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Announcements and latest updates

Right Decision Service newsletter: September 2024

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

1.Business case for permanent provision of the Right Decision Service from April 2025 onwards

This business case has now been endorsed by the HIS Board and will shortly be submitted to Scottish Government.

2. Management of RDS support tickets

To balance increasing demand with available capacity and financial resource, the RDS team and Tactuum are now working together to  implement closer management of support tickets. As a key part of this, we want to ensure clear, timely and consistent communication with yourselves as requesters.  

Editors will now start seeing new messages come through in response to support ticket requests which reflect this tightening up and improvement of our processes.

Key points to note are:

2.1 Issues confirmed by the RDS and Tactuum teams as meeting the critical/urgent and high priority criteria will continue to be prioritised and dealt with immediately.

Critical/urgent issues are defined as:

  1. The Service as a whole is not operational for multiple users. OR
  2. Multiple core functions of the Service are not operational for multiple users.

Example – RDS website outage.

Please remember to email ann.wales3@nhs.scot and his.decisionsupport@nhs.scot with any critical/urgent issues in addition to raising a support ticket.

High priority issues are defined as:

  1. A single core function of the Service is not operational for multiple users. OR:
  2. Multiple non-core functions of the Service are not operational for multiple users.

Example – Build to app not working.

2.2 Support requests that are outwith the warranty period of 12 weeks since the software was originally developed will not be automatically addressed by Tactuum. The RDS team will consider these requests for costed development work and will obtain estimate of effort and cost from Tactuum for priority issues.

2.3 Support tickets for technical issues that are not classified as bugs will not be automatically addressed by Tactuum. The definition of a bug is ‘a defect in the software that is at variance with documented user requirements.’  Issues that are not bugs will also be considered for costed development work.

The majority of issues currently in support tickets fall into category 2 or 3 above, or both.

2.4 Non-urgent requests that require a deployment (i.e a new release of RDS) will normally be factored into the next scheduled release (currently end of Nov 2024 and end of Feb 2025) unless by special agreement with the RDS team.

Please note that we plan to move in the new year to a new system whereby requests all come to an RDS support portal in the first instance and are triaged from there to Tactuum when appropriate.

We will be organising a webinar in a few weeks’ time to take you through the details of the current support processes and criteria.

3. Next scheduled deployment.

The next scheduled RDS deployment will take place at the end of November 2024.  We are reviewing all outstanding support tickets and feature requests along with estimates of effort and cost to determine which items will be included in this deployment.

We will update you on this in the next newsletter and in the planned webinar about support ticket processes.

4. Contingency arrangements for RDS

Many thanks to those of you who attended our recent webinar on the contingency arrangements being put in place to prevent future RDS outages as far as possible and minimise impact if they do occur.  Please contact ann.wales3@nhs.scot if you would like a copy of the slides from this session.

5. Transfer of CKP pathways to RDS

The NES clinical knowledge pathway (CKP) publisher is now retired and the majority of pathways supported by this tool have been transferred to the RDS. Examples include:

NHS Lothian musculoskeletal pathways

NHS Fife rehabilitation musculoskeletal pathways

NHS Tayside paediatric pathways

6. Other new RDS toolkits

Include:

Focus on frailty (from HIS Frailty improvement programme)

NHS GGC Money advice and support

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

To go live imminently:

  • Focus on dementia
  • NHS Lothian infectious diseases toolkit
  • Dumfries and Galloway Adult Support and Protection procedures
  • SIGN guideline – Prevention and remission of type 2 diabetes

 

7. Evaluation projects

We have recently analysed the results of a survey of users of the Scottish Palliative Care Guidelines toolkit.  Key findings from 61 respondents include:

  • Most respondents (64%) are frequent users of the toolkit, using it either daily or weekly. A further 25% use it once or twice per month.
  • 5% of respondents use the toolkit to deliver direct patient care and 82% use it for learning
  • Impact on practice and decision-making was rated as very high, with 80% of respondents rating these at a 4-5 on a 5 point scale.
  • Impact on time saving was also high, with 74% of respondents rating it from 3-5.
  • 74% also reported that the toolkit improved their knowledge and skills, rating these at 4-5 on the Likert scale

