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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

 

 

Maternal Sepsis (572)

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

NB  Sepsis can kill mothers AND babies. If either of this pairing is infected ensure that those looking after the mother/baby know about this promptly to ensure risk evaluation of cross-infection is made.

Sepsis remains an important cause of maternal death (1). The development of sepsis is often insidious and the physiological adaptations in normal pregnancy may mask developing sepsis or make it more difficult to identify. Once infection becomes systemic the woman’s condition can deteriorate extremely rapidly over the course of a few hours into septic shock, disseminated intravascular coagulation and multi-organ failure2. A high index of suspicion should be maintained.

Briefly learn that SIRS > sepsis > septic shock unless appropriate action taken

 SIRS (systemic inflammatory response syndrome) -  a  clinical state consisting of two or more coexisting conditions: fever or hypothermia, tachycardia, tachypnoea, and an abnormally high leukocyte count.

Severe sepsis with acute organ dysfunction has a mortality rate of 20-30%, rising to 40-50% if septic shock (sepsis with hypotension refractory to fluid resuscitation) develops. Severe Sepsis with multi-organ failure carries a mortality rate >60%3.

The purpose of this guideline is to provide a structured approach to investigation and management of these women. The screening tool is to be filed in the patient notes and completed goals documented.

  • IT IS IMPORTANT TO NOTE THAT MOST LABOURING WOMEN WILL MEET NON-PREGNANT “SIRS” CRITERIA: see MODIFIED MATERNITY SEPSIS TOOL BELOW
  • SIMILARLY, NON-PREGNANT RISK ASSESSMENTS (eg CURBS 65) DO NOT PERFORM WELL IN THE PREGNANT POPULATION.
  • IF IN DOUBT MANAGE AS SEPSIS AND THEN REVIEW DIAGNOSIS.

Signs and symptoms

Modified Early Warning Scoring System charts should be used to aid timely recognition, treatment and referral of women who have or who are developing a critical condition. These do not take into account the physiological changes in pregnancy, however, they allow a trend in the patients’ observations to be documented and acted upon. SEE SEPSIS SCREENING TOOL BELOW

In labour changes in some parameters are highlighted in red and should be considered. Err on overdiagnosis / response if in doubt

Temperature <36°C or >38°C 4

In labour a temperature of ≥ 37.5°C on 2 separate occasions at least 2 hours apart

Persistent tachycardia > 100bpm5
Or

>110bpm in labour

Tachypnoea >20 breaths per minute4
Or

>22 in labour

WCC <4 or >16 x 109 /L  4

WCC in labour >20 x 109 /L(although WCC of up to 30 have been seen in labour, a WCC of 20 is the generally recommended threshold for investigation in the literature)3,5

Oliguria <0.5mls/hour4

Arterial Hypoxaemia <8k Pa on air and/or metabolic acidosis pH <7.35 / H+ >45nmol/l

(pregnancy results in a relative respiratory alkalosis)4

Hypotension MAP <65mmHg or systolic BP <90mmHg4

Abnormal U&Es, LFTs , Coagulation 

CRP – However a normal CRP may be falsely reassuring and does not rule out systemic sepsis.  There is often a delay in CRP increase in acute sepsis.

Fetal tachycardia and/or non reassuring CTG

  • this can be evidence of intrauterine infection / choriomamnioitis
  • these changes may serve as an early warning sign for derangements in maternal end-organ systems  

Hyperglycaemia in the absence of diabetes


The Common Organisms

The organisms most commonly implicated are2:

  • Streptococcus pyogenes ( Group A strep)
  • Group B streptococcus 
  • Escherichia coli
  • Staphylococcus aureus
  • Gram- positive and gram – negative mixed infections
  • Streptococcus pneumoniae
  • Klebsiella
  • Enterococcus faecalis
  • MRSA

Investigations

Seek the organism

This should ideally be guided by the history and take place before administration of antibiotics – HOWEVER, do not delay starting antibiotic therapy.

