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Right Decision Service newsletter: October 2024

Welcome to the Right Decision Service (RDS) newsletter for October 2024.

1.Contingency arrangements for RDS outages

Development of the contingency solutions to maximise RDS resilience and minimise risk of future outages is in progress, aiming for completion by Christmas. As a reminder, these contingency arrangements  are:

  • Optimising mobile app build process
  • Mobile app always to be downloadable.
  • Serialising builds to mobile app; separate mobile app build from other editorial and end-user processes
  • Load balancing – provides failover (also enables separation of editorial processes from other processes to improve performance.)

 

In the meantime, a gentle reminder to encourage users to download essential clinical toolkits to their mobile devices so that there is an offline version always available.

 

2. New deployment with improvements.

A new scheduled deployment with minor improvements drawn from support tickets, externally funded projects, information related to outages, and feature requests will take place in early December. Key improvements planned are:

  • Deep-linking to individual toolkits within the RDS mobile app. Each toolkit will now have its own direct URL and QR code, both accessible from the app. These can be used to download the toolkit directly where users already have the RDS app installed. If the user does not yet have the RDS app installed, they will be taken to the app store to install the app and immediately afterwards the toolkit will automatically open and download. Note that this will go live a few days later than the improvements below due to the need to link up the mobile front end to the changes in the content management system.
  • Introducing an Announcement Header field to replace the hardcoded "Announcements and latest updates" text. This will enable users to see at a glance the focus of new announcements.
  • Automated daily emptying of the recycling bin (with a 30 day rolling grace period)  in the content management system. A bug preventing complete emptying of the recycling bin contributed to one of the outages earlier this year.
  • Supporting multiple passcodes (ticket 6079)
  • Expanding accordion section to show location of a search result rather than requiring user coming from a search result to manually open all sections and search again for the term.
  • Displaying first accordion section Content text as a snippet on the search results page as a fallback if default/main content is not provided
  • Displaying the context of each search result in the form of a link to the relevant parent tool/section. This will help users to choose which search result is most likely to be appropriate for their needs.
  • As part of release of the new national benzodiazepine quality prescribing guidance toolkit sponsored by Scottish Government Effective Prescribing and Therapeutics, a digital tool to support creation of benzodiazepine tapering/withdrawal schedules.

We are also seeking approval to use the NHS Scotland logo and title for the RDS app on the app stores to help with audience engagement and clarity around the provenance of RDS.

3. RDS Search, Browse and Archive/Version control enhancements

We are still hopeful that user acceptance testing for at least the Search and browse enhancements can take place before Christmas. Thank you for your patience and understanding in waiting for these improvements. Timescales have been pushed back by old app migration challenges, work to address outages, and most recently implementing the contingency arrangements.

4. Support tickets

We are aware that there continue to be some issues around a number of RDS support tickets, in part due to constraints around visibility for the RDS team of the tickets in the existing  support portal. We are investigating the potential to move to a new support ticket requesting system from early in the new year. We will organise the proposed webinar around support ticket processes once we have confirmed the way forward with the system.

Table formatting

There is a known issue with alterations in formatting of some RDS tables which seems to have arisen as a result of the 17 October deployment. Tactuum is working on a fix and on implementing additional regression testing to prevent this issue recurring.

5. New RDS toolkits

Recently launched toolkits include:

NHS Lothian Infectious Diseases

Scottish Health Technologies Group – Technology Assessment recommendations

NHS Tayside Anaesthetics and Critical Care projects – an innovative toolkit which uses PowerAutomate to manage review and response to proposals for improvement projects.

If you would like to promote one of your new toolkits through this newsletter, please contact ann.wales3@nhs.scot

A number of toolkits are expected to go live before Christmas, including:

  • Focus on dementia
  • Highland Council Getting it Right for Every Child
  • Dumfries and Galloway Adult Support and Protection procedures
  • National Waiting Well toolkit
  • Fertility Scotland National Network
  • NHS Lothian postural care for care homes

6.Sign up to RDS Editors Teams channel

We have had a good response to the recent invitation to sign up to the new Teams channel for RDS editors. This provides a forum for editors to share learning, ideas and questions and we hope to hold regular webinars on topics of interest.  The RDS team is in the process of joining participants to the channel and we’d encourage all editors to take part, using the registration form – available in Providers section of the RDS Learning and Support area.

 

7. Evaluation projects

The RDS team has worked with colleagues in NHS Grampian and the Digital Health & Care Innovation Centre to evaluate the impact of the Prevent the progress of diabetes web and mobile app in a small-scale pilot project. This app provides access to local and national resources and services targeted at people with prediabetes, a history of gestational diabetes, or candidates for remission. After just 8 weeks of using the app, 94% of patients reported increased their knowledge and understanding of diabetes, and 88% said it had increased their confidence and motivation to make lifestyle changes, highlighting specific behaviour changes. The learning from this project is informing development of a service model based on tailored support for patient groups with, high, medium and low digital self-efficacy.

Please contact ann.wales3@nhs.scot if you would like to know more about this project.

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 29th November 3-4 pm
  • Thursday 5 December 3.30 -4.30 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

The Right Decision Service:  the national decision support platform for Scotland’s health and care

Website: https://rightdecisions.scot.nhs.uk    Mobile app download:  Apple  Android

 

 

Alfentanil

Red – For medicines normally initiated and used under specialist guidance

Introduction

Description: Potent opioid, rapid onset and short duration of action.

