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Announcements and latest updates

Right Decision Service newsletter: September 2024

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

1.Business case for permanent provision of the Right Decision Service from April 2025 onwards

This business case has now been endorsed by the HIS Board and will shortly be submitted to Scottish Government.

2. Management of RDS support tickets

To balance increasing demand with available capacity and financial resource, the RDS team and Tactuum are now working together to  implement closer management of support tickets. As a key part of this, we want to ensure clear, timely and consistent communication with yourselves as requesters.  

Editors will now start seeing new messages come through in response to support ticket requests which reflect this tightening up and improvement of our processes.

Key points to note are:

2.1 Issues confirmed by the RDS and Tactuum teams as meeting the critical/urgent and high priority criteria will continue to be prioritised and dealt with immediately.

Critical/urgent issues are defined as:

  1. The Service as a whole is not operational for multiple users. OR
  2. Multiple core functions of the Service are not operational for multiple users.

Example – RDS website outage.

Please remember to email ann.wales3@nhs.scot and his.decisionsupport@nhs.scot with any critical/urgent issues in addition to raising a support ticket.

High priority issues are defined as:

  1. A single core function of the Service is not operational for multiple users. OR:
  2. Multiple non-core functions of the Service are not operational for multiple users.

Example – Build to app not working.

2.2 Support requests that are outwith the warranty period of 12 weeks since the software was originally developed will not be automatically addressed by Tactuum. The RDS team will consider these requests for costed development work and will obtain estimate of effort and cost from Tactuum for priority issues.

2.3 Support tickets for technical issues that are not classified as bugs will not be automatically addressed by Tactuum. The definition of a bug is ‘a defect in the software that is at variance with documented user requirements.’  Issues that are not bugs will also be considered for costed development work.

The majority of issues currently in support tickets fall into category 2 or 3 above, or both.

2.4 Non-urgent requests that require a deployment (i.e a new release of RDS) will normally be factored into the next scheduled release (currently end of Nov 2024 and end of Feb 2025) unless by special agreement with the RDS team.

Please note that we plan to move in the new year to a new system whereby requests all come to an RDS support portal in the first instance and are triaged from there to Tactuum when appropriate.

We will be organising a webinar in a few weeks’ time to take you through the details of the current support processes and criteria.

3. Next scheduled deployment.

The next scheduled RDS deployment will take place at the end of November 2024.  We are reviewing all outstanding support tickets and feature requests along with estimates of effort and cost to determine which items will be included in this deployment.

We will update you on this in the next newsletter and in the planned webinar about support ticket processes.

4. Contingency arrangements for RDS

Many thanks to those of you who attended our recent webinar on the contingency arrangements being put in place to prevent future RDS outages as far as possible and minimise impact if they do occur.  Please contact ann.wales3@nhs.scot if you would like a copy of the slides from this session.

5. Transfer of CKP pathways to RDS

The NES clinical knowledge pathway (CKP) publisher is now retired and the majority of pathways supported by this tool have been transferred to the RDS. Examples include:

NHS Lothian musculoskeletal pathways

NHS Fife rehabilitation musculoskeletal pathways

NHS Tayside paediatric pathways

6. Other new RDS toolkits

Include:

Focus on frailty (from HIS Frailty improvement programme)

NHS GGC Money advice and support

If you would like to promote one of your new toolkits through this newsletter, please contact ann.wales3@nhs.scot

To go live imminently:

  • Focus on dementia
  • NHS Lothian infectious diseases toolkit
  • Dumfries and Galloway Adult Support and Protection procedures
  • SIGN guideline – Prevention and remission of type 2 diabetes

 

7. Evaluation projects

We have recently analysed the results of a survey of users of the Scottish Palliative Care Guidelines toolkit.  Key findings from 61 respondents include:

  • Most respondents (64%) are frequent users of the toolkit, using it either daily or weekly. A further 25% use it once or twice per month.
  • 5% of respondents use the toolkit to deliver direct patient care and 82% use it for learning
  • Impact on practice and decision-making was rated as very high, with 80% of respondents rating these at a 4-5 on a 5 point scale.
  • Impact on time saving was also high, with 74% of respondents rating it from 3-5.
  • 74% also reported that the toolkit improved their knowledge and skills, rating these at 4-5 on the Likert scale

Key strengths identified included:

  • The information is useful, succinct, and easy to understand (31%).
  • Coverage is comprehensive (15%)
  • All information is readily accessible in one place and users value the offline access via mobile app (15%)
  • Information is reliable, evidence-based and up to date (13%)

Users highlighted key areas for improvement in terms of navigation and search functionality. The survey was very valuable in enabling us to uncover the specific issues affecting the user experience. Many of these can be addressed through content management approaches. The issues identified with search results echo other user feedback, and we are costing improvements with a view to implementation in the next RDS deployment.

