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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

Thromboprophylaxis during Pregnancy and the Puerperium (580)

Warning

Objectives

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

This guideline provides information on how to assess whether women have an increased chance of developing a venous thromboembolism (VTE) during pregnancy and the puerperium. It details the recommended thromboprophylaxis for women with an increased chance of VTE. 

All women should be assessed as to whether thromboprophylaxis is recommended at key points during the antenatal and postnatal periods. Additional assessments may be necessary if new risk factors or transient risk factors are identified. This guideline incorporates information and recommendations relating to VTE prevention and COVID-19 infection.

The care of women presenting with suspected or confirmed VTE in pregnancy is detailed in separate guideline - Thromboembolic Disease in Pregnancy & Puerperium – Acute Management.  

Scope

This guideline, for use by midwives, obstetricians, and other members of the multidisciplinary team in maternity, is based on the principles and recommendations contained within Reducing the risk of thrombosis and embolism during pregnancy and the puerperium – RCOG Green-top Guideline No 37a (April 2015).

Please report any inaccuracies or issues with this guideline using our online form
KEY PRACTICE POINTS
  • Assessment for an increased chance of VTE should, at a minimum, include:
    • Booking
    • 28 weeks
    • During any antenatal in-patient admission
    • Post-birth in the labour ward setting
    • Prior to postnatal discharge
    • During any postnatal readmission
  • Women with an increased chance of VTE should be offered thromboprophylaxis
  • Current weight is important to accurately determine VTE risk score and appropriate prophylactic dose of LMWH
  • A Quick Reference Guide and a Risk Assessment User Guide are included to support the multidisciplinary team (See appendices)

Background

VTE remains a major cause of direct maternal death in the UK (MBRRACE-UK 2021). 

Pregnancy itself predisposes women to VTE and although the absolute risk of VTE in pregnancy is low (1-2 per 1000) [RCOG 2015], the individual likelihood of thromboembolism during pregnancy and the puerperium is influenced by a wide range of factors. The likelihood of VTE can be mitigated by offering women at increased risk thromboprophylaxis.

Factors that increase the risk include pre-existing medical conditions, or circumstances, factors specific to pregnancy and birth. Additionally some risk factors (transient risk factors) may develop and/or resolve during a pregnancy. Therefore ongoing assessment of all women from early pregnancy into the puerperium is an essential part of universal care, leading to timely identification of risk factors and provision of pharmacological prophylaxis (low molecular weight heparin – LMWH) for women at increased risk.

Infection with COVID-19 may be associated with an overall increased risk of maternal VTE. Therefore, infection should be regarded as a risk factor for VTE during pregnancy and the puerperium, and included in the risk assessment. 

Risk Assessment

Risk assessment for thromboprophylaxis is ongoing throughout pregnancy and should take place during key phases in the woman’s maternity care journey. At a minimum this would include:

  • At Booking
  • At 28 weeks
  • During any antenatal in-patient admission
  • Post-birth in the labour ward setting
  • Prior to postnatal discharge
  • During any postnatal readmission

All women should be reweighed at 28 weeks’ gestation and postpartum to more accurately determine their VTE risk score and the appropriate prophylactic dose of LMWH (MBRRACE 2021).

Risk factors for VTE in Pregnancy & the Puerperium

The following table details the range of factors that increase the likelihood of VTE. 

Risk factors for VTE in pregnancy and the puerperium (RCOG GTG 37a, 2015):

Pre- existing

Previous VTE

Thrombophilia

Heritable

Antithrombin deficiency

Protein C deficiency

Protein S deficiency

Factor V Leiden

Prothrombin gene mutation

Acquired

Antiphospholipid antibodies

Persistent lupus anticoagulant and/ or moderate/ high titre anticardiolipin antibodies and/or ß₂ -glycoprotein 1 antibodies.

Medical comorbidities e.g. cancer; heart failure; active SLE, inflammatory polyarthropathy or inflammatory bowel disease; nephr?oitic syndrome; type 1 diabetes mellitus with nephropathy; sickle cell disease.

Current intravenous drug user

Age > 35 years

Obesity (BMI > 30kg/m² ) either pre pregnancy or in early pregnancy

Smoking

Gross varicose veins (symptomatic or above knee with assoc phlebitis, oedema/ skin changes)

Paraplegia

Obstetric risk factors

Multiple pregnancy

Current pre-eclampsia

Caesarean section

Prolonged labour (> 24hrs)

Mid-cavity or rotational operative delivery

Stillbirth

Preterm birth

Post partum haemorrhage (>1 litre/ requiring blood transfusion)

New onset/ transient

These risk factors are potentially reversible and may develop at later stages in gestation than the initial risk assessment or may resolve and therefore what is important is an ongoing individual risk assessment

Any procedure in pregnancy or puerperium except immediate repair of the perineum, e.g. appendicectomy, post partum sterilization

Bone fracture

Hyperemesis

Ovarian hyperstimulation syndrome

(first trimester only)

Assisted reproductive technology

(ART), in vitro fertilization (IVF)

Admission or immobility  (≥ 3 days bed rest)

e.g. pelvic girdle pain restricting mobility

Current systemic infection

(requiring intravenous antibiotics or admission to hospital)

e.g. pneumonia, pyelonephritis, post partum wound infection

Long distance travel (>4hrs)

Assessment Tools

The following table details the range of factors that increase the likelihood of VTE (RCOG GTG 37a). 

