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
There are safety concerns regarding the inappropriate use of high dose corticosteroid inhalers and the importance of ensuring that the patient’s steroid load is kept to the minimum level whilst effectively treating symptoms. It is recognised that some patients will require treatment with high-dose ICS. This indicator acts as a guide for highlighting use of inhaled high dose corticosteroids but is unable to distinguish between patients with asthma and COPD. The STU software will allow GP practices to identify patients within each cohort for review.
Patients on inhaled high dose corticosteroids (or multiple steroid preparations) should be issued with a steroid treatment card (blue) as shown below. There is an additional steroid emergency card (also shown below) which alerts patients who are dependent on long term steroids and at risk of adrenal insufficiency to the potentially serious, systemic side effects from them. A full list of steroid doses to assist with determining who should be issued with a steroid emergency card (red) is contained within the Healthcare Improvement Scotland advice18 and STU software will assist identification of these patients. The most concerning side effect is adrenal suppression, others include growth failure; reduced bone density; cataracts and glaucoma; anxiety and depression; and diabetes mellitus.31
The chart below shows that high dose corticosteroid inhaler prescribing has increased in most NHS boards since 2021.
The numerical data for NTI graphs can also be viewed here.
The most up to date national therapeutic indicator data is available here.
This guidance is not for children; therefore prescribers should refer to guidance on asthma management in children, however, there are two medication safety points to highlight. Prescribing of high dose inhaled corticosteroids in children, aged under 12 years, is of particular concern due to long term safety concerns. Children on high dose corticosteroids should be reviewed and under the care of paediatricians with a special interest in respiratory medicine. Transition from child to adult services should be considered for children with unstable asthma or co-existing risks, such as food allergies and a review carried out in children’s services to facilitate this. There is a report available using the STU utility to identify high dose corticosteroid use in children under 12 years.
When treating children with ICS:
SIGN 158 recommends the following for adults and children.6
Patients should be maintained at the lowest possible dose of inhaled corticosteroid. Reduction in inhaled corticosteroid dose should be slow as patients deteriorate at different rates. Reductions should be considered every three months, decreasing the dose by approximately 25 to 50% each time. It is difficult to set a specific threshold level of ICS inhalers for review due to their varying potencies, dosing and quantities (for example 200 actuations in most ICS MDIs and 100 doses in some ICS DPIs).
It is important to arrange for a regular review of patients as treatment is reduced. When deciding the rate of reduction, it is important to take into account the following aspects: the severity of asthma, the side effects of the treatment, time on current dose, the beneficial effect achieved, and patient preference.
The dose – response curve for inhaled corticosteroids (below)32 shows the difference in clinical effect and side effects when a corticosteroid dose is increased. At doses of 800 micrograms per day and above, the clinical benefit of increasing inhaled corticosteroid dose is outweighed by increase in side effects.
Reproduced with permission from National Library of Medicine (Hannu Kankaanranta, Aarne Lahdensuo, Eeva Moilanen, and Peter J Barnes)32
Respiratory prescribing