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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

Management of suspicious cervix in pregnancy, Gynaecology (1091)

Warning

Objectives

To define the management of women who are pregnant and are found to have a concerning cervical appearance during speculum examination

Scope

To be applied to women who are pregnant and are found to have an abnormality of their cervix.

Audience

All healthcare professionals in Greater Glasgow and Clyde including midwives, doctors and nurses involved in the care of pregnant women where a cervical abnormality has been identified.

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

Within pregnancy, speculum examinations are generally performed after a patient present with symptoms such as abnormal vaginal discharge, vaginal bleeding, pre-term labour or rupture of membranes.

History

Before the examination consider the following which can be determined by history taking.

  • Is infection suspected?
  • Has the patient had any previous treatment to her cervix?
  • Is there a history of abnormal smears?
  • Has she been sexually active recently?
  • Does she have a cervical suture or vaginal pessary in place?
  • Is she using vaginal pessaries which may change her vaginal discharge e.g. vaginal progesterone?
  • Is there a history consistent with early labour including rupture of membranes?

If cervical screening history is uncertain and the patient is ≥25 years of age, the national Scottish Cervical Call Recall System database (SCCRS) may contain relevant information.

Opportunistic cervical smears should not be taken during pregnancy within the Obstetric Department.

Diagnosis

If concerns regarding cervical appearance, it is important to describe and document the size, number, consistency and origin of any cervical lesions, along with any contact bleeding.

If any concern over appearance of cervix at examination, confirmation should be made by the on call Consultant or senior trainee (ST6/7) in the first instance.

If a vaginal infection is suspected, high vaginal swabs should be taken and consideration of STI screen.  These may include Chlamydia/Gonorrhoea nucleic acid amplification tests (NAAT) vulvovaginal swab or lesion swab for PCR medium e.g. for herpes.

Patients presenting with vaginal bleeding should be managed in line with current guidelines for Antepartum Haemorrhage or Vaginal bleeding in <24 weeks. (see relevant guidelines for gestation)

Cervical appearance during pregnancy

The appearance of the cervix can change in normal pregnancy. Features can include an increase in cervical size, a bluish appearance due to increase vascularity.  These physiological changes may appear suspicious to an inexperienced clinician (2).

Most cervical abnormalities are benign and patients can be reassured and managed conservatively.  Some changes are described below.

  • Cervical ectopy – most common benign abnormality and may be associated with increased physiological discharge, no further investigation required.
  • Nabothian Follicles/Cysts – normal finding in women of childbearing age
  • Cervicitis/inflammation of the cervix – this can be acute or chronic and are most likely associated with Sexually Transmitted Infections (HSV, chlamydia, gonnorrhoea, trichomonas). Screening with appropriate swabs should be undertaken.
  • Condyloma (genital warts) - may be present in remainder of genital tract including vagina and vulva.

Cervical Polyp –They can be found in up to 4% of women, and are commonly asymptomatic.  However, in pregnancy they may present with vaginal bleeding or antepartum haemorrhage. They can be ectocervical, endocervical or endometrial in origin.

Risk of malignancy is low estimated at <0.1% in the pre-menopausal woman (3).  If there is clinical concern that the polyp may be atypical and/or previous unresolved abnormal cervical cytology, then referral for review at colposcopy via USOC (Urgent Suspicion of Cancer) pathway should be submitted.  This should be an urgently dictated letter, which is sent to colposcopy via Scottish Care Information gateway (SCI-gateway) referral pathway by the transcribing secretary.

All patients with cervical polyps, irrespective of antenatal management should be reviewed in postnatally (obstetrics or general gynaecology) at 6-12 weeks. This should be highlighted via Alert tab in Badger, and referral made using a dictated letter, which is sent to colposcopy via SCI-gateway referral pathway by the transcribing secretary.

Suspicious cervical mass - cervical carcinoma is rare in pregnancy with estimated prevalence 1-10/10 000 pregnancies (2). 

If malignancy is suspected on clinical examination in a stable patient, then referral for review at colposcopy via USOC (Urgent Suspicion of Cancer) pathway should be submitted.  This should be an urgently dictated letter, which is sent to colposcopy via SCI-gateway referral pathway by the transcribing secretary.

Colposcopy

Referral to colposcopy should be made by senior trainee (ST6/7)/consultant by written referral including summary of pregnancy.  This should be an urgently dictated letter, which is sent to colposcopy via SCI-gateway referral pathway by the transcribing secretary.  It is useful to copy in the patient’s named Obstetrician and their own GP.

Referral should contain:

  • Patient’s named Obstetrician and contact details (may be useful to include their secretary as a contact point)
  • Presenting symptoms
  • Clinical findings indicating referral
  • Investigations undertaken e.g. swabs
  • Placental site
  • Any issues with pregnancy

Clinical assessment of the cervix will be undertaken and outcome of this examination will be shared with patient’s named consultant Obstetrician and referring clinician.

Unless the suspicion of malignancy is high at colposcopy, it is most likely that a conservative approach will be adopted.  Any further follow-up will be arranged by the colposcopist postnatally.

If a biopsy during pregnancy if felt to be warranted, this will generally be undertaken by an experienced colposcopist in a theatre setting after planning with the obstetric team. This is due to the associated increase in haemorrhage and complications.

Editorial Information

Last reviewed: 14/06/2023

Next review date: 31/05/2028

Author(s): Dr Victoria Flannigan, Consultant O&G, Dr Sandra Wong, Consultant O&G.

Approved By: Gynaecology Clinical Governance Group

Document Id: 1091

References
  1. Panayotidis, Costas & Cilly, Latika. (2013). Cervical Polypectomy during Pregnancy: The Gynaecological Perspective. J Genit Syst Disor. 2. 10.4172/2325-9728.1000108.
  2. China S, Sinha Y, Sinha D, Hillaby K. Management of gynaecological cancer in pregnancy.The Obstetrician & Gynaecologist2017;19:139–46. DOI: 10.1111/tog.1236
  3. Nelson AL, Papa RR, Ritchie JJ. Asymptomatic Cervical Polyps: Can We Just Let them Be? Women’s Health. March 2015:121-126. doi:10.2217/WHE.14.86