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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

Lidocaine plaster

Amber – For medicines normally initiated by a specialist but may be used by generalists

Introduction

Lidocaine plaster in palliative care.

Description

  • Lidocaine is a local anaesthetic effective in some types of neuropathic pain such as post-herpetic neuralgia.
  • It is available in a topical plaster formulation, with approximately 3% systemic absorption, reducing the risk of systemic adverse reactions and drug interactions.
  • The use of lidocaine plasters in palliative care is outside marketing authorisation and has not been investigated extensively. 
  • It is non-formulary in some NHS boards.

Preparations

  • Medicated plaster (10x14cm) containing 700mg (5% w/w) of lidocaine.
  • Brands include Versatis and Ralvo.

 

Indications

A palliative care specialist may recommend lidocaine plasters for:

  • localised †neuropathic pain (particularly associated with allodynia) that is unresponsive to opioids and adjuvant analgesics
  • locally painful bone †metastases unresponsive to standard treatments (paracetamol, opioids, adjuvant analgesics, radiotherapy) or when standard treatments are inappropriate, poorly tolerated or contra-indicated
  • short term treatment of localised, severe uncontrolled bone or neuropathic pain, while adjuvant analgesics are being titrated.

 

Cautions

  • Do not apply the plaster to inflamed, broken or infected skin or to wounds.
  • Use with caution in patients with severe cardiac disease; elimination may be delayed in patients with severe renal or liver impairment.

 

Drug interactions

Use with caution in patients receiving a Class I anti-arrhythmic drug (for example QTflecainide).

 

Side effects

  • Application site reactions including erythema, rash and pruritus are common.
  • Systemic allergic reactions have been reported but are very rare.

 

Dose and administration

Starting a lidocaine plaster

  • Remove any hairs with scissors; do not shave the area.
  • Plasters can be cut to size before the backing is removed without affecting drug delivery.
  • Apply one plaster directly over the painful area for up to 12 hours in each 24 hour period. The plaster free interval may reduce the risk of skin reactions. However, some patients may benefit from the patch being applied for 24 hours.
  • The plaster site should be specified on the prescription chart and on the monitoring sheet.
  • A new plaster is applied every 24 hours.

 

Titration

  • The dose is titrated to give adequate analgesia (up to a maximum of three plasters) depending on the number and size of the painful site or sites. After initiation of treatment review after 48 hours and document on monitoring sheet.
  • Monitor the patient’s pain and other analgesics; these may need to be reduced if the pain responds well to lidocaine.
  • A used plaster should be folded over and can then be put in the sharps bin or household waste.

 

Practice points

Pain assessment

  • A 0 to 10 pain scale should be used to assess the patient’s pain now and over the past
    24 hours.
  • Record the pain scores on the monitoring sheet before the plaster is applied and after 48 hours.

 

Review of lidocaine plaster

  • There is limited evidence for use of lidocaine plaster. Regular reviews should be undertaken. 
  • Most patients will respond within 2 weeks; discontinue the plaster if no benefit.
  • It is often possible to discontinue the plaster without the pain recurring as the local effect on nerve endings persists after the plaster is removed.
  • If the pain responds, try a plaster-free period after 7 days of plaster use.
  • Remove the lidocaine plaster(s) for at least 24 hours and assess the patient.
  • If the pain returns or worsens, restart the lidocaine plaster.
  • If the patient remains pain free or with stable pain, discontinue the lidocaine plaster.
  • Continued treatment - reassess with a further plaster-free trial on a monthly basis to determine whether the number of plasters needed to cover the painful area can be reduced, or if the plaster‑free period can be extended.

 

Monitoring

  • A monitoring sheet is recommended for each patient started on a lidocaine plaster.
  • If a lidocaine plaster is being used for more than one pain site, a separate monitoring sheet should be completed for each site.
  • The monitoring sheet should be updated each time the patient is assessed.
  • Check the skin site – if a local reaction occurs, the plaster may need to be stopped.

 

References

Derry S, P.J. W, Moore RA, Quinlan J. Topical lidocaine for neuropathic pain in adults. 2014 [cited 2018 Oct 08]; Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010958.pub2/epdf/standard

Galer BS, Rowbotham MC, Perander J, Friedman E. Topical lidocaine patch relieves postherpetic neuralgia more effectively than a vehicle topical patch: results of an enriched enrollment study. Pain. 1999;80(3):533-8.

Gammaitoni AR, Davis MW. Pharmacokinetics and tolerability of lidocaine patch 5% with extended dosing. Ann Pharmacother. 2002;36(2):236-40.

Meier T, Wasner G, Faust M, Kuntzer T, Ochsner F, Hueppe M, et al. Efficacy of lidocaine patch 5% in the treatment of focal peripheral neuropathic pain syndromes: a randomized, double-blind, placebo-controlled study. Pain. 2003;106(1-2):151-8.

Rowbotham MC, Davies PS, Verkempinck C, Galer BS. Lidocaine patch: double-blind controlled study of a new treatment method for post-herpetic neuralgia. Pain. 1996;65(1):39-44.