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Announcements and latest updates

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

  1. Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26th September 3-4 pm on national and local contingency planning for future RDS outages.  Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

 

2.National  IV fluid prescribing  calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids  . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery.  It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

 

  1. New toolkits

The following toolkits are now live;

  1. Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

 

  1. Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit.  We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process.  The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

 

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:
  • Thursday 5 September 1-2 pm
  • Wednesday 24 September 4-5 pm
  • Friday 27 September 12-1 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

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

Benign Lesions

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

Patient Presentation

Lipoma

  • Asymptomatic. Slow growing 
  • Dome or egg-shaped, soft, mobile sub-cutaneous nodule 

Lipoma

 

Epidermoid (sebaceous) cyst 

  • Smooth mobile flesh coloured nodule within and fixed to overlying skin 
  • Presence of punctum helps confirm diagnosis 

Epidermoid (sebaceous) cyst

 

Spider haemangioma 

  • Compressible central feeding blood vessel of variable size 
  • May be associated with high levels of oestrogen e.g pregnancy, liver cirrhosis 

 

Xanthelasma

  • Yellowish plaques nodules above and below the eyes 

Xanthelasma

 

Giant comedones 

  • Like a small cyst with punctum 

Giant comedones

 

Pyogenic granuloma 

  • Rapidly growing vascular lesion often trauma site 

Pyogenic Granuloma

 

Skin Tags 

  • Soft flesh coloured or pigmented pedunculated tags in body folds (neck, armpit, groin) 
  • Especially in obese patients and in those with type 2 diabetes 

Skin Tags

 

Seborrhoeic Warts

  • Yellow / brown greasy palpules or rough grey / black hyperkeratotic papules with ‘stuck-on’ appearance 
  • Keratin plugs or inclusion cysts may help differentiate from melanoma 
  • Often multiple 

Seborrhoeic WartsSeborrhoeic WartsSeborrhoeic Warts

 

Benign Naevi (moles)

  • Flat or raised, symmetrical, uniform border, uniform pigment, pale, dark or reddish brown 
  • May darken/enlarge during pregnancy.  If hairy may become inflamed (folliculitis) 

Benign Naevi (moles)Benign Naevi (moles)Benign Naevi (moles)

 

Dermatofibroma 

  • Firm reddish brown nodules often on the limbs. May be tender on pressure 
  • If the skin over a dermotofibroma is squeezed a dimple forms, indicating tethering of the skin to the underlying fibrous tissue 

DermatofibromaDermatofibromaDermatofibroma

 

GP Management

Referral of patients with benign tumours may be appropriate if there is: 

  • Diagnostic doubt 
  • Significant risk of neoplasm 
  • Lesion causing functional problems or significant disfiguration 
  • Lesion prone to recurrent infection 

If benign skin lesion is diagnosed, it will not be removed in secondary care for cosmetic reasons alone. 

National guidance on exceptional referral protocol is available here: 

https://www.publications.scot.nhs.uk/files/cmo-2019-05.pdf 

 

Lipoma

  • Symptomatic lesions may be removed in primary care (where this service is offered), but treatment usually not indicated 

Epidermal (sebaceous) cyst 

  • Treatment not usually indicated. Symptomatic cysts may be removed in primary care (where this service is offered). 

Spider haemangioma

  • No treatment as they may resolve spontaneously, especially in children 

Xanthelasma

  • Reassure patient, no treatment required 

Giant comedones

  • Reassure patient, content often easily expressed 

Pyogenic granuloma

  • Due to frequent bleeding, excision or curettage/cautery required 
  • Caution with lesions with an atypical history or appearance as could be a malignancy 

Skin tags 

  • If symptomatic, consider treatment in Primary Care by cryotherapy (if available) or snip/shave + cautery (where this service is offered).  

Seborrhoeic Warts

  • If diagnosis certain, reassure that no treatment is needed 
  • Treatment in Primary Care (where this service is offered), can be considered for symptomatic lesions: 
    • Cryotherapy administrated by trained nurse 
    • Curettage for large lesions  
  • Specimen to pathology 

Benign Naevi (moles)

  • Do not refer patients with moles for cosmetic removal 
  • Excise or shave benign naevi only if they meet the criteria as outlined in the exceptional referral pathway: 

https://www.publications.scot.nhs.uk/files/cmo-2019-05.pdf   

Dermatofibroma 

  • If diagnosis is certain, reassure that no treatment is needed 
  • Excision, if indicated e.g. significant pain or discomfort, is the treatment of choice 
  • Warn patient about resulting scar 
  • Send specimen to pathology 

Dermatology Referral

Criteria for referral

Lipoma

  • Lipoma only if there is diagnostic doubt 

Epidermal (sebaceous) cyst

  • If  diagnostic doubt 

Spider haemangioma

  • Referral not generally required 
  • Cautery, hyfrecation or laser only in exceptional circumstances 

Xanthelasma

  • Exceptionally consider referral 

Giant comedones

  • Referral not generally required 

Pyogenic granuloma

  • Diagnostic doubt, or for excision 

Skin Tags

  • Rarely any indication for referral to secondary care 

Seborrhoeic Warts

  • Referral only if there is diagnostic doubt. Follow pathway for suspicious pigmented lesion 

Benign Naevi (moles)

  • Referral only if there is diagnostic doubt. Follow pathway for suspicious pigmented lesion. 

Dermatofibroma

  • Referral only if there is diagnostic doubt 

Patient information resources

Copyright

Images for the ‘Skin Tags’, ‘Seborrhoeic Warts’, ‘Benign Naevi (moles)’, and ‘Dermatofibroma’ reproduced with permission from http://www.dermnetnz.org/

Editorial Information

Author(s): Adapted from Dermatology Patient Pathways.

Co-Author(s): Dermatology Specialty Delivery Group, Centre for Sustainable Delivery.