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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 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).

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.

 

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 at end 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 at the end of life when the oral route is no longer available.
  • 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.