Transdermal patches in care homes – good practice guidance

A transdermal patch is a medicated adhesive patch that is placed on the skin to deliver a specific dose of medication through the skin and into the bloodstream.

There are several types of patches and the directions for use vary with each brand of patch. It is very important to read the patient information leaflet before use. There have been several reported safety alerts related to transdermal patches; these include the potential for life-threatening harm from accidental exposure to transdermal fentanyl patches: see MHRA patient safety alert.

This guidance aims to support safer administration of transdermal patches and to highlight key issues that need to be considered when care home staff administers a patch. This guidance does not cover contraceptive or hormone replacement therapy (HRT) patches. This advice does not replace manufacturers’ instructions which should always be read for patch specific advice.

Process of applying a patch:

Always wear a glove when applying a patch.
If needed, clean the skin with water only and make sure the skin is dry (soap products can alter absorption).
Remove old patch or patches, dispose of safely before applying new one and rotate the site of application.
Check the patch application record sheet as there may be multiple patches on the individual that should be removed.

Don’t

Don’t take a drug patch out of its protective wrapper until you’re ready to apply to the skin site
Don’t use a drug patch if the seal is broken, altered, cut, or damaged in any way
Don’t use soaps, oils, lotions, alcohol, or other agents that might irritate or alter the skin site¹
Don’t expose the application site to direct external heat sources, such as heating pads¹
Don’t apply a new patch immediately after a bath or shower, or after using cream, talc or soap on the skin

Do follow the “six rights” of drug administration: Right Resident, Right Medicine, Right Route, Right dose, Right time & Resident’s right to refuse²
Do record the patch location on a patch application record sheet & MAR A patch application record sheet can be used to indicate where the patch has been previously placed³
Do provide privacy for the resident, ensure good hand hygiene, and explain the procedure
Do check the patch daily to ensure it is still attached firmly in place

Recommendations:

The residents care plan should contain a clear indication for treatment and intended
Use a personalised patch application record sheet for all patches (Appendix 1). This should be kept with the residents current Medication Administration Record (MAR) chart.
Put a cross on the body map (Appendix 1) where the patch has been applied, this will help to locate and replace old patches, and to avoid new patches been applied on the same area.³
Medication Administration Record (MAR) sheets need to be clearly annotated to highlight when the next patch change is due. The days when a patch change is not required should be clearly crossed through on the MAR sheet.⁴
If a resident is transferred to another care home unit or care setting (e.g., hospital) communicate information of the patch when it was last changed, the current location and when the next patch change is due.
When applying a patch for a resident, gloves should be If applicable, remove the old patch and dispose of it first before applying a new one.
Apply patch to clean dry, non-inflamed, non- irritated, hairless skin on upper arm or trunks. Body hair may be clipped, but do not If the site needs to be cleaned before application, use only clear water, and let the skin dry completely.
In cases where more than one patch is required, these should be placed on the same area of the body however it needs to be ensured that these do not overlap.⁵
Ensure the correct patch has been removed, since some residents may be using more than one type of patch.
It is good practice to write the date and time of the application of the new patch on the edge of the patch itself using a soft-tip permanent marker pen, taking care not to damage or tear the backing liner, so that it is visible to all care staff involved.⁶
Bathing, showering, or swimming should not affect the patch, but water should not be too
If a patch falls off, it must be documented and signed by a witness in the care plan and behind the MAR chart. A new patch should be applied and removed at the correct An interim prescription may be needed or a discussion with the GP regarding early ordering of the patch for the next medication cycle.
The patches are waterproof but avoid soaking in a hot bath, saunas, or Heat increases the rate of transdermal drug absorption and can cause toxicity – avoid direct contact with heat (e.g. hot water bottle, heat pad).⁷
If a patient has missed or has been non-compliant to their opioid (e.g. Fentanyl or Buprenorphine) patch, then you need to check with the GP before applying the next patch.
If the patient has an elevated temperature, inform the GP as the patch dose may need to be Note that drug Concentrations from opioid patches may increase if the skin temperature increases to 40°C such as with Fentanyl patches.⁸
Used patches still contain active medicine which can be fatal if it accidentally touches or sticks to somebody else’s skin. After removal fold the patch in half over on itself so that the adhesive side sticks together. Residential homes should dispose of used patches via their usual pharmaceutical waste arrangements for instant destruction. Nursing homes should place used patches into their CD denaturing kit.⁹
If the brand of a patch is changed to another by the prescriber, in particular with controlled drugs such as Fentanyl Patches, counselling should be sought from your GP or community pharmacist. Drug concentration may vary between different brands.¹⁰
Avoid cutting patches if possible and cutting a patch will make the use ‘off-licence’. The release mechanism of the medicine could be adversely affected and release more medicine than intended. Always discuss and obtain authorisation from the prescriber if a patch is intended to be cut.
For a resident who is confused, the upper back (see appendix 1) maybe a preferred site to apply the patch to avoid unintended removal of patch. Refer to local procedures on capacity and consent.