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Announcements and latest updates

Right Decision Service newsletter: October 2024

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

1.Contingency arrangements for RDS outages

Development of the contingency solutions to maximise RDS resilience and minimise risk of future outages is in progress, aiming for completion by Christmas. As a reminder, these contingency arrangements  are:

  • Optimising mobile app build process
  • Mobile app always to be downloadable.
  • Serialising builds to mobile app; separate mobile app build from other editorial and end-user processes
  • Load balancing – provides failover (also enables separation of editorial processes from other processes to improve performance.)

 

In the meantime, a gentle reminder to encourage users to download essential clinical toolkits to their mobile devices so that there is an offline version always available.

 

2. New deployment with improvements.

A new scheduled deployment with minor improvements drawn from support tickets, externally funded projects, information related to outages, and feature requests will take place in early December. Key improvements planned are:

  • Deep-linking to individual toolkits within the RDS mobile app. Each toolkit will now have its own direct URL and QR code, both accessible from the app. These can be used to download the toolkit directly where users already have the RDS app installed. If the user does not yet have the RDS app installed, they will be taken to the app store to install the app and immediately afterwards the toolkit will automatically open and download. Note that this will go live a few days later than the improvements below due to the need to link up the mobile front end to the changes in the content management system.
  • Introducing an Announcement Header field to replace the hardcoded "Announcements and latest updates" text. This will enable users to see at a glance the focus of new announcements.
  • Automated daily emptying of the recycling bin (with a 30 day rolling grace period)  in the content management system. A bug preventing complete emptying of the recycling bin contributed to one of the outages earlier this year.
  • Supporting multiple passcodes (ticket 6079)
  • Expanding accordion section to show location of a search result rather than requiring user coming from a search result to manually open all sections and search again for the term.
  • Displaying first accordion section Content text as a snippet on the search results page as a fallback if default/main content is not provided
  • Displaying the context of each search result in the form of a link to the relevant parent tool/section. This will help users to choose which search result is most likely to be appropriate for their needs.
  • As part of release of the new national benzodiazepine quality prescribing guidance toolkit sponsored by Scottish Government Effective Prescribing and Therapeutics, a digital tool to support creation of benzodiazepine tapering/withdrawal schedules.

We are also seeking approval to use the NHS Scotland logo and title for the RDS app on the app stores to help with audience engagement and clarity around the provenance of RDS.

3. RDS Search, Browse and Archive/Version control enhancements

We are still hopeful that user acceptance testing for at least the Search and browse enhancements can take place before Christmas. Thank you for your patience and understanding in waiting for these improvements. Timescales have been pushed back by old app migration challenges, work to address outages, and most recently implementing the contingency arrangements.

4. Support tickets

We are aware that there continue to be some issues around a number of RDS support tickets, in part due to constraints around visibility for the RDS team of the tickets in the existing  support portal. We are investigating the potential to move to a new support ticket requesting system from early in the new year. We will organise the proposed webinar around support ticket processes once we have confirmed the way forward with the system.

Table formatting

There is a known issue with alterations in formatting of some RDS tables which seems to have arisen as a result of the 17 October deployment. Tactuum is working on a fix and on implementing additional regression testing to prevent this issue recurring.

5. New RDS toolkits

Recently launched toolkits include:

NHS Lothian Infectious Diseases

Scottish Health Technologies Group – Technology Assessment recommendations

NHS Tayside Anaesthetics and Critical Care projects – an innovative toolkit which uses PowerAutomate to manage review and response to proposals for improvement projects.

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

A number of toolkits are expected to go live before Christmas, including:

  • Focus on dementia
  • Highland Council Getting it Right for Every Child
  • Dumfries and Galloway Adult Support and Protection procedures
  • National Waiting Well toolkit
  • Fertility Scotland National Network
  • NHS Lothian postural care for care homes

6.Sign up to RDS Editors Teams channel

We have had a good response to the recent invitation to sign up to the new Teams channel for RDS editors. This provides a forum for editors to share learning, ideas and questions and we hope to hold regular webinars on topics of interest.  The RDS team is in the process of joining participants to the channel and we’d encourage all editors to take part, using the registration form – available in Providers section of the RDS Learning and Support area.

