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					                                                                       SHEFFIELD PCT
                                                                  Framework of NICE Guidance
                                                                                                                                                                April 2009

Guideline   Title                      Summary                                                                              Implications              Review       Local
No                                                                                                                                                     Date        Action
TA170       Rivaroxaban for the        Rivaroxaban, within its marketing authorisation, is recommended as an option for     NICE state that this      None
            prevention of venous       the prevention of venous thromboembolism in adults having elective total hip         guidance is for primary   stated
            thromboembolism            replacement surgery or elective total knee replacement surgery.                      and acute care.
            after total hip or total
            knee replacement in                                                                                             NICE state that this
            adults                                                                                                          will impact on PBR.

                                                                                                                            NICE state that this
                                                                                                                            guidance is unlikely to
                                                                                                                            result in a significant
                                                                                                                            change in NHS
                                                                                                                            resource above levels
                                                                                                                            already identified in
                                                                                                                            previous NICE costing
                                                                                                                            work. It may though
                                                                                                                            have the potential to
                                                                                                                            produce savings.
CG84        Diarrhoea and              N.B. The quick reference guide can be found at:                                      NICE state that this       t.b.c.
            vomiting in children       http://www.nice.org.uk/Guidance/CG84/QuickRefGuide/pdf/English                       guidance is for primary
                                                                                                                            and acute care.
                                       Diagnosis
                                        Perform stool microbiological investigations if:                                   NICE state that
                                           – you suspect septicaemia or                                                     diagnosis, treatment
                                           – there is blood and/or mucus in the stool or                                    and management of
                                           – the child is immunocompromised.                                                diarrhoea and vomiting
                                       Assessing dehydration and shock                                                      due to gastroenteritis
                                        Use table 1 (see page 8 of QRG) to detect clinical dehydration and shock.          can be in primary care
                                       Fluid management                                                                     or secondary care.
                                        In children with gastroenteritis but without clinical dehydration:                 Where it is in
                                           – continue breastfeeding and other milk feeds                                    secondary care it will
                                           – encourage fluid intake                                                         affect activity levels
                                           – discourage the drinking of fruit juices and carbonated drinks, especially in   commissioned under
                                             those at increased risk of dehydration (see box 2, page 7 of QRG)              PBR.
                                           – offer oral rehydration salt (ORS) solution as supplemental fluid to those at
                                             increased risk of dehydration (see box 2, page 7 of QRG).                      NICE state that this




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                                                                   SHEFFIELD PCT
                                                              Framework of NICE Guidance
                                                                                                                                                           April 2009

Guideline   Title                  Summary                                                                                  Implications              Review   Local
No                                                                                                                                                     Date    Action
                                      In children with clinical dehydration, including hypernatraemic dehydration:         guidance is unlikely to
                                       – use low-osmolarity ORS solution (240–250 mOsm/l)1 for oral rehydration             result in a significant
                                         therapy                                                                            change in resource
                                       – give 50 ml/kg for fluid deficit replacement over 4 hours as well as                use in the NHS.
                                         maintenance fluid
                                       – give the ORS solution frequently and in small amounts
                                       – consider supplementation with their usual fluids (including milk feeds or water,
                                         but not fruit juices or carbonated drinks) if they refuse to take sufficient
                                         quantities of ORS solution and do not have red flag symptoms or signs (see
                                         table 1, page 8 of QRG)
                                       – consider giving the ORS solution via a nasogastric tube if they are unable to
                                         drink it or if they vomit persistently
                                       – monitor the response to oral rehydration therapy by regular clinical
                                         assessment.
                                      Use intravenous fluid therapy for clinical dehydration if:
                                       – shock is suspected or confirmed
                                       – a child with red flag symptoms or signs (see table 1, page 8) shows clinical
                                         evidence of deterioration despite oral rehydration therapy
                                       – a child persistently vomits the ORS solution, given orally or via a nasogastric
                                         tube.
                                      If intravenous fluid therapy is required for rehydration (and the child is not
                                       hypernatraemic at presentation):
                                       – use an isotonic solution, such as 0.9% sodium chloride, or 0.9% sodium
                                         chloride with 5% glucose, for both fluid deficit replacement and maintenance
                                       – for those who required initial rapid intravenous fluid boluses for suspected or
                                         confirmed shock, add 100 ml/kg for fluid deficit replacement to maintenance
                                         fluid requirements, and monitor the clinical response
                                       – for those who were not shocked at presentation, add 50 ml/kg for fluid deficit
                                         replacement to maintenance fluid requirements, and monitor the clinical
                                         response
                                       – measure plasma sodium, potassium, urea, creatinine and glucose at the
                                         outset, monitor regularly, and alter the fluid composition or rate of
                                         administration if necessary
                                       – consider providing intravenous potassium supplementation once the plasma
                                         potassium level is known.




