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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: Benzodiazepine with anti-epileptic properties.

Specialist palliative care involvement is essential.

note: syringe pump and syringe driver are both relevant terms

Preparations

Tables are best viewed in landscape mode on mobile devices

Route

Preparation

Licence type

Oral

500 microgram tablets

2mg tablets

500micrograms/5ml and 2mg/5ml oral solution

2.5mg/ml oral drops

 

 

 

Oral drops are †unlicensed

Injection

1mg/1ml with water for injection 1ml diluent

Unlicensed in the †UK - needs to be imported

 

Indications

Licensed

  • Epilepsy
  • Myoclonus

†Unlicensed

  • Neuropathic pain
  • Restless legs syndrome
  • Terminal restlessness
  • Anxiety and panic attacks

Cautions

  • Chronic respiratory disease.
  • Moderate hepatic impairment.
  • Renal impairment (not dialysed). Start at low doses and increase according to response.
  • Consider gradual reduction if treatment has to be stopped and patient has a history of epilepsy.

 

Contra-indications

Clonazepam is contra-indicated for use in patients with:

  • acute pulmonary insufficiency
  • myasthenia gravis
  • severe hepatic impairment
  • severe respiratory insufficiency
  • sleep apnoea syndrome.

If the patient is in the last days of life, these are not absolute contra-indications. Careful titration is however necessary.

  • Drug interactions:
    • clonazepam is extensively metabolised by CYP3A4 to inactive metabolites
    • reduced effect - clonazepam effect may be reduced by co-administration of CYP3A4 inducers, such as carbamazepine, high dose dexamethasone and phenobarbital
    • increased effect: inhibitors of CYP3A4, such as bicalutamide, erythromycin, high dose fluconazole and haloperidol may enhance the effect of clonazepam
    • clonazepam and phenytoin have unpredictable effects on each other’s plasma concentrations - clonazepam may or may not alter phenytoin plasma concentration, whereas phenytoin may decrease the plasma concentration of clonazepam. Monitor the phenytoin plasma level if given concurrently with clonazepam and adjust dose if necessary
    • effect on clonazepam’s metabolism by other drugs may persist for several days after discontinuation of the causative drug - be aware of the potential for interaction: doses may need to be adjusted.
  • Side effects:
    • drowsiness (dose dependent), impaired psychomotor skills, fatigue, cognitive impairment and hypotonia
    • start with a low dose and titrate up to minimise unwanted effects.

Note: use of benzodiazepines in elderly patients increases the risk of falls and fractures. 

 

Dose and administration

  • Dose recommendations depend on the indication.
  • For continuous subcutaneous infusion (CSCI) administering the same dose as oral therapy is recommended.
  • In elderly patients, the initial dose should not exceed 500 micrograms/24 hours if newly prescribed.

 

Oral route

500 micrograms at night (250 micrograms if concerned about drowsiness), up to 4mg/day.

 

Subcutaneous route

Common dose range in palliative care:

  • 1mg to 4mg over 24 hours
  • doses up to 8mg in 24 hours have been used.

The dose of clonazepam should be carefully adjusted to individual requirements, and used with caution in patients with chronic respiratory disease, renal or moderate hepatic impairment.

Manufacturers also state the stability of the diluted clonazepam is maintained for up to 12 hours, although there are reports of CSCI administration over 24 hours without apparent unexpected effect.

 

Diluent

  • Use the diluent ampoule (Water for Injection) supplied with the clonazepam ampoules if administering the clonazepam as a bolus injection. The clonazepam ampoule must be diluted prior to a bolus administration.
  • If administering clonazepam via a syringe pump over 24 hours (CSCI), there is no need to use the diluent ampoule supplied in the box as the clonazepam will be administered diluted in the syringe pump. Use sodium chloride 0.9% as the diluent if clonazepam is to be administered on its own.

 

Compatibility

  • It has been shown that sorption into PVC infusion sets occurs with clonazepam injection. The clinical significance of this effect is yet to be determined, although another study has shown that significant loss of clonazepam (up to 50%) does occur when infused through PVC tubing over 24 hours. Use of non-PVC tubing solved this problem.

Please check with specialist palliative care pharmacists for further information/compatibilities. 

 

References

Twycross R, Wilcock A, Howard P. Palliative Care Formulary PCF6. 6th ed. England: Pharmaceutical Press; 2017.

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