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Announcements and latest updates

Welcome to the Right Decision Service (RDS) newsletter for August 2024.

  1. Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26th September 3-4 pm on national and local contingency planning for future RDS outages.  Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

 

2.National  IV fluid prescribing  calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids  . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery.  It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

 

  1. New toolkits

The following toolkits are now live;

  1. Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

 

  1. Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit.  We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process.  The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

 

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:
  • Thursday 5 September 1-2 pm
  • Wednesday 24 September 4-5 pm
  • Friday 27 September 12-1 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.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

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

Expectant Management of First Trimester Miscarriage (679)

Objectives

This guideline is designed for use within the Early Pregnancy Assessment Services across GGC. The objective is to provide safe management for women diagnosed with a non-continuing pregnancy who wish expectant management up to 12 weeks gestation.

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

Management (as per NICE)

Current NICE guidance [1,2] advises use of expectant management for 7–14 days as the first-line management strategy for women with a confirmed diagnosis of miscarriage. Explore management options other than expectant management if:

  • expectant management is not acceptable or
  • the woman is at increased risk of haemorrhage (for example, she is in the late first trimester) or
  • she has previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) or
  • she is at increased risk from the effects of haemorrhage (for example, if she has coagulopathies or is unable to have a blood transfusion) or
  • there is evidence of infection.

Explain what expectant management involves and that most women will need no further treatment (successful for 70-80% patients). Give all women oral and written information about what to expect throughout the process, advice on pain relief and where and when to get help in an emergency. Also provide women with oral and written information about further treatment options – medical or surgical (MVA or under GA). Written consent is not mandatory.

Give an appointment for 2-3 weeks’ time and offer a repeat scan. The patient should then be reviewed at 2-weekly intervals if she continues to opt for conservative management. Consider checking FBC/CRP. If ongoing bleeding and/or positive pregnancy test, the patient needs review and USS. Discuss alternative management options of miscarriage.

Exclusion criteria

Women who are/have:

  • Haemodynamically unstable
  • Hb <100g/l
  • Twin or higher order pregnancy
  • Specific haematological disorder (consider on individual basis) or would refuse blood products (e.g. Jehovah’s Witness)
  • Women must live or be able to stay locally so as to be able to access emergency admission if required and be able to attend within 1 hour.

Additional Management

  • Anti-D – not required for cases of complete miscarriage under 12+0 weeks gestation where there has been no formal intervention to evacuate the uterus. Anti-D IM required in non-sensitised Rh negative mothers if >12 weeks or if associated with heavy bleeding3 (dose as per current local guideline).
  • Antibiotic prophylaxis should not be given routinely and should only be given based on individual clinical indications.
  • Ensure appropriate patient information given – written leaflet given where possible.
  • If there are any concerns, or at the patient’s request, appropriate review should be arranged.
  • Ensure women understand the expected size of fetus and placenta to be passed.
  • Ensure the patient has analgesia at home or can prescribe analgesia such as Co-codamol if none available.
  • Inform all relevant primary care professionals of pregnancy outcome and management. Cancel any antenatal clinic appointments or scans.
  • Discuss histopathological examination and disposal of pregnancy products in line with trust policy. If tissue is passed at home, this can be appropriately disposed of at the time or can be brought in to hospital for pathology/genetics if the patient wishes. If POC are passed in hospital, signed agreement for sensitive disposal by the hospital is required (SD7 form).

Patient counselling and follow-up support is particularly important for women who adopt an expectant approach. They should be aware that complete resolution may take several weeks. Women and their families should be fully informed regarding the likely course of events, and given information on how to access the appropriate services in an emergency situation.

Appendix 1 SD7 form

SD7 form

Editorial Information

Last reviewed: 01/04/2019

Next review date: 01/04/2024

Author(s): Ruth Jewell.

Approved By: Gynaecological Clinical Governance Group

Document Id: 679

References
  1. NICE. Ectopic pregnancy and miscarriage: diagnosis and initial management [CG154]. 2019.
  2. NICE pathway for medical management of incomplete or missed miscarriage. 2015.
  3. Qureshi H et al. British Committee for Standards in Haematology (BCSH) guideline for the use of anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn. Transfusion Medicine. 2014; 24(1): pp8-20.