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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

Early Pregnancy Assessment Service Ultrasound Protocol (502)

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

Applicable Unit Policy Documents 

  • EPAS Ultrasound Management Plan
  • EPAS Ultrasound Report on Badger net

Patient privacy and dignity must be maintained at all times. 

On arrival in the department, the patient should be scanned trans-abdominally in the first instance, to exclude major pelvic pathology, or advanced pregnancy. 

A full bladder is essential. 

If more information is required then the patient should be prepared for a trans-vaginal scan. 

An explanation should be given and latex allergy excluded (all departments should be using latex free gloves and probe covers).

Should a TV scan be declined, this must be documented on the ultrasound report on Badger net.

Measurements should be taken of the CRL if there is a fetal pole, or measurements of the mean sac diameter of the gestation sac +/- yolk sac if no fetus is found. 

The pouch of Douglas and adnexal regions must be examined. 

Any tenderness should be recorded. 

The recommendations of the Royal College of Obstetricians and Gynaecologists/ Royal College of Radiologists (RCOG/RCR) as detailed in the GGC protocol for diagnosis of non-continuing pregnancy must be adhered to, with follow up appointment arranged if indicated. (Attached as Appendix I and II)

If any doubt exists then a medical opinion must be sought. 

If an ectopic pregnancy is suspected, a medical opinion must be sought immediately and the patient told to await review. 

On completion of the scan, the findings should be communicated to the patient in a compassionate manner and she should be referred to the midwifery staff for continuity of care. 

All reports must be recorded on Badger net with the authorisation box completed as your electronic signature.

Appendix I: The Management of Early Pregnancy Loss

Addendum to GTG No 25 (Oct 2006): The Management of Early Pregnancy Loss

Recent research suggests that given inter-observer variability in ultrasound measurements and the greater variation in early embryonic growth than has hitherto been assumed, a more conservative approach to the diagnosis of early pregnancy loss is warranted. 

The studies from Imperial College London, Queen Mary, University of London and the Katholieke Universiteit Leuven, Belgium published in the November 2011 issue of Ultrasound in Obstetrics and Gynaecology concluded that current definitions used to diagnose miscarriage could lead to an incorrect diagnosis and they call for clearer evidence-based guidance on detecting miscarriage through ultrasound scans. 

Having carefully considered these papers, we recommend adoption of the following interim guidance with immediate effect:

  1. Ultrasound diagnosis of miscarriage should only be considered with a mean gestation sac diameter >/= 25mm (with no obvious yolk sac), or with a fetal pole with crown rump length >/=7mm (the latter without evidence of fetal heart activity)
  2. Transvaginal ultrasound scan should be performed in all cases where there is uncertainty.
  3. Where there is any doubt about the diagnosis and/or a woman requests a repeat scan, this should be performed at an interval of at least one week from the initial scan before medical or surgical measures are undertaken for uterine evacuation. No growth in gestation sac size or CRL is strongly suggestive of a non-viable pregnancy in the absence of embryonic structures.

These revised values for 'mean gestation sac diameter' and 'crown rump length' do not imply that previously used values were wrong, nor that diagnosis of miscarriage in the past has been unsafe, This interim guidance suggests a more cautious approach is warranted, pending more definitive data becoming available. It extends the criteria included in the RCOG Green Top Guideline No 25, which recommended a conservative approach with mean gestation sac diameter <20mm or fetal CRL <6mm. 

Authors:

  • Christoph Lees MRCOG on behalf of the RCOG Ultrasound Advisory Group
  • Kim Hinshaw FRCOG Lead author, Green Top Guideline No. 25  Philip Owen FRCOG Chair, RCOG Guidelines Committee
  • David Richmond FRCOG RCOG Vice President (Standards)

19th October 2011

RCOG clinical guideline The Management of Early Pregnancy Loss

Appendix II: GGC Diagnosis of Non- Continuing Pregnancy

Ultrasound diagnosis of miscarriage should only be considered when:

  • Mean Gestation Sac Diameter >/= 25mm (with no obvious yolk sac) on Transvaginal scan
  • A fetal pole with Crown Rump Length (CRL) >/= 7mm on Transvaginal scan (without evidence of fetal heart activity)
  • A fetal pole with Crown Rump Length (CRL) >/= 32mm on Transabdominal scan (without evidence of fetal heart activity)

A second Sonographer (with at least one years post competency experience) MUST physically rescan the woman to confirm the diagnosis. If this is not possible the same day then another scan should be performed by a DIFFERENT Sonographer at a time that suits patient/department or at an interval of at least one week from the initial scan if the scan is performed by the SAME Sonographer.

Sonographers MUST ensure the name and authorisation boxes are completed on Badger net.

In all cases, where there is any doubt about the diagnosis and/or a woman requests a repeat scan, this should be performed at an interval of at least one week from the initial scan before medical or surgical measures are undertaken for uterine evacuation.

Editorial Information

Last reviewed: 03/05/2024

Next review date: 16/11/2028

Author(s): Donna Bean.

Version: 2

Approved By: Maternity Governance Group

Document Id: 502