 

7. Evaluation projects

The RDS team has worked with colleagues in NHS Grampian and the Digital Health & Care Innovation Centre to evaluate the impact of the Prevent the progress of diabetes web and mobile app in a small-scale pilot project. This app provides access to local and national resources and services targeted at people with prediabetes, a history of gestational diabetes, or candidates for remission. After just 8 weeks of using the app, 94% of patients reported increased their knowledge and understanding of diabetes, and 88% said it had increased their confidence and motivation to make lifestyle changes, highlighting specific behaviour changes. The learning from this project is informing development of a service model based on tailored support for patient groups with, high, medium and low digital self-efficacy.

Please contact ann.wales3@nhs.scot if you would like to know more about this project.

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

  • Friday 29th November 3-4 pm
  • Thursday 5 December 3.30 -4.30 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.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   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

 

The Right Decision Service:  the national decision support platform for Scotland’s health and care

Website: https://rightdecisions.scot.nhs.uk    Mobile app download:  Apple  Android

 

 

Manual Vacuum Aspiration (MVA) for treatment of miscarriage and retained pregnancy tissue (1078)

Objectives

To provide guidance to clinical teams undertaking MVA in the management of early pregnancy loss.

Audience

All healthcare workers in GGC involved in the care of women experiencing early pregnancy loss including doctors, nurses, midwives, EPAS staff, A&E staff

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

Manual Vacuum Aspiration (MVA) is an option for women for the management of early pregnancy loss or retained tissue.

NICE suggest surgical or medical management can be offered when expectant treatment is not acceptable to the woman or has failed.  The Miscarriage Association and the Association of Early Pregnancy Units support discussing with women all options that are clinically appropriate and locally available.

MVA has been shown to be a safe and effective procedure and compared with Electric Vacuum aspiration management under general anaesthetic.  Advantages include quicker recovery, shorter hospital stay, lower cost, reduced waiting time and avoids the risks associated with general anaesthesia.

Complication rates (infection, retained tissue, bleeding, perforation and intrauterine adhesions) are similar to those of electric vacuum aspiration. 

MVA can also be used in an emergency situation as it can be performed quickly in a clinical room, providing there is access to an ultrasound machine, MVA supplies, resuscitation equipment and a trained nurse is present.  

Inclusion Criteria

Ultrasound features (see NICE guidance for diagnostic criteria of miscarriage, below indicates suitability for MVA procedure)

  •  Ultrasound diagnosis of early embryonic miscarriage where Crown Rump Length (CRL) does not exceed 25mm on TVUSS
  • Ultrasound diagnosis of anembryonic pregnancy ≤ 10 weeks gestation where there is no CRL and Mean Gestation Sac (MGS) does not exceed 40mm on TVUSS
  • Ultrasound diagnosis of an incomplete miscarriage with RPOC measuring less than 5cm mean diameter on TVUSS
  • Ultrasound diagnosis as above with failed medical management of miscarriage

Patient characteristics

  • Motivated and well counselled woman who can tolerate a speculum examination, bearing in mind that the procedure will be performed under local anaesthetic with the patient still awake.
  • No clinical signs of infection - fever/offensive discharge/ generalized lower abdominal pain.
  • An emergency procedure can be carried out in the event of heavy vaginal bleeding where an ultrasound scan has previously confirmed a non-continuing pregnancy of less than 10 weeks gestation.

Contraindications

  • pregnancy >10 week period of gestation by Ultrasound measurements
  • Bleeding disorders/ Current Anti-coagulant treatment
  • Signs of active Infection
  • Allergy to local anaesthetic
  • Mobility issues affecting positioning on couch with footrests
  • Hb <10
  • Women with Uterine anomalies or suspected molar pregnancy should be discussed with consultant prior to procedure

Note - Previous caesarean section is not a contra-indication to MVA, providing ultrasound excludes scar implantation

Complications

MVA is safe but like all procedures there is a small risk of complications. The risk of complications with an MVA are similar to surgical uterine evacuation under general anaesthesia but without the complications caused by general anaesthetic.

