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
Check for expired indications (e.g. temporary loss of mobility that has now resolved)
Much more effective for stroke prevention in AF than antiplatelets
CAUTION: Bleeding events. Avoid combinations of anticoagulants, antiplatelets, NSAIDs.
Ensure patient adherence to dosing/monitoring regimen
NOTE: Antiplatelets are no longer indicated for primary prevention of CHD.
Aspirin plus clopidogrel indicated for a maximum of 12 months after ACS only.
CAUTION: Bleeding events. Avoid combinations of anticoagulants, antiplatelets, NSAIDs.
Consider anti-platelets as part of secondary prevention strategy after CVD events.
First line anti-platelet for secondary stroke prevention is clopidogrel (rather than dipyridamole)
Usually essential for symptom control in heart failure
Note: Not indicated for dependent ankle oedema (consider medication causes, e.g. CCBs
CAUTION: AKI and electrolyte disturbances.
Advise patient to stop during intercurrent illness (See Sick Day Rule Cards); is U&E monitoring robust?
CAUTION: Hyperkalaemia. Risk factors include: CKD (CI if eGFR<30ml/min), dose >25mg/d, co-treatment with ACEI/ARBs, amiloride, triamterene, potassium supplements.
CAUTION: Toxicity! Risk factors are: CKD, dose>125micrograms daily, poor adherence, hypokalaemia, drug-drug interactions.
Rarely effective; rarely indicated long term
Use short term only when nocturnal leg cramps cause regular disruption of sleep.
Review effectiveness regularly.
Adherence/Patient centeredness
CAUTION: Thrombocytopenia, blindness, deafness.
Consider reducing antianginal treatment if mobility has decreased
CAUTION: Hypotension (consider use of other BP lowering drugs; avoid the combination of nitrates with PDE-5 inhibitors)
Recommended for primary and secondary prevention in patients at high risk of CVD
CAUTION: Rhabdomyolysis: Check interactions (e.g. fibrates, dihydropyridines, antiinfectives).
Consider need for and intensity of treatment in light of life expectancy and ADR risk
Limited evidence supporting tight BP control in the older frail group.
Individualise BP targets for primary and secondary prevention of CVD guidelines.
Consider need for and intensity of treatment in light of CVD risk life expectancy and ADR risk
Usually essential for rate and angina control in CHD and CHF (and often in AF).
BNF recommends up-titration of beta-blocker doses in CHF to evidence based target doses.
CAUTION: Bradycardia in combination with diltiazem/verapamil, digoxin and amiodarone.
Usually essential for symptom control in CHF. For other potential benefits: see NNT Table
BNF recommends up-titration of ACEI/ARB doses in CHF to evidence based doses.
CAUTION: Acute Kidney Injury. Avoid combination with NSAIDs and advise patient to stop when at risk of dehydration (See Sick Day Rule Cards).
CAUTION: Constipation, ankle oedema
Dihydropyridines – CAUTION: Reflex tachycardia/cardiodepression: Avoid nifedipine in CHD/CHF
Diltiazem/verapamil – CAUTION: Bradycardia in comb. with beta-blockers or digoxin (digoxin levels increased)
Recommended in moderate to severe CHF: See NNT section
CAUTION: Hyperkalaemia. Risk factors: CKD, combination with ACEI/ARB, triamterene, amiloride
CAUTION: AKI. Avoid combination with NSAIDs and advise patient to stop when at risk of dehydration
Polypharmacy guidance