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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

Manual Vacuum Aspiration (MVA) for treatment of miscarriage and retained pregnancy tissue (1078)

Objectives

To provide guidance to clinical teams undertaking MVA in the management of early pregnancy loss.

Audience

All healthcare workers in GGC involved in the care of women experiencing early pregnancy loss including doctors, nurses, midwives, EPAS staff, A&E staff

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

Manual Vacuum Aspiration (MVA) is an option for women for the management of early pregnancy loss or retained tissue.

NICE suggest surgical or medical management can be offered when expectant treatment is not acceptable to the woman or has failed.  The Miscarriage Association and the Association of Early Pregnancy Units support discussing with women all options that are clinically appropriate and locally available.

MVA has been shown to be a safe and effective procedure and compared with Electric Vacuum aspiration management under general anaesthetic.  Advantages include quicker recovery, shorter hospital stay, lower cost, reduced waiting time and avoids the risks associated with general anaesthesia.

Complication rates (infection, retained tissue, bleeding, perforation and intrauterine adhesions) are similar to those of electric vacuum aspiration. 

MVA can also be used in an emergency situation as it can be performed quickly in a clinical room, providing there is access to an ultrasound machine, MVA supplies, resuscitation equipment and a trained nurse is present.  

Inclusion Criteria

Ultrasound features (see NICE guidance for diagnostic criteria of miscarriage, below indicates suitability for MVA procedure)

  •  Ultrasound diagnosis of early embryonic miscarriage where Crown Rump Length (CRL) does not exceed 25mm on TVUSS
  • Ultrasound diagnosis of anembryonic pregnancy ≤ 10 weeks gestation where there is no CRL and Mean Gestation Sac (MGS) does not exceed 40mm on TVUSS
  • Ultrasound diagnosis of an incomplete miscarriage with RPOC measuring less than 5cm mean diameter on TVUSS
  • Ultrasound diagnosis as above with failed medical management of miscarriage

Patient characteristics

  • Motivated and well counselled woman who can tolerate a speculum examination, bearing in mind that the procedure will be performed under local anaesthetic with the patient still awake.
  • No clinical signs of infection - fever/offensive discharge/ generalized lower abdominal pain.
  • An emergency procedure can be carried out in the event of heavy vaginal bleeding where an ultrasound scan has previously confirmed a non-continuing pregnancy of less than 10 weeks gestation.

Contraindications

  • pregnancy >10 week period of gestation by Ultrasound measurements
  • Bleeding disorders/ Current Anti-coagulant treatment
  • Signs of active Infection
  • Allergy to local anaesthetic
  • Mobility issues affecting positioning on couch with footrests
  • Hb <10
  • Women with Uterine anomalies or suspected molar pregnancy should be discussed with consultant prior to procedure

Note - Previous caesarean section is not a contra-indication to MVA, providing ultrasound excludes scar implantation

Complications

MVA is safe but like all procedures there is a small risk of complications. The risk of complications with an MVA are similar to surgical uterine evacuation under general anaesthesia but without the complications caused by general anaesthetic.

Complications related to the procedure are uncommon or rare—they include:

  • Heavy bleeding (haemorrhage) (3%)
  • Infection (3%)
  • The need for a repeat operation if not all the pregnancy tissue is removed (3%)
  • Perforation (tear) of the womb that may need repair (less than 1 in 1000)
  • Adhesions or scar tissue within the womb.

Organisation of MVA procedure

  • Elective MVA procedures are currently performed on sites in the North and South or the City and within Clyde. The procedure will be organised by contacting EPAS or via the gynaecology emergency team at each of the units.
  • Provide Patient information leaflet outlining Elective MVA with contact numbers for EPAS, local gynaecology ward, and ward or clinic area for planned procedure.  Include details of admission procedure (day, date, time)
  • Discuss and complete Procedure Consent form
  • Discuss and complete Form 2 (Sensitive Disposal of pregnancy tissue) with original to be sent to pathology on day of procedure, with a copy for patient notes and an additional copy for the patient.
  • Obtain FBC and Group and Save (valid for 72 hours)
  • Prescribe Misoprostol 400 mcg Sublingual to be taken 2 – 3 hours prior to procedure
  • Prescribe analgesia to be taken 1 hour before procedure, suggested regime is  Paracetamol 1g oral or Cocodamol 8/500 x 2 tablets oral and Ibuprofen 800mg oral
  • Advise patient to have breakfast or light lunch as normal the day of the procedure

Pre-procedure Assessment on day of procedure

  • Review with nursing and medical staff involved with procedure
  • Confirm paperwork complete and medication has been taken as directed
  • Confirm blood results and request Anti-D if required
  • Baseline observations to be recorded in notes (Temperature, Pulse and Blood Pressure)

Post-procedure Assessment

  • Women should be observed in a recovery area after the procedure for at least 1 hour
  • Observations should be obtained and recorded (Temperature, Pulse and Blood Pressure)
  • Vaginal blood loss to be monitored
  • Patients can eat and drink and should be offered refreshments
  • Check Rhesus status and administer Anti-D if required

Prior to discharge

  • Patient may be discharged home an hour after procedure if well and vaginal loss is not excessive
  • Discuss performing a home pregnancy test in 4 weeks and where to contact if it remains positive
  • Discuss return of periods and future fertility
  • Discuss and provide contraception if required
  • Ensure patient has phone numbers for EPAS and local gynaecology ward
  • Offer support and give contacts from The Miscarriage Association if needed
  • Ensure discharge letter for GP is complete

Editorial Information

Last reviewed: 23/03/2023

Next review date: 31/03/2028

Author(s): Sarah Woldman.

Version: 1

Approved By: Gynaecology Clinical Governance Group

Document Id: 1078

References

BPAS – Mannual Vaccum Aspiration Clinical Guideline – March 2008 Manual Vacuum Aspiration (durbinglobal.com)

Manual Vacuum Aspiration: an outpatient alternative for surgical management of miscarriage.  The Obstetrican and Gynaecologist (TOG) 2015;17:157–61

Terminology for pregnancy loss prior to viability: a consensus statement from the ESHRE early pregnancy special interest group A.M. Kolte1,*, L.A. Bernardi2, O.B. Christiansen1,3, S. Quenby4,

R.G. Farquharson5, M. Goddijn6, and M.D. Stephenson7 on behalf of the ESHRE Special Interest Group, Early Pregnancy, Human Reproduction, Vol.30, No.3 pp. 495–498, 2015

110   Ectopic pregnancy and miscarriage: diagnosis and initial management.  NICE guideline [NG126] Published 17 April 2019, updated 24 November 2021

Mean sac diameter | Radiology Reference Article | Radiopaedia.org

Abortion care, Cervical priming before surgical abortion NICE guideline NG140 Evidence reviews September 2019 Abortion care review M: Cervical priming before surgical abortion (nice.org.uk)