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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

 

 

Antenatal Fetal HR Monitoring Outpatient (675)

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

There is a recognised need for fetal monitoring for high risk patients. Although there is no clear evidence that antenatal cardiotocography improves perinatal outcome (Grivell et al, 2015) the main purpose of CTG recordings is to identify when there is concern about fetal well-being to enable interventions to be carried out before the fetus is harmed (Beckmann 2014).

The aim of this guideline is to provide a standardised approach to CTG interpretation within the antenatal setting in high risk patients.

Antepartum cardiotocography (CTG) should be considered in women of 26+0 gestation and above. CTG’s carried out before 28 weeks should be performed and interpreted with caution, the decision to do so must be made on an individual basis by a senior obstetrician. The fetal autonomic nervous system is not mature and therefore the patterns of fetal heart rate which may be expected at later gestations are not present. Also there is increased possibility of signal loss and poor quality CTG at earlier gestations (Afors and Chandraharan, 2011). All CTG traces should be peer reviewed by a trained team member. However, all normal CTG traces on fetuses below 32 weeks gestation should also be peer reviewed by an obstetrician (≥ST2) prior to discharging the woman home.

If CTG is of poor quality there should be early recourse to ultrasound location of the fetal heart rate (ideally within 20 minutes).

 

Abdominal examination

A full abdominal examination should be carried out and documented prior to commencing a CTG trace. Ensure the woman has emptied her bladder and is comfortable. Measure fundal height in centimetres, palpate and document the findings. The fetal heart should be auscultated with a Pinard or doptone prior to commencement (Perinatal Institute 2018).

Documentation/ Labelling CTG

All CTG traces  should be labeled with the woman’s name and CHI , the date and time the CTG was commenced , The fetal heart rate on doptone prior to commencing the ctg and the maternal pulse.

Cardiotocography interpretation

When reviewing the cardiotocograph (CTG) trace it is important to assess and document any contractions and all four features of fetal heart rate;

  • Baseline rate
  • Baseline variability
  • Presence or absence of decelerations
  • Presence of accelerations

It is also important to record maternal heart rate. Where there is any difficulty in categorising or interpreting a CTG trace, a review by a senior midwife or obstetrician should be obtained.

The RCOG Green-top Guideline on the management of reduced fetal movements recommends that interpretation of the antenatal CTG fetal heart rate pattern can be assisted by adopting the NICE classification of fetal heart rate features as indicated in their intrapartum care guideline. Therefore, as is the case when classifying intrapartum CTGs, it would seem reasonable to use a structured pro forma to ensure the use of consistent terminology. However, using an intrapartum pro forma is not appropriate as it acknowledges that some decelerations are acceptable in labour, which clearly cannot be the case for antenatal CTGs where there are no contractions.

 

Baseline rate (beats/minute) This is the average fetal heart rate within a ten minute window.

Baseline variability (beats/minute) This refers to the variation of fetal heart rate from one beat to the next. Variability occurs as a result of the interaction between the nervous system, chemoreceptors, baroreceptors and cardiac responsiveness.

 Accelerations are an abrupt increase in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds. The presence of fetal heart rate accelerations, even with reduced baseline variability, is generally a sign that the baby is healthy.

Decelerations are an abrupt decrease in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds.

Any decelerations on an antenatal CTG should be considered abnormal and prompt medical review.

This pro forma has been adapted from PROMPT training and should be utilised for the classification of CTG traces in non-labouring women only.

Antenatal CTG

Reassuring

Non-reassuring

Baseline rate (bpm)

110-160 Rate:

Less than 109

More than 161

Sinusoidal pattern for 10mins or more

Variability (bpm)

5 bpm or more

Less than 5 bpm for more than 40 minutes

Acceleration

Present

None for 40 minutes

Decelerations

None

Unprovoked deceleration/s

Decelerations related to uterine tightening (not in labour)

Opinion

Normal CTG

(all features reassuring)

Abnormal CTG                       (1 or

more non-reassuring features)

 

Antenatal CTG classification

Normal:       A CTG where all four features fall into the ‘reassuring’ category.