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                                                                   SHEFFIELD PCT
                                                              Framework of NICE Guidance
                                                                                                                                                             April 2009

Guideline   Title                  Summary                                                                                  Implications               Review    Local
No                                                                                                                                                      Date     Action
                                   Nutritional management
                                    After rehydration:
                                       – give full-strength milk straight away
                                       – reintroduce the child‟s usual solid food
                                       – avoid giving fruit juices and carbonated drinks until the diarrhoea has stopped.
                                   Information and advice for parents and carers
                                    Advise parents, carers and children that:
                                       – washing hands with soap (liquid if possible) in warm running water and careful
                                         drying are the most important factors in preventing the spread of
                                         gastroenteritis
                                       – hands should be washed after going to the toilet (children) or changing
                                         nappies (parents/carers) and before preparing, serving or eating food
                                       – towels used by infected children should not be shared
                                       – children should not attend any school or other childcare facility while they
                                         have diarrhoea or vomiting caused by gastroenteritis
                                       – children should not go back to their school or other childcare facility until at
                                         least 48 hours after the last episode of diarrhoea or vomiting
                                       – children should not swim in swimming pools for 2 weeks after the last episode
                                         of diarrhoea.
CG85        Glaucoma                N.B. Within the quick reference guide, the text (below) is interspersed with a          NICE state that this       January
                                    number of algorithms and flowcharts. Where reference is made to a page,                 guidance is for primary     2100
                                    please refer to: www.nice.org.uk/nicemedia/pdf/CG85QuickRefGuide.pdf                    and acute care.              (sic)

                                   Providing information                                                                    NICE state that “Cost
                                   Offer people the opportunity to discuss their diagnosis, prognosis and treatment,        implications likely as a
                                   and provide them with relevant information in an accessible format at initial and        result of additional
                                   subsequent visits. This may include information on the following:                        monitoring activity for
                                    their specific condition, its life-long implications and prognosis for keeping their   people with ocular
                                       sight                                                                                hypertension and
                                    that COAG in the early stages and OHT and suspected COAG are                           suspected glaucoma.
                                       symptomless                                                                          Implications for both
                                    that once lost, sight cannot be recovered, although most people treated for            primary and secondary
                                       COAG will not go blind                                                               care.”
                                    that glaucoma can run in families and that family members may wish to be




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                                                                      SHEFFIELD PCT
                                                                 Framework of NICE Guidance
                                                                                                                                              April 2009

Guideline   Title                  Summary                                                                                Implications   Review   Local
No                                                                                                                                        Date    Action
                                           tested for the disease
                                          the importance of the person‟s role in their own treatment, how to apply eye
                                           drops, and the use of compliance aids
                                          the different types of treatment options and the need for regular monitoring
                                          methods of investigation during assessment
                                          how long each appointment is likely to take and whether the person will need
                                           any help to attend support groups
                                          Letter of Vision Impairment (LVI), Referral of Vision Impairment (RVI) and
                                           Certificate of Vision Impairment (CVI) registration
                                          Driver and Vehicle Licensing Agency (DVLA) regulations. KPI

                                   Diagnosis for people with OHT, suspected COAG or COAG
                                   See the diagnosis flowchart on page 6.
                                    At diagnosis offer:
                                       – IOP measurement using Goldmann applanation tonometry
                                       – CCT measurement
                                       – peripheral anterior chamber configuration and depth assessments using
                                          gonioscopy
                                       – visual field measurement using standard automated perimetry
                                       – optic nerve assessment, with dilatation, using stereoscopic slit lamp
                                          biomicroscopy with fundus examination. KPI
                                    If clinical circumstances rule out standard methods of assessment, use
                                       alternatives.
                                    Obtain an optic nerve head image.
                                    Ensure the following are available at each clinical episode:
                                       – records of all relevant previous tests and images
                                       – records of past medical history which could affect drug choice
                                       – current systemic and topical medication
                                       – glaucoma medication record
                                       – drug allergies and intolerances. KPI

                                   Tests offered at monitoring to people with OHT, suspected COAG or COAG
                                   For recommended monitoring intervals see the flowcharts on pages 8–10 for
                                   people with OHT or suspected COAG, and on pages 12–13 for people with COAG.




