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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

 

 

Fentanyl nasal spray (PecFent)

Red – For medicines normally initiated and used under specialist guidance

Introduction

Description: Contains fentanyl, a potent opioid analgesic with a rapid onset of action.

Do not confuse with Alfentanil

Third line opioid: only for use with specialist advice

Preparations

  • PecFent contains fentanyl in a gel-based spray, administered intranasally, available as 100 microgram or 400 microgram per dose products containing 8 doses per bottle or
    32 dose pack available (4 x 8 doses per bottle).
  • Most NHS boards have only approved one or two rapid acting fentanyl products for use in their area. Refer to your local Formulary (Abstral and Effentora medicine information sheets).
  • Rapid acting fentanyl products have different absorption and elimination characteristics and are not interchangeable. Start with the lowest dose and titrate very carefully if the patient is changed to a different product.
  • The brand name should always be included in the prescription.

 

Indications

  • Rapid acting fentanyl preparations are SMC approved for restricted use in NHSScotland; for the management of opioid responsive, breakthrough pain in adults requiring regular opioid therapy for chronic cancer pain.
  • Use is restricted to patients where other oral opioids (for example immediate-release morphine or immediate-release oxycodone) are unsuitable, ineffective or not tolerated.
  • Patients must have been on a stable dose of a regular opioid for at least 7 days equivalent to at least 60mg of oral morphine or 30mg of oral oxycodone in 24 hours or a 25 micrograms/hour fentanyl patch before rapid acting fentanyl is used.
  • Opioids with a rapid onset of action can be effective in breakthrough pain where background cancer pain is well controlled but the patient has:
    • pain related to a particular event (for example movement, dressing changes)
    • pain that occurs spontaneously, is sudden in onset, is moderate to severe, but may not last long.

 

Cautions

  • Hepatic metabolism to an inactive metabolite is slower when higher doses of fentanyl are used.
  • Rapid acting fentanyl products can have a variable and unpredictable half life which in some products can be up to 22 hours.
  • Liver impairment: lower doses and slower titration are needed in severe liver disease.
  • Renal impairment: no initial dose reduction. May accumulate gradually over time in patients with Grade 4-5 chronic kidney disease. Fentanyl is not removed by dialysis.
  • Monitor patients with liver or renal impairment and reduce the dose if side effects develop.
  • Avoid in patients with severe chronic obstructive pulmonary disease or respiratory depression.

 

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.
  • Nasal decongestants (for example oxymetazoline) decrease absorption.

Manufacturers warn of a risk of serotonin toxicity when fentanyl is used in combination with other serotoninergic drugs.

 

Side effects

  • Similar to other opioids: nausea, dizziness, sedation, delirium.
  • Rapid acting fentanyl preparations can accumulate if repeated doses are given.
  • Monitor the patient closely for opioid side effects; review the dose and dosing interval.
  • Titrated naloxone is only indicated in life-threatening, opioid induced respiratory depression (refer to Naloxone guideline).

 

Dose and administration

  • Rapid acting fentanyl preparations must be individually titrated to an effective dose; patients should be monitored closely during the initial dose titration period.
  • The effective dose of rapid acting fentanyl cannot be predicted from the dose of regular opioid being used to manage background pain.
  • The licensed titration regimen may be too complex for some care settings and too rapid for some patients. In specialist palliative care there is little consensus on the most appropriate way to titrate the rapid acting fentanyl preparations – refer to local specialist advice. The regimen below is used by some specialists but is unlicensed (patients under specialist palliative care may have the dose escalated more quickly):
  • Start with the lowest dose of the fentanyl nasal spray (PecFent 100 micrograms):
    • one dose of PecFent can be given to treat an episode of pain or 5 to 10 minutes before an event anticipated to cause pain
    • if the patient is still in pain after taking one dose of PecFent as above, a dose of their usual immediate-release oral opioid is given
    • wait for 4 hours before treating another episode of breakthrough pain with PecFent
    • the dose of PecFent can be increased if it is effective and well tolerated, usually after 24 to 48 hours.
  • Patients whose initial dose is 100 micrograms and who require a higher dose due to lack of effect can be prescribed two 100 microgram sprays (one in each nostril) for their next breakthrough pain episode.
  • If this is unsuccessful, prescribe the higher concentration formulation
    (400 micrograms/spray) and give one 400 microgram spray for the next episode of pain.
  • If this dose is unsuccessful give two 400 microgram sprays (one spray in each nostril – maximum dose is 800 micrograms). Palliative care specialists may recommend an individualised titration regimen.
    • Continue to monitor the patient carefully.
    • A maximum of 4 episodes of breakthrough pain in 24 hours should be treated with fentanyl nasal spray.
  • Make sure background pain is well controlled with regular opioids and other analgesics.
  • If pain remains poorly controlled, review the patient, reassess the background analgesia, and consider other approaches to pain management.

Rapid acting fentanyl should be discontinued if it is ineffective or no longer needed.

 

Practice points

  • Seek advice from a specialist about use of rapid acting fentanyl products.
  • Fentanyl is 100 to 150 times more potent than oral morphine; titrate and monitor carefully.
  • Even the lowest strength preparations can accumulate and cause opioid toxicity.
  • Different rapid acting fentanyl products should not be used at the same time.
  • The GP, community nurse and community pharmacist should be informed.
  • The unscheduled care service should be informed that the patient is receiving a third line opioid under specialist supervision.
  • Fentanyl nasal spray (PecFent®) can be prescribed by the patient’s GP in liaison with local palliative care specialists.
  • If the product has not been used for 5 days, re-prime by spraying once. Discard bottle
    60 days after first opening.
  • Patients may not always feel the spray so should be encouraged to listen for the audible click.
  • The patient should have information about who to contact if there are any queries or problems relating to use of PecFent® in the community.

 

Resources

Summary of product characteristics for PecFent from the electronic medicines compendium:

 

References

Davies A. The management of cancer related breakthrough pain: recommendations of a task group of the Association for Palliative Medicine. European Journal of Pain; 2009, 13 (4): 331-338.