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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

Twin Pregnancy Ultrasound Guideline (330)

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

Gestational Age, Chorionicity and Amnionicity

Women should be offered a first trimester USS (< 14+0 weeks) to estimate gestational age and determine chorionicity and amnionicity.

Chorionicity and amnionicity should be determined by the number of placental masses, the presence of amniotic membranes and membrane thickness, the lambda or T-sign.

Clear nomenclature should be assigned e.g inferior and superior, or left and right, in a twin or triplet pregnancy to ensure consistency throughout pregnancy.

If a multiple pregnancy presents after 14+0 weeks then determination of chorionicity and amnionicity could also take into account discordant fetal sex if required.

If TAUSS views are poor because of a retroverted uterus or a high BMI, use a transvaginal ultrasound scan to determine chorionicity and amnionicity.

The largest baby should be used to calculate the estimated date of delivery for the pregnancy.

A photographic record should be placed in the patient’s hospital held records documenting the ultrasound appearance of the membrane attachment to the placenta and an electronic / hard drive record stored. Chorionicity must be checked by senior sonographer

If there is still doubt about the chorionicity, the woman should be referred to medical staff for chorionicity assessment without delay.

Following this if there is still doubt, the pregnancy should be managed as monochorionic until proved otherwise.

Screening

Referral should be made for counselling for antenatal screening for combined trisomy (21,18,13) following the diagnosis of a twin pregnancy (fetal medicine at QEUH, Day Care counselling midwife PRM, Screening midwife Clyde). This should ideally be prior to the 11+2 to 14+1 week scan.

The test of choice for twin pregnancies is first trimester combined screening. Every opportunity must be made to maximise the offer of first trimester combined screening. Chance results to be reported are:

  • a term chance of T21 and a term chance of T18/T13
  • a term chance of T21 only
  • a term chance of T18/T13 only

First trimester combined screening will be reported in a dichorionic twin pregnancy as a chance for each fetus whereas in a monochorionic twin pregnancy it will be reported as a chance per pregnancy.

Women who ‘miss’ or have unsuccessful first trimester screening for aneuploidy should be offered second trimester screening for T21. Chance results are reported as a pregnancy related chance that is not fetal specific.

Monochorionic Twins

Fetal ultrasound assessment should be performed every two weeks in uncomplicated monochorionic twins from 16+0 weeks onwards until delivery.

Scans at 16 and 20 weeks (detailed anomaly scan) should be performed by a medical sonographer. The detailed fetal anomaly scan should include extended cardiac views (5 standard views).

At every ultrasound, the following should be assessed and recorded:

  • liquor volume (LV) should be assessed in each sac and deepest vertical pool (DVP)
  • Umbilical artery pulsatility index (UAPI)*
  • Fetal bladders should be assessed.
  • Middle Cerebral Artery Peak Systolic Velocity (MCA PSV)

*See Umbilical Artery Pulsatility Index Chart

Increase the frequency of diagnostic monitoring for TTTS in the woman’s 2nd and 3rd trimester to at least weekly if there are concerns about differences between the babies’ amniotic fluid level (a difference in DVP depth of 4cm or more). Include Doppler assessment of the umbilical artery flow for each baby.

Refer for medical scan if LV DVP>8 cm or <2cm before 20 weeks or LV DVP >10cm or <2cm after 20 weeks. If abnormality confirmed discussion with fetal medicine at QEUH is indicated.

Staging of Twin-to-twin transfusion syndrome (TTTS)

Stage Description

I

II

III

IV

V

Poly/oligohydramnios with bladder of the donor still visible

Bladder of the donor no longer visible

Presence of either absent or reverse end-diastolic velocity of the umbilical artery, reverse flow in either twin

Hydrops in either twin

Demise of one or both twins prior to surgery

From 16+0 weeks fetal biometry (HC, AC and FL) should be assessed and abdominal circumference (AC) and Estimated fetal weight (EFW) recorded for each twin. The discordance in EFW should be calculated and documented in monochorionic twins at each visit:

([EFW larger fetus − EFW smaller fetus] ÷ EFW larger fetus) × 100

Increase diagnostic monitoring in the 2nd and 3rd trimesters to at least weekly, and include Doppler assessment of the umbilical artery flow for each baby, if there is an EFW discordance of 20% or more and/or the EFW of any of the babies is below the 10th centile for gestational age.

