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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

 

 

Adrenal Crisis: Avoidance in Pregnant Women at Risk (520)

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

Glucocorticoid dependent obstetric patients are not encountered commonly, however appropriate care is crucial to avoid potentially life threatening acute adrenal crisis. In order to avoid a precipitous fall in BP during anaesthesia or in the immediate postoperative period, anaesthetists must know whether a patient is taking or has been taking glucocorticoids. 

Signs of acute adrenal crisis include severe dehydration, pale clammy skin, sweating, rapid and shallow breathing, hypotension, dizziness, vomiting and diarrhoea and severe drowsiness or loss of consciousness.

Women at risk [1]

  1. All women requiring long term glucocorticoid replacement (for example as a result of pituitary disease or congenital adrenal hyperplasia, or women with Addison’s disease). These women will usually be receiving the equivalent of 20-25mg hydrocortisone per day and are likely to be dependent on this replacement.1
  2. Women receiving exogenous glucocorticoid may now be dependent on this and develop adrenal crisis if they are stopped suddenly. This group of women includes:
    1. Patients taking the equivalent of 5mg prednisolone per day for more than FOUR See Appendix 1 for more detail.2
    2. Patients on more than the equivalent of 40mg prednisolone per day for more than 7 days2
    3. Patients on long term high dose inhaled steroids. See Appendix 2 for more detail.2
    4. High doses of topical steroids (e.g. ≥200g per week of potent or very potent steroids). See Appendix 3 for more detail. 2

Mineralocorticoids

Note that women with adrenal disease (e.g. Addisons disease or previous bilateral adrenalectomy) may also be receiving mineralocorticoid replacement, usually in the form of fludrocortisone. This also needs to be considered and likely continued.

Factors which can precipitate Adrenal Crisis

  • Infection.
  • Major surgery (e.g. caesarean section).
  • Malabsorption of oral steroids (e.g. due to vomiting).
  • Major stress (e.g. labour).
  • Discontinuation of glucocorticoids (hydrocortisone, prednisolone, dexamethasone).

Peripartum Steroid Management [4]

Caesarean Section

On day of surgery

  • Normal morning dose of steroid.
  • 100 mg hydrocortisone IV just before anaesthesia. Then:
  • Double oral glucocorticoid dose for 48 hours.

Unless the patient is not tolerating oral intake, or is vomiting or unwell, in which case:

  • 50 mg hydrocortisone IM 6 hours until eating and drinking normally.
  • Once well, return to oral dose as above. After 48 hours:
  • If well, return to patient’s normal dose.

Induction of Labour

  • Continue normal dose of steroid until labour diagnosed.

Labour

When labour is diagnosed:

  • 100 mg hydrocortisone IV at onset of labour.

Then:

  • Commence infusion of hydrocortisone at 200mg IV over 24hr

OR

  • 50mg hydrocortisone every 6hrs IM.

Then:

  • Double oral glucocorticoid dose for 48 hours postpartum.
  • Unless the patient is not tolerating oral intake, or is vomiting or unwell, in which case use the IM route as above.

After 48 hours:

  • If well, return to patient’s normal dose.

Special Points

All women at risk of adrenal crisis should consider carrying a Steroid Emergency Card to alert healthcare professionals.

Women who are deficient in glucocorticoids are also at risk of hypoglycaemia. 

  • Check capillary blood glucose and a formal laboratory glucose when first assessed and if the patient develops any symptoms of hypoglycaemia. 

If patient becomes hypotensive, drowsy or peripherally shut down, give 100mg hydrocortisone IM or

IV immediately. (Intravenous doses should be administered over 10 minutes.) 

IM hydrocortisone is preferable to IV since it has a more sustained release. 

Use hydrocortisone sodium phosphate or hydrocortisone sodium succinate, not hydrocortisone acetate. 

