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Right Decision Service newsletter: May 2024

Welcome to the Right Decision Service (RDS) newsletter for May 2024.

Issues with RDS and Umbraco access

A fix was deployed on Thursday 30th May to address the stability issues experienced with the Right Decision Service over recent weeks. These arose principally when multiple toolkits were built simultaneously or successively to the mobile app  We are hopeful that the stability issues are now resolved. If you encounter any problems with this newly deployed site, please email ann.wales3@nhs.scot and onivarova@tactuum.com immediately as well as raising an Urgent support ticket.

Thank you again for your patience while we have been resolving these issues.

New editor request form

A form to request creation of new editors, or updates to existing editor details, is available in the Standard Operating Procedures toolkit  .

Redesign and improvements to RDS

The timeline for this work has been slightly delayed because effort has been diverted to addressing the recent stability issues.  However, the redesign of search, browse, archiving and version control have now been through a second round of testing and Tactuum is beginning to work on amendments.  We now plan to go out to user acceptance testing in July 2024 and will let you know when we are ready to do this.

Deep linking direct to individual toolkits on the mobile app

We are awaiting clarification from Tactuum on the time and effort required for this development. We should hear this week and I will let you know as soon as information is available.

New feature requests

Once we have completed the current redesign and deep linking we will be able to take stock of outstanding new feature requests and update you on what can be achieved within available resource.

Training

Introductory webinars for new RDS editors will be held on the following dates:

  • Thursday 27 June 11 am – 12 pm
  • Wednesday 3rd July 3.15 pm – 4.15 pm

To book to attend one of these webinars, please contact Olivia.graham@nhs.scot , stating your name, job title, health board and preferred date for training.

The RDS Learning working group is also progressing work on “train the trainer” resources for RDS editors and toolkit leads. These resources include:

  • A module on clinical and care governance for RDS content
  • A step by step introduction to the toolkit development process.
  • Video learning bytes to introduce key editorial features and functions.

We aim to have initial content available on the RDS Learning area by end of June/early July.

Evaluation

Thanks to Fergus Donachie in NHS Dumfries and Galloway and Sheila Grecian in NHS Lothian, who have shared the results of user surveys for their referral management and diabetes & endocrinology toolkits. The results provide excellent insights into how RDS is improving practice and saving time for clinicians. And there are also helpful suggestions for improving the service.

This all provides valuable material to support the business case to Scottish Government for the next stages of RDS development. If you have carried out local evaluation we would be very pleased to hear from you.

New toolkits

The following RDS toolkits are now live:

The Right Decisions toolkit for SIGN 171: Management of diabetes in pregnancy.

SIGN 168: Assessment, diagnosis, care and support for people with dementia and their carers. This toolkit is live and just awaiting final editorial review to remove the “in development” status.

Living well with dementia - for everyone. We recommend that you use the mobile version of this toolkit, as the web version contains only informational resources. The mobile app provides access to the Dementia wellbeing diary, which enables people in early post-diagnostic stages and their carers to keep track of their wellbeing outcomes. Each wellbeing outcome is linked to resources and services supporting that outcome. The mobile toolkit also provides a digital version of the “Getting to know me” form, and a range of resources and tools for people living with dementia and their carers. Four HSCPs have localised this app to include directories of local support services, but this generic app is available for anyone in any location to use.

The following toolkits are due to go live imminently:

  • SARCS (Sexual Assault Response Coordination Service)
  • Child protection procedures (North Lanarkshire)
  • NHS Lothian neonatal guidelines

Toolkits in development

Some of the toolkits the RDS team is currently working on:

Waiting Well – national toolkit for healthcare professionals. This toolkit is being developed for the Scottish Government Waiting Well team in collaboration with NHS GGC knowledge services staff. It provides healthcare teams in NHS Boards and HSCPs with guidance and tools to develop and implement their action plans to support people on waiting lists with access to information, signposting to local community assets and services, and to professional support and services.

NHS Borders RefHelp – referral guidance for NHS Borders. Work is about to start on a similar toolkit for NHS Tayside.

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

Thank you to everyone who has completed the retrospective Quality Assurance checklist. I am pleased to say that the latest report was well-received within Healthcare Improvement Scotland, with positive comments on the commitment shown by NHS Boards and other organisations to ensuring the quality and safety of their content on the RDS.

 

Implementation projects

A knowledge exchange session to share learning about implementation of patient and public-facing RDS apps is scheduled for 28th June 11 am – 12 pm.  This will include sharing key points from a recent literature review, and the results of early tests of change of implementing the ‘Being a partner in my care’ app, which aims to help citizens to become active partners in Realistic Medicine. 

If you would like to attend this session and have not yet received an invitation, please contact ann.wales3@nhs.scot .

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

 

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

 

The Right Decision Service:  the national decision support platform for Scotland’s health and care

Website: https://rightdecisions.scot.nhs.uk    Mobile app download:  Apple  Android

 

Atopic eczema

Warning

Atopic eczema: Atopic dermatitis is a chronic inflammatory genetically-determined eczematous dermatosis associated with an atopic diathesis (elevated circulating IgE levels, Type I allergy, asthma and allergic rhinitis). Atopic eczema is manifested by intense pruritus, exudation, crusting, excoriation and lichenification. In people with pigmented skin, eczema may appear within a colour range of pink, red and purple, or a subtle darkening of existing skin colour, and can have an extensor and/or papular pattern. Estimates vary, but figures suggest that it affects 10-30% of children and 2-10% of adults. No difference in prevalence based on sex and ethnicity. Around 70–90% of cases occur before 5 years of age. Atopic dermatitis may  first develop in adulthood.  Increased prevalence of atopic eczema in children with an affected parent. There is a higher prevalence of atopic eczema in urban areas. 

