SNAPLOCK POLYTHENE BAG FOR DISPENSING DRUGS IN GOVERNMENT HOSPITALS IN SRI LANKA

1
SNAP-LOCK POLYTHENE BAG FOR DISPENSING DRUGS IN
GOVERNMENT HOSPITALS IN SRI LANKA

• SENARATHNA L (1), SAMARANAYAKE A (2),
• KUMARAGE S (3), SENEVIRATHNA A (4), KAPPAGODA S
  (5)
• (1)OX-COL COLABORATION, DEPARTMENT OF CLINICAL
  MEDICINE, COLOMBO GOVERNMENT HOSPITALS
  (2)MATALE, (3)GAMPOLA, (4)MEDAWACHCHIYA, (5)KANDY.

2
ABSTRACT

• SNAP-LOCK POLYETHYLENE MINI BAGS FOR
  DISPENSING DRUGS IN SRI LANKA
• Senarathna L, Samaranayake A, Kumarage S,
  Senevirathna A, Kappagoda S.
• Ox-Col Collaboration, Department of Medicine,
  Colombo Government Hospitals in Matale, Gampola,
  Medawachchiya and Kandy.
• Problem Statement Outpatient drugs are
  dispensed free of charge in government hospitals
  in Sri Lanka, usually as loose capsules or
  tablets wrapped in paper. Storage is often
  inappropriate, risking reduced drug potency due
  to humidity and sunlight and mixing up of tablets
  with similar appearance. A snap lock
  polyethylene bag (cost, USD 0.02) containing a
  drug information card was recently introduced for
  each drug. Objectives To determine acceptability
  of and patient attitude toward payment for
  snap-lock bags. Design Observational study
  comparing two hospitals. Setting and Study
  Population Two government hospitals in the
  Central Province of Sri Lanka, one that charged
  money for the bags and one that did not. We
  traced pharmacy records and interviewed patients
  and pharmacists. Two hundred outpatients using
  bags were randomly selected (100 from each
  hospital). Pharmacists from clinics answered a
  questionnaire Outcome Measures Use of bags
  initially and after 10 months percentage of
  patients coming with the bag to subsequent
  clinics initially and after 10 months patient
  attitude toward payment for bags acceptability
  of bag to patients and pharmacists. Results
  Payment for bags initially reduced their uptake
  (73 with payment 100 without) uptake of bags
  in paying hospitals increased to 95 after 10
  months. Patient acceptance was high - 82 of
  patients brought the bag to the next clinic
  after 10 months, this increased to 91. There was
  no difference between hospitals. Opening the bag
  caused difficulties during the first month in
  both hospitals 35 of patients cut or tore the
  bag to open it. Education by pharmacists reduced
  this to 5. An average of 65 of patients (60 in
  nonpaying hospital, 70 in paying hospital)
  agreed to pay money and thought an acceptable
  payment would motivate them to bring the bag
  back. In both hospitals, 95 of patients liked
  the bag, particularly since it prevented tablet
  mix-ups. Fourteen pharmacists in both hospitals
  agreed that the bags enhanced the quality of
  their dispensing. Conclusions Acceptance of the
  newly introduced bags was good in both hospitals
  acceptance was slower but still substantial where
  patients were charged for the bag. Pharmacist
  workload increased when the bags were first
  issued due to patient unfamiliarity and the time
  spent enclosing the drug information card, but
  workload subsequently decreased below previous
  levels with reuse of bag and card. Both patients
  and pharmacists thought that the bags were an
  improvement. Our experience suggests that
  polyethylene bags may be useful to prevent mixing
  of tablets/capsules to improve home storage of
  drugs and, with the card, to provide appropriate
  drug information. Proper use of the bags also
  suggests patients willingness to contribute
  appropriately to their health care.

