National Institute for Health and Care Excellence

Noted (AI summary) NICE states they will not be creating guidance on ECG interpretation, suggesting other bodies are more appropriate. MFT describes updates to their electronic discharge summary template to include medication updates and concerns.

Noted (AI summary) NHS England expresses condolences and refers to NICE guidance on Apixaban. They highlight that the Regional Chief Pharmacist in the Midlands will review the report and consider learnings for ICBs. They note that the local trust is best placed to address concerns around communication and access to records and that their regional Midlands colleagues have made the ICB aware of the concerns. NICE will further consider the issues raised through their guideline surveillance process to see if an update to the guideline is required and will share the report with Agilio Software for their awareness. The Department acknowledges concerns about national guidance on DOACs and communication between medical staff. They note existing NICE guidance and resources from the British Society for Haematology. CQC will contact the Trust Chief Pharmacist to establish whether the pharmacy was informed and involved in the outcomes of the Trust investigation. The Trust revised its view on the likely cause of the stroke. Bespoke Immediate Life Support sessions have been run across the Cardiology unit, delivered by the Resus Team and Cardiology ACPs. Safety Practice Alerts will be issued reminding staff of clear documentation re stopping/re-starting of DOACs, to be reviewed daily, and the alerts will be incorporated into the Trust's updated Oral Anticoagulant Guideline. The trust will also improve handover processes and ensure the new Electronic Patient Record system highlights information around pausing medication. Audits will be performed in 2026.

Noted (AI summary) NICE acknowledges the concerns and explains its guideline on venous thromboembolism risk assessment, noting that it does not recommend a particular risk assessment tool and that clinicians should choose a tool that best fits the patient's clinical circumstances. The Department of Health and Social Care will work with NHS England to consider the VTE risk assessment tool, in light of the concerns raised.

Noted (AI summary) NHS England acknowledges the coroner's concerns, notes that the BSG is updating guidance, and states they will support the implementation of any changes; they have shared the report with relevant NHS Trusts and ICBs and are monitoring reports nationally. NICE acknowledges the coroner's concerns and notes that the relevant CKS is being updated by Agilio Software; NICE will consider the issues raised through its guideline surveillance process. The BSG plans to issue a statement to members and publish a journal letter regarding management of patients with coronary stents on anticoagulants needing endoscopy, recommending switching to aspirin or discussing with interventional cardiology.

Noted (AI summary) Greater Manchester Integrated Care has delivered training sessions on ARFID and made all Stockport pediatricians aware of the recent Royal College of Child Psychiatrists published guidance in relation to ARFID. Information/learning has been shared across NHS Greater Manchester ICB. NICE has concluded that it is not best placed to develop guidance on avoidant/restrictive food intake disorder, and in particular in medical emergencies in eating disorders. They will refer the report to their surveillance team for consideration when the eating disorders guideline is next reviewed.

Noted (AI summary) NICE clarifies that it has not published a guideline on managing chickenpox, but it does publish a Clinical Knowledge Summary (CKS) on its website. They have shared the report with Agilio Software, the external company who develop the CKS. The Royal College of Paediatrics and Child Health (RCPCH) will share information and suggestions for local improvement from the coroner's report with its members via its patient safety portal. They are engaging with NHS England and the Patient Safety Commissioner on implementing Martha's Rule nationally and support the recommendation for a universal varicella vaccination programme.

Noted (AI summary) The practice reviewed the call recording and held a training afternoon on telephone triage and call handling. They highlighted the process of flagging calls for concern and discussed presentations of pulmonary emboli, and intend to audit details recorded by reception staff. NICE acknowledges the concerns, explains the guideline development process for venous thromboembolism prophylaxis, and notes that guidelines are not mandatory and are reviewed periodically.

Noted (AI summary) NIVAS plans to publish guidelines in 2024 concerning the use of real time ultrasound guidance for central venous catheter insertion and the identification and management of inadvertent arterial puncture. They will also give the subject prominence at their annual conference in June 2024. The Association of Anaesthetists, Royal College of Anaesthetists, Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS) will ensure that updated "Safe Vascular Access" guidance has more explicit recommendations for checking CVC placement. The ICS is also developing a guideline for managing inadvertent arterial puncture during CVC insertion. NICE acknowledges the concerns but states that existing National safety standards for invasive procedures (NatSSIPs), ICS CVC Insertion Safety Checklist 2023, and AAGBI guidance already provide recommendations, and they do not consider that further NICE guidance would add to existing national recommendations. The Department of Health and Social Care acknowledges concerns about the absence of a national policy on CVC placement, but states that existing NICE guidance and national safety standards should inform local standards. They do not consider further action is needed at this time as the clinician departed from existing national recommendations, NICE guidelines and Trust policy.

Noted (AI summary) NICE has made recommendations on the use of antidepressants in their guidelines on the treatment of anxiety and published guidance on safe prescribing of antidepressants, but considers that the MHRA would be best placed to address concerns regarding monitoring requirements. MHRA reviewed available evidence from the fluoxetine Summary of Product Characteristics, data from the UK Yellow Card Scheme, literature and the advice of their Expert Advisory Group and determined that routine blood level monitoring of antidepressants for all patients on treatment is not advised, although may be helpful in certain circumstances.

Noted (AI summary) The MHRA acknowledged concerns about DVT risk guidance for young women on oral contraceptives and immobility after accidents, the MHRA will request the manufacturers of these products to update their SmPCs and PILs with the new information as expected following the VTE review.

