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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

Lower Uterine Caesarean Section (LUCS), Breech Delivery (342)

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

Applicable unit policies:

Breech presentation is a common indication for Caesarean.

The mother has consented on the basis that this is a less traumatic method of delivery for the baby.

It is sometimes difficult to deliver the after-coming head (ACH) at caesarean section and to explain why this was the case to the parents. This is more common with patients with oligohydramnios.

The following minimise the risk and/ or manages the problem.

  1. Read the notes and gain maximum information about type of Breech (i.e. extended, flexed), placenta site, etc.
  2. Remember that the baby may be big as well as breech!
  3. Make an appropriate skin incision: err on a larger incision than you might make for a Cephalic presentation. The shape of the Head may be unusual (doliocephalic, brachycephalic)
  4. Remember that there is no point in making a large skin incision and then a narrower sheath incision! Make as much room as you can. Lateral incision of the peritoneum may help.
  5. Establish where the fetal back lies.
  6. Once the uterotomy is made, as the baby is being drawn down, get your assistant to follow the head with their hand: this encourages neck flexion and reduces chance of head extension.
  7. Once the body is delivered deliver the ACH in the manner described for vaginal delivery.
  8. If there is entrapment DO NOT PANIC. You are still in the optimal environment.
  9. Do NOT simply pull harder!!!
  10. Consider Wrigley’s Forceps to ACH if there is enough room and deliver as per vaginal breech instructions.
  11. Identify where the entrapment is:
    • Skin: enlarge incision with care: a scalpel is best, pointing sharp edge away from baby.
    • Sheath: digital extension if possible, Scissors before scalpel.
    • Uterotomy: try digital extension. If not use scissors with aim to create a “J” to avoid damage to broad ligament vessels.
    • Remember Forceps to ACH may now work.
    • Consider GTN (see GTN link at top of guidelines)
    • If all else fails, a vertical uterotomy (inverted T) may be necessary: beware the anterior placenta!
  12. Paired cord pH samples
  13. Document carefully.
  14. Explain to couple what happened. This is of particular importance if a uterotomy is extended and VBAC no longer a future option.

Unusual manoeuvres.

Internal podalic version (IPV) This may be necessary to deliver:

  • a second twin at CS or at a vaginal birth
  • if there is an immediate need to deliver baby.
  • Tranverse lie caesarean section.

Documentation will inevitably be retrospective and must be clear.

Method of IPV

A fetal foot is identified by recognizing a heel through intact membranes. The foot is grasped and pulled gently and continuously lower into the birth canal (or through uterotomy at CS). The membranes are ruptured as late as possible. The baby is then delivered as an assisted breech or breech extraction with pelvi-femoral traction, Lovset’s manoeuvre to the shoulders if required and a controlled delivery of the head. This procedure is easiest when the transverse lie is with the back superior or posterior. If the back is inferior or if the limbs are not immediately palpable, do not panic, follow the curve of the back and down and round to find the leg. Confirm you have a foot before applying traction. This will minimise the risk of the unwelcome experience of bringing down a fetal hand and arm in the mistaken belief that it is a foot.

If ultrasound is immediately available to an experienced sonographer this may help identify where the limbs are.

A few seconds of calm consideration and accurate assessment will almost certainly result in an effective delivery manoeuvre.

Editorial Information

Last reviewed: 31/08/2018

Next review date: 31/12/2022

Author(s): Julie Murphy.

Version: 3

Approved By: Obstetrics Clinical Governance Group

Document Id: 342