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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

 

 

Red – For medicines normally initiated and used under specialist guidance

Introduction

Description

Anaesthetic agent used with specialist supervision as a third-line analgesic to manage complex pain. It is an N-methyl-D-aspartate (NMDA) receptor inhibitor. This use is outside the UK marketing authorisation.

 

Preparations

(Note: Will need indication for use on prescription, for example ‘for nerve pain’)

Ketamine injection

  • Used by subcutaneous injection/ infusion.
  • Specialists occasionally give ketamine IV – see below.
  • Preparations: 10mg/ml (20ml ampoule), 50mg/ml (10ml vial)

Ketamine oral solution

  • 50mg/5ml (unlicensed specials medicine)
  • (This is the preferred strength but other options are available)
  • Injection may be given orally

Ketamine is a Schedule 2 CD (Controlled Drug), therefore all prescriptions must satisfy CD prescription requirements to be valid and include details of the dose, form, strength, directions for use and total quantity (in both words and figures). It must also follow CD storage and recording regulations.

Sample prescription

 

Indications

†Unlicensed

  • Neuropathic pain poorly responsive to titrated opioids and oral adjuvant analgesics (for example antidepressant and/or anticonvulsant) particularly when there is abnormal pain sensitivity - allodynia, hyperalgesia or hyperpathia.
  • Complex ischaemic limb pain or phantom limb pain.
  • Poorly controlled incident bone pain (often has a neuropathic element).
  • Complex visceral/abdominal neuropathic pain.

 

Cautions

  • Use low doses, carefully monitored, in cardiac failure, cerebrovascular disease, ischaemic heart disease.
  • If used for over 3 weeks and there is a need to stop treatment, discontinue ketamine gradually.
  • Consider dose reduction in severe hepatic impairment.

 

Contra-indications

  • Do not use ketamine if patient has raised intracranial pressure; uncontrolled hypertension, delirium or recent seizures; history of psychosis.

 

Drug interactions

  • Ketamine interacts with theophylline (tachycardia, seizures) and levothyroxine (monitor for hypertension, tachycardia).
  • Diazepam increases the plasma concentration of ketamine.
  • Refer to relevant British National Formulary (BNF) section for further information.

 

Side effects

  • Hallucinations, dysphoria and vivid dreams.
  • Hypertension, tachycardia, raised intracranial pressure.
  • Sedation at higher doses.
  • Erythema and pain at infusion site.
  • Urinary tract symptoms, for example frequency, urgency, urge incontinence, dysuria and haematuria. (Where there is no evidence of bacterial infection, consider discontinuing ketamine and seeking urology advice.)

 

Dose and administration

Starting ketamine

  • Ketamine is started on the recommendation of a palliative medicine consultant. This is usually done in an inpatient setting.
  • Very occasionally, a patient may need to start ketamine in the community. The route of choice is generally oral ketamine. The palliative medicine consultant will liaise closely with the GP, community nurse, and unscheduled care service.
  • 24-hour palliative medicine advice will be available.
  • Patients starting ketamine will be taking a regular opioid. Ketamine may restore the patient’s opioid sensitivity and lead to opioid toxicity.
  • The specialist may recommend changing to a short acting, regular opioid before starting ketamine, particularly if the patient has side effects from the current opioid dose.
  • Monitor closely for signs of opioid toxicity (for example sedation, confusion); reduce opioid dose by one third if the patient is drowsy and seek advice.
  • Hallucinations/dysphoria. If the patient is not drowsy this is more likely to be a ketamine side effect than due to opioids.
  • Give QThaloperidol oral 500micrograms to 1mg twice daily or SC 1mg to 2mg once daily. Midazolam SC 2mg as needed can also be used.
  • Preventing ketamine dysphoria – consider oral QThaloperidol 500micrograms to 1mg daily when starting ketamine. It can be stopped when the patient’s ketamine dose is stable.

 

Dose and administration – oral ketamine

  • Ketamine can be started using the oral route or patients may be changed from an SC infusion when pain is controlled.
  • Starting dose: 5mg to 10mg four times daily.
  • Increase dose in 5mg to 10mg increments.
  • Usual dose range: 10mg to 60mg four times daily.

 

Dose and administration – subcutaneous ketamine infusion

  • Starting dose: 50mg to 150mg/24 hours.
  • Review daily; increase dose in 50mg to 100mg increments.
  • Usual dose range: 50mg to 600mg/24 hours (higher doses are occasionally used in specialist units).

 

Administration

  • Prepare a new syringe every 24 hours.
  • Dilute ketamine with sodium chloride 0.9%.
  • Check the syringe is not cloudy and protect it from light.
  • Ketamine stability and compatibility – refer to syringe pump ketamine compatibility table.
  • Dispose of the ketamine vial in accordance with the local policy.
  • Rotate the SC infusion site daily to prevent site reactions. If these occur, increase the volume of sodium chloride 0.9% used to dilute the ketamine if possible and/or add a maximum of 1mg of dexamethasone injection to the ketamine infusion.

 

Converting from a 24-hour SC ketamine infusion to oral ketamine

  • Oral ketamine is more potent than SC ketamine (due to liver metabolism). Many patients require a dose reduction of 25 to 50% when changing to oral ketamine.
  • Prescribe the oral ketamine in divided doses - four times daily.
  • Titrate dose in 5mg to 10mg increments.
  • Some specialists stop the SC infusion when the first dose of oral ketamine is given. Others gradually reduce the infusion dose as the oral dose is increased.

