sought
to administer midazolam for this indication rather than it being included as part of a PGD to allow it
given without senior clinical advice in place first. MD suggested removing it from the PGD until the
EoLC protocols have been established.
AC asked for an added indication to allow midazolam to be given to patients presenting with
seizures who are tolerant to diazepam. MH to update the PGD.
Action: MH to update Midazolam PGD to include indication permitting the administration of
midazolam for seizures in patients who are tolerant to diazepam.
Action: MH to remove ref to EOLC from indications on page 2 of PGD,
Action: MH to include agitation etc as part of chemical restraint procedure PGD
Action: MH to update PGD with two strengths midazolam required as Chemical Restraint is IM
(10mg/2mL).
Action; AF to source pricing via Lloyds for Midazolam 10mg/2ml ampoules
Action: NA to review body weight tables in Midazolam PGD for IM dosing of midazolam.
Morphine: request for morphine to be administered to patients with a GCS<8 due to trauma related
head injury. JH confirmed a PGD would be required for this as it is not included in a JRCALC protocol
6
Action: MH to prepare morphine PGD for Advance paramedics only with enhanced protocols for post
rosc administration and enhance dosing.
Ketamine: AC requested that any ketamine administration to patients under 12 years of age are
approved via a doctor first for advanced analgesia only. AC requested to clarify ‘following
administration of morphine’ statement further. MJ requested an additional morphine PGD for APs
then some of the exclusion criteria listed in the ketamine PGD can be removed. AC requested that
any repeat / multiple doses required must be authorised by a doctor first.
Action: MH to amend ketamine PGD
Next meeting agreed to be held on the 8th November.
7