Abnormal: A CTG with any non reassuring features (including any decelerations).

When an abnormal CTG is identified, it should be reviewed by an experienced obstetrician as soon as possible (within 30 minutes) to make a clear individualised action plan

 

Conservative measures

If there are any concerns about the baby’s wellbeing, be aware of the possible underlying causes and start one or more of the following conservative measures based on assessment of the most likely causes: encourage the woman to mobilise or adopt an alternative position ( and to avoid being supine); offer intravenous fluids if the woman is hypotensive or tachycardic.

All cardiotocograph traces must be peer reviewed prior to completion by either a member of midwifery staff or an obstetrician and documented appropriately. If conservative measures fail to resolve an abnormal CTG trace, immediate review by an obstetrician should be sought and a clear and concise plan documented.

 

Preterm Fetal Monitoring

Antepartum cardiotocography should be considered in women of 26+0 weeks gestation and above. Any CTG carried out before 26 weeks should be performed and interpreted with caution. The decision to do so must be based on an individual basis by a consultant obstetrician.

Evidence suggests that the baseline fetal heart rate in preterm fetuses is at the higher end of the normal range for a term fetus for physiological reasons, but that this reverts to the range more consistent with term fetuses as gestation advances. However, any rate more than 160 bpm should be defined as tachycardia across all preterm gestational ages. The baseline variability may be reduced at preterm gestations for physiological reasons. However, at term, fetal heart rate variability is an important clinical indicator of fetal acid base balance and oxygenation of the autonomic nerve centres within the brain (NICE 2015).

Fetal heart rate decelerations are common and normal at very early preterm gestations (26 weeks and less) reflecting immature development of cardioregulatory mechanisms. The presence of shallow or short-lived decelerations in very preterm babies should not be considered necessarily as indicative of hypoxia when all other CTG features are reassuring.

From 32 weeks, baseline fetal heart rate and variability should be similar to that in term fetuses and accelerations with an amplitude of more than 15 beats from the baseline should be present as an indicator of fetal wellbeing. Decelerations can be interpreted as for the term fetus (NICE, 2015).

Editorial Information

Last reviewed: 11/04/2019

Next review date: 01/04/2024

Author(s): Julie Murphy.

Approved By: Obstetrics Clinical Governance Group

Document Id: 675

References

Afors, K. and Chandraharan, E. (2011) Use of Continuous Electronic Fetal Monitoring in a Preterm Fetus: Clinical Dilemmas and Recommendations for Practice. Journal of Pregnancy Volume 2011, Article ID 848794. Available at https://www.hindawi.com/journals/jp/2011/848794/

Beckmann, M. (2014) National German Guideline: Guideline on the use of CTG During Pregnancy and Labour. Geburtsh Frauenheilk.

Grivell RM, Alfirevic Z, Gyte GML, Devane D. Antenatal cardiotocography for fetal assessment (2015). Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD007863. DOI: 10.1002/14651858.CD007863.pub4.

Kopecky, E, Ryan, M, Barrett et al (2000) Fetal response to maternally administered morphine. American Journal of Obstetrics and Gynaecology. Vol 183-2, August Available at https://ac.els-cdn.com/S0002937800746710/1-s2.0S0002937800746710- main.pdf?_tid=77089bd4-3733-4276-9b11- f5216d79c2f0&acdnat=1521122523_2af4473790c63d9f12e65e3d59fd5cbe

National Institute for Health Care and Excellence (2017) Intrapartum Care (NICE Guideline CG190) Available at: https://www.nice.org.uk/guidance/cg190

National Institute for Health Care and Excellence (2015) Preterm Labour and Birth (NICE Guideline 25) Available at:https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0080792/pdf/PubMedHealth_PM H00

80792.pdf

Perinatal Institute (2018) Fetal Growth- Fundal Height Measurements. Available online at:

https://www.perinatal.org.uk/FetalGrowth/FundalHeight.aspx