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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

Postoperative Haematuria following Surgery (714)

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

Post-operative haematuria may be noted immediately in theatre or develop later when the patient is on the ward and can range in colour from rosy to dark red.  Haematuria could be a sign of urinary tract injury and therefore this must be considered, however clear urine does not exclude injury.

Injury of the urinary tract is the most common major complication of gynaecological laparoscopic surgery and can result in significant morbidity.  The risk of urinary tract injury is higher in laparoscopic cases compared to open.  The incidence of bladder injury is between 1-2% and the ureter is injured in 0.5-2.5% of all gynaecological procedures.  

Ideally, an injury should be identified and repaired during the primary operation, but vigilance in the immediate postoperative period may lead to early recognition and intervention.  Ureteric injuries are often not identified intra-operatively or may present later due to thermal or ischaemic injury that was not evident at the time of operation.

Lower urinary tract injury carries the potential for substantial morbidity including infection, fistula formation, and renal failure.  

In patients at high risk consider prophylactic pre-operative intervention such as insertion of ureteric stent/catheters prior to dissection to facilitate dissection and identification of potential injury to ureters intra-operatively.

If haematuria is noted in theatre at the end of a case (e.g. when removing the drapes) let the consultant know and don’t move patient / wake her up until it has been discussed.  If not expected, they may consider bladder assessment with cystoscopy depending on the procedure performed. Cystocopy would not exclude ureteric injury.

Risk factors for urinary tract injury

  • Endometriosis +/- resection of endometriosis
  • Cancer
  • Intra-abdominal adhesions
  • Severe prolapse
  • Obesity
  • Pregnant uterus
  • Fibroids
  • Previous pelvic surgery / previous pelvic sepsis
  • Hysterectomy (laparoscopic > open)

Causes of postoperative haematuria

  • Traumatic catheterisation / traction on catheter
  • Instrumentation of the bladder or ureters (e.g. cystoscopy, ureteric stents, biopsy)
  • Urinary tract infection
  • Missed bladder or ureteric injury
  • Urinary tract injury that was repaired intraoperatively will likely have haematuria develop as any clot / bleeding resolves, but also consider multiple sites of injury are possible

Clinical signs suggestive of urinary tract injury

  • Air in catheter bag at the end of a laparoscopic abdominal procedure
  • Suprapubic or flank pain
  • Low grade pyrexia
  • Haematuria
  • Oliguria
  • Possible peritonitis
  • Ileus
  • Raised inflammatory markers
  • Deranged renal function
  • Leakage of urine per vagina (usually presents later)
  • “Bypassing” of urethral catheter – may be fistula and not bypassing
  • Higher than expected drain output post op (high creatinine in drain fluid)

Management of postoperative haematuria

  • Leave catheter in situ until a minimum of 24hrs after haematuria resolves or as instructed by consultant responsible for the patient’s care
  • Consider urinary tract injury if haematuria persists and postoperative recovery not progressing as expected
  • Hydrate the patient
  • Clearly document urine volumes passed on fluid balance chart
  • Keep catheter on free drainage (ensure no blockage or flip-flo valves)
  • Exclude UTI (Dipstick tests are not useful in catheterised patients. If UTI is suspected, send urine samples for laboratory culture and commence empirical antibiotics as per local policy whilst results are awaited.)
  • Discuss with consultant in charge of the patient’s care

In most cases, CT IVU will be the primary investigation, however, discussion with the responsible consultant and radiology / urology should take place at an early stage to guide appropriate imaging.

Editorial Information

Last reviewed: 04/02/2020

Next review date: 01/02/2025

Author(s): Ros Jamieson.

Approved By: Gynaecology Clinical Governance Group

Reviewer name(s): Mr Nkem Umez-Eronini, Consultant Urological Surgeon, Dr Karen Guerrero, Consultant Urogynaecologist, Dr Veenu Tyagi, Consultant Urogynaecologist .

Document Id: 704

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