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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

Vaginal Discharge Management (317)

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

Recurrent symptoms, symptoms of PID, postpartum or post abortion, post gynaecological instrumentation or pregnant

Offer face to face appointment in an appropriate clinic, i.e TOPAR/ GU Complex / Urgent Care or in the case of post partum infection refer back to Obstetric services.

Investigations

  • Examination and pH
  • Microscopy (*dry slide for Gram staining and **wet prep)
  • Endocervical GC culture (if plates available)
  • High Vaginal Swab (⁂HVS) if recurrent or persistent
  • Vulvovaginal CT/GC NAAT

Management of results (please refer to appropriate guidelines)

  • Trichomonas Vaginalis (TV) seen – TV
  • pH >4.5 +/- Clue cells and abnormal flora – BV
  • pH <4.5 +/- Yeast cells – Candida
  • Gram Negative Diplococci (GNDC) seen – GC
  • High AV score: discuss with senior

*Dry slide (vaginal and cervix) for Gram stain.
**Wet prep taken from the vaginal posterior fornix. Connect a HVS is taken using a charcoal swab for wet prep.
⁂ HVS – taken from lateral vaginal wall. Stored at 4°C for maximum 48 hours.

Microscopy venue: Sandyford Central.
CONNECT: If microscopy requested please leave the registration form of client with the Connect nurse to follow up client with result.

Aerobic Vaginitis (AV)

Defined as “Disruption of the lactobacillary (LB) flora, accompanied by signs of inflammation and the presence of predominantly aerobic microflora composed of enteric commensals or pathogens.”

Vaginal Flora Grade – Modified Hay-Ison Score

Grade

Description

0

No flora

I

Normal vaginal flora (LB alone)

II

Mixed

III

Abnormal

IV

Gram positive cocci only

AV Donder’s Score

This is calculated from a WET film. Not all people who can read slides are trained to do this assessment please confirm on the day. It is based on the following criteria, each given a score from 0-2.

  1. Lactobacillary (LB) flora
  2. Number of leucocytes
  3. Proportion of toxic leucocytes
  4. Background flora
  5. Proportion of parabasal cells (epithelial damage)

Severity

  • Mild 1-4
  • Moderate 5-6
  • Severe 7-10
  • Scores above 5-6 (moderate) or 7 or higher (severe) require clinician to consider AV as well as other causes for an inflammatory vaginitis, including TV and Group A streptococcus.
  • Always take a HVS culture swab (self-taken is fine) if moderate or high AV score.
  • No clear evidence base for treatment. Discuss with senior clinician. Consider using clindamycin vaginal cream (covers aerobic organisms) instead of metronidazole

Advice on vaginal health

Advice should be given to the client that some factors may affect normal vaginal health causing a disruption to the normal flora and pH.

Some causes of irritation include:

  • Antibiotics
  • Some types of clothing (tightly fitted/synthetic material)
  • Over-washing/bathing douching or the use of shower gels or antiseptic agents, bath oils
  • Avoid using feminine hygiene sprays, perfumes or wipes
  • Avoid using daily pads or fragranced sanitary products
  • Avoid use of flavoured/coloured condoms or lubricant
  • Avoid using fabric conditioner and biological washing powder

Advise to wash with water or a soap substitute. Offer and prescribe soap substitutes such as aqueous cream or emulsifying ointments.

Consider providing a Sandyford genital skin information leaflet via SMS

Editorial Information

Last reviewed: 04/03/2024

Next review date: 31/03/2025

Author(s): Kay McAllister.

Version: 5

Approved By: Gynaecology Clinical Governance Group

Document Id: 317

References

BASHH CEG UK National Guideline on the Management of Bacterial Vaginosis 2012  [accessed Mar 2022]
Donders G, Bellen G, Rezeberga D. Aerobic vaginitis in pregnancy. BJOG 2011. DOI: 10.1111/j,1471-0528.2011.03020.x. [accessed Mar 2022]
Sherrard J, Wilson J, Donders G, Mendling W, Jensen JS. 2018 European (IUSTI/WHO) International Union against sexually transmitted infections (IUSTI) World Health Organisation (WHO) guideline on the management of vaginal discharge. Int J STD AIDS. 2018 Nov;29(13):1258-1272. doi: 10.1177/0956462418785451. Epub 2018 Jul 27. PMID: 30049258