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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

Warning

Background

The following diagram gives an overview of the primary care pathway (through to the interface with secondary care) based on presentation at General Practice. 

National Headache Pathway Builder

Pathway Recommendations

Most patients presenting to health services with headaches have primary headache (up to 95% presenting to primary care and over 50% presenting to A&E). The most common primary headache is migraine, making up the majority of these patients. Most patients with migraine can be adequately managed in primary care. Some patients, particularly those with more frequent headache may need input from secondary care.

The following diagram lists the important red, amber and green flags:

RED FLAGS

Most patients do not have serious secondary headache. Red flags indicate the need for urgent
assessment to exclude a secondary cause. The most consistent indicators for serious secondary
causes for headache are:


1) Thunderclap (sudden onset) headache (consider SAH and its differential)
2) New focal neurological deficit on examination (e.g. hemiparesis)
3) Systemic features (considering GCA, infection such as meningitis or encephalitis, etc)
4) New progressive headache in a patient over 50 (most headaches presenting in patients
over 50 are benign, but there is an increased risk of secondary pathology with
increasing age)

Thunderclap headache is usually occipital or global. It is defined as a severe abrupt onset
headache, usually reaching its peak instantaneously, but headache can progress over up to 5
minutes. The main consideration is subarachnoid haemorrhage, but other causes include cervical
artery dissection, intracranial haemorrhage, posterior circulation stroke, cerebral venous sinus
thrombosis and spontaneous intracranial hypotension. Anyone presenting with a thunderclap
headache should have a same day referral (which may be through A&E), even in delayed
presentations.

A new focal neurological symptom (eg seizure) or sign (eg hemiparesis) in a patient with a new
progressive headache indicates the possibility of an intracranial pathology and this should prompt
an urgent referral for assessment and appropriate imaging. The referring clinical should decide
whether this merits attendance at A&E, a call to the appropriate specialist service or an urgent
referral. Specific syndromes that may indicate the possibility of a brain tumour are listed below, but
extra dural / sub dural haematomas, cerebral venous sinus thrombosis, viral encephalitis and
other intracranial pathology can present similarly.


Headache suggesting the possibility of a brain tumour
1) New headache plus sub-acute progressive focal neurology
2) New headache plus seizures
3) New headache with personality or cognitive change not suggestive of dementia, with no
psychiatric history and confirmed by witness

Fever, neck stiffness and rash should raise the consideration of infection such as meningitis and
constitutional symptoms and scalp tenderness should raise the consideration of Giant Cell Arteritis
(GCA).

Most headache in older patients will have a benign cause (mainly migraine), but the clinician
should have a lower threshold for considering a secondary cause in an older patient with a new
persisting or worsening headache. Anyone over 50 with a new headache should have a CRP +/-
plasma viscosity +/- ESR + FBC as per local protocol to consider GCA. Anyone where this is a
serious consideration should have an urgent referral and consideration of steroids as per local
protocol.

AMBER FLAGS 

Features that may indicate a secondary cause but may also be seen in primary headaches:
1) Changes in headache intensity with changes of posture (upright consider low pressure /
headache when lying flat consider high pressure)
2) Worsening/Triggering headache with Valsalva (e.g. coughing, straining)
3) Atypical aura (duration >1 hour or including motor weakness)
4) Progressive headache (worsening over weeks or longer)
5) Head trauma within the last month
6) Previous history of cancer or HIV
7) Re-attendance to A&E or GP surgery with progressively worsening headache severity or
frequency

Consider a secondary cause if any of these are present.

Orthostatic headache should have a consistent onset / worsening on assuming an upright posture
and offset / significant improvement on lying flat. This should be differentiated from headache
which improves on lying still, which is a feature of migraine. Early assessment and treatment of
Spontaneous Intracranial Hypotension (SIH) improves outcomes and patients with orthostatic
headache should be referred urgently. Further information is available in the consensus guidelines
on SIH.

 

Headache wakening the patient, headache present on wakening which then improves after
assuming an upright posture and Valsalva headache (headache triggered by coughing or other
Valsalva manoeuvres) raises the possibility of raised intracranial pressure. Headache present on
wakening which improves after assuming an upright posture may also be due to cervicogenic
headache and obstructive sleep apnoea or other causes of nocturnal hypoventilation. Migraine
starting in sleep is the commonest cause for wakening with a headache (especially if the
headache is intermittent). It is also important to consider Medication Overuse Headache as
“wearing off” of the overused medication during sleep can result in wakening with a headache
which then improves with taking the overused medication. These patients are likely to have
migraine.


Normal imaging does not exclude raised intracranial pressure and it is important to examine the
patient for papilloedema. An urgent optician assessment should be considered where the clinician
is not confident undertaking ophthalmoscopy. More detail on the assessment and management of
Intracranial Hypertension can be found on (insert link). Due to risk to vision, patients should be
referred same day as per local protocol, usually to ophthalmology in the first instance.


A history of cancer, immunosuppression (including HIV) and recent head trauma in a patient with
new progressive headache should raise the consideration of secondary brain tumour, infection or
intracranial haemorrhage. These patients usually have other features in addition to headache.

Features that do not help to differentiate primary from secondary headaches are:
1) Severity
2) Treatment response

GREEN FLAGS 

Features that are supportive of a diagnosis of primary headache:
1) Recurrent episodic headache, particularly with features of migraine
2) Long history of daily headache

If there are no concerning features then it is appropriate to manage these patients for migraine.

Other features that are pointers to migraine include a previous migraine history and a family
history of migraine.

