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Announcements and latest updates

Right Decision Service newsletter: September 2024

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

1.Business case for permanent provision of the Right Decision Service from April 2025 onwards

This business case has now been endorsed by the HIS Board and will shortly be submitted to Scottish Government.

2. Management of RDS support tickets

To balance increasing demand with available capacity and financial resource, the RDS team and Tactuum are now working together to  implement closer management of support tickets. As a key part of this, we want to ensure clear, timely and consistent communication with yourselves as requesters.  

Editors will now start seeing new messages come through in response to support ticket requests which reflect this tightening up and improvement of our processes.

Key points to note are:

2.1 Issues confirmed by the RDS and Tactuum teams as meeting the critical/urgent and high priority criteria will continue to be prioritised and dealt with immediately.

Critical/urgent issues are defined as:

  1. The Service as a whole is not operational for multiple users. OR
  2. Multiple core functions of the Service are not operational for multiple users.

Example – RDS website outage.

Please remember to email ann.wales3@nhs.scot and his.decisionsupport@nhs.scot with any critical/urgent issues in addition to raising a support ticket.

High priority issues are defined as:

  1. A single core function of the Service is not operational for multiple users. OR:
  2. Multiple non-core functions of the Service are not operational for multiple users.

Example – Build to app not working.

2.2 Support requests that are outwith the warranty period of 12 weeks since the software was originally developed will not be automatically addressed by Tactuum. The RDS team will consider these requests for costed development work and will obtain estimate of effort and cost from Tactuum for priority issues.

2.3 Support tickets for technical issues that are not classified as bugs will not be automatically addressed by Tactuum. The definition of a bug is ‘a defect in the software that is at variance with documented user requirements.’  Issues that are not bugs will also be considered for costed development work.

The majority of issues currently in support tickets fall into category 2 or 3 above, or both.

2.4 Non-urgent requests that require a deployment (i.e a new release of RDS) will normally be factored into the next scheduled release (currently end of Nov 2024 and end of Feb 2025) unless by special agreement with the RDS team.

Please note that we plan to move in the new year to a new system whereby requests all come to an RDS support portal in the first instance and are triaged from there to Tactuum when appropriate.

We will be organising a webinar in a few weeks’ time to take you through the details of the current support processes and criteria.

3. Next scheduled deployment.

The next scheduled RDS deployment will take place at the end of November 2024.  We are reviewing all outstanding support tickets and feature requests along with estimates of effort and cost to determine which items will be included in this deployment.

We will update you on this in the next newsletter and in the planned webinar about support ticket processes.

4. Contingency arrangements for RDS

Many thanks to those of you who attended our recent webinar on the contingency arrangements being put in place to prevent future RDS outages as far as possible and minimise impact if they do occur.  Please contact ann.wales3@nhs.scot if you would like a copy of the slides from this session.

5. Transfer of CKP pathways to RDS

The NES clinical knowledge pathway (CKP) publisher is now retired and the majority of pathways supported by this tool have been transferred to the RDS. Examples include:

NHS Lothian musculoskeletal pathways

NHS Fife rehabilitation musculoskeletal pathways

NHS Tayside paediatric pathways

6. Other new RDS toolkits

Include:

Focus on frailty (from HIS Frailty improvement programme)

NHS GGC Money advice and support

If you would like to promote one of your new toolkits through this newsletter, please contact ann.wales3@nhs.scot

To go live imminently:

  • Focus on dementia
  • NHS Lothian infectious diseases toolkit
  • Dumfries and Galloway Adult Support and Protection procedures
  • SIGN guideline – Prevention and remission of type 2 diabetes

 

7. Evaluation projects

We have recently analysed the results of a survey of users of the Scottish Palliative Care Guidelines toolkit.  Key findings from 61 respondents include:

  • Most respondents (64%) are frequent users of the toolkit, using it either daily or weekly. A further 25% use it once or twice per month.
  • 5% of respondents use the toolkit to deliver direct patient care and 82% use it for learning
  • Impact on practice and decision-making was rated as very high, with 80% of respondents rating these at a 4-5 on a 5 point scale.
  • Impact on time saving was also high, with 74% of respondents rating it from 3-5.
  • 74% also reported that the toolkit improved their knowledge and skills, rating these at 4-5 on the Likert scale

Key strengths identified included:

  • The information is useful, succinct, and easy to understand (31%).
  • Coverage is comprehensive (15%)
  • All information is readily accessible in one place and users value the offline access via mobile app (15%)
  • Information is reliable, evidence-based and up to date (13%)

Users highlighted key areas for improvement in terms of navigation and search functionality. The survey was very valuable in enabling us to uncover the specific issues affecting the user experience. Many of these can be addressed through content management approaches. The issues identified with search results echo other user feedback, and we are costing improvements with a view to implementation in the next RDS deployment.