Complications related to the procedure are uncommon or rare—they include:

  • Heavy bleeding (haemorrhage) (3%)
  • Infection (3%)
  • The need for a repeat operation if not all the pregnancy tissue is removed (3%)
  • Perforation (tear) of the womb that may need repair (less than 1 in 1000)
  • Adhesions or scar tissue within the womb.

Organisation of MVA procedure

  • Elective MVA procedures are currently performed on sites in the North and South or the City and within Clyde. The procedure will be organised by contacting EPAS or via the gynaecology emergency team at each of the units.
  • Provide Patient information leaflet outlining Elective MVA with contact numbers for EPAS, local gynaecology ward, and ward or clinic area for planned procedure.  Include details of admission procedure (day, date, time)
  • Discuss and complete Procedure Consent form
  • Discuss and complete Form 2 (Sensitive Disposal of pregnancy tissue) with original to be sent to pathology on day of procedure, with a copy for patient notes and an additional copy for the patient.
  • Obtain FBC and Group and Save (valid for 72 hours)
  • Prescribe Misoprostol 400 mcg Sublingual to be taken 2 – 3 hours prior to procedure
  • Prescribe analgesia to be taken 1 hour before procedure, suggested regime is  Paracetamol 1g oral or Cocodamol 8/500 x 2 tablets oral and Ibuprofen 800mg oral
  • Advise patient to have breakfast or light lunch as normal the day of the procedure

Pre-procedure Assessment on day of procedure

  • Review with nursing and medical staff involved with procedure
  • Confirm paperwork complete and medication has been taken as directed
  • Confirm blood results and request Anti-D if required
  • Baseline observations to be recorded in notes (Temperature, Pulse and Blood Pressure)

Post-procedure Assessment

  • Women should be observed in a recovery area after the procedure for at least 1 hour
  • Observations should be obtained and recorded (Temperature, Pulse and Blood Pressure)
  • Vaginal blood loss to be monitored
  • Patients can eat and drink and should be offered refreshments
  • Check Rhesus status and administer Anti-D if required

Prior to discharge

  • Patient may be discharged home an hour after procedure if well and vaginal loss is not excessive
  • Discuss performing a home pregnancy test in 4 weeks and where to contact if it remains positive
  • Discuss return of periods and future fertility
  • Discuss and provide contraception if required
  • Ensure patient has phone numbers for EPAS and local gynaecology ward
  • Offer support and give contacts from The Miscarriage Association if needed
  • Ensure discharge letter for GP is complete

Editorial Information

Last reviewed: 23/03/2023

Next review date: 31/03/2028

Author(s): Sarah Woldman.

Version: 1

Approved By: Gynaecology Clinical Governance Group

Document Id: 1078

References

BPAS – Mannual Vaccum Aspiration Clinical Guideline – March 2008 Manual Vacuum Aspiration (durbinglobal.com)

Manual Vacuum Aspiration: an outpatient alternative for surgical management of miscarriage.  The Obstetrican and Gynaecologist (TOG) 2015;17:157–61

Terminology for pregnancy loss prior to viability: a consensus statement from the ESHRE early pregnancy special interest group A.M. Kolte1,*, L.A. Bernardi2, O.B. Christiansen1,3, S. Quenby4,

R.G. Farquharson5, M. Goddijn6, and M.D. Stephenson7 on behalf of the ESHRE Special Interest Group, Early Pregnancy, Human Reproduction, Vol.30, No.3 pp. 495–498, 2015

110   Ectopic pregnancy and miscarriage: diagnosis and initial management.  NICE guideline [NG126] Published 17 April 2019, updated 24 November 2021

Mean sac diameter | Radiology Reference Article | Radiopaedia.org

Abortion care, Cervical priming before surgical abortion NICE guideline NG140 Evidence reviews September 2019 Abortion care review M: Cervical priming before surgical abortion (nice.org.uk)