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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

 

 

Postnatal management of fetal arrhythmias (1081)

Objectives

To ensure a seamless transition from fetal to postnatal life of babies receiving a prenatal diagnosis of an arrhythmia.

Audience

This guideline is for neonatologists and paediatric cardiology teams, caring for babies with a prenatal diagnosis of a fetal arrhythmia.

Fetal arrhythmias are uncommon and the incidence of structural cardiac abnormalities in fetuses with irregular heart rhythms is low (<2%). Ectopic beats are estimated to be present in around 1% of unselected pregnancies and in the majority of cases will resolve before delivery.

Fetal tachycardia can result in significant morbidity and mortality if left untreated in utero. The ideal management is to treat the tachycardia prior to delivery so that the fetus is delivered in a non-hydropic state, at term, without evidence of tachycardia. Prenatal therapy is guided by the fetal cardiology and fetal medicine team jointly and in our institution 1st line maternal therapy is often flecainide. The addition of second line therapy is required in resistant cases. Therapy is carefully considered, implemented and monitored due to the potential adverse effects to the mother and fetus.

1. Fetal Irregular Heart Rhythm

a) If extrasystoles persist after birth

  • Remain on PNW for 48 hours before discharge home
  • 12 lead ECG
    • Mon-Fri 9-5pm arrange with cardiology department (84437), out of hours/weekend to be undertaken by the neonatal team
  • Auscultate HR for 1 minute
    • If ectopic every 10 beats - discuss with cardiology oncall (84440) whether a 24 hour ECG is required
    • If less frequent, no further investigations required but the baby should remain on PNW until 48 hrs old
  • Discuss 24 hour ECG with cardiology consultant and arrange f/u as required
  • If ventricular extra-systoles (VEs) on ECG, discuss with cardiology consultant or oncall cardiology registrar (84440)

b) If extra-systoles have resolved prior to birth

  • No postnatal follow-up or investigation is indicated.

2. Fetal Tachycardia

a) Failure to cardiovert medically during fetal life

  • Admit to NICU
  • Inform on call cardiology consultant or cardiology registrar (84440) immediately
  • Continuous ECG monitoring
  • Baseline echocardiogram and 12 lead ECG
  • Medical therapy/cardioversion as per on call cardiologist advice

b) Successful medical cardioversion during fetal life

  • Admit to NICU for 48 hours before transfer to PNW.
  • NEWS observations to be undertaken on PNW for 48 hours before discharge home.
  • Request cardiology consult (84440) within normal working hours if in sinus rhythm and cardiovascularly stable
  • Baseline echocardiogram and 12 lead ECG
  • Ensure parents are taught and competent at checking the heart rate by measuring the pulse/listening with stethoscope or ear.
  • Families will be provided with an information leaflet before discharge home, detailing monitoring and measuring heart rate – cardiac nurse specialists will provide leaflet.
  • Parents should assess the heart rate at least twice daily when baby settled.
  • Cardiac Nurse Specialists will discuss the additional benefits of an OwletTM monitor if parents wish to purchase for additional reassurance.
  • On discharge, parental advice to seek urgent medical attention if evidence of poor feeding, or tachycardia i.e. >180bpm when baby settled.
  • Provide contact details for the cardiac nurse specialists for non urgent support between outpatient clinics:
    CardiacSpecialist.NursesPaeds@ggc.scot.nhs.uk (0141 452 4925)
  • Arrange Cardiology OPC for 2 weeks post discharge.

  • If tachycardia recurs before discharge, therapy and f/u as per on call cardiologist advice

Editorial Information

Last reviewed: 03/05/2023

Next review date: 31/05/2025

Author(s): Dr Lindsey Hunter; Dr Karen McLeod; Lorraine Mulholland; Kathleen O’Reilly; Dr Andrew MacLaren.

Version: 1

Approved By: Paediatric Cardiology & Neonatology

Reviewer name(s): A Powls; M Worrall; G Bell.

Document Id: 1081

References
  1. FAST Trial – Fetal Atrial Flutter and Supraventricular Tachycardia Trial. Multicentre, international registry and RCT. Jeaggi et al, Toronto Sick Kids Hospital, Toronto, Canada.
  2. Jaeggi E, Ohman A. Fetal and Neonatal Arrhythmias. Clin Perinatol. 2016 Mar;43(1):99-112.
  3. Simpson J, Silverman N. Diagnosis of cardiac arrhythmias during fetal life. In: Gembruch U, editor. Fetal Cardiology. London: Martin Dunitz; 2003. p. 333-344.
  4. Vergani P, Mariani E, Ciriello E, Locatelli A, Strobelt N, Galli M, Ghidini A. Fetal arrhythmias: natural history and management. Ultrasound med Bio 2005 Jan;31(1):1-6
  5. Van Engelen AD, Weijtens O, Brenner JI, Kleinman CS, Copel JA, Stoutenbeek P, et al. Management outcome and follow-up of fetal tachycardia. J Am Coll Cardiol 1994;24(5):1371-5.
  6. Simpson JM, Sharland GK. Fetal tachycardias: management and outcome of 127 consecutive cases. Heart 1998;79(6):576-81.
  7. Frohn-Mulder IM, Stewart PA, Witsenburg M, Den Hollander NS, Wladimiroff JW, Hess J. The efficacy of flecainide versus digoxin in the management of fetal supraventricular tachycardia. Prenat Diagn 1995; 15(13):1297-302.
  8. Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial. N Engl J Med 1991;324(12):781-8.
  9. Fouron JC. Fetal arrhythmias: the Saint-Justine hospital experience. Prenat Diagn 2004;24(13):1068-80.