If the patient is unwell postpartum (e.g. vomiting or fever), delay return to normal dose beyond the 48 hour period stated above. If the patient is nil by mouth, ensure adequate intravenous fluid replacement (e.g. 0.9% sodium chloride or Hartmann’s solution). 

Monitor electrolytes and BP post-partum: 

  • BP every 4 hours.
  • U&Es daily for 2-3 days.

Appendix 1 Long-term oral glucocorticoids (ie 4 weeks or longer)

Long-term oral glucocorticoids (ie 4 weeks or longer) – Taken from Society of Endocrinology, Exogenous steroids treatment in adults2

MedicineDose (*) 
Beclometasone 625 microgram per day or more 
Betamethasone750 microgram per day or more 
Budesonide1.5mg per day or more (***) 
Deflazacort 6mg per day or more 
Dexamethasone 500 microgram per day or more (**)4
Hydrocortisone 15mg per day or more (**)
Methylprednisolone4mg per day or more 
Prednisone5mg per day or more 
Prednisolone5mg per day or more  

(*) dose equivalent from BNF except (**) where dose reflects that described in the guideline by Simpson et al (2020)4 and (***) based on best estimate

Appendix 2 Inhaled glucocorticoid doses

Inhaled glucocorticoid doses - Taken from Society of Endocrinology, Exogenous steroids treatment in adults2

Medicine

Dose (*)5

Beclometasone          

(as non-proprietary, Clenil, Easihaler, or Soprobec)

More than 1000 microgram per day 

Beclometasone         

(as Qvar, Kelhale or Fostair )       

More than 500 microgram per day

(check if using combination inhaler and MART regimen) 

Budesonide      

More than 1000 microgram per day 

(check if using combination inhaler and MART regimen) 

Ciclesonide                          

More than 480 microgram per day 

Fluticasone propionate  

More than 500 microgram per day 

Fluticasone furoate          

(as Trelegy and Relvar)

More than 200 microgram per day 

Mometasone                     

More than 800 microgram per day 

(*) dose equivalent - NICE Inhaled corticosteroid doses for NICE’s asthma guideline (2018)

Appendix 3 Topical glucocorticoids

Topical glucocorticoids. 2

Topical steroid treatments

Potency of steroid 

Beclometasone dipropionate 0.025%

Potent 

Betamethasone dipropionate 0.05% and higher

Potent 

Betamethasone valerate 0.1% and higher

Potent 

Clobetasol propionate 0.05% and higher

Very potent 

Diflucortolone valerate 0.1%

Potent 

Diflucortolone valerate 0.3%

Very Potent 

Fluocinonide 0.05%

Potent 

Fluocinolone acetonide 0.025%

Potent 

Fluticasone propionate 0.05%

 Potent 

Hydrocortisone butyrate 0.1%

Potent 

Mometasone 0.1%

Potent

Triamcinolone acetonide 0.1%

Potent

All other topical glucocorticoids available in the UK are either mild or moderate potency.

Editorial Information

Last reviewed: 22/04/2022

Next review date: 01/04/2027

Author(s): Andrew Thomson.

Version: 2

Approved By: Obstetrics Clinical Governance Group

Document Id: 520

References
  1. Wass JAH, Arlt W. How to Avoid precipitating an acute adrenal crisis. BMJ. 2012; 345: e6333
  2. Erskine D, Simpson H. Exogenous Steroids Treatment in Adults. Adrenal Insufficiency and Adrenal Crisis – Who is at risk and how should they be managed safely. Society for Endocrinology and the British Association of Dermatologists.
  3. Woodcock et al. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency. Anaesthesia. 2020; 75: 654-663.
  4. Simpson H, Tomlinson J, Wass J, Bean J, Arlt W. Guidance for the prevention and emergency management of adult patients with adrenal insufficiency. Clinical Medicine (London). 2020; 20 (4): 371-378.
  5. Inhaled corticosteroid doses for NICE’s asthma Guideline. July 2018.