 

 Dose and administration – parenteral ketamine

  • Palliative medicine consultants or anaesthetists occasionally administer SC or IV ketamine as single or ‘pulsed’ doses for severe pain or to cover painful procedures.
  • Specialists have used IV ketamine infusions to manage ischaemic limb pain.

 

Practice points

Patient monitoring

  • Patients who are at risk of hypertension, tachycardia, respiratory depression or opioid toxicity should only start ketamine in a clinical area able to monitor them 2 to 4 hourly for the first 24 hours.
  • All patients should be medically reviewed at least once daily until stable, and then weekly.
  • Once the pain is controlled, the palliative medicine specialist may recommend a gradual reduction in the dose of opioid and/or ketamine.

 

Blood pressure

  • Check blood pressure is normal or well controlled before starting ketamine. Record a baseline blood pressure.
  • Check blood pressure one hour after the first dose of oral ketamine or starting a SC infusion.
  • Check blood pressure 24 hours after the first dose of ketamine, then daily.
  • If blood pressure increases 20mmHg above baseline inform the patient’s doctor.
  • If blood pressure remains elevated 20mmHg above baseline on repeated measurement, stop the ketamine and seek advice from a palliative medicine specialist.

 

 Pulse

  • Record a baseline pulse rate.
  • Check pulse one hour after the first dose of ketamine or starting SC infusion.
  • Check pulse 24 hours after the first dose of ketamine, then daily.
  • If pulse rate increases 20bpm above baseline or rises above 100bpm, inform the patient’s doctor.
  • If there is no other cause of tachycardia, seek advice from a palliative medicine specialist.

 

Respiratory rate

  • Record a baseline respiratory rate.
  • The palliative medicine specialist will advise on frequency of monitoring.
  • If respiratory rate decreases to 10 breaths/minute inform medical staff. Seek advice from a palliative medicine specialist.
  • Naloxone (in small titrated doses) is only required for reversal of life-threatening respiratory depression due to opioid analgesics, indicated by:
    • a low respiratory rate, fewer than 8 respirations/minute
    • oxygen saturation below 85%, patient cyanosed.
  • Naloxone should not be given in large bolus doses as it can precipitate an acute opioid withdrawal reaction. Refer to Naloxone guideline.

 

Dysphoria, hallucinations, vivid dreams

Assess patient daily until ketamine dose is stable; then stop any regular QThaloperidol or midazolam.

 

Patient and carer advice points

  • There can be a delay of several days in obtaining further supplies of ketamine. Advise patients to ensure new supplies are requested in adequate time.
  • The taste of ketamine can be unpleasantly bitter. Patients can suck or chew on something sweeter after taking. Other flavours can also be requested.

 

References

Prommer EE. Ketamine for pain: An update of uses in Palliative Care. Journal of Palliative Medicine 2012;15(4):474-483.

Quibell R, Prommer EE, Mihalyo M. Ketamine. Journal of Pain & Symptom Management 2011;41(3):640-649.

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

Hanks G et al. The Oxford Textbook of Palliative Medicine (Fourth edition). Oxford Univeristy Press, 2010.

Fallon M, Welsh J. The role of ketamine in pain control. European Journal of Palliative Care 1996; 3:143-146.

Mercadante S. Ketamine in cancer pain: an update. Palliative Medicine 1996; 10: 225-230.

Edmonds P. The role of ketamine in the management of chronic pain. CME Bulletin Palliative Medicine 1998; 1:3-5.

Grant I, Nimmo W, Clements J. Pharmacokinetics and analgesic effects of IM and oral ketamine. British Journal of Anaesthesia 1981; 53:805-809.

Enarson M, Hays H, Woodroffe M. Clinical experience with oral ketamine. Journal Pain & Symptom Management 1999; 5: 384-386.

Bell RF. Low-dose subcutaneous ketamine infusion and morphine tolerance. Pain 1999; 83: 101-103.

Fitzgibbon E, Hall P, Schroder C et al. Low Dose Ketamine as an Analgesic Adjuvant in Difficult Pain Syndromes: A Strategy for Conversion from Parenteral to Oral Ketamine. Journal Pain & Symptom Management 2002; 23(2): 165-170.

Beitez-Rosario M, Feria M, Salinas-Martin A. A retrospective comparison of the dose ratio between subcutaneous and oral ketamine. Journal Pain & Symptom Management 2003; 25: 400-402.

Kannan T, Saxena A, Bhatnagar, Barry A. Oral ketamine as an adjuvant to oral morphine for neuropathic pain in cancer patients. Journal Pain & Symptom Management 2002; 23: 6065.

Bell R, Eccleston C, Kalso E. Ketamine as an adjuvant to opioids for cancer pain (Cochrane Review). In: The Cochrane Library. Issue 3, 2004. Oxford: Update Software.

Hocking G, Cousins M. Ketamine in chronic pain management: an evidence-based review. AnaesthAnalg. 2003; 97: 1730-9.

Visser E, Schug S. The role of ketamine in pain management. Biomedicine and Pharmacotherapy 2006; 60: 341-348.

Webster L, Walker M. Safety and efficacy of prolonged outpatient ketamine infusions for neuropathic pain. American Journal of Therapeutics 2006; 13: 300-5.

 

Stability references

Watson D, Lin M, Morton A et al. Compatibility and stability of dexamethasone sodium phosphate and ketamine hydrochloride subcutaneous infusions in polypropylene syringes. Journal Pain & Symptom Management 2005; 30: 80-86.

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

Dickman A, Schneider J and Varga J. The Syringe Driver (Third Edition). Oxford University Press 2011.