3
Background

• Government Hospitals issue outpatient medication
  as loose tablets or capsules wrapped in paper.
• Appropriate storage difficult due to high
  humidity temperature.
• Possible deterioration in drug potency /or
  product formulation (discolouration, loss of
  tablet coating, capsule melting, loss of potency)
  e.g. phenytoin, amitriptyline
• Tablets with similar appearance may be mixed up
• Limited opportunity to provide written drug
  information with product.
• To overcome these issues four hospitals recently
  introduced a snap lock polythene bag for
  dispensing tablets/capsules.
• Some hospitals issued for free, others charged
  per bag

4
Ordinary Paper Wrapping
Paper bags used to dispense tablets/capsules
Tablets wrapped in papers
5
Newly Introduced Bags
Snap-lock closure
Drug information card
6
Aims

• We set up an observational study in two hospitals
  to assess the effect of payment on
• Patient compliance
• Initial use of snap lock bags
• Ongoing use of snap lock bags at 10 months
• Feedback by users
• Patients attitude(, ease of use, dosing errors)
• Pharmacists attitude (patient education, ease of
  use, impact on workload).

7
Methodology

• Two Base hospitals were selected, both serving
  100 000 clinic patients per year.
• One hospital charged USD0.02 per bag.
• One hospital issued bags free of charge.
• 100 patients systematically selected from each
  hospital.
• Cross section of all the patients coming to
  clinics.
• Patients requiring ongoing medication therapy and
  receiving gt2 weeks supply per dispensing

8
Methodology cont

• Each patient interviewed to assess
• Acceptance of bags and the provision of drug
  information
• Compliance/confidence (subjective)
• Each pharmacist interviewed to assess
• Impact of bags on the dispensing process
• Opportunities for provision of drug information
• Overall effect on work load
• Statistics analysed using Chi-square test

9
Results

• Requirement for payment reduced the uptake of the
  bags initially
• 73 with payments, 100 free of charge
• Uptake of bags in the payment hospital increased
  to 95 after 10 months (plt0.0001)
• Initial concerns over payment settled
• Pharmacist education (verbal written on card)
• Encouraged use by other patients

10
Patient acceptance

• During first month, 35 of patients cut or tore
  the bag to open
• ? to 5 at 10 months due to pharmacist education
  (plt0.0001)
• 82 of patients brought the bag to the next
  clinic after first month.
• ? to 91 at 10 months (pN/S)
• No difference in outcome between hospitals

11
Patient and Pharmacist feedback

• 95 of patients at both hospitals liked the bag.
• Prevents tablet mix-ups because of separate
  packaging
• Improved patient confidence
• Prevents spoilage of medication (protection from
  H2O)
• 100 of pharmacists in both hospitals accepted
  bag
• Initially increased time of dispensing (selecting
  bag, filling drug information sheet, education of
  patient)
• Reuse of the bag subsequently reduce their work
  load.
• Less repetition of instructions and drug
  information
• Overall, it was felt that he bag improved the
  quality of dispensing

12
Discussion and Future Directions

• Our experience suggests that snap-lock bags may
  help prevent mixing of tablets/capsules, improve
  home storage and to provide drug information.
• Should they be introduced Island-wide?
• Are further studies needed to measure the impact
  of the drug information card and to confirm
  improved compliance?
• Patients are willing to contribute to the cost of
  their health care that is currently free of
  charge.
• This may help maintain the provision of quality
  and affordable health care for patients in Sri
  Lanka.
• The challenge lies in implementation of other
  programs

13
Discussion and Future Directions cont.

• Other dose forms or administration aids (eg.
  typed labels, blister strips or unit-of-use packs
  for selected patients) may improve outcomes such
  as patient compliance and prevent mediation
  misadventure and waste.
• Given restrictions in resources, the
  practicalities of this in the current health
  system are not clear
• Feasibility of these or other alternatives should
  be addressed by the Sri Lankan Ministry of Health
• This may be in cooperation with WHO, IDA
  (International Dispensary Association), NGOs,
  others

14
Acknowledgements

• We are grateful for the assistance of the
  following
• Prof Krishantha Weerasuriya (WHO SEARO)
• Dr Michael Eddleston (UK, Sri Lanka)
• Dr Darren Roberts (Australia, Sri Lanka)
• Hospital Directors at Matale Gampola
• Chief Pharmacists at Matale Gampola Base
  Hospitals
• Pharmacists at Matale and Gampola Base Hospitals