8.RDS High risk prescribing (polypharmacy) decision support embedded in Vision and EMIS primary care E H R systems

This decision support software, sponsored by Scottish Government Effective Prescribing and Therapeutics Division,  is now available for all primary care clinicians across NHS Tayside. Board-wide implementation is also planned for NHS Lothian, and NHS GGC, NHS Ayrshire and Arran and NHS Dumfries and Galloway have initial pilots in progress. The University of Dundee has been commissioned to evaluate impact of this decision support software on prescribing practice.

9. Video tutorials for RDS editors

Ten bite-size (5 mins or less) video tutorials for RDS editors are now available in the “Resources for providers of RDS tools” section of the RDS.  These cover core functionality including Save and preview, content page and media management, password management and much more.

10. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Wednesday 23rd October 4-5 pm
  • Tuesday 29th October 11 am -12 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.)

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

 

Medical Termination of Pregnancy Protocol (513)

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

< 10 + 0 WEEKS GESTATION

Mifepristone Day

  • Ensure case-notes and appropriate documentation available.
  • Check consent form is signed
  • Check certificate A has 2 signatures.
  • Ensure confirmed intra-uterine pregnancy.
  • Complete paperwork in ICP/electronic record
  • Check the patient is sure of their decision.
  • Administer mifepristone 200mg PO in accordance with drug kardex. Patient may go home thereafter.
  • Advise patient to return to the place of administration if she vomits within 1 hour.
  • Ensure advice is given to the patient regarding pain and/or bleeding she may experience over the following 24-48 hours.
  • Ensure the patient has the ward telephone number.
  • Advise the patient to bring appropriate clothing for admission.

Misoprostol Day
48 hours following mifepristone.

  • Nurse enquires about pain/bleeding/passage of products of conception.
  • Check BP, pulse and temperature.
  • Explain the procedure to the patient.
  • Patient is NOT routinely required to fast.
  • Confirm contraceptive plan, and prescribe/administer as indicated.
  • Misoprostol 800 micrograms PV.
  • Diclofenac 100mg PR as prophylactic analgesia unless contraindicated. (If contra-indicated cocodamol 30/500 PO).
  • Patient to use bed pan throughout procedure to aid identification of POC.
  • If products ARE passed, follow the discharge procedure.

If no POC passed within 6 hours:

  • If POC are not passed within 4 hours administer 400 micrograms of misoprostol sublingually.
  • If no POC passed within one hour, perform speculum examination to ensure POC are not in cervix/vagina.

If POC are not identified following a second dose of misoprostol or during vaginal examination:

  • If pain and bleeding are satisfactory, the patient should be discharged home. The patient should be offered either follow-up scan by appointment at Sandyford after 7-14 days or a pregnancy test after 21 days. If the patient chooses the latter option, the pregnancy test kit should be supplied to the patient on discharge. If she chooses the scan option, then Sandyford contact details should be given so that she can make an appointment.
  • For patients who are <10 + 0 weeks gestation and pass what is thought to be incomplete POC – follow up is scan is NOT required. Advise the patient that bleeding is to be expected, however ensure ward contact details are given so that the patient can contact staff should they be concerned that their bleeding is heavier than anticipated.  

If excessive bleeding occurs before/after POC passed:

  • Perform speculum examination to evacuate clot and remove any POC identified.
  • If bleeding continues contact middle grade or consultant gynaecologist.
  • Fast patient.
  • Site venflon.
  • Check P/BP/T/O2 saturation every 15 minutes/high-flow facial O2 if bleeding continues.
  • Send FBC.
  • Cross-match and check clotting screen if signs of shock.
  • Give misoprostol 400 micrograms sublingually.
  • Give ergometrine 500 micrograms IM unless contra-indicated for the patient. This can be given at the same time as misoprostol, as it will be effective before the misoprostol has its maximum effect.
  • If bleeding persists or there are clinical signs of shock (tachycardia, hypotension), an urgent surgical evacuation should be arranged by medical staff.

