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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

Late booking in pregnancy: management of women who book after 22+0 weeks gestation (629)

Objectives

The aim of this guideline is to provide information on the management of women with an unknown estimated delivery date, or who book with maternity services after 22+0 weeks gestation.

This does not apply to women who attend NHS GG&C maternity services after 22+0 weeks who have received antenatal care elsewhere.

Audience

This guideline should be used by all Maternity staff working within NHS GG&C.

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

Accurate dating of pregnancy is crucial for determining gestational age. The British Medical Ultrasound Society (BMUS) guidelines state that the most accurate measurement for dating a pregnancy is a crown rump length, taken between 6 and 13+0 weeks gestation. After this the pregnancy should be dated by head circumference (HC) or femur length. Pregnancies without ultrasonic examination before 22+0 weeks should be considered sub-optimally dated.

Booking late is known to be associated with poorer obstetric and neonatal outcomes. These women often have complex social issues.

 

Roles & Responsibilities

It is the role and responsibility of all staff to ensure women who are booking late are offered the first available appointment and have a full history taken at booking, including exploration into the reason for booking late. Appropriate referrals should be made in a timely manner and obstetric review should be sought as required.

First Visit/Point of contact

NICE (2021) guidance recommends women are offered a first (booking) appointment with a Midwife by 10 weeks gestation.

  • Women booking at >22 weeks should receive obstetric led care with universal midwifery care. See Antenatal Pathways.
  • The reason for late booking should also be explored (Sussex Child Protection and Safeguarding Procedures, 2022). (Appendix 1).
  • If there are any concerns in regards to the woman’s mental health or any causes for concern for the welfare of the unborn baby then necessary referrals should be made (Appendix 2).
  • Booking bloods (Appendix 3) including for screening for blood born viruses (BBV’s) should be obtained urgently. This should be performed at first hospital contact which may be in Day Care/Maternity Assessment. This should not be deferred until the next antenatal clinic.
    *Note that the results of communicable diseases can affect the management of pregnancy and birth. See NHS GGC Virology Guidance.
  • Inform patient that an accurate EDD cannot be offered. Explain that they are too late to be offered screening for Down syndrome. First trimester screening period, for Downs, Edwards and Pataus syndrome, is when the crown rump length (CRL) is 45-84mm (approximately 11 to 14+1 weeks gestation). Second trimester screening period for Downs syndrome only is 14+2 to 20 weeks gestation.
  • Perform USS for fetal anomaly and fetal growth.
  • A clinical estimate of gestational age will be provided by the consultant obstetrician following the first scan and this will be used to guide management.

 

Subsequent Visits

  • Women should have serial growth scans every 4 weeks, followed by medical review, within the ANC.
  • Suspected fetal growth restriction, oligohydramnios or abnormal end diastolic flow on umbilical artery Doppler should be managed in keeping with local policy.
  • When Estimated Fetal Weight (EFW) reaches 10th centile for 37 weeks gestation (>2321g), USS for assessment of growth, LV and Doppler should be offered every 2 weeks.

Offer induction of labour for usual obstetric reasons or if the pregnancy has reached 41 weeks by the best clinical estimate. See Induction of labour.

 

Previous Caesarean Birth

  • If patient is suitable and wishes VBAC – manage as per VBAC guideline.
  • If birth by caesarean is required birth at best estimate of 39-40 weeks gestation

Appendix 1: Reasons for late booking

Reasons for late booking could include but are not limited to (Sussex Child Protection & Safeguarding Procedures, 2022):

  • Mental illness
  • Domestic/sexual abuse
  • Exploitation
  • Substance misuse
  • Learning disabilities
  • Fear of social work involvement
  • Desire to minimise or avoid medicalisation of pregnancy and childbirth
  • Incestuous or unknown paternity
  • Where paternity is a result of rape or infidelity
  • Consideration must also be given of women presenting for a termination of pregnancy (TOP) but being unable to have a TOP due to advanced gestation of pregnancy
  • Fear of negative and/or unsupportive reactions from others eg young people
  • Refugees/Asylum Seekers/Undocumented individuals

Appendix 2: Referrals

Referrals should be considered, but not limited to:

  • Special Needs in Pregnancy Services (SNIPS) – via Badger
  • Social Work – via TRAK
  • Maternal and Neonatal Psychology Interventions (MNPI) –via Badger
  • Health Visitor (HV) – via Badger (GP can also provide contact details)
  • Perinatal Mental Health Service – via referral form
  • Family Nurse Partnership (FNP) – via Badger

Appendix 3: Booking bloods

Booking bloods should include:

  • Full blood count (FBC)
  • Ferritin
  • Group and Save (G&S)
  • HIV/Syphilis/Hepatitis B
  • Haemoglobinopathy Screen

Search in ‘item’ box – “Glasgow Antenatal booking set”.
Add on ferritin.

Editorial Information

Last reviewed: 26/02/2024

Next review date: 08/02/2029

Author(s): Rachel Bradnock, Heather Richardson, Emma Ritchie.

Version: 3

Approved By: Maternity Clinical Governance Group

Document Id: 629

References

  1. NICE guideline NG201: Antenatal care 2021

  2. Sussex child protection: Concealed pregnancy 2022

  3. Loughna P, Chitty L, Evans T, Chudleigh T. Fetal size and dating: charts recommended for clinical obstetric practice. Ultrasound 2009; 17(3): 161-167

  4. The American College of Obstetricans and Gynaecologists. Committee Opinion Number 688 – Management of suboptimally dated pregnancies. Vol. 129, No. 3, March 2017