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Announcements and latest updates

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

  1. Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26th September 3-4 pm on national and local contingency planning for future RDS outages.  Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

 

2.National  IV fluid prescribing  calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids  . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery.  It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

 

  1. New toolkits

The following toolkits are now live;

  1. Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

 

  1. Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit.  We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process.  The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

 

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:
  • Thursday 5 September 1-2 pm
  • Wednesday 24 September 4-5 pm
  • Friday 27 September 12-1 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.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

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

Red – For medicines normally initiated and used under specialist guidance

Introduction

Description: Potent opioid.
Fourth-line opioid: only for use with specialist advice.

note: syringe pump and syringe driver are both relevant terms

Preparations

Tables are best viewed in landscape mode on mobile devices

Route

Preparation

Available strengths

Oral

Immediate release hydromorphone

Palladone®  capsules

1.3mg, 2.6mg

Modified release (long acting) hydromorphone

Palladone SR®  capsules

2mg, 4mg, 8mg, 16mg, 24mg


Immediate release† hydromorphone liquid

10mg/ml (other strengths can be made on
request)

Unlicensed preparation but can be made to order
(contact local non-sterile pharmacy production
unit via specialist pharmacist)

Injection

 

Palladone injection® 

Used as a subcutaneous infusion or as a
subcutaneous bolus injection.

 

 

2mg/ml

10 mg/ml

20 mg/ml

50 mg/ml

Licensed preparation available via wholesalers
(made by NAPP Pharmaceuticals)

Non formulary in some NHS boards

 

Indications

Must have specialist input. Fourth-line oral and injectable analgesic for moderate to severe opioid responsive pain in patients unable to tolerate oral morphine/oxycodone, subcutaneous diamorphine/morphine or oxycodone due to persistent side effects (for example sedation, confusion, hallucinations, itch).

 

Cautions

  • Immediate release and modified release capsules have similar names. Some NHS boards recommend prescribing by brand name to avoid confusion.
  • Frail or elderly patients need smaller doses less frequently and slower titration.

 

  • Liver impairment:
    • Reduced clearance (may need reduced dosing frequency). Note that the summaries of product characteristics (SPC) list hepatic impairment as a contra-indication, but this would not preclude its use in palliative care. Patients with moderate hepatic impairment should be started at a lower dose and closely monitored during dose titration.

 

  • Renal impairment:
    • Reduced excretion (may need reduced dosing frequency). 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). Check renal handbook.

 

  • Drug interactions:
    • Similar to other strong opioids such as morphine/oxycodone. Hydromorphone may be expected to have additive effects when used in conjunction with alcohol, other opioids, or drugs that cause central nervous system (CNS) depression (for example sedatives, hypnotics, general anaesthetics, phenothiazines, tranquilisers). Respiratory depression, hypotension and profound sedation or coma may occur. 

 

  • Side effects:
    • Opioid side effects similar to morphine/oxycodone - monitor for opioid toxicity.
    • Constipation: prescribe a laxative to be taken regularly and anti-emetic as needed (for example metoclopramide).
    • Drowsiness: hydromorphone may cause drowsiness, impairing mental and/or physical ability. If affected do not drive or operate machinery. Avoid alcohol.

 

Dose and administration

Immediate release oral hydromorphone

  • Prescribe 4 hourly regularly and use the same dose as required for breakthrough pain.

  • The capsules can be opened and the contents sprinkled on cold, soft food.

 

Modified release (long acting) oral hydromorphone (Palladone SR®)

  • Prescribe 12 hourly, with a 1/6th to 1/10th of the 24-hour dose as immediate release oral hydromorphone for breakthrough pain.

  • Palladone SR® capsules can be opened (if difficulty when swallowing the SR capsules) and the contents sprinkled on cold, soft food, but the granules should NOT be broken, chewed, dissolved or crushed as this could lead to a rapid release of the drug and a potential overdose. Seek pharmacy advice if the patient has a feeding tube.

 

Hydromorphone injection

  • Continuous subcutaneous infusion in a 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 (max 6 doses in 24 hours).

  • Diluent: water for injection.

  • Refer to stability and compatibility tables in Syringe pump guideline.

  • Sodium chloride 0.9% can also be used as a diluent. Seek specialist palliative care/pharmacy advice.

Dose conversions

Hydromorphone is approximately 7.5 times more potent than morphine.

 

Tables are best viewed in landscape mode on mobile devices

Morphine dosage

Hydromorphone dosage

Oral morphine 10mg

≈oral hydromorphone 1.3mg

Oral hydromorphone 10mg

≈subcutaneous hydromorphone 5mg

Subcutaneous morphine 30mg

≈subcutaneous hydromorphone 4mg

Subcutaneous diamorphine 20mg

≈subcutaneous hydromorphone 4mg

 

  • As with all opioid conversions, these are approximate (≈) doses.
  • 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.

 

Practice points

  • The GP, community pharmacist, district nurse and unscheduled care service should be informed that the patient is receiving this fourth-line opioid, for example via eKIS.
  • Hydromorphone can be prescribed by the patient’s GP for the indications/uses listed in liaison with local palliative care specialists.
  • Patients should receive an initial supply on discharge to allow adequate time for the community pharmacist to order the preparation(s) required.
  • At high background maintenance doses of long acting hydromorphone, the burden of the number of immediate release hydromorphone capsules for the breakthrough analgesic dose should be considered.

 

References

Ashley C, Currie A.  Renal Drug Handbook.  3rd Edition. Radcliffe Publishing. 2009.

Dickman A, Schneider J. The Syringe Driver. 4th ed: Oxford University Press; 2016.

Summary of Product Characteristics (SPC) http://www.medicines.org.uk/emc/search

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