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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 patches

Green – For medicines routinely initiated and used by generalists

Introduction

Description: Potent opioid analgesic in a topical patch lasting 72 hours (on specialist advice some patients may require the patch to be changed every 48 hours).

"Safety Alert: IT IS BEST PRACTICE TO REMOVE ALL TRANSDERMAL PATCHES FOR MRI SCANS. THIS IS OF PARTICULAR IMPORTANCE FOR FENTANYL AND BUPRENOPRHINE PATCHES WHICH CAN CAUSE SERIOUS OVERDOSE IF NOT REMOVED PRIOR TO SCAN" 

 

Preparations

Tables are best viewed in landscape mode on mobile devices

Format Dose Examples
Matrix patch 12, 25, 37.5, 50, 75,100 micrograms/hour Matrifen®, Fencino®, Mezolar®, Osmanil®, Opiodur®, Yemex®, Mylafent®, Victanyl®
Reservoir patch 25, 50, 75,100 micrograms/hour Tilofyl®, Fentalis®

It is recommended that patients should ideally stay on the same formulation and should not switch between a matrix and a reservoir patch. Consult local guidance for preferred brand.

 

Indications

  • Second line opioid for moderate to severe opioid responsive pain.
  • Pain must be stable.
  • Oral and subcutaneous routes are not suitable.
  • Patient unable to tolerate morphine/ diamorphine due to persistent side effects.
  • Compliance is poor, but supervised patch application is possible.

 

Cautions

  • Fentanyl is a potent opioid analgesic; check the dose conversion carefully. 100 to 150 times more potent than oral morphine.
  • A 25micrograms/hour fentanyl patch is equivalent to about 60mg to 90mg of oral morphine in 24 hours.
  • Frail or elderly patients may need lower doses and slower titration.
  • Heat/pyrexia increases the absorption of fentanyl and can cause toxicity.  Avoid direct contact with heat (for example hot water bottle, heat pad). Showering is possible as the patches are waterproof, but patients should avoid soaking in a hot bath, sauna or sunbathing. If the patient has a persistent temperature of 39◦C, the patch dose may need reviewed - use anti-pyretic measures.
  • Liver impairment: dose reduction may be needed in severe liver disease.
  • Renal impairment: no initial dose reduction. May accumulate gradually over time. Monitor patient and reduce dose. Fentanyl is not usually removed by dialysis.
  • Do not cut patches, cutting patches makes them 'off-label'
  • Remove patches before MRI

Drug interactions

  • Hepatic metabolism is reduced by grapefruit juice and a number of medications (for example fluconazole, QTclarithromycin, QTerythromycin): check British National Formulary (BNF).
  • Alcohol and CNS depressants increase side effects.
  • Anticonvulsants may reduce its effect. Refer to BNF.
  • Manufacturers warn of a risk of serotonin toxicity when fentanyl is used in combination with other serotonergic drugs.

Side effects

  • Similar to other opioids (dizziness, sedation, delirium) but less constipation and possibly less nausea.
  • If signs of opioid toxicity (for example sedation, delirium), remove the patch and seek advice. Fentanyl will be released from the site for up to 24 hours. Monitor the patient for 24 to 48 hours.
  • Naloxone (in small titrated doses) is only needed for life-threatening respiratory depression (refer to Naloxone guideline).
  • An allergic reaction to the patch adhesive can occur – consider switching brand of patch, change opioid or consider one to two doses of a 50micrograms to 100micrograms beclometasone dipropionate inhaler on to site prior to application of patch.

 

Dose and administration

Starting a fentanyl patch

  • Do not start in the last days of life
  • Choose a suitable patch - matrix patch allows titration in smaller increments.
  • Calculate the dose of fentanyl from the conversion chart given here or seek advice. Patch strengths can be combined to provide an appropriate dose.
  • Patches are licensed for dose initiation and titration.
  • Make sure the patient takes another regular opioid for the first 12 hours after the patch is first applied to allow the fentanyl to reach therapeutic levels (refer to Switching opioid to fentanyl patch table below).
  • An immediate release opioid (for example oral morphine or morphine SC) must be available 1 to 2 hourly, as required, for breakthrough pain or to treat any opioid withdrawal symptoms (diarrhoea, abdominal pain, nausea, sweating). These can occur during the fentanyl initiation period due to the variable time to reach steady state. The correct 4 hourly equivalent dose should be used.
  • Fentanyl is often less constipating than morphine; half dose of any laxative and titrate.

Switching opioid to fentanyl patch

Tables are best viewed in landscape mode on mobile devices

Current opioid Switching procedure
Immediate release (quick acting) morphine or oxycodone Apply patch; continue the immediate release opioid 4 hourly for the next 12 hours.
Modified release (long acting) 12 hourly morphine or oxycodone Apply patch when the last dose of a 12 hourly, modified release opioid is given.
Subcutaneous infusion of morphine, diamorphine, oxycodone or alfentanil Apply the patch and continue the infusion for the next 8 to 12 hours, then stop the infusion.

Adjusting the fentanyl patch dose

  • Review the fentanyl patch dose after 72 hours; drug levels will be at steady state.
  • If the patient shows signs of opioid toxicity (drowsiness, confusion), reduce the dose and reassess the pain. Seek advice.
  • If the patient still has pain which is opioid responsive, titrate the fentanyl dose in 12micrograms to 25 micrograms/hour increments depending on the patch strength in use. Remember to include the breakthrough doses used. It will take 12 to 24 hours for the new dose to take effect so give breakthrough analgesia at the correct dose, as required. If there is a significant increase in the number of breakthrough doses required seek specialist advice.