Refer women with a monochorionic twin pregnancy to a tertiary level fetal medicine centre if there is an EFW discordance of 25% or more and the EFW of either of the babies is below the 10th centile for gestational age because this is a clinically important indicator of selective fetal growth restriction.

Selective intrauterine growth restriction (growth discordance of >20%). Approximately 10-15 % of MCDA twins

Stage Description

I

II

III

Growth discordance but positive diastolic velocities in both fetal umbilical arteries.

Growth discordance with absent or reversed end-diastolic velocities (AREDV) in one or both fetuses.

Growth discordance with cyclical umbilical artery diastolic waveforms (positive followed by absent then reversed end-diastolic flow in a cyclical pattern over several minutes [intermittent AREDV; iAREDV]).

Offer weekly USS monitoring for TAPS from 16 weeks of pregnancy using middle cerebral artery peak systolic velocity (MCA-PSV) to women who pregnancies are complicated by:

  • feto-fetal transfusion syndrome that has been treated by fetoscopic laser therapy or
  • selective fetal growth restriction (defined by an EFW discordance of 25% or more and an EFW of any of the babies below the 10th centile for gestational age)

Aim for delivery between 36+0 and 36+6 for uncomplicated MCDA twins after which point continuing the pregnancy increases the risk of fetal death

For monochorionic monoamniotic twins birth should be planned between 32+0 and 33+6

Dichorionic Twins

Fetal anomaly scan can be performed by sonographer if there are no other obstetric reasons for a medical FAS.

Growth USS should be performed every 4 weeks from 24 weeks onwards. Estimated fetal weight, umbilical artery PI and deepest vertical pool of liquor should be measured at each visit.

Fetal weight discordance should be calculated for dichorionic twins:

([EFW larger fetus − EFW smaller fetus] ÷ EFW larger fetus) × 100

Increase monitoring in 2nd and 3rd trimesters to at least weekly, and include Doppler assessment of the umbilical artery flow for each baby if there is EFW discordance of 20% or more and/or the EFW of any of the babies is below the 10th centile for gestational age.

Refer women with a dichorionic twin pregnancy to a tertiary level fetal medicine centre if there is an EFW discordance of 25% or more and the EFW of any of the babies is below the 10th centile for gestational age because this is a clinically important indicator of selective fetal growth restriction.

Aim for delivery between 37+0 and 37+6 for uncomplicated DCDA twins as after this point continuing the pregnancy increases the risk of fetal death.

Appendix: Umbilical Artery Pulsatility Index (UAPI) Reference Chart

> 95th percentile is abnormal

Appendix: MONOCHORIONIC DIAMNIOTIC TWINS – antenatal appointments

(File in notes)

Monochorionic diamniotic twins - antenatal appointments - pdf

Appendix: DICHORIONIC DIAMNIOTIC TWINS –antenatal appointments

(File in notes)

Dichorionic diamniotic twins - antenatal appointments - pdf

Editorial Information

Last reviewed: 24/10/2023

Next review date: 31/10/2028

Author(s): Victoria Watson ST7 PRM, Donna Bean, Lead Sonographer Obstetrics and Gynaecology.

Version: 3

Approved By: Maternity Clinical Governance Group

Document Id: 330

References
  1. NICE [NG137. Twin and triplet pregnancy. 2019.
  2. Khalil A. ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. Ultrasound in Obstetrics and Gynaecology. ISUOG. November 2015.
  3. NHS Fetal Anomaly Screening Programme (FASP). Public Health England. September 2019.