8.RDS High risk prescribing (polypharmacy) decision support embedded in Vision and EMIS primary care E H R systems

This decision support software, sponsored by Scottish Government Effective Prescribing and Therapeutics Division,  is now available for all primary care clinicians across NHS Tayside. Board-wide implementation is also planned for NHS Lothian, and NHS GGC, NHS Ayrshire and Arran and NHS Dumfries and Galloway have initial pilots in progress. The University of Dundee has been commissioned to evaluate impact of this decision support software on prescribing practice.

9. Video tutorials for RDS editors

Ten bite-size (5 mins or less) video tutorials for RDS editors are now available in the “Resources for providers of RDS tools” section of the RDS.  These cover core functionality including Save and preview, content page and media management, password management and much more.

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

  • Wednesday 23rd October 4-5 pm
  • Tuesday 29th October 11 am -12 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.)

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

 

6. Menstrual and Perimenopausal Migraine Guidance

National Waiting Times Board - Centre for Sustainable Delivery

Background

Oestrogen levels vary throughout a women’s life with greater fluctuations happening during puberty and the perimenopause. 

There is an increase frequency of migraine associated to periods of oestrogens fluctuations1.  

The oestrogens level mirror changes in migraine prevalence. Migraine may dissappear around or after menopause and there may be a worsening frequency of migraine or menstrual migraine during the perimenopause.  

Menstrual migraine refers to the episodes of migraine that start on day - 2 to +3 of menstruation in at least 2 or 3 menstrual cycles. If there are no other migraine attacks during the cycle, such migraine is called pure menstrual migraine. If there are migraine attacks at other times, then it is called menstrually related migraine2. 

Menstrual migraine is usually more severe, more prolonged and more refractory to treatment than non-menstrual migraines3.  

It is during the oestrogen withdrawal that happens at the menstrual phase of the cycle when there is an increased risk of migraine. The increase uterine prostaglandin release may also have a role in the risk of migraine4. 

Treatment of menstrual migraine

Treatment of menstrual migraine starts by optimising acute treatment, bearing in mind that menstrual migraine tends to be more severe, prolonged and refractory.  

When acute treatment is not effective, then one may consider different prophylactic approaches.  

Standard prophylactic medication can be used in menstrually related migraine when there are other migraine attacks during the cycle; but it may not be effective for pure menstrual migraine, when targeted prophylactic approach is likely to be more adequate.  

Targeted perimenstrual prophylaxis can only be used when menstruation is regular and predictable because the prophylaxis has to be started before the onset of the menstrual attack5.  

Examples include:  

  • Frovatriptan on day -2 at 5mg twice a day followed by 2.5mg twice a day for 5 days 
  • Naproxen 500mg daily from day -14 to day + 7 or shorter courses from day -1 to day +7
  • Estradiol gel 1.5mg daily from day -5 for 7 days.  

Another approach would be to supress menstruation  

A) by supressing all ovarian activity: Examples include: 

  • Continous combined hormonal contraceptive (Ethinylestradiol). This also treats menopausal symptoms and healthy women can take it up until age 50. It is contraindicated in migraine with aura.  
  • Injectable progestin-only contraceptives (Medroxyprogesterone acetate) 
  • Oral progestin-only contraceptives (Desogestrel 75mg) 

 

B) by supressing prostaglanding release (reducing menstrual bleeding) with progestin-releasing intrauterine device. Oestrogen withdrawal still occurs with this option.  

 

Hormonal replacement treatment during perimenopause:

As opposed to contraceptive hormones (Ethinylestradiol), hormonal replacement therapy (Estradiol) does not supress ovarian activity and can increase hormone fluctuations and therefore the risk of migraines during perimenopause.  

Hormonal replacement treatment postmenopause:

Transdermal oestrogen (estradiol) or continuous progestogen option may be used in the postmenopause to help minimising hormone fluctuations.  

Estradiol is not contraindicated in migraine with aura. Transdermal route is preferred over oral tablets due to more stable serum hormone levels associated with nonoral routes6.  

Referral to secondary care

Migraine is the most likely diagnosis for a patient attending primary care with headache. Many of these patients will be successfully managed in primary care. If there is a clear diagnosis of migraine we recommend acute +/- preventative treatment (as detailed in acute and prophylactic sections).  

Where prophylactic treatment is not successful after three prophylactic drugs, consider referral to relevant secondary care services as per local arrangements. 

If there is diagnostic uncertainty or concern about a secondary cause, at this point consider open access CT as an alternative to secondary referral. 

Editorial Information

Last reviewed: 11/10/2023

Next review date: 01/04/2025