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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

Intrauterine Fetal Death (IUFD) and Anaesthesia (618)

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

Background

Intrauterine fetal death (IUFD) refers to babies with no signs of life in utero1. Late IUFD (>24 weeks gestation) is relatively common with the stillbirth rate in Scotland being approximately 5 in 1000 total births. Most women will be suitable for vaginal delivery and many will have been induced. The main complications relate to coagulopathy and sepsis. Prolonged expectant management carries higher risks. In addition to being a distressing time for the woman and her family, stillbirth is rated more painful than live birth and more analgesia may be utilised.

General measures

  • Women should be offered the opportunity to discuss options for analgesia with the duty anaesthetist
  • All analgesia modalities should be available – including regional analgesia (if no contraindications)
  • Blood should be sent for full blood count, coagulation screen (including Fibrinogen), urea and electrolytes and CRP

Analgesia Options

  • Equanox (Entonox)
  • IM Opioids – Administered in line with midwifery guidelines
  • IV Opioids – Either Morphine or Remifentanil PCA can be considered and delivered in accordance with local guidelines (table gives the advantages and disadvantages of each)
  • Epidural – If bloods satisfactory and no suggestion of coagulopathy or sepsis then epidural analgesia can be administered in accordance with local protocols

Regional Analgesia

Up-to-Date blood results for full blood count, urea and electrolytes, coagulation Screen (including fibrinogen) and CRP should be reviewed prior to epidural. Any abnormalities should be discussed with a consultant anaesthetist. It should always be considered that the complications of epidural abscess or vertebral canal haematoma could be catastrophic. A conservative approach is advised.

Incidence of Coagulopathy and Sepsis

There is a widely quoted figure of a 3.1% incidence of signs of sepsis during induction of labour for IUFD2. However, this is a small series of 96 patients and there are no details on the definition of the episode. All labours will have a baseline incidence of sepsis.

In the same series of 96 patients there were no incidences of coagulopathy or haemorrhage. In a retrospective cohort study of coagulopathy 12 of 104 (11%) of patients presenting with IUFD after 24 weeks had a complication of coagulopathy3. However, this appears to have been defined on the need for blood transfusion. In addition, in the majority of cases this was associated with a clinical syndrome (preeclampsia, HELLP, uterine rupture). In the other cases there were statistically significant abnormalities in platelet count, PT, APTT and Fibrinogen at presentation. 

Caesarean Section

Caesarean Section will occasionally be indicated. General Anaesthesia is usually most appropriate in this context, however circumstances may necessitate an alternative approach (eg morbid obesity). Patients should be recovered in accordance with Association of Anaesthetists of Great Britain and Ireland Safety Guideline on Immediate Post-anaesthesia Recovery. Management of the patient in a single room must not compromise post-anaesthesia monitoring.

Table of Remifentanil vs Morphine PCA for IUFD

Advantages 

Disadvantages

Morphine PCA

Pain relief/sedation will persist between contractions which may be advantageous in the distressed patient 

Pain relief may be inadequate for peak contractions

Analgesia will continue and cover for post-delivery pain relief

Morphine side effects may occur including; nausea, constipation, itch. 

In majority of cases the patient can be left for brief periods by the midwifery team 

Remifentanil PCA

Provides superior analgesia during peak of contractions

Requires constant monitoring by the midwifery team

Any Side effects are quickly eliminated  

Requires more active participation by the mother with less opportunity to sleep/rest between contractions 

Offers no post delivery analgesia. 

Editorial Information

Last reviewed: 17/01/2022

Next review date: 17/01/2025

Author(s): Tom Pettigrew.

Version: 2

Approved By: Obstetric Clinical Governance Group

Document Id: 618

References
  1. Royal College of Obstetricians and Gynaecologists Green-top guideline 55. Late intrauterine death and stillbirth. October 2010 https://www.rcog.org.uk/globalassets/documents/guidelines/gtg55.pdf  
  2. Medical management of late intrauterine death using a combination of mifepristone and misoprostol. - Wagaarachchi PT, Ashok PW, Narvekar NN, Smith NC, Templeton A. 2002 Apr;109(4):443-7.
  3. intrauterine foetal death and delivery complications associated with coagulopathy: a retrospective analysis of 104 cases. -Tempfer, Brunner, Bentz, Langer, Reinthaller, Hefler in J Womens’ Health (Larchmt), 2009 April; 18(4): 469-74.