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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

 

 

Hypertension Pre-eclampsia Severe Management (403)

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

Criteria for inclusion

Any woman with severe proteinuric hypertension where the decision has been made to deliver, and one of the following criteria is met:

A

  • Hypertension ≥ 140/90 mmHg
  • Proteinuria ≥3g in 24 hours / 2+ on dipstick testing Plus AT LEAST one of the following:
    • Headache, visual disturbance, epigastric pain
    • Clonus ≥ 3 beats
    • Platelet count <100 x109, AST >50 iu/litre

B

  • Severe Hypertension, not responding to oral medication
  • Systolic ≥ 160 mm Hg, or
  • Diastolic ≥ 110 mm Hg, or
  • MAP ≥ 125 mm Hg

C

  • Eclampsia

Antihypertensive treatment

  • Consultant Obstetrician/Senior Anaesthetistmust be informed of all patients starting on this guideline

  • MAP > 140 mm Hg is an obstetric emergency

  • No evidence that one particular drug is superior for treatment. Labetalol tends to be the first line drug of choice in this locality.

  • Continuous fetal monitoring is necessary because lowering of maternal BP may lead to fetal distress, particularly if there is associated IUGR

  • Automated oscillometric devices may underestimate BP

  • Commence MEWS chart (use one large bold box per hour)

  • MAP >140 mm Hg - measure BP every 5 minutes

  • MAP 125 -140 mm Hg - measure BP every 15 minutes

  • Aim for gradual reduction in BP to around 130-140 / 90 - 100 mmHg (MAP < 125)

  • Site 2 x wide bore IV cannula (14g, ideally ; at least 16g)

  • Check “BP bloods”: (U+E, LFT, urate, FBC +/- coagulation if platelet count is < 150 or previous abnormality) 6 hourly if patient stable.

  • Group and save.

  • Foley catheter and hourly urine volumes commenced

  • Continuous pulse oximetry

Antihypertensive treatment for hypertensive crisis (flowchart)

If Labetalol contraindicated or above labetalol regime has failed to control blood pressure - Second Line Agent (Hydralazine OR Nifedipine) (flowchart)

Antihypertensive drugs

Labetalol:

Contraindications including:

Asthma, Bronchospasm, Uncontrolled heart failure

IV bolus:    

50 mg over 5 minutes
i.e. 10 mls of 5 mg/ml
Can be repeated; and/or followed by infusion (see chart)

Infusion preparation: 

Prepare 5 mg/ml infusion
i.e.  300 mg Labetalol in 60mls
Commence infusion at 50 mg (10 mls) per hour.

Nifedipine:

Contraindications including: Hypersensitivity to nifedipine, or to other dihydropyridines because of the theoretical risk of cross-reactivity, or to any of the excipients, Angina, Recent MI, Aortic Stenosis
  (Care with Magnesium Sulphate – see note below*)
Preparation:  10 mg capsule orally (swallowed whole)
Repeated doses of 10 mg can be given at 6 hourly intervals

Hydralazine:

Contraindications:

Hypersensitivity to hydralazine or dihydralazine

Connective tissue disorders
Severe tachycardia and heart failure with high output cardiac failure (e.g. in thyrotoxicosis)
Myocardial insufficiency due to mechanical obstruction (e.g. in the presence of aortic or mitral stenosis or constructive pericarditis)
Isolated right ventricular failure due to pulmonary hypertension (cor pulmonale)
Dissecting aortic aneurysm
IV bolus: 5 mg slowly over 5 minutes
Prepare 1 mg/ml bolus: reconstitute 20 mg Hydralazine to 20 mls with normal saline. IV bolus of 5 mls (5mg)
Boluses can be repeated at 20 minute intervals, but may be simpler to start infusion
(A 5 mg dose can be effective for 6 hours)
Infusion preparation:   Prepare 1 mg/ml infusion i.e.  40 mg Hydralazine made to 40mls with normal saline.
Infuse at 10 mg (10 mls) per hour

*Note

There are 2 case reports of neuromuscular blockade resulting from simultaneous use of Nifedipine and Magnesium Sulphate.  However, 1,469 women were assigned to receive Magnesium Sulphate and Nifedipine in the Magpie trial, and no such blockade was reported.  Similarly, no adverse events were reported in RCTs comparing Hydralazine with Nifedipine in which all, or some, women received magnesium sulphate.  The risk of neuromuscular blockade is therefore likely to be low.

Seizure prophylaxis

In severe preeclampsia consideration must be given to commencing seizure prophylaxis. This should be discussed with the consultant obstetrician when informing them of the patient presentation. 

Magnesium Sulphate is the drug of choice unless there are specific contra indications to its use (pre-existing cardiac disease, acute renal failure, Myasthenia gravis).

Paediatricians should be informed if Magnesium Sulphate has been administered prior to delivery.

