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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.

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With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

Manual Vacuum Aspiration (MVA) for treatment of miscarriage and retained pregnancy tissue (1078)

Objectives

To provide guidance to clinical teams undertaking MVA in the management of early pregnancy loss.

Audience

All healthcare workers in GGC involved in the care of women experiencing early pregnancy loss including doctors, nurses, midwives, EPAS staff, A&E staff

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

Manual Vacuum Aspiration (MVA) is an option for women for the management of early pregnancy loss or retained tissue.

NICE suggest surgical or medical management can be offered when expectant treatment is not acceptable to the woman or has failed.  The Miscarriage Association and the Association of Early Pregnancy Units support discussing with women all options that are clinically appropriate and locally available.

MVA has been shown to be a safe and effective procedure and compared with Electric Vacuum aspiration management under general anaesthetic.  Advantages include quicker recovery, shorter hospital stay, lower cost, reduced waiting time and avoids the risks associated with general anaesthesia.

Complication rates (infection, retained tissue, bleeding, perforation and intrauterine adhesions) are similar to those of electric vacuum aspiration. 

MVA can also be used in an emergency situation as it can be performed quickly in a clinical room, providing there is access to an ultrasound machine, MVA supplies, resuscitation equipment and a trained nurse is present.  

Inclusion Criteria

Ultrasound features (see NICE guidance for diagnostic criteria of miscarriage, below indicates suitability for MVA procedure)

  •  Ultrasound diagnosis of early embryonic miscarriage where Crown Rump Length (CRL) does not exceed 25mm on TVUSS
  • Ultrasound diagnosis of anembryonic pregnancy ≤ 10 weeks gestation where there is no CRL and Mean Gestation Sac (MGS) does not exceed 40mm on TVUSS
  • Ultrasound diagnosis of an incomplete miscarriage with RPOC measuring less than 5cm mean diameter on TVUSS
  • Ultrasound diagnosis as above with failed medical management of miscarriage

Patient characteristics

  • Motivated and well counselled woman who can tolerate a speculum examination, bearing in mind that the procedure will be performed under local anaesthetic with the patient still awake.
  • No clinical signs of infection - fever/offensive discharge/ generalized lower abdominal pain.
  • An emergency procedure can be carried out in the event of heavy vaginal bleeding where an ultrasound scan has previously confirmed a non-continuing pregnancy of less than 10 weeks gestation.

Contraindications

  • pregnancy >10 week period of gestation by Ultrasound measurements
  • Bleeding disorders/ Current Anti-coagulant treatment
  • Signs of active Infection
  • Allergy to local anaesthetic
  • Mobility issues affecting positioning on couch with footrests
  • Hb <10
  • Women with Uterine anomalies or suspected molar pregnancy should be discussed with consultant prior to procedure

Note - Previous caesarean section is not a contra-indication to MVA, providing ultrasound excludes scar implantation

Complications

MVA is safe but like all procedures there is a small risk of complications. The risk of complications with an MVA are similar to surgical uterine evacuation under general anaesthesia but without the complications caused by general anaesthetic.

Complications related to the procedure are uncommon or rare—they include:

  • Heavy bleeding (haemorrhage) (3%)
  • Infection (3%)
  • The need for a repeat operation if not all the pregnancy tissue is removed (3%)
  • Perforation (tear) of the womb that may need repair (less than 1 in 1000)
  • Adhesions or scar tissue within the womb.

Organisation of MVA procedure

  • Elective MVA procedures are currently performed on sites in the North and South or the City and within Clyde. The procedure will be organised by contacting EPAS or via the gynaecology emergency team at each of the units.
  • Provide Patient information leaflet outlining Elective MVA with contact numbers for EPAS, local gynaecology ward, and ward or clinic area for planned procedure.  Include details of admission procedure (day, date, time)
  • Discuss and complete Procedure Consent form
  • Discuss and complete Form 2 (Sensitive Disposal of pregnancy tissue) with original to be sent to pathology on day of procedure, with a copy for patient notes and an additional copy for the patient.
  • Obtain FBC and Group and Save (valid for 72 hours)
  • Prescribe Misoprostol 400 mcg Sublingual to be taken 2 – 3 hours prior to procedure
  • Prescribe analgesia to be taken 1 hour before procedure, suggested regime is  Paracetamol 1g oral or Cocodamol 8/500 x 2 tablets oral and Ibuprofen 800mg oral
  • Advise patient to have breakfast or light lunch as normal the day of the procedure

Pre-procedure Assessment on day of procedure

  • Review with nursing and medical staff involved with procedure
  • Confirm paperwork complete and medication has been taken as directed
  • Confirm blood results and request Anti-D if required
  • Baseline observations to be recorded in notes (Temperature, Pulse and Blood Pressure)

Post-procedure Assessment

  • Women should be observed in a recovery area after the procedure for at least 1 hour
  • Observations should be obtained and recorded (Temperature, Pulse and Blood Pressure)
  • Vaginal blood loss to be monitored
  • Patients can eat and drink and should be offered refreshments
  • Check Rhesus status and administer Anti-D if required

Prior to discharge

  • Patient may be discharged home an hour after procedure if well and vaginal loss is not excessive
  • Discuss performing a home pregnancy test in 4 weeks and where to contact if it remains positive
  • Discuss return of periods and future fertility
  • Discuss and provide contraception if required
  • Ensure patient has phone numbers for EPAS and local gynaecology ward
  • Offer support and give contacts from The Miscarriage Association if needed
  • Ensure discharge letter for GP is complete

Editorial Information

Last reviewed: 23/03/2023

Next review date: 31/03/2028

Author(s): Sarah Woldman.

Version: 1

Approved By: Gynaecology Clinical Governance Group

Document Id: 1078

References

BPAS – Mannual Vaccum Aspiration Clinical Guideline – March 2008 Manual Vacuum Aspiration (durbinglobal.com)

Manual Vacuum Aspiration: an outpatient alternative for surgical management of miscarriage.  The Obstetrican and Gynaecologist (TOG) 2015;17:157–61

Terminology for pregnancy loss prior to viability: a consensus statement from the ESHRE early pregnancy special interest group A.M. Kolte1,*, L.A. Bernardi2, O.B. Christiansen1,3, S. Quenby4,

R.G. Farquharson5, M. Goddijn6, and M.D. Stephenson7 on behalf of the ESHRE Special Interest Group, Early Pregnancy, Human Reproduction, Vol.30, No.3 pp. 495–498, 2015

110   Ectopic pregnancy and miscarriage: diagnosis and initial management.  NICE guideline [NG126] Published 17 April 2019, updated 24 November 2021

Mean sac diameter | Radiology Reference Article | Radiopaedia.org

Abortion care, Cervical priming before surgical abortion NICE guideline NG140 Evidence reviews September 2019 Abortion care review M: Cervical priming before surgical abortion (nice.org.uk)