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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

Urticaria

Urticaria: A heterogeneous group of disorders characterized by dermal and/or subcutaneous and submucosal oedema. The most common underlying mechanism is release of histamine from mast cells with consequent capillary dilatation and tissue oedema. This is responsible for the weals of spontaneous and most inducible urticarias. A variety of other mechanisms are involved in other urticarial disorders. In the UK, approximately 15% of people experience urticaria at some time in their lives and the lifetime prevalence of chronic urticaria is 0.5–1%. For around 40–50% of people with urticaria, the cause of their condition is unknown. Symptoms of duration of less than 6 weeks are considered acute, and beyond this are chronic urticaria. 

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

Treatment/therapy

Mild: does not impact significantly on activities of daily living 

  • For people with urticaria with an identifiable and avoidable cause/trigger give advice regarding avoidance of triggers 
  • Stop any histamine-releasing drugs if able, e.g. aspirin, codeine, ACE inhibitors, non-steroidal anti-inflammatory drugs; if possible, treat potential sources of infection; avoid triggers for inducible urticarias (such as heat, cold, etc). 
  • Offer a low-sedating antihistamine at standard licenced dose (for example cetirizine, loratadine or fexofenadine) for up to 3 months.

Moderate: symptomatic but does not impact on sleep/normal activities of daily living 

  • For people with urticaria with an identifiable and avoidable cause/trigger give advice regarding avoidance of triggers 
  • Stop any histamine-releasing drugs if able, e.g. aspirin, codeine, ACE inhibitors, non-steroidal anti-inflammatory drugs; if possible, treat potential sources of infection; avoid triggers for inducible urticarias (such as heat, cold, etc). 
  • Offer a low-sedating antihistamine at standard licenced dose (for example cetirizine, loratadine or fexofenadine) for 3-6 months. If not controlled on once daily, consider double dose or increasing up to quadruple dose, reducing to lower doses when symptoms controlled. 
  • Suggest a FBC differential, ESR/CRP and TSH/TFT for patients where symptoms persist. 

Severe: frequent or significant lesions. Impacts on sleep or daily activities 

  • For people with urticaria with an identifiable and avoidable cause/trigger give advice regarding avoidance of triggers (stop histamine-releasing drugs and avoid triggers for inducible urticarias, as for mild/moderate urticaria) 
  • Offer a low-sedating antihistamine at standard licenced dose (for example cetirizine, fexofenadine, or loratadine) for 3-6 months. If not controlled on once daily, consider double dose or increasing to quadruple dose, reducing to lower doses when symptoms controlled 
  • Give a short course of an oral corticosteroid (for example prednisolone 40 mg daily for 4-5 days) in addition to the low-sedating oral antihistamine if not controlled. Longer term steroids are not advised for chronic urticaria management in primary care. 
  • Referral if an oral corticosteroid is indicated in a child younger than 16 years of age.   
  • If rebound symptoms occur, seek specialist advice. Do not repeat the course of oral corticosteroid. 
  • Suggest a FBC differential, ESR/CRP and TSH/TFT. 
  • NICE guidance recommends montelukast as a second-line agent (unlicenced indication)

Referral management

Mild: does not impact significantly on activities of daily living 

Manage in primary care, seek advice and guidance if there is diagnostic uncertainty. 

 

Moderate: symptomatic but does not impact on sleep/normal activities of daily living 

Manage in primary care, seek advice and guidance if there is diagnostic uncertainty, particularly where individual lesions last more than 24 hours and/or fade with bruises (not bruising due to scratching) and/or are painful, or if there are systemic symptoms such as arthralgia or fever, or if there are persistently high inflammatory markers. This may suggest urticarial vasculitis, or diseases with urticaria-like rashes. 

Consider referral when symptoms are not well controlled on antihistamine treatment, or when disease is having a significant effect on quality of life.  

 

Severe: frequent or significant lesions. Impacts on sleep or daily activities 

Seek advice and guidance if there is diagnostic uncertainty, particularly where individual lesions last more than 24 hours and/or fade with bruises (not bruising due to scratching) and/or are painful, or if there are systemic symptoms such as arthralgia or fever, or if there are persistently high inflammatory markers. This may suggest urticarial vasculitis, or diseases with urticaria-like rashes. 

Consider referral when symptoms are not well controlled on antihistamines or other treatments listed above, or when disease is having a significant effect on quality of life. Refer people with forms of chronic inducible urticaria that may be difficult to manage in primary care, for example, solar or cold urticaria. 

Refer people with acute severe urticaria which is thought to be due to a food or latex allergy – check locally whether referral to specialist immunology services more appropriate. 

  • There are other treatment options in secondary care, including omalizumab and ciclosporin. 

Clinical resources

DLQI clinical tool: https://www.cardiff.ac.uk/medicine/resources/quality-of-life-questionnaires/dermatology-life-quality-index  

UAS7 clinical tool:  

NICE CKS – Urticaria: 

NICE scenarios – Managing urticaria:  

BAD Urticaria guidelines (2007):  

PCDS guidance – Chronic spontaneous urticaria  

BSACI- Urticaria:  The EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis and management of urticaria - Zuberbier - 2021 – Allergy 

DermnetNZ – Urticaria   

Clinical Tips

  • Patients with urticaria have a higher incidence of thyroid receptor antibodies than the general population. 
  • Check C4 levels (complement) in patients with angioedema without urticaria. 
  • UAS7 can be a useful tool in estimating severity and response to treatment. 
  • Chronic spontaneous urticaria is rarely associated with food allergy, and patch testing is unhelpful and not recommended. 

Patient information resources

  1. BAD leaflet – Urticaria and angioedema
  2. Patient.info leaflet – Urticaria
  3. NHS Conditions- Hives
  4. Angioedema
  5. NHS Inform Scotland- Urticaria (Hives) 

ICD search category(s)

Inflammatory 

ICD11 code - EB00 

Editorial Information

Last reviewed: 11/04/2023

Next review date: 11/04/2025

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