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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

 

 

 

Estimated Due Date (EDD) Ultrasound Scan (501)

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

EDD should be calculated from the first scan ≥ 11+ 2 weeks gestational age (≥ 45mm).

If the initial scan is performed < 11+2 weeks gestation, the patient should have a return appointment at approximately 12-13 weeks gestation to perform optimal dating +/- NT measurements.
(Refer to Screening / Non-screening Pathways)

Upper and lower limbs must be assessed as well as cranial anatomy

Parameters to be Used for Calculation of EDD and Associated Downs Syndrome Screening Method

As adapted from Chudleigh, Loughna & Evans (2011) from BMUS.

Parameter 

Parameter used for establishing EDD

Down’s Syndrome Screening method

CRL < 45.0mm

Unable to date. Re-scan at 12-13 weeks gestation

N/A

CRL 45.0mm – 84.0mm

CRL

First Trimester CUBS 

CRL >84mm  and HC< 101.0mm

Unable to date.  Re-scan ≥ 14+2 weeks gestation

No screening until EDD confirmed

HC ≥ 101.0mm – 172.0mm

HC

Second Trimester Bloods only (AFP)

1st Trimester dating (CRL 45.0mm-84.0mm)

Recommended criteria for measurement of CRL for pregnancy dating (UKNSC, 2015):

CRL DETAIL TO BE DEMONSTRATED
MIDLINE SECTION
  • Sagittal section of the fetus with the head in line with the full length of the body
  • Echogenic tip of the nose
  • Rectangular shape of the palate
  • Translucent Diencephalon
  • CRL axis should be between 0-30 degrees to horizontal
  • Clearly defined crown and rump 
POSITION
  • Pocket of fluid, at least equivalent in size to the width of the palate, should be visible between the fetal chin and chest 
  • Fetal palate angle should be 30º to 60º relative to the horizontal 
  • Nasal tip should be level or above the anterior abdominal wall 
MAGNIFICATION
  • Entire CRL section should fill over 60% of the screen 
CALIPER PLACEMENT
  • Correct calliper placement on outer borders of crown and rump
  • Longest length of the fetus should be measured
IMAGE ARCHIVING
  • The CRL should be measured at least twice and the maximum measurement that meets the criteria should be recorded 
  • The image demonstrating the measured CRL which has been reported should be archived

2nd Trimester dating (HC ≥ 101.0mm – 172.0mm)

The HC should be calculated using the recommended values of Altman and Chitty as per BMUS recommendations.

Technique for calculation of HC:

A cross-sectional view of the fetal head at the level of the ventricles should be obtained. The image should have the midline echo lying as close as possible to the horizontal plane.

The following landmarks should be identified and the image frozen:

  • rugby ball shape;
  • centrally positioned, continuous midline echo broken at one third of its length by the cavum septum pellucidum;
  • anterior walls of the lateral ventricles centrally placed around the midline;
  • the choroid plexus should be visible within the posterior horn of the ventricle in the distal hemisphere.
  • Callipers should be placed on the outer border of the occipital and frontal bones as close as possible to the midline across the longest part of the skull.

If HC measurements cannot be made then EDD should be calculated using the femur length (FL)

Technique for calculation of FL:

The image should be obtained with the femur lying as close as possible to the horizontal plane. The full length of the bone should be visualised with soft tissue visible at both ends. Calipers should be placed at the centre of the ‘U’-shape at each end of the bone.

Third Trimester (Late Booker: HC > 232mm)

After 25 completed weeks the patient will be classed as ‘LATE BOOKER'.

All three measurement parameters [HC, AC and FL] should be obtained.

An EDD will be calculated from the HC measurement and entered on Badgernet. On the ultrasound report page type in comments ‘EDD based on HC >25 weeks GA’ and create a LATE BOOKER alert.

Multiple Pregnancy

If there is discrepancy in the sizes between the fetuses, the EDD should be calculated from the largest fetus, using the criteria above.

Establishing Gestational Age Prior to Visualisation of a Live Embryo

Gestational age may be assessed from measurements of the mean sac diameter (MSD). This is calculated from the maximal diameters of the gestation sac (in mm) in the longitudinal and transverse views on transvaginal scan. The Mean gestation sac volume should be calculated where a transvaginal examination is declined using the full bladder technique.

An EDD should only be generated once a live embryo or fetus has been identified measuring ≥ 45mm.

Ultrasound EDD/Screening Pathway – Singleton (patients who wish Downs syndrome screening)

Ultrasound: Establishing EDD/Screening pathway - Singleton (Patients who decline T21 screening)

Editorial Information

Last reviewed: 31/05/2022

Next review date: 31/05/2026

Author(s): Donna Maria Bean.

Version: 2

Approved By: Obstetrics Clinical Governance Group

Document Id: 501

References

Altman DG & Chitty LS (1997). New charts for ultrasound dating of pregnancy. Ultrasound Obstet Gynecol 10:174-91

Antenatal Care: Routine care for the pregnant healthy woman. National Institute of Clinical Excellence (NICE) Guildeline.

Chudleigh, T., Loughna, P and Evans, T. (2011). A practical solution to combining dating and screening for down’s syndrome. Education & Training 1:154-71

Fetal Anomaly Screening Programme Handbook for Ultrasound Practitioners. UKNSC  April 2015.

Fetal Size and Dating:Charts Recommended for Clinical Obstetric Practice. BMUS, Jan 2008

Guidelines for Professional Working Standards. Ultrasound Practice. United Kingdom Association of Sonographers. October 2008