Welcome to the Right Decision Service (RDS) newsletter for April 2024.
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.
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.
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.
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.
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
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
Quality assurance and governance
Service innovation and workforce development
A few examples of toolkits published to live in the last month:
Some of the toolkits the RDS team is currently working on:
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.
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.
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
Read section 5 of SIGN 157 here
Recommendations
All patients at risk of delirium should have a medication review conducted by an experienced healthcare professional.
Good Practice
Areas with patients at high risk of delirium, such as trauma orthopaedic wards, should have protocols for commonly required medication (eg analgesia and anti-emesis) that contain choices for first-line treatments which minimise the risk of causing delirium.
See the evidence base in section 5.2 SIGN 157 here
Observational evidence suggests that exposure to certain medicines increases the odds of delirium developing and that medication review can decrease rates of delirium.80-83
An approach to medication review and prescribing in people who are experiencing, or are at increased risk of, delirium, covers three broad areas.
Benzodiazepines markedly increase the odds of delirium developing in a variety of settings (OR 3.0 95% CI 1.3 to 6.8) and should not be used unless in specific circumstances such as management of alcohol withdrawal or acute seizure management.81
Opiates can also cause delirium but they remain a vital class of drug for treating pain. It is important to remember that pain in itself can precipitate delirium.
A systematic review cited an OR of delirium associated with treatment with opioids of 2.5 (95% CI 1.2 to 5.2).81 However, the main opioid in the review, which carries the highest risk, is pethidine (OR 2.7, 95% CI 1.3 to 5.5), which is anticholinergic and rarely used in the UK. More commonly used opioids such as morphine (OR of delirium 1.2, 95% CI 0.6 to 2.4) and fentanyl (OR of delirium 1.5, 95% CI 0.6 to 4.2) were not significantly associated with delirium.81
The opioid with the lowest odds of causing delirium was oxycodone but this still had a confidence interval that crossed 1 (OR 0.7, 95% CI 0.3 to 1.6).81
When using opiate analgesia titrate to the minimal effective dose to achieve pain control and minimise side effects.
If opiates are used laxatives should be prescribed to prevent constipation which can contribute to delirium.
The NHSScotland polypharmacy guideline contains information on medication to avoid or reduce in older people, some of which is aimed at reducing falls by reducing medications that can cause delirium. Medications recommended to avoid, stop or reduce the dose if possible include:
The guideline also contains practical information on how to safely reduce chronic medication with potential for withdrawal such as benzodiazepines.87
No antipsychotics are licensed for the prophylaxis of delirium. There is insufficient evidence of benefit to recommend the use of antipsychotic prophylaxis in patients at risk of developing delirium.
See the evidence base in section 5.2, SIGN 157 here
There remains controversy over whether dexmedetomidine can reduce the incidence of delirium in both critically ill patients and those in the perioperative setting.
Many of the trials which indicate a benefit have used other sedative agents, including benzodiazepines in the control group. It remains unclear if dexmedetomidine reduces delirium or merely reduces the need for delirogenic drugs. Since there are potential physiological concerns relating to the widespread adoption of dexmedetomidine for prophylaxis, in addition to cost implications, it cannot be recommended for the prevention of delirium.
See the evidence base in section 5.3, SIGN 157here
Ketamine
One systematic review included four RCTs which reported the incidence of postoperative delirium when comparing ketamine to placebo. Overall, the incidence of postoperative delirium did not differ between the control and intervention groups. The quality of each RCT was low, so the review concluded that the effect of ketamine on postoperative delirium is unclear. The largest RCT reported an increase in postoperative hallucinations and nightmares with ketamine use.106
Melatonin
Systematic reviews identified four RCTs on the use of melatonin to prevent delirium in medical and surgical settings.63,107,108 Results were inconclusive.
One small RCT in 88 patients found a melatonin receptor agonist reduced the incidence (24.4% v 46.5%) and duration (0.78 v 1.4 days) of delirium in critically ill patients.109
Risk Reduction and Management of Delirium (SIGN)