Third-line opioid: only for use with specialist advice.

Caution: Do not confuse with Fentanyl. Fentanyl is four times more potent than alfentanil. 

Preparations

Tables are best viewed in landscape mode on mobile devices

Injection 1mg in 2ml
5mg in 10ml (not routinely used) 5mg in 1ml (high strength)		 Ampoules
  • Used as a subcutaneous infusion or sublingually. (The ampoules can be opened and administered sublingually ⴕ).
  • A high concentration preparation (5mg in 1ml) can be ordered.
Caution with high strength preparation; refer to local policy for its use.
Sublingual/
buccal spray		 5mg/5ml (1 metered dose = 140 micrograms) 5ml spray Pharmacist can order spray on a named patient basis if advised by a palliative care specialist (check local NHS board for availability).

 

Indications

  • Third-line injectable opioid for moderate to severe opioid responsive pain in patients unable to tolerate morphine, diamorphine or oxycodone due to persistent side effects (for example sedation, confusion, hallucinations, itch). Refer to Pain management, Choosing and changing opioids guidelines.
  • Injectable analgesic for moderate to severe, opioid responsive pain in patients with Stage 4 to 5 chronic kidney disease (eGFR less than 20ml/min) although specialists may recommend earlier, or severe acute renal impairment.
  • Episodic/incident pain:
    • pain often related to a particular event (for example movement, dressing changes); sudden in onset, can be severe, but may not last long
    • different from breakthrough pain occurring when the dose of regular analgesic has worn off
    • assessed and treated independently of the regimen used to manage any continuous/background pain. 

 

Cautions

  • Liver impairment: reduced clearance.
    Dose reduction of 30 to 50% may be necessary.
  • Renal impairment: no dose reduction needed.
    Not removed by dialysis.

Drug interactions

  • Hepatic metabolism is reduced by grapefruit juice and a number of medications, for example fluconazole, QTclarithromycin, QTerythromycin: refer to British National Formulary (BNF).
  • Alcohol and central nervous system depressants increase side effects
  • Anticonvulsants may reduce its effect. Refer to BNF.

Side effects

Similar to other opioids: nausea, dizziness, sedation, delirium, rarely respiratory depression.

 

Dose and administration

  1. Alfentanil for moderate to severe opioid responsive pain
    • Continuous subcutaneous infusion in a CME T34 syringe pump over 24 hours.
    • Stability and compatibility – refer to CME T34 syringe pump compatibility tables.
    • Titrate on the advice of a specialist.
    • Prescribe doses of over 1000micrograms in milligrams (mg).
    • Prescribe 1/6th to 1/10th of the 24 hour dose hourly for breakthrough pain as alfentanil has a very short duration of action. The same dose can be given subcutaneously or sublingually. Sometimes other opioids with a longer duration of action are used for breakthrough pain.  If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review.  If more than 6 doses are required in 24 hours seek advice or review.

  2. Alfentanil for episodic/ incident pain
    • Starting dose: 100micrograms.
    • Give a dose five minutes before an event likely to cause pain, for example, a painful dressing change; repeat if needed.
    • Increase dose according to response.  This dose is titrated independently of the background dose.
    • Give by subcutaneous injection or sublingually at the same dose.
    • Consider an alfentanil spray if the patient is being discharged home (check local health board for availability).

 

Dose conversions

Alfentanil is approximately (≈) 30 times more potent than oral morphine.

Tables are best viewed in landscape mode on mobile devices

Oral morphine 30mg ≈ subcutaneous alfentanil 1mg (1000micrograms)
Subcutaneous morphine 15mg ≈ subcutaneous alfentanil 1mg (1000micrograms)
Subcutaneous diamorphine 10mg ≈ subcutaneous alfentanil 1mg (1000micrograms)
Oral oxycodone 15mg ≈ subcutaneous alfentanil 1mg (1000micrograms)
Subcutaneous oxycodone 7.5mg ≈ subcutaneous alfentanil 1mg (1000micrograms)

 

A patient whose pain is controlled on a subcutaneous alfentanil infusion can be converted to a fentanyl patch. Apply the patch and stop the infusion 12 hours later. Seek advice for dose conversions as cross titration may be necessary.

  • Dose conversions should be conservative and doses rounded down.
  • Monitor the patient carefully so that the dose can be adjusted if necessary.
  • If the patient has opioid toxicity, reduce dose by approximately 1/3rd when changing opioid (refer to Choosing and changing opioids guideline).

 

Practice points

  • The community pharmacist, GP and community nurse should be informed as preparations may not be readily available.
  • The unscheduled care service should be informed that the patient is receiving this third-line opioid.
  • Alfentanil can be prescribed by the patient’s GP for the indications listed in liaison with local palliative care specialists.

 

Resources

Professional
Royal Pharmaceutical Society. Palliative Drugs. 2018 [cited 2018 Oct 02]; Available from: http://www.palliativedrugs.com/.

 

References

Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage. 2004;28(5):497-504.

Urch CE, Carr S, Minton O. A retrospective review of the use of alfentanil in a hospital palliative care setting. Palliat Med. 2004;18(6):516-9.