Each risk factor is allocated a score between 1 and 4. The use of antenatal and postnatal thromboprophylaxis will depend on the total risk score as follows:

  • If total score ≥ 4 antenatally, consider thromboprophylaxis from the first trimester
  • If total score 3 antenatally, consider thromboprophylaxis from 28 weeks
  • If total score ≥ 2 postnatally, consider thromboprophylaxis for at least 10 days
  • If admitted to hospital antenatally consider thromboprophylaxis
  • If prolonged admission (≥ 3 days) or readmission to hospital within the puerperium consider thromboprophylaxis

The total risk score will be calculated automatically in the VTE Risk Assessments section of the electronic patient record (BadgerNet).

For patients with an identified bleeding risk, the balance of risks of bleeding and thrombosis should be discussed in consultation with a haematologist with expertise in thrombosis and bleeding in pregnancy.

Following comprehensive history-taking the Midwife/Doctor will complete and document their risk assessment findings within the woman’s BadgerNet maternity case records. 

Supporting tools include: 

  • Thromboprophylaxis Risk Assessment and Management Quick Reference Guide [Appendix 1]
  • VTE Risk Assessment User Guide 2022 [Appendix 2]
    • This user guide includes additional information to support the interpretation of risk factors
  • Hospital Electronic Prescribing and Medicines Administration (HEPMA)

Management Plan

If the woman is identified as requiring thromboprophylaxis with LMWH it is essential that a care plan is made by a Healthcare Professional (HcP) and documented in the Actual Management Plan section within BadgerNet. The timing of thromboprophylaxis commencement will depend on the number of risk factors (see supporting appendices):

  • Any HcP who is uncertain about the need for thromboprophylaxis or the ongoing management plan of patients should seek assistance from a colleague with an interest in medical disorders in pregnancy.

  • Drug contraindications must be considered.

  • Midwives can assess for and administer thromboprophylaxis. Prescribing thromboprophylaxis is an obstetric/medical remit.
  • Some women, in the postnatal period, may be suitable for midwife administration and supply of postnatal thromboprophylaxis as per the Patient Group Direction (PGD) for enoxaparin. Midwives should refer to the PGD for more details.
  • Women receiving antenatal thromboprophylaxis should be advised that if they experience any vaginal bleeding or once labour begins they should not inject any further LMWH until reviewed by an obstetrician and an ongoing plan of care documented.

  • Breast-feeding is not contraindicated during post-natal thromboprophylaxis management with LMWH.

Dose of LMWH for Thromboprophylaxis

The LMWH preparation of choice in NHS GGC is enoxaparin. The appropriate dose is calculated from the woman’s most recent weight.

Woman’s most recent weight

Dose of enoxaparin

<50 kg

20 mg daily

50 – 90.9 kg

40 mg daily

91 – 130.9 kg

60 mg daily

131– 170 kg

80 mg daily

>170 kg

0.6 mg/kg/daily

Other LMWH preparations that may be considered (for example if a woman develops an allergic skin reaction to enoxaparin) include dalteparin and tinzaparin. The doses of these LMWHs are also calculated from the woman’s most recent weight.

Woman’s most recent weight

Dose of dalteparin

Dose of tinzaparin (75 units/kg/day

<50 kg

2500 units daily

3500 units daily

50 – 90.9 kg

5000 units daily

4500 units daily

91 – 130.9 kg

7500 units daily

7000 units daily

131– 170 kg

10 000 units daily

9000 units daily

>170 kg

75 units/kg/day

75 units/kg/day

COVID-19 Infection and VTE Prevention

Infection with SARS-CoV-2 may also be associated with an overall increased risk of maternal VTE. This risk is likely to be multifactorial, including a hypercoagulable state associated with the infection, the reduced mobility resulting from self-isolation at home or hospital admission, and other associated obstetric or maternal morbidities (Coronavirus (COVID-19) Infection in Pregnancy – information for healthcare professionals. Version 15. 2022). 

