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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

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.