Diagnosis of primary headache syndromes

Migraine is the commonest primary headache presenting to both primary and secondary care. It is however important to consider other primary headache disorders as per the following table. 

Headache feature  Migraine (with or without aura)  Cluster headache  Tension-type headache 
Frequency  Majority of patients presenting to both primary and secondary care (94% of people presenting in primary care with episodic headache will have migraine)  Rare - 1 in 1,000  Very common, but not  often seen in primary or secondary care as usually mild and self-managed 
Duration of headache 

4 – 72 hours in adults 

1 – 72 hours in young people 

15 minutes to 3 hours  30 minutes – continuous 
Pain location 

Unilateral or bilateral 

(head, face or neck) 

Unilateral (around the eye, above the eye and along the side of the head/face) 

Bilateral 

(head, face or neck) 

Pain quality 

Pulsating 

(throbbing or banging in young people) 

Variable (can be sharp, boring, burning, throbbing or tightening) 

Pressing/tightening 

(non-pulsating) 

Pain intensity  Moderate or severe  Severe or very severe  Mild or moderate 
Effect of activities 

Aggravated by, or causes avoidance of, routine activities of daily living 

(e.g. prefer to stay still or go to bed) 

Restlessness or agitation  Not aggravated by routine activities of daily living 
Other symptoms 
  • Photophobia (sensitivity to light) 
  • Phonophobia (sensitivity to sound) 
  • Nausea and/or vomiting 
  • Allodynia (sensitivity to touch) 
  • Cranial autonomic symptoms 
  • Aura (lasts 5 – 60 minutes) can include: 
  • Flickering lights, spots or lines and/or partial loss of vision 
  • Sensory symptoms such as numbness and/or pins and needles 
  • Speech disturbance 

Cranial autonomic symptoms on the same side as the headache: 

  • Red and/or watery eye 
  • Nasal congestion and/or runny nose 
  • Swollen eyelid 
  • Forehead and facial sweating 
  • Constricted pupil and/or drooping eyelid 

Patients with cluster can get migrainous symptoms and aura 

None 

Please note that this table may require scrolling to view all content.

Migraine is differentiated into episodic and chronic migraine 

Patients with episodic have migraine on 14 or less days per month (high frequency episodic migraine 10-14 days per month). 

Patients with chronic migraine have 15 or more days of headache per month 8 of which should meet criteria for migraine. Chronic migraine therefore usually presents with a mixture of milder background headache and migraine. 

Information to help with diagnosis of headache

  • Patients with migraines often underplay their symptoms 
  • Recurrent ‘sinus headache’ and/or dizziness is usually migraine 
  • In patients with chronic migraine, there is usually background headache with superimposed migraine days 
  • In patients taking acute treatment on >10 days/month, consider medication overuse headache 
  • Most patients waking with headache have migraine or medication overuse headache (withdrawal of overused analgesia overnight) 
  • Menstrual headache is almost always migraine and migraine usually improves in pregnancy 
  • Most patients with migraine are sensitive to head movement during a migraine so bending, coughing or sneezing during a migraine may make headache worse (motion sensitivity) 
  • Most patients with migraine don't have aura  
  • 40% of migraine is bilateral 

Referral to secondary care (migraine)

Migraine is the most likely diagnosis for a patient attending primary care with headache. Many of these patients will be successfully managed in primary care. If there is a clear diagnosis of migraine we recommend acute +/- preventative treatment (as detailed in the acute and preventative treatment sections).  

Where preventative treatment is not successful after a trial of three preventative medications at an adequate dose and for an adequate length of time, consider referral to relevant secondary care services as per local arrangements.

If there is diagnostic uncertainty or concern about a secondary cause, consider open access CT as an alternative to secondary care referral. 

Patient lifestyle advice for migraine

Patients should be directed to the resources available on NHS Inform to for lifestyle advice. Where consultation time allows the following key points should be made in relation to lifestyle. 

  1. Regular sleep pattern. 
  2. Regular eating pattern / don’t skip meals (more frequent small meals may help). 
  3. Regular fluid intake but limit alcohol, and limit caffeine from tea, coffee and some soft drinks. 
  4. Regular physical activity/exercise 
  5. Regular breaks from computers/phone screens  
  6. Relaxation activities such as mindfulness, yoga or meditation 

Manage potential triggers as needed; e.g. avoid perfumes, certain food triggers if applicable, bright, flashing or flickering lights (consider wearing sunglasses when outside or in bright, flashing or flickering light) 

Further advice is available from the Migraine Trust on 0808 802 0066 or https://migrainetrust.org/what-we-do/our-information-and-support-service/ 

References and further resources

SIGN 155 Clinician Guidance:  

SIGN 155 Pharmacological management of migraine 2023 update 

SIGN 155 patient guidance: 

SIGN Migraine patient booklet PAT155 (revised 2022) 

Heads up podcasts from the National Migraine Centre: 

Heads Up podcast - National Migraine Centre 

British Association for the Study of Headache - Headache management system 

Headache UK Optimal clinical pathway for adults with headache and facial pain. NNAG (National Neurosciences Advisory Group). 2023.

Optimal clinical pathway for adults with headache and facial pain — National Neurosciences Advisory Group (nnag.org.uk) 

Mollan S. et al. Evaluation and Management of adult idiopathic intracranial hypertension. Practical Neurology. 2018. Evaluation and management of adult idiopathic intracranial hypertension (bmj.com) 

Cheema S. et al. Multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension. JNNP. 2023. https://jnnp.bmj.com/content/early/2023/05/04/jnnp-2023-331166 

Editorial Information

Last reviewed: 11/10/2023

Next review date: 01/04/2025