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Right Decision Service newsletter: April 2024

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

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

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.