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
21/08/24:
The new peri-operative care pathway for patients with diabetes undergoing surgery or procedures that require a period of starvation (fasting) and new variable rate intravenous insulin infusion (VRIII) protocol will be launched in January 2020. This section will be updated with appropriate PECOS codes for ordering documentation as they become available.
Pre-assessment checklist - perioperative pathway for patients with diabetes undergoing surgery or procedures that require a period of starvation (fasting) pre-assessment checklist is accessed here
Day of surgery checklist - Perioperative pathway for patients with diabetes undergoing surgery or procedures that required a period of starvation) is accessed here
| Short-acting insulin preparations | Long-acting insulin preparations | Pre-mixed insulin preparations |
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Insulin | Day before going into hospital | Day of surgery | ||
Surgery in morning | Surgery in afternoon | If VRIII being used | ||
Long-acting – morning (for example: Lantus, Levemir, Humulin I, Tresiba, Insulatard, Insuman Basal, Toujeo, Abasaglar) | Take as normal | Reduce insulin dose by 20%. | Reduce insulin dose by 20%. Blood glucose will be checked on admission. Resume normal insulin the morning after the surgery or procedure, if eating and drinking. | Continue at 80% of usual dose |
Long-acting –evening (for example: Lantus, Levemir, Humulin I, Tresiba, Insulatard, Insuman Basal, Toujeo, Abasaglar) | Lantus, Levemir, Tresiba, Toujeo, Abasaglar: Reduce dose by 20%. Humulin I, Insulatard, Insuman Basal Take as normal | Resume normal insulin with evening meal if patient able to manage fluids and a snack after surgery. For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required. | Resume normal insulin with evening meal if patient able to manage fluids and a snack after surgery. For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required. | Continue at 80% of usual dose |
Twice or three times daily mix (for example: Novomix 30, Humulin M3, Humalog Mix 25, Humalog Mix 50, Insuman Comb 15, Insuman Comb 25, Insuman Comb 50) | Take as normal | Take half normal dose in the morning. Check blood glucose on admission. VRIII may be required until patient resumes diet. For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required. If patient able to manage fluids and a snack after surgery, resume normal dose with evening meal (or with lunch, if taking three times daily insulin). | Take half normal dose in the morning. If patient receiving three times daily mix insulin, omit lunchtime dose. Check blood glucose on admission. VRIII may be required until patient resumes diet. For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required. If patient able to manage fluids and a snack after surgery, resume normal dose with evening meal. | Stop until eating and drinking normally |
2, 3, 4 or 5 injections daily – any combination of background insulin combined with short-acting insulin at mealtimes (“basal bolus” regimens) (for example Long acting insulins:Lantus, Levemir, Humulin I, Tresiba, Insulatard, Insuman Basal, Toujeo, Abasaglar Short acting insulins:Actrapid, Novorapid, Humalog, Apidra, Humulin S, Insuman Rapid, Fiasp, Hypurin Porcine Neutral, (Hypurin Bovine Neutral - discontinued) | Long acting insulin: Morning – Take as normal Evening – Reduce dose by 20% for Lantus, Levemir, Tresiba, Toujeo and Abasaglar only. For other-long acting insulins, take normal dose (Humulin I, Insulatard, Insuman Basal) | Long-acting insulin: Morning - Reduce dose by 20%. Blood glucose will be checked on admission. Resume normal insulin the morning after the surgery or procedure, if eating and drinking. Evening – Resume normal insulin with evening meal if patient able to manage fluids and a snack after surgery. For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required. | Long-acting insulin: Morning – Reduce dose by 20%. Blood glucose will be checked on admission. Resume normal insulin the morning after the surgery or procedure, if eating and drinking. Evening - Resume normal insulin with evening meal if patient able to manage fluids and a snack after surgery. For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required. | Continue long acting background insulin at 80% of usual dose |
Short acting insulin: take as normal day before surgery. | Do not take short-acting insulin if no breakfast is eaten. If patient able to manage fluids and a snack after surgery, restart short-acting insulin with lunch. For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required. | Take usual morning dose of short-acting insulin if breakfast is eaten. Do not take lunchtime dose. If patient able to manage fluids and a snack after your surgery, restart short-acting insulin with evening meal For more prolonged surgery or if post-operative nausea and vomiting, monitor blood glucose – VRIII may be required. | Stop until eating and drinking normally | |
Printable version of the table can be found here
Medication | Day before going into hospital | Day of surgery | |||
Patient for a.m. surgery | Patient for p.m. surgery | After surgery | Specific considerations | ||
Metformin | No bowel prep: Take as normal Bowel prep: Omit all doses | Omit all doses | Omit all doses | Recommence 48 hoursafter surgery (see specific considerations) | Withhold until 48 hours post-operation. Resume if patient eating and drinking, ensure eGFR>40mL/min/1.73m2 , serum creatinine <150micromol/L, no sepsis, no overt heart failure and no hypovolaemia. |
Sulfonylureas (e.g. gliclazide, glipizide, glibenclamide, glimeperide) | Take as normal | Omit morning dose | Omit morning dose. If taken twice daily take evening doseonly if eating | Recommence when eating and drinking normally | |
Pioglitazone | Take as normal | Omit on day of surgery | Omit on day of surgery | Recommence when eating and drinking normally | |
DPP IV inhibitor (e.g. sitagliptin, vidagliptin, saxagliptin, alogliptin, linagliptin) | Take as normal | Omit morning dose | Omit morning dose | Recommence when eating and drinking normally | |
GLP-1 analogue (e.g. exenatide, liraglutide, lixisenatide, dulaglutide) | Take as normal | Omit all doses | Omit all doses | Recommence when eating and drinking normally | If pancreatitis is suspected promptly discontinue If eGFR < 30mL/min/1.73m2 do not use. |
SGLT-2 inhibitors (e.g. dapagliflozin, canagliflozin, empagliflozin) | Omit all doses | Omit on day of surgery | Omit on day of surgery | Treatment may be restarted once fully recovered from surgery | Rare but serious cases of diabetic ketoacidosis have been reported in patients on SGLT inhibitor treatment for Type 2 diabetes. The risk of diabetic ketoacidosis must be considered in the event of non- specific symptoms such as nausea, vomiting, anorexia, abdominal pain, excessive thirst, difficulty breathing, confusion, unusual fatigue or sleepiness. Treatment should be interrupted in patients who are hospitalised for major surgical procedures or acute serious medical illnesses. In both cases, treatment with SGLT inhibitors can be restarted once the patient’s condition has stabilised. |
| Acarbose | Take as normal | Omit morning dose if breakfast not taken | Take morning dose if eating. Do not take lunchtime dose | Recommence when eating and drinking normally | |
| Meglitinide (repaglinide or nateglinide) | Take normal | Omit morning dose if breakfast not taken | Take morning dose if eating breakfast | Recommence when eating and drinking normally | |
Printable version of the table can be found here
Each ward will have a supply of these prescription forms and further supplies should be accessed via PECOS.
Patient instruction leaflet for patients with diabetes undergoing surgery or procedures requiring a period of starvation - Information for patients with diabetes controlled by subcutaneous injections of insulin is accessed here.
Patient instruction leaflet for patients with diabetes undergoing surgery or procedures requiring a period of starvation - Information for patients with diabetes controlled by tablets or by injections of GLP-1 analogues - Byetta (exanatide), Bydureon (long-acting exenatide), Victoza (liraglutide), Lyxumia (lixisenatide), Ozempic (semaglutide) or Trulicity (dulaglutide) is accessed here.
TAM (Treatments and Medicines) NHS Highland