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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

Adrenal Crisis: Avoidance in Pregnant Women at Risk (520)

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

Glucocorticoid dependent obstetric patients are not encountered commonly, however appropriate care is crucial to avoid potentially life threatening acute adrenal crisis. In order to avoid a precipitous fall in BP during anaesthesia or in the immediate postoperative period, anaesthetists must know whether a patient is taking or has been taking glucocorticoids. 

Signs of acute adrenal crisis include severe dehydration, pale clammy skin, sweating, rapid and shallow breathing, hypotension, dizziness, vomiting and diarrhoea and severe drowsiness or loss of consciousness.

Women at risk [1]

  1. All women requiring long term glucocorticoid replacement (for example as a result of pituitary disease or congenital adrenal hyperplasia, or women with Addison’s disease). These women will usually be receiving the equivalent of 20-25mg hydrocortisone per day and are likely to be dependent on this replacement.1
  2. Women receiving exogenous glucocorticoid may now be dependent on this and develop adrenal crisis if they are stopped suddenly. This group of women includes:
    1. Patients taking the equivalent of 5mg prednisolone per day for more than FOUR See Appendix 1 for more detail.2
    2. Patients on more than the equivalent of 40mg prednisolone per day for more than 7 days2
    3. Patients on long term high dose inhaled steroids. See Appendix 2 for more detail.2
    4. High doses of topical steroids (e.g. ≥200g per week of potent or very potent steroids). See Appendix 3 for more detail. 2

Mineralocorticoids

Note that women with adrenal disease (e.g. Addisons disease or previous bilateral adrenalectomy) may also be receiving mineralocorticoid replacement, usually in the form of fludrocortisone. This also needs to be considered and likely continued.

Factors which can precipitate Adrenal Crisis

  • Infection.
  • Major surgery (e.g. caesarean section).
  • Malabsorption of oral steroids (e.g. due to vomiting).
  • Major stress (e.g. labour).
  • Discontinuation of glucocorticoids (hydrocortisone, prednisolone, dexamethasone).

Peripartum Steroid Management [4]

Caesarean Section

On day of surgery

  • Normal morning dose of steroid.
  • 100 mg hydrocortisone IV just before anaesthesia. Then:
  • Double oral glucocorticoid dose for 48 hours.

Unless the patient is not tolerating oral intake, or is vomiting or unwell, in which case:

  • 50 mg hydrocortisone IM 6 hours until eating and drinking normally.
  • Once well, return to oral dose as above. After 48 hours:
  • If well, return to patient’s normal dose.

Induction of Labour

  • Continue normal dose of steroid until labour diagnosed.

Labour

When labour is diagnosed:

  • 100 mg hydrocortisone IV at onset of labour.

Then:

  • Commence infusion of hydrocortisone at 200mg IV over 24hr

OR

  • 50mg hydrocortisone every 6hrs IM.

Then:

  • Double oral glucocorticoid dose for 48 hours postpartum.
  • Unless the patient is not tolerating oral intake, or is vomiting or unwell, in which case use the IM route as above.

After 48 hours:

  • If well, return to patient’s normal dose.

Special Points

All women at risk of adrenal crisis should consider carrying a Steroid Emergency Card to alert healthcare professionals.

Women who are deficient in glucocorticoids are also at risk of hypoglycaemia. 

  • Check capillary blood glucose and a formal laboratory glucose when first assessed and if the patient develops any symptoms of hypoglycaemia. 

If patient becomes hypotensive, drowsy or peripherally shut down, give 100mg hydrocortisone IM or

IV immediately. (Intravenous doses should be administered over 10 minutes.) 

IM hydrocortisone is preferable to IV since it has a more sustained release. 

Use hydrocortisone sodium phosphate or hydrocortisone sodium succinate, not hydrocortisone acetate. 

