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Early identification and management of lithium toxicity

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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 3^rd 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:

Acute oncology guidelines (NHS Lothian. Password protected. Please contact decisionsupport@nhs.scot if you would like to be put in touch with the toolkit owner to request the password.)
SPEG (Scottish Paediatric Endocrine Group)
Patient Information Leaflets (NHS Borders)
Respiratory prescribing – national guidance from Scottish Government Effective Prescribing and Therapeutics Division.

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

Symptoms of lithium toxicity

Symptoms of toxicity include;

coarse tremor
muscle twitches
gastric upset including diarrhoea
muscle weakness
unsteady gait/falls
slurred speech
blurred vision
drowsiness
confusion

Services should have a low threshold of suspicion for toxicity and undertake additional levels to confirm or discount toxicity as a matter of urgency.

Identifying toxicity in the community

Ensure patients, carers and staff receive education about:

Situations and issues that might lead to toxicity
Signs and symptoms of toxicity
Seeking medical help if they develop any signs or symptoms indicative of toxicity
Not to buy medicines over counter without speaking to a pharmacist
Staying adequately hydrated
Seeking medical help if they have vomiting or diarrhoea for more than 24 hours
Attending for regular blood tests

Community staff should be vigilant for signs of toxicity at every clinical contact.

Identifying toxicity in hospital

Implementing the ward bundle will provide systems to identify toxicity in hospital

What to do if toxicity occurs

Stop lithium immediately.
Provide any necessary supportive medical care.
Take a level.
Any level of 1.5mmol/L or higher should be considered a medical emergency and admission to an acute hospital may be required. Be aware that levels may continue to rise for 24-48 hours after stopping lithium.
Identify and address potential causes.
Do not restart lithium until levels return to the normal range and then only if treatment is deemed clinically necessary.

Last reviewed: 06/12/2023

Next review date: 01/08/2025

Author(s): PMG-MH.

Version: 1

Author email(s): PrescribingManagementGroup.MentalHealth@ggc.scot.nhs.uk.

Approved By: PMG-MH

Reviewer name(s): Lead Clinical Pharmacist, Clinical Effectiveness Pharmacist.