Not all treatment options may be listed in this guidance. Please refer to local formulary for a complete list.

Treatment/ therapy

Mild: Localised areas of dry skin, infrequent itching (with or without small areas of redness or altered pigmentation). Little impact on everyday activities, sleep and psychosocial wellbeing. 

  • Prescribe generous amounts of emollients (patient’s preference); advise frequent, liberal, daily use.  
  • Prescribe a mild topical corticosteroid (e.g. hydrocortisone 1%) for areas of red skin or altered pigmentation. Continue treatment for 48 hours after flare is controlled. 
  • Consider prescribing a one-month trial of non-sedating antihistamines only in cases of severe itch or urticaria. Review every three months if suitable. 
  • Do not routinely take a skin swab for microbiological testing in people with secondary bacterial infection of eczema at the initial presentation; In people who are not systemically unwell, do not routinely offer either a topical or oral antibiotic for secondary bacterial infection of eczema. 

 

Moderate: Localised areas of dry skin, frequent itching, redness or altered pigmentation in skin of colour (with or without excoriation and localised skin thickening). Moderate impact on everyday activities and psychosocial wellbeing, frequently disturbed sleep. 

  • Prescribe generous amounts of emollients (patient’s preference); advise frequent, liberal, daily use. 
  • Prescribe a moderately potent topical corticosteroid if skin is inflamed (e.g. betamethasone valerate 0.025%, clobetasone butyrate 0.05%). Continue treatment for 48 hours after flare is controlled.  
  • Prescribe a mild potency topical corticosteroid for delicate face/flexural skin areas (e.g. hydrocortisone 1%); increase to moderate potency corticosteroid if necessary. Continue treatment for maximum of 5 days. 
  • Prescribe topical calcineurin inhibitors for facial eczema unresponsive to moderate topical corticosteroids e.g. Tacrolimus (0.03% if aged 2-12; 0.1% b.d. if aged over 12) or pimecrolimus. 

For frequent flares consider:  

  • A step-down treatment using lower potency corticosteroid (typically a class down from what is used for flare) 
  • Intermittent treatment on two consecutive days of the week (weekend) or twice-weekly (e.g. every 3-4 days).  

 

 

Severe: Widespread areas of dry skin, incessant itching, redness or altered pigmentation in skin of colour (with or without excoriation, extensive skin thickening, bleeding, oozing and cracking). Severe limitation of everyday activities and psychosocial functioning, nightly loss of sleep. 

  • Prescribe generous amounts of emollients (patient’s preference); advise frequent, liberal, daily use.  
  • Prescribe a potent topical corticosteroid for inflamed areas, e.g. betamethasone valerate 0.1% or mometasone 0.1%, on the body. Continue treatment for 48 hours after flare is controlled.  

Oral corticosteroids should be reserved for use in the treatment of severe flares, often while waiting for referral to secondary care  

Secondary infection 

  • Prescribe systemic antibiotics if patients are systemically unwell with suspected secondary bacterial infection.  
  • For people with secondary bacterial infection of eczema that is worsening or has not improved, consider sending a skin swab for microbiological testing. (flucloxacillin 1st line; erythromycin if penicillin allergic or resistance to flucloxacillin). 
  • Eczema herpeticum - Prescribe systemic aciclovir and refer patient as medical emergency if eczema herpeticum (widespread herpes simplex virus) is suspected with atopic eczema (sudden onset of painful, uniform grouped vesicles/erosions). 

 

Referral Management

  • Manage mild in primary care, do not refer.  
  • Manage moderate in secondary care service if multiple treatments in primary care have failed, or if patient’s mental health is being adversely affected by their eczema. 
  • Refer to secondary/tertiary care if the atopic eczema is severe and has not responded to optimum topical therapy (potent corticosteroids on the body). 
  • Refer as an emergency if eczema herpeticum is suspected, and in cases of erythroderma (>70-90% of body surface area). 

Clinical tips

  • The diagnosis is unlikely to be atopic eczema if there is no itch. 
  • Suspect food allergy in children who have reacted previously to food with immediate symptoms, or in infants and young children with moderate to severe eczema not responding to optimum management, particularly if associated with gastrointestinal symptoms. 
  • Long-term use of appropriate emollient therapy is important. Patients with generalised eczema require up to 500g per week of emollient. Applying emollients from the fridge can help with itch. Avoid aqueous cream as a leave-on emollient, due to high risk of skin irritation. 
  • Consider allergic contact dermatitis if condition not improving, and the given treatment is felt to be causing a further reaction.  
  • Consider allergic contact eczema when there is a change in pattern of eczema – e.g. hand and face eczema 
  • Occlusive dressings such as wet wraps (YouTube video: How to apply wet wraps) or dry bandages can help penetration of corticosteroid and can help break the itch-scratch cycle (should be avoided when infected). Beware the risk of atrophy with prolonged occlusion. 
  • Topical calcineurin inhibitors are useful second-line agents, particularly for facial eczema. They can be used intermittently for maintenance. Initial stinging often occurs but tends to improve with continued use. Avoid in infected eczema. 
  • With recurrent infected eczema, consider swabbing the nose of patients and family members to look for staphylococcus aureus carriage to help guide decolonisation regimens. 

ICD search categories

Inflammatory 

ICD11 code - EA80

Editorial Information

Last reviewed: 30/05/2023

Next review date: 30/05/2025

Author(s): Adapted from the BAD Referral Guidelines.

Version: BAD 1

Co-Author(s): Publisher: Centre for Sustainable Delivery, Scottish Dermatological Society.

Approved By: Scottish Dermatological Society