Magnesium Sulphate:

Loading Dose (by hand):                      

  • 4 grams IV over 5 minutes
    (Add 4 grams (8 mls of 50%) Magnesium Sulphate to 12 mls Normal Saline)          

Maintenance Infusion Dose:

  • IV infusion 1 gram Magnesium Sulphate per hour                 

Maintenance Infusion Preparation:

  • 10 grams (20 mls of 50%) Magnesium Sulphate made up to 50 mls by adding to 30 mls normal saline in a 60 ml luer lock syringe
  • Infusion rate is 1 gram (5 mls) per hour via an syringe driver

Infusion is maintained at 1 gram/hr for 24 hours provided:

  • Respiratory rate > 14 per minute
  • Urine output > 25mls/hour, and
  • Patellar reflexes are present (use arm reflexes if regional anaesthesia)

NB:  The volume of the Magnesium Sulphate infusion must be included as part of  the total fluid maintenance infusion for the patient of 85ml/hour

Recurrent Seizures on Treatment:

  • Give a 2nd bolus dose of Magnesium Sulphate 2 grams over 5 minutes by hand (do not stop infusion)
  • add 2 grams (4 mls of 50%) Magnesium Sulphate to 6 mls of Normal Saline
  • One dose only

If further seizures despite 2nd bolus give Diazepam 10mg IV.  Intubation may be required to protect airway and ensure adequate oxygenation.

Magnesium Sulphate – Patient Monitoring:

Reflexes:

  • Patellar reflexes after completion of loading dose and hourly whilst on maintenance dose (use arm reflexes if functional regional anaesthesia).
  • If reflexes are absent stop infusion until reflexes return and check Magnesium level.

Oxygen Saturation / Respiratory Rate:

  • Continuous O2 saturation should be assessed.
  • Perform respiratory rate every 15 minutes
  • If O2 saturation < 94% or respiratory rate < 14 / min, administer O2 (4 L/min via Hudson mask), stop Magnesium Sulphate infusion and call anaesthetist. Check Magnesium level. Consider antidote

Urine Output:

Monitor hourly.

If >20 ml/h - continue Magnesium Sulphate infusion.

If 10 - 20 ml/h & creatinine <150mmol/l - continue as protocol and recheck Magnesium level every 2 hours.

If 10 - 20 ml/h & creatinine > 150mmol/l (or urea >10) - recheck Magnesium levels immediately and every 2 hours. Decrease infusion rate to 0.5gram/hour.

If < 10 ml/h - stop infusion and check Magnesium level.

Biochemical Monitoring (Magnesium levels):  This is not routine. If required then see below.

The Therapeutic range is 2-4 mmol/l.

Low If < 2 mmol/l - Maintain infusion at current rate.  Recheck in 2 hours.

Therapeutic If 2 -3.5 mmol/l - Continue infusion at current rate. Recheck in 2 hours if clinical indication remains.

High If 3.55 - 5 mmol/l - STOP INFUSION for 15 min and then recommence at half previous infusion rate and recheck in 1 hour.

Very High If > 5mmol/l - STOP INFUSION and consider antidote. See below for further details.

Magnesium Sulphate toxicity and management:

Clinical Features

   Mg level

Action

Loss of Patellar reflexes
Weakness
Nausea, Flushing
Double vision
Slurred speech
Somnolence 

circa 5 mmol/l

STOP INFUSION

GIVE ANTIDOTE
10 ml of 10% Calcium Gluconate (1gram)
Slow IV inject over 10 mins. 
CHECK Magnesium level.  

Muscle Paralysis

circa 6-7.5 mmol/l

STOP INFUSION

GIVE ANTIDOTEAS ABOVECHECK
Magnesium level.  

Respiratory Arrest
Cardiac Arrest 

circa 12 mmol/l

STOP INFUSION

INSTITUTE CPR 
2222 CALL Obstetric and cardiac arrest team INTUBATE AND VENTILATE
GIVE ANTIDOTE AS ABOVE 
CHECK Magnesium level

Fluid balance

  • The main risk is of pulmonary oedema to iatrogenic fluid overload.
  • Patients should be fluid restricted (85mls per hour of total input).
  • Document hourly urine output on MEWS chart
  • Oliguria is common in severe pre-eclampsia.
  • The natural diuresis may not occur for at least 12 hours post delivery.
  • Renal failure is uncommon.

  • Furosemide should be reserved for pulmonary oedema and prescription must be discussed with consultant obstetrician.

  • In persisting oliguria U&Es should be checked 6 hourly.
  • In persisting oliguria: urine osmolality that is not concentrated, or high potassium levels indicates renal failure and renal physicians should be contacted.

  • CVP monitoring can be misleading.
  • Consultant obstetrician on-call must be informed if CVP line is considered.

Delivery

  • Delivery is the definitive treatment for severe pre-eclampsia/eclampsia
  • Mother MUST be stabilised prior to delivery irrespective of circumstances (e.g. fetal distress)
  • HDU support is required post delivery
  • ITU if ventilated

De-escalating intravenous Labetalol infusion (post delivery)

  • Once BP stable, in the region of 140 / 90 mm Hg, reduce infusion rate by 50mg / hour.

  • When infusion rate is at 50mg / hour, reduce to 25mg / hour.

  • If BP remains stable at 25mg / hr for one hour, give Labetalol 200mg orally and discontinue IV infusion 30 minutes later.

  • Prescribe antenatal dose of Labetalol.

  • If not on antihypertensive medication antenatally, commence Labetalol 200mg tds.

  • Anticipate conversion to oral medication within 12 hours of delivery.

  • Women who have required intravenous antihypertensives generally need to continue some form of antihypertensive medication in the immediate postnatal period.

  • If on antihypertensive medication prior to pregnancy consider re-prescribing those agents instead.

Editorial Information

Last reviewed: 15/12/2015

Next review date: 11/01/2021

Author(s): Janet Brennand.

Version: 2

Approved By: Obstetrics Clinical Governance Group

Document Id: 403