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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

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.