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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

Postmenopausal bleeding (486)

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

Post menopausal Bleeding (PMB) is defined as unscheduled bleeding after one year of amenorrhoea. Women with this symptom are at increased risk of endometrial cancer and require urgent assessment. 

Referral

Patients with PMB should be seen within 2 weeks of referral to allow compliance with the 62 day National Guideline on cancer treatment times. To facilitate this all PMB referrals should be upgraded to ‘Urgent’ when letters are vetted. Where possible, patients should be assessed at a dedicated PMB/ one-stop clinic.

History

A full medical history is required including smear history. Particular attention should also be paid to drug history including HRT use, current or past tamoxifen use and use of anticoagulants such as warfarin, heparin and clopidogrel which many women take for cardiac problems.

Examination

All women with PMB should undergo speculum and bimanual pelvic examination. This can be facilitated by use of a virgin speculum. Patients should have an EUA if, despite these measures, examination proves impossible

Investigation

The initial investigation of choice is the measurement of endometrial thickness by transvaginal ultrasound scan. Endometrial biopsy is reserved for those women whose endometrial thickness exceeds a specified cut-off as follows:

  • Group 1: Women who have never used any HRT OR have not used HRT for more than one year OR are using continuous combined HRT.

Endometrial biopsy is required if the endometrial thickness exceeds 3mm.

  • Group 2: Women who are using sequential HRT OR have done so in the past year.

Endometrial biopsy is required if the endometrial thickness exceeds 5mm.

If the histology report in either group states ‘insufficient tissue for analysis’ and the ET has been thickened then the patient should have a hysteroscopy, if this hasn’t already been done, and a repeat biopsy.

  • Group 3:  Women who are current users of tamoxifen.

Tamoxifen is associated with distortion of the endometrial architecture.

Consequently, ultrasonography is a poor means of detecting endometrial cancer in this group. All such women should undergo hysteroscopy and endometrial biopsy.

Other Issues

  • This guideline refers to women who present with PMB for the first time. Those with recurrent symptoms after 6 months should be re-investigated, and women with persistent bleeding within 6 months of initial investigation should undergo hysteroscopy and endometrial biopsy.

  • There is no published evidence regarding the assessment of PMB in women taking Selective Estrogen Receptor Modifiers (SERMs) other than tamoxifen, eg Raloxifene. It is recommended that the precautionary principle applies and these women be treated in the same way as those taking tamoxifen i.e. undergo hysteroscopy and endometrial biopsy.

  • Transabdominal ultrasound scan may be used as a complementary investigation e.g. if the uterus is particularly enlarged or a wider view of the abdomen is required. It may also be used in the assessment of the small number of women in whom transvaginal scanning is technically impossible.

  • There is no evidence to support the use of endometrial thickness measurements and the associated cut-offs in the assessment of women with peri-menopausal bleeding. These women should undergo clinical evaluation as per menstrual disorder patients.

  • If an IUS or IUCD is in situ, patients should undergo transvaginal scan and biopsy. The coil may be left in place but will compromise the validity of ET measurements (hence the need for biopsy).

  • Endometrial biopsy is also required if:
    • there is an incomplete/poor view on ultrasound i.e the endometrial stripe is not seen along its length.
    • there is fluid within the endometrial cavity.
    • there is irregularity of the endometrial echo, regardless of the ET measurement. These women should also undergo hysteroscopy.

The preceding version of this GG&C guideline referenced SIGN guideline No.61 – The Investigation of Postmenopausal Bleeding (2002). This was withdrawn in February 2015. In the absence of any current national guidance, this revised version refers to current good practice standards. 

Editorial Information

Last reviewed: 14/07/2022

Next review date: 14/07/2025

Author(s): Morton Hair.

Version: 4

Approved By: Gynaecology Clinical Governance Group

Document Id: 486