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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

Mild Ventriculomegaly on Antenatal Ultrasound (916)

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

Fetal ventriculomegaly is a common finding on antenatal ultrasound and is defined as an atrial measurement of ≥ 10mm of the posterior horn of the lateral ventricle (1). It can be further subdivided into mild 10-12mm, moderate 13- 15mm and severe >15mm (2). It has a prevalence of approximately 1% (3). Ventriculomegaly has a range of causes; normal variation, aneuploidy, genetic syndromes, primary brain structural abnormalities, congenital infections, cerebrovascular accidents and intracranial haemorrhage. Prognosis and corresponding counselling of the parents is dependent on the cause of the ventriculomegaly, the antenatal progression and any co-existing abnormalities(4). It is therefore vitally important to look for  any underlying aetiologies and co-existing CNS and non-CNS abnormalities in order to present the parents with the most relevant and accurate information.

Diagnosis

Accurate measurement of the ventricles is important in both defining ventriculomegaly and also assessing progression. The fetal head should be scanned in the axial plane at the level of the frontal horns and the cavum septum pellucidum (CSP) (the same level at which a head circumference is taken), at an appropriate magnification that the head fills the screen. The callipers should be placed at the internal margins of the atrial walls at the level  of the parietal occipital groove and the glomus of the choroid plexus, perpendicular to the axis of the ventricle.

Although the distal ventricle is always easier to see than the proximal one because of reflection of the ultrasound beams from the fetal skull, both ventricles should be checked; ventriculomegaly is unilateral in 50-60% cases and bilateral in 40-50% (5).

Ultrasonography

Once ventriculomegaly has been diagnosed, there should be a detailed, sonographic evaluation of the neuroanatomy by a medical sonographer. Whether this is by transabdominal or transvaginal ultrasound will depend on the preference of the patient, the sonographer and the fetal position.

Other, non-CNS structures should also be carefully assessed including fetal biometry looking for evidence of growth restriction, the heart and any markers of intrauterine infection.

Testing for genetic disorders

Parents should be offered invasive, diagnostic testing and chromosomal microarray (CMA). 

Between 0-5% (2, 5) of fetuses with apparently isolated m i l d ventriculomegaly will have an underlying abnormal karyotype, most commonly Trisomy 21 and a further 10-15% will have abnormalities found on CMA.  

Testing for fetal infection

Congenital infections, most commonly cytomegalovirus (CMV), toxoplasmosis, parvovirus and Zika have been associated with mild ventriculomegaly in around 8% of cases (5). Parents should be offered tests for CMV, toxoplasmosis and parvo virus (regardless of history of known exposure or symptoms). Women with mild fetal ventriculomegaly who have been to a Zika area and not yet tested should be offered a test.

Fetal MRI

Fetal MRI (fMRI) can be a useful adjunct to ultrasound if the relevant radiological expertise and technology is available. The additional information will depend on the size of the ventricles as well as the quality of the original ultrasound and the level of expertise in the practitioner. The chance that fMRI will find important, clinically relevant additional brain abnormalities not picked up on ultrasound varies in the literature from 1-14% with the most recent studies putting the figure at 5-6% (5). The most common abnormality picked up on fMRI after being missed on ultrasound is agenesis of the corpus callosum.

Women wishing to have a fetal MRI, to look for additional brain abnormalities that may affect the prognosis, after appropriate counselling should be referred to fetal medicine department for review.

  • The fetal medicine department will arrange the MRI
  • Fetal medicine will review again after MRI to discuss results.
  • Thereafter the patient will go back to their own unit, unless otherwise indicated and delivery will be planned in their own unit.

Follow up antenatal ultrasound examinations

There are no data on optimal timings of follow up assessments once a diagnosis has been made. A suggested pragmatic approach would be 4-weekly assessments. Progression of ventriculomegaly is an important prognostic indicator; evidence suggests that 5% progress during pregnancy (5).

Delivery

The timing and mode of delivery should be planned as per normal obstetric indications. An alert should be placed on the electronic BadgerNet record to ensure that neonatologists are made aware of the antenatal diagnosis.

Cord bloods should be taken with parental consent for chromosomal analysis and congenital viral infections from those infants who didn’t have antenatal testing.

Postnatal follow up should be arranged by the neonatologists prior to discharge from hospital.

Prognosis

Most of the statistics quoted in the literature are based on whether the ventriculomegaly is apparently isolated or not; true isolation will only be able to be confirmed postnatally. Neurodevelopmental delay in case of isolated unilateral mild or moderate ventriculomegaly is thought to be 6% (5); in bilateral isolated ventriculomegaly this rises to 8-12% (7). This may not be dramatically higher than the background population risk. Long-term prognosis also depends on associated findings and the positive results of any investigations. 

Parents should be offered antenatal counselling by paediatricians to discuss prognosis and postnatal care in greater detail. A patient information leaflet from ISUOG and a link to further information is below.

Further information

Melchiorre, K & Bhide, Amarnath & Gika, Artemis & Pilu, G & Papageorghiou, A.T. (2009). Counseling in isolated mild ventriculomegaly. Ultrasound in Obstetrics & Gynecology

Patient Information:

ISUOG. Ventriculomegaly
"This leaflet is to help you understand what Ventriculomegaly is, what tests you need, and the implication of having been diagnosed with Ventriculomegaly for you, your baby and your family."

Editorial Information

Last reviewed: 01/04/2021

Next review date: 01/04/2024

Author(s): Rachel Bradnock.

Approved By: Obstetrics Clinical Governance Group

Document Id: 916

References
  1. International Society of Ultrasound in Obstetrics and Gynecology Education Committee. Sonographic examination of the fetal central nervous system: guidelines for performing the ‘basic examination’ and the ‘fetal neurosonogram’. Ultrasound Obstet Gynecol 2007; 29: 109 – 116.
  2. Society for Maternal-Fetal Medicine (SMFM): Fox NS et al. Mild Fetal Ventriculomegaly: diagnosis, evaluation and management. SMFM Consult Series 45 2018.
  3. Pilu G, Hobbins JC. Sonography of fetal cerebrospinal anomalies. Prenat Diagn 2002; 22: 321 – 330.
  4. Scala C, Familiari A, Pinas A, Papageorghiou T, Bhide A, Thilaganathan B, Khalil A. Perinatal and long-term outcomes in fetuses diagnosed with isolated unilateral ventriculomegaly: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2017; 49: 450–459
  5. Griffiths PD, Brackley K, Bradburn M, et al. Anatomical subgroup analysis of the MERIDIAN cohort: ventriculomegaly. Ultrasound Obstet Gynecol 2017;50:736-44.
  6. RCOG/RCM/PHE/HPS Clinical Guidelines. Zika Virus Infection and Pregnancy. Updated Feb 2019.
  7. Pagani G, Thilaganathan B, Prefumo F. Neurodevelopmental outcome in isolated mild fetal ventriculomegaly: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2014; 44: 254 – 260.