Fentanyl patches in the last days of life

  • Continue the fentanyl patch, changing it every 72 hours.
  • If a new, opioid responsive pain develops, use subcutaneous morphine as required for breakthrough pain. Use the conversion chart to calculate the dose of morphine. If the patient is known to be renally impaired alfentanil may be a more appropriate choice (eGFR less than 20ml/min although specialists may recommend earlier – refer to Renal disease in the last days of life).
  • After 24 hours, the breakthrough doses of morphine given in that period can be totalled and this dose of morphine administered as an SC infusion in a syringe pump over the next 24 hours in addition to the fentanyl patch.

Switching a fentanyl patch

  • If switching from a fentanyl patch to any other strong opioid by any other route, specialist palliative care advice should be sought.

 

Dose conversions

  • All opioid dose conversions are approximate.
  • Patients should be monitored closely so that the dose can be adjusted if necessary.
  • Manufacturers of the various formulations of fentanyl have issued different recommendations for dose conversion, as have drug regulatory bodies.
  • Fentanyl is approximately 100 to 150 times more potent than oral morphine; the table below provides a guide to dose conversions, but if in doubt seek advice.

Tables are best viewed in landscape mode on mobile devices

24 hour oral morphine dose Fentanyl patch dose (micrograms per hour) Immediate release oral morphine (1) Suggested breakthrough dose (refer to guidance in dose and administration above)
30mg to 60mg 12 5mg to 10mg
60mg to 90mg 25 10mg to 15mg
90mg to 120mg 37 15mg to 20mg
120mg to 180mg 50 20mg to 30mg
180mg to 240mg 62 30mg to 40mg
240mg to 300mg 75 40mg to 50mg
300mg to 360mg 87 50mg to 60mg
360mg 100 60mg

(1) The above table is based on the use of 1/6th of the 24 hour oral morphine dose.

Converting from fentanyl given by IV infusion or via a PCA device. This conversion is not routine practice. Liaise with a specialist. If pain is stable the patient may be considered for conversion to a fentanyl patch.

Fentanyl patch care

  • Apply to intact, non-hairy skin on the upper trunk or upper arm; avoid areas treated with radiotherapy, scar tissue or oedematous areas.
  • Apply each new patch to a different skin site; clean the skin with water only as soap products can alter absorption. Make sure skin is dry. Following removal of both parts of the protective liner, the patch should be pressed firmly in place with the palm of the hand for approximately 30 seconds, making sure the contact is complete, especially around the edges.
  • Record the date, time and site if the patch is changed by different people.
  • Change the patch every 72 hours at about the same time of day.
  • Check the patch daily (or as per local guidance) to ensure it is still in place.
  • If patch adherence is poor, check local guidance for advice – micropore tape may be recommended; fentanyl is unsuitable for patients with marked sweating.
  • Used patches still contain active drug. When removed, fold the patch in half with the adhesive side inwards. Dispose of it safely (sharps bin for in-patients, domestic waste in the community). Wash your hands after patch changes.

 

Practice points

  • Fentanyl patches are used for moderate to severe, stable pain.
  • Fentanyl patches are licensed to be applied whole. In clinical practice where small (less than 12 micrograms/hour) dose titrations are required for safe opioid management and to overcome short term supply issues, patches that are matrix formulation may be cut diagonally however this procedure is unlicensed and specialist advice should be sought. Reservoir patch formulations must not be cut.  Dispose of the unused part of the patch safely as described in the fentanyl patch care section.
  • Record the daily patch check and ensure this information is communicated in medicines documentation/reports if the patient transfers care setting
  • Do not change fentanyl patches to another opioid in a dying patient, continue the fentanyl patch and use an additional opioid as required via CSCI.
  • Do not initiate fentanyl patches in the last days of life.
  • Ensure patients understand the safe use, storage and disposal of the patch, and the importance of not heating the skin under the patch.

 

References

Ahmedzai S, Brooks D. Transdermal fentanyl versus sustained-release oral morphine in cancer pain: preference, efficacy, and quality of life. The TTS-Fentanyl Comparative Trial Group. J Pain Symptom Manage. 1997;13(5):254-61.

Caraceni A, Hanks G, Kaasa S, Bennett MI, Brunelli C, Cherny N, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol. 2012;13(2):e58-68.

Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage. 2004;28(5):497-504. Epub 2004/10/27.

Donner B, Zenz M, Strumpf M, Raber M. Long-term treatment of cancer pain with transdermal fentanyl. J Pain Symptom Manage. 1998;15(3):168-75.

Fine PG. Fentanyl in the treatment of cancer pain. Semin Oncol. 1997;24(5):20-7.

NICE. Palliative care for adults: strong opioids for pain relief CG140. 2016 [cited 2018 Oct 02]; Available from: https://www.nice.org.uk/guidance/cg140.

Twycross R, Wilcock A, Howard P. Palliative Care Formulary PCF6. 6th ed. England: Pharmaceutical Press; 2017.

Watson M, Lucas C, Hoy A, Wells J. Oxford Handbook of Palliative Care. 2nd ed: Oxford University Press; 2009.