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Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

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

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 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

 

 

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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