Noted (AI summary) NHS England acknowledges the need for better guidance on managing oesophageal stenting and will work with AUGIS and NICE to develop national, evidence-based advice. The Greater Manchester Cancer Alliance will develop a clear pathway for the management of oesophageal stenting. NICE acknowledges the concerns about oesophageal strictures and limited guidance and will log the report and consider further the concerns regarding contraindications for stenting.

Noted (AI summary) NICE acknowledges the report but states that responsibility for the BNF content lies with BMJ Group and the Royal Pharmaceutical Society, so they cannot comment on the concerns raised. BNF Publications will use communications, including a newsletter and social media, to remind users how to find drug class information within content, including monographs and treatment summaries.

Noted (AI summary) NICE acknowledges the concerns but states that existing guidelines on fever, sepsis, and sore throat should be considered. They highlight that a specific guideline on Group A streptococcus has not been requested and that rapid tests were not recommended for routine adoption. MFT expresses concern for better clinician awareness of GAS and its management, and has liaised with relevant bodies to raise their concerns. They recommend the development of comprehensive, nationwide guidance for clinicians on GAS, similar to existing guidance for meningococcal disease. The Department of Health and Social Care highlights NHS England's interim clinical guidance on Group A Streptococcus and a public campaign to inform parents about symptoms. They also mention plans to implement Martha's Rule to allow rapid review of deteriorating patients. The RCPCH has shared information and suggestions for local improvement from the report with its paediatric members via its patient safety portal and will share the information for discussion with the RCPCH Clinical Quality in Practice group in October.

Noted (AI summary) The Trust provides a chronology of events regarding a prednisolone dosage reduction error and states that the treating and discharging physicians were aware of the dosage error and that it caused no harm to Mr. Roberts, therefore requiring no action by the GP. BNF Publications will add "diverticular disease (increased risk of diverticular perforation)" to the "Cautions" section of all corticosteroid monographs in the BNF, actioned for the August online monthly update.

Noted (AI summary) NICE acknowledges the concerns and notes that its new guideline on adrenal insufficiency covers identification, emergency management, and prevention of adrenal crisis during physiological stress, including trauma. The guideline committee includes paramedic co-optees and other relevant health professionals. NHS England reports that the JRCALC guidelines will be amended to improve understanding of administering steroids in cases of trauma, and that a Regulation 28 Working Group discusses all PFD reports to identify emerging trends. WMAS highlighted existing JRCALC guidance updates regarding steroid usage for adrenal crisis (2017, 2020, 2022), communication to staff via clinical times briefings, and the introduction of steroid emergency cards. WMAS also apologized for an administrative error that led to the lead investigator not receiving the inquest disclosure bundle and stated that the legal team aims to attend as many inquests as possible. Worcestershire Acute Hospitals NHS Trust has amended its guideline to include clear advice for all patients in the Emergency Department requiring admission, delivered teaching sessions to surgical trainees and T&O junior doctors, shared a lesson of the week, and made changes to ED admission documents to include prompts on time-critical medications. AACE is revising JRCALC guidance to emphasize steroid administration to patients suffering trauma or physiological stress, engaging with the Addison's Disease Self-Help Group and The Addison's Clinical Advisory Panel Chair. AACE is also aware of the development of an educational e-learning package for call handlers to improve understanding of Addison's disease and steroid-dependent patients, which will be trialled in Yorkshire and potentially rolled out to other ambulance services. The Society for Endocrinology highlights existing resources and the NICE guideline in development, commits to reviewing resources once NICE guidelines are written and ensuring pre-hospital care is covered more clearly, and is liaising with ambulance services to ensure triage information includes the need to send a category 2 ambulance.

Noted (AI summary) NHS England refers to NICE guidance and Clinical Knowledge Summaries for managing febrile seizures, and notes work underway to review training on child death review processes and support for families. They are also considering the Surrey Heartlands Integrated Care System’s Child Death Review and discussing reports to prevent future deaths. The Royal College of Emergency Medicine acknowledges the complex nature of managing febrile seizures and expresses willingness to collaborate with other organizations to develop further evidence-based guidance. The AACE has made medical directors and lead paramedics aware of the circumstances and asked them to review JRCALC guidance and local pathways. They also reminded ambulance trusts of the NASMeD guidance on conveying children by operational ambulance clinicians. NICE believes existing guidance (CG137, replaced by NG217) and Clinical Knowledge Summaries sufficiently cover assessment of febrile seizures. They are participating in system-level discussions with NHS England and the Royal College of Paediatrics and Child Health regarding SUDIC research and action.

Noted (AI summary) The Home Office, after consulting with the Department for Health and Social Care, believes that appropriate measures are already in place to reduce the risk of accidents involving liquid morphine and has no plans to introduce additional controls. NICE believes its existing guideline [NG46] on controlled drugs: safe use and management is sufficient, including recommendations for healthcare professionals to advise patients on safe storage and appropriate use. The MHRA will work with marketing authorisation holders to update product information for Oramorph, highlighting the need for secure storage and supervision after dilution.

Noted (AI summary) NICE has updated its guideline on head injury [CG176] but the guideline committee did not find convincing evidence that a history of coagulopathies should be an indication for a head CT in the absence of other signs and symptoms, with the exception of someone taking oral anticoagulants or antiplatelets, so have not added this to recommendation 1.4.12.