  • Take a History and examine the patient
  • Blood cultures
  • Midstream specimen of urine
  • Stool cultures
  • Vaginal swabs
  • Wound/perineal swabs
  • Placental swabs if delivered
  • Baby/fetal swabs if delivered
  • Chest X ray
  • Throat swabs
  • Imaging of the abdomen if suspected intra-abdominal sepsis
  • Breast examination
  • Wound examination
  • Consider the need for:
    • Lumbar puncture
    • Respiratory secretions culture

Bloods

  • FBC +/- blood film
  • COAGULATION STUDIES
  • UREA AND ELECTROLYTES
  • CRP
  • LFT
  • LACTATE
  • Group and Save (X-match if appropriate : see separate MSBOS)
  • Consider Blood Gas analysis (NOT ROUTINE)

Serum lactate

A measure of tissue perfusion and prognostic indicator4.  This can be performed on a venous or arterial blood gas.  A lactate of >4 mmol/l is indicative of tissue hypoperfusion.

  • 2.1- 3.9 Intermediate
  • > 4 Severe

Management

Antibiotics

  • Broad spectrum intravenous antibiotics can be life saving. Immediate aggressive treatment should be initiated as each hour of delay is associated with a measurable increase in mortality3. 
  • Microbiology advice should be sought in severe sepsis or septic shock.
  • Breastfeeding may limit the use of some antimicrobials.
  • If no response after 24-48hrs of antibiotics consider change/addition of antibiotics under microbiology guidance.

See the Antibiotics Policy for Obstetric Patients GG&C guideline. The following table summarises GGC Antibiotic guidance in SEPSIS only. 

Haemodynamic Management

  • Loss of vasomotor tone, myocardial depression and increased vascular permeability contribute to the real risk of pulmonary oedema3. Fluid therapy should be titrated against the womans urine output, blood pressure and central venous pressure (if CVP line in place).
  • Initial fluid bolus of 500mls Hartmanns over 30 mins (caution in PET)
  • Hourly urine output >25mls/hr
  • Mean arterial pressure >65mmHg (used in discussion with anaesthetics)
    • Vasopressors indicated if the MAP is <65mmHg after adequate fluid resuscitation 
  • Consideration of central venous monitoring
    • if CVP line in place aim for CVP 8-12 mmHg 

 

Blood Products

  • Transfuse if Hb<70g/L until in the range 70 to 90g/L2
  • Keep platelet >50 x109/L if there is a significant risk of bleeding or if surgery or invasive procedures are planned
  • Be guided by haematological advice

 

Focus of infection

The focus of infection may need surgical evacuation, drainage or excision of necrotic tissue , e.g. uterine evacuation or breast, wound or pelvic abscess drainage 

 

Thromboprophylaxsis

  • TEDS
  • Low molecular weight heparin2
    • Prophylactic dose based on most recent weight
    • Once platelet count reviewed

 

The Fetus

  • The decision regarding timing and mode of delivery will be made by a consultant obstetrician.
  • During the intrapartum period continuous electronic fetal monitoring should be employed in gestations from 26+0 weeks. Below this gestation, discuss fetal monitoring with the Consultant Obstetrician. 
  • If delivery is required the choice of anaesthesia will be made after discussion with a Consultant Anaesthetist.
  • The paediatric team must be informed of any neonate born to a mother with suspected sepsis

 

Multidisciplinary Team

  • Consultant Obstetrician
  • Consultant Anaesthetist
  • Intensive care specialists
  • Microbiology
  • Haematology
  • Appropriate specific specialty (e.g. Surgical, renal etc.)
  • Pharmacy

 

Indications for Referral to ITU2

  • Cardiovascular - Hypotension or raised serum lactate persisting despite fluid resuscitation, suggesting the need for inotrope support
  • Respiratory - Pulmonary oedema/ Mechanical ventilation/ Airway protection
  • Renal - Renal dialysis
  • Neurological - Significantly decreased conscious level
  • Miscellaneous - Multi-organ failure/ Uncorrected acidosis/ Hypothermia

Referral to ITU should be from a discussion with the consultant obstetrician and consultant anaesthetist.

Once referral for ITU care has been made, the patient should continue receiving at least level 2 care until transferred out of the Obstetric HDU.  This includes maintaining CVP ≥ 8 mmHg, MAP >65mmHg (used in discussion with anaesthetics) and monitoring of appropriate bloods.

There is no place in this guideline for the use of high dose corticosteroids or recombinant human activated protein C

 

Editorial Information

Last reviewed: 17/09/2019

Next review date: 31/12/2022

Author(s): Julie Murphy.

Version: 2

Approved By: Obstetrics Clinical Governance Group

Document Id: 572

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