DISCHARGE PROCEDURE FOR ALL PATIENTS

  • Record the patient’s BP, pulse and temperature prior to discharge.
  • Contraception must be supplied or a contraceptive plan agreed.
  • Anti-D is NOT required for rhesus negative women.
  • All patients with a multiple pregnancy require a follow-up scan at Sandyford

Scan Post TOP

If scan shows RPOC < 3cm – advise patient to seek referral if increased PV bleeding, pain or offensive PV loss.

If scan shows RPOC > 3cm the patient should be offered surgical evacuation of uterus if clinically indicated i.e. excessive bleeding.

If the patient declines surgical evacuation she may be managed conservatively with anti-biotics (co-amoxiclav 375mg TID for 7 days). A further scan will be required after 7-10 days to ensure RPOC is decreasing in size.

If scan shows a continuing pregnancy the patient should be given the option of MTOP or STOP depending on their gestation.

Protocol for MTOP 10-18 weeks gestation

Mifepristone Day

  • Ensure case-notes and appropriate documentation available.
  • Check consent form is signed
  • Check certificate A has 2 signatures.
  • Ensure confirmed intra-uterine pregnancy.
  • Complete paperwork in the ICP/electronic record.
  • Check the patient is sure of their decision.
  • Administer mifepristone 200mg PO in accordance with drug kardex. Patient may go home thereafter.
  • Advise patient to return to the place of administration if they vomit within 1 hour.
  • Ensure advice is given to the patient regarding pain and/or bleeding they may experience over the following 24-48 hours.
  • Ensure the patient has the ward telephone number.
  • Advise the patient to bring appropriate clothing for admission.

Misoprostol Day
48 hours following mifepristone.

  • Nurse enquires about pain/bleeding/passage of products of conception.
  • Check BP, pulse and temperature.
  • Explain the procedure to the patient.
  • Patient is NOT routinely required to fast.
  • Confirm contraceptive plan, and prescribe/administer as indicated.
  • Administer Misoprostol 800 micrograms PV.
  • Diclofenac 100mg PR as prophylactic analgesia unless contraindicated. (If contra-indicated cocodamol 30/500 PO).
  • After 3 hours administer 400 micrograms of misoprostol sublingually and repeat at 3 hourly intervals until abortion occurs.
  • Analgesia and anti-emetics should be administered as required.
  • Patient to use bedpan throughout procedure to aid identification of POC.
  • Following the delivery of foetus either with or without the placenta, syntometrine (ergometrine 500 micrograms with oxytocin 5 units) 1ml IM should be administered.
  • If the placenta is not passed within the hour of syntometrine being administered, the patient should be examined vaginally and placenta retrieved if possible.
  • If the placenta is not retrieved, site venflon, fast patient, and arrange theatre. Check FBC/coagulation screen if heavy bleeding.
  • Whilst awaiting theatre, administer misoprostol 400 micrograms sublingually. This should be repeated after a further 3 hours if still awaiting theatre.
  • Heavy PV bleeding following passage of placenta requires medical review to assess need for surgical evacuation of uterus. See “management of excessive bleeding” in <10 + 0 week section of guideline above.

Failure to Abort After 24 hours of Misoprostol 10 - 13 + 0 weeks

Surgical evacuation should be offered to patient.
If surgery declined/contraindicated follow guidance below.

Failure to Abort After 24 hours of Misoprostol > 13 + 0 weeks

  • Continue to give misoprostol 400 micrograms sublingually
  • 4 hourly BP/P/T. Commence NEWS chart.
  • PV assessment should be carried out by experienced medical staff 24 hours from commencing misoprostol.
  • If abortion has not occurred after 48 hours of misoprostol, further management must be discussed with a consultant gynaecologist.
  • Management will depend on the condition of the individual patient, pyrexia and gestation.
  • Ultrasound scan should be performed to exclude abdominal pregnancy/uterine rupture.
  • Consider day 3 of misoprostol if membranes intact.

DISCHARGE PROCEDURE FOR ALL PATIENTS

  • Record the patient’s BP, pulse and temperature prior to discharge.
  • Contraception must be supplied or a contraceptive plan agreed.
  • Anti-D prophylaxis MUST be given to ALL rhesus negative women over 10 weeks.
  • All patients with a multiple pregnancy require a follow-up scan at Sandyford

Editorial Information

Last reviewed: 01/12/2020

Next review date: 31/12/2025

Author(s): Nikki Harvey.

Version: 4 (Revised December 2020)

Approved By: Gynaecology Clinical Governance Group

Document Id: 513