If the patient is unwell postpartum (e.g. vomiting or fever), delay return to normal dose beyond the 48 hour period stated above. If the patient is nil by mouth, ensure adequate intravenous fluid replacement (e.g. 0.9% sodium chloride or Hartmann’s solution). 

Monitor electrolytes and BP post-partum: 

  • BP every 4 hours.
  • U&Es daily for 2-3 days.

Appendix 1 Long-term oral glucocorticoids (ie 4 weeks or longer)

Long-term oral glucocorticoids (ie 4 weeks or longer) – Taken from Society of Endocrinology, Exogenous steroids treatment in adults2

MedicineDose (*) 
Beclometasone 625 microgram per day or more 
Betamethasone750 microgram per day or more 
Budesonide1.5mg per day or more (***) 
Deflazacort 6mg per day or more 
Dexamethasone 500 microgram per day or more (**)4
Hydrocortisone 15mg per day or more (**)
Methylprednisolone4mg per day or more 
Prednisone5mg per day or more 
Prednisolone5mg per day or more  

(*) dose equivalent from BNF except (**) where dose reflects that described in the guideline by Simpson et al (2020)4 and (***) based on best estimate

Appendix 2 Inhaled glucocorticoid doses

Inhaled glucocorticoid doses - Taken from Society of Endocrinology, Exogenous steroids treatment in adults2

Medicine

Dose (*)5

Beclometasone          

(as non-proprietary, Clenil, Easihaler, or Soprobec)

More than 1000 microgram per day 

Beclometasone         

(as Qvar, Kelhale or Fostair )       

More than 500 microgram per day

(check if using combination inhaler and MART regimen) 

Budesonide      

More than 1000 microgram per day 

(check if using combination inhaler and MART regimen) 

Ciclesonide                          

More than 480 microgram per day 

Fluticasone propionate  

More than 500 microgram per day 

Fluticasone furoate          

(as Trelegy and Relvar)

More than 200 microgram per day 

Mometasone                     

More than 800 microgram per day 

(*) dose equivalent - NICE Inhaled corticosteroid doses for NICE’s asthma guideline (2018)

Appendix 3 Topical glucocorticoids

Topical glucocorticoids. 2

Topical steroid treatments

Potency of steroid 

Beclometasone dipropionate 0.025%

Potent 

Betamethasone dipropionate 0.05% and higher

Potent 

Betamethasone valerate 0.1% and higher

Potent 

Clobetasol propionate 0.05% and higher

Very potent 

Diflucortolone valerate 0.1%

Potent 

Diflucortolone valerate 0.3%

Very Potent 

Fluocinonide 0.05%

Potent 

Fluocinolone acetonide 0.025%

Potent 

Fluticasone propionate 0.05%

 Potent 

Hydrocortisone butyrate 0.1%

Potent 

Mometasone 0.1%

Potent

Triamcinolone acetonide 0.1%

Potent

All other topical glucocorticoids available in the UK are either mild or moderate potency.

Editorial Information

Last reviewed: 22/04/2022

Next review date: 01/04/2027

Author(s): Andrew Thomson.

Version: 2

Approved By: Obstetrics Clinical Governance Group

Document Id: 520

References
  1. Wass JAH, Arlt W. How to Avoid precipitating an acute adrenal crisis. BMJ. 2012; 345: e6333
  2. Erskine D, Simpson H. Exogenous Steroids Treatment in Adults. Adrenal Insufficiency and Adrenal Crisis – Who is at risk and how should they be managed safely. Society for Endocrinology and the British Association of Dermatologists.
  3. Woodcock et al. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency. Anaesthesia. 2020; 75: 654-663.
  4. Simpson H, Tomlinson J, Wass J, Bean J, Arlt W. Guidance for the prevention and emergency management of adult patients with adrenal insufficiency. Clinical Medicine (London). 2020; 20 (4): 371-378.
  5. Inhaled corticosteroid doses for NICE’s asthma Guideline. July 2018.