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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

Obesity in Gynaecology (587)

Warning

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

Obesity is predicted to become the UK’s leading health problem and is more common in women, affecting 26.1% in the UK compared to 16.4% two decades ago (1). It is a risk factor for many gynaecological conditions such as menstrual disorders, PCOS, endometrial pathology, subfertility and pelvic floor dysfunction.

Definitions of Body Mass Index (BMI): kg/m2
Normal BMI 20 – 24.9
Overweight BMI 25-29.9
Obese BMI 30-39.9
Morbidly obese BMI >/= 40

 

Pre-operative counselling / consent

BMI should be available before counselling and written consent is obtained as surgical and anaesthetic risks rise with increasing BMI. Many gynaecological conditions will respond favourably to weight loss e.g. menstrual disorders, PCOS, subfertility, prolapse and stress incontinence. Non-surgical management of the obese patient with benign disease is often most clinically appropriate. There should be clear discussion and documentation of which medical treatment options have been offered and whether they were accepted or declined.

In situations where surgery is deemed necessary for benign disease, weight loss is desirable and should be advised. The increased risks of common intra- and post-operative complications such as bleeding, visceral damage, wound infection, thromboembolism and respiratory tract infection should also be discussed and documented.

Theatre planning

Pre-operative planning should take place in order to reduce the risk.

  • Requirement for in-patient management will depend on local day surgery BMI limit
  • Obese patients will require longer list time (surgical and anaesthetic)
  • Theatre tables generally support a weight of 300Kg and extenders are available to increase bed width. Local specifications should be ascertained prior to operating on a morbidly obese patient
  • Appropriate measures for moving and handling must be taken eg. appropriate staffing, hover mattresses etc
  • Surgical Equipment – special equipment requirements such as Alexis retractors, long ports/instruments, ligasure / ligasure atlas short etc should be communicated to the theatre team in advance
  • Surgical assistance – the appropriate skill-mix and number of assistants should be arranged
  • HDU/ITU bed should be booked in advance of surgery if likely to be required

Anaesthetic considerations

Obese women have an increased risk of anaesthetic difficulty and complications, related to their obesity, as well as the presence of medical co-morbidities. Specialist expertise is required to address:

  • difficult venous access
  • difficult airway access
  • co-morbidities (altered cardio-respiratory function/disease, hypertension/IHD, diabetes and obstructive sleep apnoea)
  • altered drug metabolism

Intra-operative surgical considerations

Laparoscopic surgery has significantly lower morbidity than open surgery for obese patients however this will depend on the surgical expertise available. Surgery may be more complicated due to:

  • Altered surface landmarks
  • Difficult access – especially with pannus (Risk of collateral damage, complications may be difficult to access and repair)
  • Bowel falls in to view
  • Difficult positioning/slippage with Trendelenberg tilt
  • Higher risk of conversion from laparoscopic to open surgery

Clinical evidence increasingly suggests that alternative laparotomy entry sites ( high transverse avoiding the pannus) may lead to lower SSI (surgical site infection) rates.

Post-operative care

Obesity is NOT a contraindication to Enhanced Recovery After Surgery guidance.

Obese patients may require HDU care post-operatively to cater for additional needs in the immediate post-operative period. Forward planning may be required if specialist beds/hoists/commodes/chairs are required in order to aid mobility and reduce risk of post-operative ileus and pressure sores.

The risk of thrombo-embolic disease is increased in the obese patient. Early mobilisation, leg exercises, adequate hydration and correctly fitted anti-embolism stockings (either above or below the knee) as recommended by SIGN 122 should be instituted to reduce risk (2). Weight adjusted dosage of low molecular weight heparin should be given subcutaneously as per the relevant guideline.

Obesity also contributes to a greater risk of post-operative sepsis, in particular surgical site infection. There are no specific recommendations for routine administration of additional prophylactic antibiotics. Early intervention and treatment should be initiated however, should post operative sepsis becomes evident.

Editorial Information

Last reviewed: 18/09/2017

Next review date: 31/03/2024

Author(s): Joy Simpson.

Approved By: Gynaecology Clinical Governance Group

Document Id: 587

References

1) Statistics on obesity, physical activity and diet: England, 2012. NHS Information Centre for Health and Social Care; 2012

2) SIGN 122, Prevention and management of venous thromboembolism, October 2014

3) SIGN 104, Antibiotic prophylaxis in surgery, April 2014.