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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

Expectant Management of First Trimester Miscarriage (679)

Objectives

This guideline is designed for use within the Early Pregnancy Assessment Services across GGC. The objective is to provide safe management for women diagnosed with a non-continuing pregnancy who wish expectant management up to 12 weeks gestation.

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

Management (as per NICE)

Current NICE guidance [1,2] advises use of expectant management for 7–14 days as the first-line management strategy for women with a confirmed diagnosis of miscarriage. Explore management options other than expectant management if:

  • expectant management is not acceptable or
  • the woman is at increased risk of haemorrhage (for example, she is in the late first trimester) or
  • she has previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) or
  • she is at increased risk from the effects of haemorrhage (for example, if she has coagulopathies or is unable to have a blood transfusion) or
  • there is evidence of infection.

Explain what expectant management involves and that most women will need no further treatment (successful for 70-80% patients). Give all women oral and written information about what to expect throughout the process, advice on pain relief and where and when to get help in an emergency. Also provide women with oral and written information about further treatment options – medical or surgical (MVA or under GA). Written consent is not mandatory.

Give an appointment for 2-3 weeks’ time and offer a repeat scan. The patient should then be reviewed at 2-weekly intervals if she continues to opt for conservative management. Consider checking FBC/CRP. If ongoing bleeding and/or positive pregnancy test, the patient needs review and USS. Discuss alternative management options of miscarriage.

Exclusion criteria

Women who are/have:

  • Haemodynamically unstable
  • Hb <100g/l
  • Twin or higher order pregnancy
  • Specific haematological disorder (consider on individual basis) or would refuse blood products (e.g. Jehovah’s Witness)
  • Women must live or be able to stay locally so as to be able to access emergency admission if required and be able to attend within 1 hour.

Additional Management

  • Anti-D – not required for cases of complete miscarriage under 12+0 weeks gestation where there has been no formal intervention to evacuate the uterus. Anti-D IM required in non-sensitised Rh negative mothers if >12 weeks or if associated with heavy bleeding3 (dose as per current local guideline).
  • Antibiotic prophylaxis should not be given routinely and should only be given based on individual clinical indications.
  • Ensure appropriate patient information given – written leaflet given where possible.
  • If there are any concerns, or at the patient’s request, appropriate review should be arranged.
  • Ensure women understand the expected size of fetus and placenta to be passed.
  • Ensure the patient has analgesia at home or can prescribe analgesia such as Co-codamol if none available.
  • Inform all relevant primary care professionals of pregnancy outcome and management. Cancel any antenatal clinic appointments or scans.
  • Discuss histopathological examination and disposal of pregnancy products in line with trust policy. If tissue is passed at home, this can be appropriately disposed of at the time or can be brought in to hospital for pathology/genetics if the patient wishes. If POC are passed in hospital, signed agreement for sensitive disposal by the hospital is required (SD7 form).

Patient counselling and follow-up support is particularly important for women who adopt an expectant approach. They should be aware that complete resolution may take several weeks. Women and their families should be fully informed regarding the likely course of events, and given information on how to access the appropriate services in an emergency situation.

Appendix 1 SD7 form

SD7 form

Editorial Information

Last reviewed: 01/04/2019

Next review date: 01/04/2024

Author(s): Ruth Jewell.

Approved By: Gynaecological Clinical Governance Group

Document Id: 679

References
  1. NICE. Ectopic pregnancy and miscarriage: diagnosis and initial management [CG154]. 2019.
  2. NICE pathway for medical management of incomplete or missed miscarriage. 2015.
  3. Qureshi H et al. British Committee for Standards in Haematology (BCSH) guideline for the use of anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn. Transfusion Medicine. 2014; 24(1): pp8-20.