The principles of care include:

  • Women who are self-isolating at home should stay hydrated and mobile.
  • Women should have a VTE risk assessment performed during their pregnancy in line with RCOG Green-top Guideline No. 37a. Infection with SARS-CoV-2 should be considered a transient risk factor and trigger reassessment.
  • If healthcare professionals are concerned about the risk of VTE during a period of self- isolation, a clinical VTE risk assessment (in person or by virtual means) should be performed, and thromboprophylaxis considered and prescribed on an individual basis.
  • Local procedures should be followed to ensure women are supplied with low molecular weight heparin (LMWH), particularly where they cannot attend hospital during periods of self-isolation.
  • Thromboprophylaxis initiated for pregnant women who are self-isolating should be continued until they have recovered from the acute illness and are mobilising normally again.
  • All pregnant women admitted with confirmed or suspected COVID-19 should be offered prophylactic LMWH, unless birth is expected within 12 hours or there is significant risk of haemorrhage.
  • For women with severe complications of COVID-19, the appropriate drug and regimen of thromboprophylaxis should be discussed with a multidisciplinary team (MDT), including a senior obstetrician or clinician with expertise in managing VTE in pregnancy.
  • All pregnant women who have been hospitalised and have had confirmed COVID-19 should be offered thromboprophylaxis for 10 days following hospital discharge. A longer duration of thromboprophylaxis should be considered for women with persistent morbidity.

If women are admitted with confirmed or suspected COVID-19 within 6 weeks postpartum, they should be offered thromboprophylaxis for the duration of their admission and for at least 10 days after discharge. Consideration should be given to extending this until 6 weeks postpartum for women with significant ongoing morbidity. 

Thromboprophylaxis during labour and delivery, including the use of regional anaesthesia and analgesia

Thromboprophylaxis during labour and delivery

  • Women receiving prophylactic doses of LMWH during the antenatal period should be reviewed by a Senior Obstetrician before term (37+0 weeks) and a plan for labour/birth documented.
  • It is important to discuss the implications of treatment with LMWH for regional anaesthesia and analgesia with the women before labour or caesarean section – the obstetrician (and/or obstetric anaesthetist) should inform all women taking LMWH about regional anaesthesia and labour. All women should be given access to the patient information leaflet – ‘Information for pain relief during labour or delivery for pregnant patients on blood thinning medications’ (available on Staffnet and on BadgerNet).

Regional anaesthesia or analgesia 

  • This may be considered following discussion with a senior anaesthetist
  • An individual management plan should be documented in the patient’s notes

To minimise or avoid the risk of epidural haematoma

  • Regional techniques should not be used until at least 12 hours after the previous prophylactic dose of LMWH
  • When a woman presents while on a therapeutic regimen of LWMH regional techniques should not be employed for at least 24 hours after the last dose of LMWH.
  • LMWH should not be given for 4 hours after use of spinal anaesthesia or after the epidural catheter has been removed; the epidural catheter should not be removed within 12 hours of the most recent injection.

Postnatal Risk Assessment

To be completed for every woman by the Midwife/Doctor:

  • immediately following delivery prior to transfer to postnatal ward
  • on postnatal readmission

The Postnatal VTE Risk Assessment form should be completed on BadgerNet. The result of the VTE Risk Assessment should also be included in the Postnatal Management Plan section within BadgerNet.

Prescription, if required, should be completed in the Hospital Electronic Prescribing and Medicines Administration (HEPMA) prior to transfer to the ward.

Postnatal Management of Thromboprophylaxis

Early mobilisation and avoidance of dehydration is recommended for all postnatal women.

For women with a risk score of > 2 postnatally, it is recommended that thromboprophylaxis with LMWH is offered and administered for at least 10 days. LMWH dosage is graduated based on the woman’s most recent weight. 

For women considered to be at higher risk of postpartum VTE (for example women who required LMWH thromboprophylaxis antenatally), the recommended duration of thromboprophylaxis is 6 weeks. VTE risk assessment should be continued in the postnatal period and the decision to extend thromboprophylaxis beyond 10 days should be made by a senior clinician.

Postnatal – Self Administration of LMWH

Women who require LMWH injection on discharge from the ward setting should be encouraged and supported to self-administer in the community setting.

Women will be shown the correct method by the ward midwife and have the opportunity to self-administer under supervision and this should be documented in the patient’s electronic record. 

Use of Anti-Embolism Stockings (AES)

The evidence supporting the use of graduated elastic compression stockings is varied. Pregnant women considered to be at an increased risk of VTE and have a contraindication to LMWH, should be advised to wear AES when immobilised/hospitalised during the antenatal period (RCOG 2015, SIGN 2010).

Accurate fitting and careful instruction in the correct application of the hosiery is essential to avoid discomfort and assist rather than prevent venous return.

For women who are risk of VTE postnatally and have a contraindication to LMWH, AES should be considered. Compliance factors should be evaluated and the option of below the knee AES explored. 

APPENDIX 1 Thromboprophylaxis Risk Assessment and Management Quick Reference Guide

APPENDIX 2: VTE risk assessment– User guide 2022

Editorial Information

Last reviewed: 25/04/2023

Next review date: 30/04/2026

Author(s): Andrew Thomson, Catherine Bagot.

Version: 2

Approved By: Obstetrics Clinical Governance Group

Document Id: 580