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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

Ectopic Pregnancy Medical Management (116)

Please report any inaccuracies or issues with this guideline using our online form

Methotrexate

  1. Antimetabolite and antifolate drug which is an established, effective and safe treatment for unruptured ectopic pregnancy and treatment of PUL.
  2. Success rates are around 80-90%.
  3. Careful patient selection is paramount- consultant review is required.
  4. Avoid aspirin or anti inflammatory drugs for 1 week after administration.
  5. Avoid alcohol, vitamins containing folic acid, intercourse, and travel out with the local area until follow up is complete.
  6. The vast majority of patients who have methotrexate will go on to have a subsequent intra-uterine pregnancy.

Patient selection

  1. Diagnosis of ectopic pregnancy or PUL confirmed according to EPAS guidelines.
  2. Patient clinically stable with minimal or no symptoms.
  3. No contra-indications to medical management.
  4. Patient fully counselled regarding treatment options and wishes medical management.
  5. Patient is able and willing to comply with follow up for several weeks - the average follow up time is 35 days.
  6. Patient agrees to avoid pregnancy until follow - up complete and three months after methotrexate.

Contra-indications to medical management

  1. Fetal cardiac activity.
  2. Concurrent intrauterine pregnancy (heterotopic pregnancy).
  3. Significant free intraperitoneal fluid.
  4. Serum HCG≥ 5000 iu/l.
  5. Abnormal renal or hepatic function- discuss with consultant if deranged.
  6. Adnexal mass ≥ 4 cm.
  7. Hb ≤ 100g/l, WCC≤ 2 x 109/l , platelets ≤100 x 10 9/ l
  8. Immunodeficiency.
  9. Patient currently breast feeding.
  10. Patient unwilling to avoid pregnancy for 3 months

Adverse effects

Most side effects are usually mild:

  • Nausea, diarrhoea, stomatitis.

More serious side effects are rare:

  • Impaired liver function, bone marrow suppression- usually reversible.

Abdominal pain occurs in about 75% of patients 3-7 days after methotrexate. This “separation pain” can be difficult to distinguish from pain due to rupture. If patient presents with concerning symptoms, carry out ultrasound to look for free fluid +/or admit for observation and senior review.

There is a 7% risk of tubal rupture following methotrexate.

Pre- treatment Investigations

  1. Serum HCG
  2. FBC, U+E, LFTs, blood group
  3. Height and weight. Calculate Surface Area-copy and paste the following into a web browser:
    https://www.medicinescomplete.com/#/calculators?calcId=body-surface-area

    (use the Dubois formula, weight in kg and height in centimetres)

  4. Offer Chlamydia screening.
  5. Pharmacy prescription to be completed by senior medical staff.

Treatment Schedule

Day 1. Methotrexate administration day

  1. Ensure patient has had appropriate counselling and information sheet.
  2. Ensure consent form signed.
  3. Ensure patient contact details are clearly documented in notes.
  4. Ensure patient has EPAS contact numbers and gynaecology ward number for out- of -hours advice
  5. Inform GP of diagnosis and treatment- see GP information leaflet.
  6. Administer methotrexate 50 mg/m2  IM-see methotrexate prescription form for dose banding according to surface area.

Day 4. EPAS Review

  1. Check serum HCG

Day 7. EPAS Review

  1. Check serum HCG
  2. If HCG on day 7 has fallen by 15% or more from day 4 levels, check HCG weekly until < 5iu/l.
  3. If HCG has not fallen by at least 15%, discuss with senior medical staff. In carefully selected cases, it may be appropriate to repeat HCG levels on day 10.
  4. If HCG has risen, refer to senior medical staff to discuss option of laparoscopy or a second dose of methotrexate.
  5. Approximately 15% of women will require a second dose of methotrexate.
  6. Very rarely, a third dose may be appropriate- this must be a consultant decision.

Second Dose of Methotrexate

  1. Ensure treatment criteria still fulfilled and discuss case with Consultant
  2. Transvaginal scan.
  3. FBC, U+E, LFT.

Further Follow up

  1. Check HCG levels weekly until <5iu/l
  2. If levels plateau or rise, discuss with senior medical staff
  3. Discharge patient when HCG < 5iu/l.

Contraception

There are no absolute contra-indications to specific forms of contraception after an ectopic, other than usual cautions, but the use of a copper coil should be limited to patients for whom no other methods are suitable.

Subsequent pregnancies

Advise to attend EPAS early in next pregnancy to confirm location.

Appendix: Methotrexate for ectopic pregnancy

Methotrexate for ectopic pregnancy (pdf)

Editorial Information

Last reviewed: 23/07/2021

Next review date: 01/07/2024

Author(s): Lynne Thomson.

Version: 4

Approved By: Gynaecology Clinical Governance Group

Document Id: 116

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