Welcome to the Right Decision Service (RDS) newsletter for August 2024.
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.
The following toolkits are now live;
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.
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.
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
Best practice guidance: poster, presentation
Wound swabs SHOULD NOT be taken routinely or from an uninfected wound
Wound swabs CANNOT be used to diagnose and/or exclude infection.
Results need to be reviewed in context of the clinical picture
Refer to: Hospital: Paediatrics (Skin and Soft Tissue Infection - Cellulitis)
Flucloxacillin dose
Penicillin Allergy or Known MRSA#: Doxycycline dose (Pregnant: Clarithromycin dose)
Duration: 5 days; up to 10-14 days may be required if severe/extensive/slow to respond
Facial infection, not requiring admission
Co-Amoxiclav dose
Penicillin Allergy or Known MRSA#: Doxycycline dose + Metronidazole dose (Pregnant: Clarithromycin dose + Metronidazole dose)
Duration: 7 days
Reserve topical antibiotics for very localised lesions.
Topical Fusidic Acid 2% cream can be prescribed in community pharmacies via Pharmacy First for adults/children in minor/localised, uncomplicated cases.
Minor/localised: topical Fusidic Acid 2% dose
Severe/extensive or bullous: Flucloxacillin dose
Penicillin Allergy or MRSA suspected#: Doxycycline (Pregnant: Clarithromycin) dose
Duration: 5 days
Advise on self-care management strategies to reduce recurrence.
Topical clotrimazole 1% dose, miconazole 2% dose or terbinafine 1% dose cream
Marked inflammation: Add topical hydrocortisone 1% (BD, up to 7 days)
Duration: consult selected product literature
Refer to:
Confirm with nail clippings prior to treatment.
Offer oral antifungal if confirmed fungal nail infection and self-care measures alone and/or topical treatment are not successful or appropriate.
Terbinafine dose
Duration:
Refer to: NICE / CKS Fungal nail infection
Refer to: Hospital: Paediatrics (Skin and Soft Tissue Infection - Human / Animal bite)
Assess type and severity (incl. causative animal), wound depth and site, and whether it is infected or not. Consider need for antibiotic prophylaxis, as per NICE guidance.
Assess tetanus and rabies risk.
For human bites assess HIV and hepatitis risk.
Send a wound swab for culture if discharge is present (purulent or non-purulent). To ensure appropriate laboratory testing, clinical details must state this is a human / animal bite (detail which animal).
Co-amoxiclav dose
Penicillin Allergy: Doxycycline dose + Metronidazole dose (Pregnant: discuss with Microbiology)
Duration:
Antibiotic therapy is to treat infection, NOT heal ulcers / wounds.
Do NOT use wound swabs to diagnose infection - wound infection is a clinical diagnosis (see IWII 2022 Wound Infection Continuum: Diagnosis of Wound Infection).
Do NOT routinely culture uninfected wounds.
Wound Swabs (how to swab) / bone culture samples should be obtained prior to initiation of antibiotic therapy. Clinical details should include "diabetes" to ensure appropriate laboratory testing.
Determine severity of wound infection (mild/moderate/severe*), as per IWGDF/IDSA Infection guideline, to determine most appropriate antibiotic therapy.
Follow Acute Foot Deterioration in a Patient Living with Diabetes Pathway. Consider referral to Diabetes Foot Clinic.
Flucloxacillin dose
Penicillin Allergy or Known MRSA# or Non-antibiotic naïve: Doxycycline dose
Duration: 7 days
Consider need for Secondary Care assessment (e.g. surgical input required). If no complicating factors, likely can be manged in Primary care with oral antibiotics.
Co-amoxiclav dose
Penicillin Allergy or Known MRSA# or Non-antibiotic naïve: Doxycycline or Co-trimoxazole or Clindamycin dose
Duration: 7 days; may need up to 14 days if slow response. If osteomyelitis is diagnosed 4 - 6 weeks of therapy is usually indicated.
Requires hospital admission for IV antibiotics and assessment
Treat erythema migrans empirically.
Prophylactic antibiotic in the absence of signs/symptoms following a tick bite is NOT recommended.
Base need for serology testing on algorithm within the SLDTRL User Manual:
Click image for larger version / pdf.
All serology requests must include: symptoms, time between tick bite / possible exposure and onset of illness. Samples with inadequate clinical details (e.g. ?lyme, tick bite) will not be referred for testing.
For management guidance and antibiotic choice/duration, refer to NICE Lyme disease guidance.
Advise two applications one week apart.
Treat all household members and sexual contacts.
Pregnant women can be treated.
Treat entire body below ear/chin including under nails.
Include face and scalp in under 2's and elderly patients.
Permethrin 5% cream dose (adults and children >2 months)
Second line: Malathion 0.5% liquid dose (adults and children >6 months)
Refer to: NICE/CKS: Management of Scabies
Send a wound swab for culture if discharge is present (purulent or non-purulent). Include relevant clinical details.
If there is no clinical improvement on empirical therapy, consider adjusting antibiotics according to swab results.
Do NOT use wound swabs to diagnose infection - wound infection is a clinical diagnosis (see IWII 2022 Wound Infection Continuum: Diagnosis of Wound Infection).
Flucloxacillin dose
Penicillin Allergy or Known MRSA#: Doxycycline dose (Pregnant or Breast Feeding: Clarithromycin dose) Duration: 5 - 7 days
PLEASE REFER TO Obstetrics and Gynaecology Antimicrobial Formulary
Advise women to continue breastfeeding, including from affected breast if possible.
Encourage simple analgesia for pain/discomfort.
Send breast milk sample for culture in cases of treatment failure.
Identify and manage predisposing factors e.g. breastfeeding problems - refer health visitor or NHS breastfeeding support.
Flucloxacillin dose
Penicillin Allergy or Known MRSA#: Clarithromycin dose or Co-trimoxazole*dose
No improvement after 48 hours, and hospital admission is not required
Co-amoxiclav dose
Penicillin Allergy or Known MRSA#: Clarithromycin dose (or Co-trimoxazole*,dose) + Metronidazole dose
* Avoid during pregnancy and whilst breastfeeding: in the first 6 weeks after birth, where there is a possibility of G6PD deficiency, or if baby is jaundiced. Seek Microbiology advice.Duration: 7 - 14 days, depending on severity and response
Refer to: NICE Mastitis and Breast Abscess
NHS Dumfries & Galloway Antimicrobial Handbook