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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

Urticaria

Urticaria: A heterogeneous group of disorders characterized by dermal and/or subcutaneous and submucosal oedema. The most common underlying mechanism is release of histamine from mast cells with consequent capillary dilatation and tissue oedema. This is responsible for the weals of spontaneous and most inducible urticarias. A variety of other mechanisms are involved in other urticarial disorders. In the UK, approximately 15% of people experience urticaria at some time in their lives and the lifetime prevalence of chronic urticaria is 0.5–1%. For around 40–50% of people with urticaria, the cause of their condition is unknown. Symptoms of duration of less than 6 weeks are considered acute, and beyond this are chronic urticaria. 

Treatment/therapy

Mild: does not impact significantly on activities of daily living 

  • For people with urticaria with an identifiable and avoidable cause/trigger give advice regarding avoidance of triggers 
  • Stop any histamine-releasing drugs if able, e.g. aspirin, codeine, ACE inhibitors, non-steroidal anti-inflammatory drugs; if possible, treat potential sources of infection; avoid triggers for inducible urticarias (such as heat, cold, etc). 
  • Offer a low-sedating antihistamine at standard licenced dose (for example cetirizine, loratadine or fexofenadine) for up to 3 months.

Moderate: symptomatic but does not impact on sleep/normal activities of daily living 

  • For people with urticaria with an identifiable and avoidable cause/trigger give advice regarding avoidance of triggers 
  • Stop any histamine-releasing drugs if able, e.g. aspirin, codeine, ACE inhibitors, non-steroidal anti-inflammatory drugs; if possible, treat potential sources of infection; avoid triggers for inducible urticarias (such as heat, cold, etc). 
  • Offer a low-sedating antihistamine at standard licenced dose (for example cetirizine, loratadine or fexofenadine) for 3-6 months. If not controlled on once daily, consider double dose or increasing up to quadruple dose, reducing to lower doses when symptoms controlled. 
  • Suggest a FBC differential, ESR/CRP and TSH/TFT for patients where symptoms persist. 

Severe: frequent or significant lesions. Impacts on sleep or daily activities 

  • For people with urticaria with an identifiable and avoidable cause/trigger give advice regarding avoidance of triggers (stop histamine-releasing drugs and avoid triggers for inducible urticarias, as for mild/moderate urticaria) 
  • Offer a low-sedating antihistamine at standard licenced dose (for example cetirizine, fexofenadine, or loratadine) for 3-6 months. If not controlled on once daily, consider double dose or increasing to quadruple dose, reducing to lower doses when symptoms controlled 
  • Give a short course of an oral corticosteroid (for example prednisolone 40 mg daily for 4-5 days) in addition to the low-sedating oral antihistamine if not controlled. Longer term steroids are not advised for chronic urticaria management in primary care. 
  • Referral if an oral corticosteroid is indicated in a child younger than 16 years of age.   
  • If rebound symptoms occur, seek specialist advice. Do not repeat the course of oral corticosteroid. 
  • Suggest a FBC differential, ESR/CRP and TSH/TFT. 
  • NICE guidance recommends montelukast as a second-line agent (unlicenced indication)

Referral management

Mild: does not impact significantly on activities of daily living 

Manage in primary care, seek advice and guidance if there is diagnostic uncertainty. 

 

Moderate: symptomatic but does not impact on sleep/normal activities of daily living 

Manage in primary care, seek advice and guidance if there is diagnostic uncertainty, particularly where individual lesions last more than 24 hours and/or fade with bruises (not bruising due to scratching) and/or are painful, or if there are systemic symptoms such as arthralgia or fever, or if there are persistently high inflammatory markers. This may suggest urticarial vasculitis, or diseases with urticaria-like rashes. 

Consider referral when symptoms are not well controlled on antihistamine treatment, or when disease is having a significant effect on quality of life.  

 

Severe: frequent or significant lesions. Impacts on sleep or daily activities 

Seek advice and guidance if there is diagnostic uncertainty, particularly where individual lesions last more than 24 hours and/or fade with bruises (not bruising due to scratching) and/or are painful, or if there are systemic symptoms such as arthralgia or fever, or if there are persistently high inflammatory markers. This may suggest urticarial vasculitis, or diseases with urticaria-like rashes. 

Consider referral when symptoms are not well controlled on antihistamines or other treatments listed above, or when disease is having a significant effect on quality of life. Refer people with forms of chronic inducible urticaria that may be difficult to manage in primary care, for example, solar or cold urticaria. 

Refer people with acute severe urticaria which is thought to be due to a food or latex allergy – check locally whether referral to specialist immunology services more appropriate. 

  • There are other treatment options in secondary care, including omalizumab and ciclosporin. 

Clinical resources

DLQI clinical tool: https://www.cardiff.ac.uk/medicine/resources/quality-of-life-questionnaires/dermatology-life-quality-index  

UAS7 clinical tool:  

NICE CKS – Urticaria: 

NICE scenarios – Managing urticaria:  

BAD Urticaria guidelines (2007):  

PCDS guidance – Chronic spontaneous urticaria  

BSACI- Urticaria:  The EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis and management of urticaria - Zuberbier - 2021 – Allergy 

DermnetNZ – Urticaria   

Clinical Tips

  • Patients with urticaria have a higher incidence of thyroid receptor antibodies than the general population. 
  • Check C4 levels (complement) in patients with angioedema without urticaria. 
  • UAS7 can be a useful tool in estimating severity and response to treatment. 
  • Chronic spontaneous urticaria is rarely associated with food allergy, and patch testing is unhelpful and not recommended. 

Patient information resources

  1. BAD leaflet – Urticaria and angioedema
  2. Patient.info leaflet – Urticaria
  3. NHS Conditions- Hives
  4. Angioedema
  5. NHS Inform Scotland- Urticaria (Hives) 

ICD search category(s)

Inflammatory 

ICD11 code - EB00 

Editorial Information

Last reviewed: 11/04/2023

Next review date: 11/04/2025

Author(s): Adapted from the BAD Referral Guidelines.

Version: BAD 1

Co-Author(s): Publisher: Centre for Sustainable Delivery, Scottish Dermatological Society.

Approved By: Scottish Dermatological Society