Key strengths identified included:

  • The information is useful, succinct, and easy to understand (31%).
  • Coverage is comprehensive (15%)
  • All information is readily accessible in one place and users value the offline access via mobile app (15%)
  • Information is reliable, evidence-based and up to date (13%)

Users highlighted key areas for improvement in terms of navigation and search functionality. The survey was very valuable in enabling us to uncover the specific issues affecting the user experience. Many of these can be addressed through content management approaches. The issues identified with search results echo other user feedback, and we are costing improvements with a view to implementation in the next RDS deployment.

8.RDS High risk prescribing (polypharmacy) decision support embedded in Vision and EMIS primary care E H R systems

This decision support software, sponsored by Scottish Government Effective Prescribing and Therapeutics Division,  is now available for all primary care clinicians across NHS Tayside. Board-wide implementation is also planned for NHS Lothian, and NHS GGC, NHS Ayrshire and Arran and NHS Dumfries and Galloway have initial pilots in progress. The University of Dundee has been commissioned to evaluate impact of this decision support software on prescribing practice.

9. Video tutorials for RDS editors

Ten bite-size (5 mins or less) video tutorials for RDS editors are now available in the “Resources for providers of RDS tools” section of the RDS.  These cover core functionality including Save and preview, content page and media management, password management and much more.

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

  • Wednesday 23rd October 4-5 pm
  • Tuesday 29th October 11 am -12 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.)

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

 

Fentanyl buccal (Effentora)

Amber - For medicines normally initiated by a specialist but may be used by generalists

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

  • This guideline is for the use of Effentora – a buccal fentanyl tablet (available as 100, 200, 400, 600, 800 micrograms).  Alternatively the tablet can be placed sublingually.

Most NHS boards have only approved one or two rapid acting fentanyl products for use in their area. Check your local Formulary (refer to Abstral and PecFent 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, can be 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 dose if side effects develop.
  • Avoid in severe chronic obstructive pulmonary disease or respiratory depression.
  • Mouth ulcers, mucositis or dry mouth can affect absorption.
  • Effentora® has a high sodium content.

 

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.
  • 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 – check 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 buccal fentanyl tablet (Effentora® 100 micrograms):
      • one dose of Effentora® can be given to treat an episode of pain or 5 to 10 minutes before an event anticipated to cause pain.
      • if the patient can be monitored and is not at risk of opioid toxicity, a second tablet of 100 micrograms can be given after 30 minutes, if required.
      • if the patient is still in pain after taking one or two tablets of Effentora® as above, a dose of their usual immediate release oral opioid can be given.
      • wait for 4 hours before treating another episode of breakthrough pain with Effentora® – refer to table below

 

Tables are best viewed in landscape mode on mobile devices

Strength of FIRST buccal tablet per episode of breakthrough pain

Strength of SECOND buccal tablet to be taken 30 minutes after first tablet, if required

100 micrograms

100 micrograms

200 micrograms

200 micrograms

400 micrograms

200 micrograms

600 micrograms

200 micrograms

800 micrograms

NONE – efficacy & safety of doses > 800 micrograms have not been evaluated.

 

  • A maximum of 4 episodes of breakthrough pain in 24 hours should be treated with buccal fentanyl tablets.
  • The dose of Effentora® can be increased in a step-wise manner if it is showing some effect and is well tolerated, usually after 24 to 48 hours. Palliative care specialists may recommend an individualised titration regimen.
    • Continue to monitor the patient carefully.
  • 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 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 buccal tablets (Effentora®) can be prescribed by the patient’s GP in liaison with local palliative care specialists.
  • The patient should have information about who to contact if there are any queries or problems relating to use of Effentora® in the community.

 

Resources

Summary of product characteristics for Effentora from 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.

Twycross R & Wilcock A. Palliative Care Formulary, (Fourth Edition). Palliativedrugs.com Ltd, Nottingham, 2011