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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

 

 

 

Oxycodone

Green – For medicines routinely initiated and used by generalists

Introduction

Description: Potent, synthetic opioid analgesic; used second line.

Preparations

Tables are best viewed in landscape mode on mobile devices

Route

Preparation

Dosage

Oral

Immediate release oxycodone Shortec® capsules other brands also available

Shortec®, OxyNorm® and generic liquid and concentrate

5mg, 10mg, 20mg

 

1mg/ml, 10mg/ml

 

Modified release (long acting) oxycodone - 12 hourly preparation (twice daily)

Longtec® and other brands available

Note: depending on brand not all strengths available

 

24 hourly preparation (once daily)

Onexila XL® 

 

 

5mg, 10mg, 15mg, 20mg, 30mg, 40mg, 60mg, 80mg, 120mg (refer to local guidance for preferred brand - not all strengths may be stocked)

 

10mg, 20mg, 40mg, 80mg

(non-formulary, risk of wrong preparation being prescribed)

Injection

Oxycodone injection

Shortec®, OxyNorm® and generic injection available

10mg/ml, 20mg/2ml, *50mg/ml (*non‑formulary in some NHS boards)

 

Indications

  • Second line oral and injectable analgesic for moderate to severe opioid responsive pain in patients unable to tolerate oral morphine, subcutaneous morphine or diamorphine due to persistent side effects (for example sedation, confusion, hallucinations, itch).
  • Refer to Pain management and Choosing and changing opioids guidelines.

 

Cautions

  • Immediate release, modified release and injection preparations have similar names. Take care when prescribing, dispensing or administering oxycodone.
  • Frail or elderly patients need smaller doses less frequently and slower titration.
  • Liver impairment - reduced clearance.
    • Avoid in patients with moderate to severe liver impairment.
  • Renal impairment - reduced excretion.
    • Titrate slowly and monitor carefully in mild to moderate renal impairment. Avoid in chronic kidney disease stages 4 to 5 (eGFR less than 30ml/min). 

Drug interactions

  • No clinically significant pharmacokinetic drug interactions.

 

Side effects

  • Opioid side effects similar to morphine. Monitor for opioid toxicity.
  • Prescribe a softener+/-stimulant laxative and an anti-emetic as needed (for example metoclopramide).

 

Dose and administration

  •  Immediate release oral oxycodone:
    • Prescribe 4 hourly regularly and use 1/6th to 1/10th of the 24 hour dose as required for breakthrough pain.

or

  • Modified release (long acting) oral oxycodone.
    • Prescribe 12 or 24 hourly depending on preparation, with 1/6th to 1/10th  of the 24 hour dose as immediate release oral oxycodone for breakthrough pain.
    • Biphasic action; a rapid release is followed by a controlled release phase. If the patient has pain when the dose of modified release (long acting) oxycodone is given, wait an hour before giving a breakthrough dose of immediate release oxycodone.

 

  • Oxycodone injection:
    • Continuous subcutaneous infusion in a CME T34 syringe pump over 24 hours.
    • In addition, prescribe 1/6th to 1/10th  of the 24 hour infusion dose subcutaneously, 1 to 2 hourly as required for breakthrough pain. If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review.  If more than 6 doses are required in 24 hours seek advice or review.
    • With higher subcutaneous infusion doses, consideration needs to be given to the volume of breakthrough medication. Typically an upper limit of 2ml (for example 20mg oxycodone) is acceptable by the subcutaneous route in a single site. Consider use of the high strength oxycodone injection form if available or an alternative opioid, for example diamorphine for doses greater than 20mg.
    • Dilutent: water for injections.
    • Dose conversions are given below. Seek advice if patient needs more than three ‘as required’ doses in 24 hours for breakthrough pain without acceptable benefit.

 

  • Stability and compatibility – refer to syringe pump subcutaneous infusion tables.

 

Dose conversions

Oxycodone is approximately twice as potent as morphine

Tables are best viewed in landscape mode on mobile devices

Oxycodone dose conversions

≈ oral morphine 30mg

≈ oral oxycodone 15mg

≈ subcutaneous oxycodone 7-8mg

Subcutaneous morphine 30mg

≈ subcutaneous oxycodone 15mg

Subcutaneous diamorphine 20mg

≈ subcutaneous oxycodone 15mg

 

  • As with all opioid conversions, these are approximate (≈) doses. Opioid conversions and ratios may vary depending on the resource used. These conversions are a consensus of use in practice in Scotland and based on manufacturers’ conversion factor.
  • Dose conversions should be conservative and doses rounded down.
  • Monitor the patient carefully so that the dose can be adjusted if necessary.
  • If the patient has opioid toxicity, reduce the dose by 1/3rd when changing opioid (refer to Choosing and changing opioids guideline).

 

References

King SJ et al. A systematic review of oxycodone in the management of cancer pain. Palliative Medicine 2011;25(5):454-470.

Caraceni A et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EPAC. Lancet Oncology 2012;13:e58-68.

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

Twyross R et al. Palliative Care Formulary (Fourth edition. Palliativedrugs.com, Nottingham, 2011.

Electronic Medicines Compendium, Napp Pharmaceuticals Ltd. Oxynorm capsules, liquid & solution for injection and Oxycontin tablets. Summary of Product Characteristics. Updated September 2009-July 2011.

Shah S, Hardy J. Oxycodone: a review of the literature. European J Palliative Care 2001; 8: 93-96.