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Right Decision Service newsletter: April 2024

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

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Chronic Pelvic Pain, initial management (487)

Warning

Please report any inaccuracies or issues with this guideline using our online form

Chronic Pelvic Pain (CPP) is defined by the RCOG as intermittent or constant pain in the lower abdomen or pelvis of at least 6 months’ duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy. It is a symptom and not a diagnosis. CPP is common in the UK with a  prevalence in primary care comparable with that of low back ache, asthma or migraine.

Aetiology

There is frequently more than one component to CPP. The experience of pain is affected by physical, psychological and social factors. Possible causes are listed below:

  • Gynaecological causes-These include endometriosis, adenomyosis, ovarian pathology, pelvic inflammatory disease (PID), dense vascular adhesions (division of other adhesions confers no benefit)
  • Gastrointestinal causes-These include IBS (symptoms can be exacerbated cyclically with menses), constipation (common cause of dyspareunia), inflammatory bowel disease, Coeliac disease
  • Urological causes-These include recurrent UTIs, interstitial cystitis
  • Musculoskeletal causes-Musculoskeletal abnormality can be a primary source of CPP or an additional component resulting from postural changes. Referral to physiotherapy may be useful.
  • Nerve entrapment-Nerve entrapment in scar tissue, fascia or a narrow foramen may cause pain and dysfunction in the distribution of that nerve. Typically this pain is highly localised and exacerbated by particular movements. Incidence of nerve entrapment after one pfannensteil incision is 3.7%
  • Psychological and social issues-Depression and sleep disorders are common in women with CPP. For some women childhood sexual or physical abuse may initiate a cascade of events or reactions which make an individual more likely to develop CPP as an adult.

Assessment

Assessment should aim to identify contributory factors rather than assign causality to a single pathology. Adequate time should be allowed for the woman to explain her symptoms and ideas about her CPP including any specific anxieties she may have regarding possible cause. A favourable initial consultation has been shown to be associated with improved recovery rates. The multi-factorial nature of CPP should be discussed and explored from the start of the consultation.

History

  • Nature and pattern of pain
  • Association with menstrual cycle, intercourse, movement, posture
  • Association with bowel symptoms such as bloating, stool frequency and type, pain on defaecation.
  • Association with bladder symptoms such as frequency, dysuria
  • Psychological co-morbidity e.g. depression, sleep disorder
  • Detailed drug history with particular reference to analgesia (e.g. dose and type), anxiolytics and antidepressants which can exacerbate constipation
  • “Red flag” symptoms suggestive of life threatening disease (e.g. rectal bleeding, new bowel symptoms >50 yrs, new onset of pain post-menopause, pelvic mass, excessive weight loss, irregular bleeding >50 yrs, suicidal ideation) should be excluded and managed appropriately.

Examination and Investigation

  • Abdominal palpation
  • Bimanual vaginal examination
  • Screening for STI in particular Chlamydia and gonorrhoea should be offered
  • Transvaginal ultrasound scan (TVS), to exclude pelvic pathology e.g. endometriomas, should ideally be carried out at the time of initial vaginal examination. If this resource is unavailable, ultrasound should be carried out as an interval procedure.
  • Diagnostic laparoscopy is a second-line investigation if other therapeutic interventions fail and should NOT be used as a first-line investigation in the absence of abnormality on vaginal examination or TVS. A negative laparoscopy has not been shown to positively benefit women’s health beliefs or pain outcome. Laparoscopy should only be performed when there is a high index of suspicion of significant adhesive disease, endometrioma(s) requiring surgical intervention or where endometriosis is suspected in a woman not suitable for hormonal treatment. In these circumstances the laparoscopy should be performed by a surgeon capable of surgically treating these pathologies.

Therapeutic options

  • Cyclical pain or history suggestive of endometriosis in the absence of TVS findings of disease requiring surgery - In women not wishing to conceive, hormonal treatments to suppress ovarian function can be tried – combined hormonal contraception (pills, patches etc.), desogestrel (other POPs do not inhibit ovulation), levonorgestrel-intrauterine system (52mg), medroxyprogesterone acetate 30mg/d for 3-6 months, GnRH analogues (should only be prescribed following discussion with a senior gynaecologist, add-back HRT should be prescribed to reduce side-effects). If conception is desired or hormonal treatment is contraindicated then simple analgesia should be offered and laparoscopy with a view to treatment of endometriosis should be considered.
  • Symptoms of IBS/constipation - Dietary advice and a trial of soluble fibre (e.g.Fybogel) plus an anti-spasmodic and/or peppermint oil should be offered.
  • Urogenital or bowel symptoms other than IBS - Referral to urology or gastroenterology
  • Musculoskeletal symptoms - Referral to physiotherapy
  • Nerve entrapment symptoms or pain not manageable with simple analgesia in the absence of TVS or laparoscopic abnormality - Referral to pain management service
  • LUNA is ineffective in the management of CPP.

Editorial Information

Last reviewed: 01/06/2016

Next review date: 30/06/2021

Author(s): Claire Higgins.

Version: 2

Approved By: Gynaecology Clinical Governance Group

Document Id: 487

References