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                                                                      SHEFFIELD PCT
                                                                 Framework of NICE Guidance
                                                                                                                                                 April 2009

Guideline   Title                  Summary                                                                                   Implications   Review   Local
No                                                                                                                                           Date    Action
                                          Offer standard automated perimetry to:
                                            – all people who have established COAG
                                            – people suspected of having visual field defects who are being investigated
                                               for possible COAG.
                                           People with diagnosed OHT or suspected COAG with confirmed normal visual
                                           fields may be monitored using supra-threshold perimetry.
                                          Where a defect has previously been detected use the same visual field
                                           measurement strategy for each visual field test.
                                          Offer Goldmann applanation tonometry and Van Herick‟s test at each
                                           monitoring assessment.
                                          Repeat CCT measurement and gonioscopy when clinically indicated.
                                          Offer stereoscopic slit lamp biomicroscopic examination of the optic nerve head
                                           at monitoring assessments.
                                          If there is no adequate view of the optic nerve head and surrounding area,
                                           ensure pupils are dilated before assessment.
                                          Obtain a new optic nerve head image if there is a change in status.

                                   Monitoring and treatment for people with OHT or suspected COAG
                                   See the OHT pathway on pages 8–9 and the suspected COAG pathway on page
                                   10.
                                    „Pharmacological treatment‟ refers to a prostaglandin analogue, beta-blocker,
                                       carbonic anhydrase inhibitor or sympathomimetic, or a preservative-free
                                       preparation if the person is allergic to preservatives. More than one agent may
                                       be needed concurrently.
                                    Check there are no relevant comorbidities or potential drug interactions before
                                       offering medication.
                                    Monitor at regular intervals people with OHT or suspected COAG
                                       recommended to receive medication, according to their risk of conversion to
                                       COAG (see OHT pathway on pages 8–9). KPI
                                    Offer people with OHT or suspected COAG with high IOP treatment based on
                                       estimated risk of conversion to COAG using IOP, CCT and age (see OHT
                                       pathway on pages 8–9). KPI




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                                                                   SHEFFIELD PCT
                                                              Framework of NICE Guidance
                                                                                                                                                April 2009

Guideline   Title                  Summary                                                                                  Implications   Review   Local
No                                                                                                                                          Date    Action
                                   Monitoring and treatment for people with COAG
                                   See the COAG pathway on pages 12–13.
                                    „Pharmacological treatment‟ refers to a prostaglandin analogue, beta-blocker,
                                      carbonic anhydrase inhibitor or sympathomimetic, or a preservative-free
                                      preparation if the person is allergic to preservatives. More than one agent may
                                      be needed concurrently.
                                    Check there are no relevant comorbidities or potential drug interactions before
                                      offering medication.
                                    Monitor at regular intervals people with COAG according to their risk of
                                      progression to sight loss (see COAG pathway on pages 12–13). KPI
                                    Offer people newly diagnosed with early or moderate COAG, and at risk of
                                      significant visual loss in their lifetime, treatment with a prostaglandin analogue.
                                      KPI
                                    Offer surgery with pharmacological augmentation (MMC or 5-FU)† as indicated
                                      to people with COAG who are at risk of progressing to sight loss despite
                                      treatment. Offer them information on the risks and benefits associated with
                                      surgery. KPI
                                    Offer people with advanced COAG surgery with pharmacological augmentation
                                      (MMC or 5-FU)†as indicated. Offer them information on the risks and benefits
                                      associated with surgery.

                                   †At the time of publication (April 2009), MMC and 5-FU did not have UK marketing
                                   authorisation for this indication. Informed consent should be obtained and
                                   documented. Both drugs should be handled with caution and in accordance with
                                   guidance issued by the Health and Safety Executive.

                                   Organisation of care
                                    Refer people with suspected optic nerve damage or repeatable visual field
                                      defect, or both, to a consultant ophthalmologist for consideration of a definitive
                                      diagnosis and formulation of a management plan. KPI
                                    Diagnosis of OHT and suspected COAG and formulation of a management
                                      plan should be made by a suitably trained healthcare professional with:
                                      – a specialist qualification (when not working under the supervision of a
                                        consultant ophthalmologist) and




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                                                                      SHEFFIELD PCT
                                                                 Framework of NICE Guidance
                                                                                                                                                        April 2009

Guideline   Title                  Summary                                                                                     Implications      Review     Local
No                                                                                                                                                Date      Action
                                           – relevant experience.
                                          Diagnosis of OHT and suspected COAG and preliminary identification of
                                           COAG should be made by a healthcare professional trained in case detection
                                           and referral refinement who is able to identify abnormalities based on relevant
                                           clinical tests and assessments.
                                          People with a diagnosis of OHT, suspected COAG or COAG should be
                                           monitored and treated by a trained healthcare professional who has all of the
                                           following:
                                           – a specialist qualification (when not working under the supervision of a
                                              consultant ophthalmologist)
                                           – relevant experience
                                           – ability to detect a change in clinical status. KPI
                                          Monitoring and treatment of people with OHT, suspected COAG and
                                           established COAG should be carried out by healthcare professionals trained to
                                           make relevant management decisions.
                                          Monitoring (but not treatment) of people with a confirmed diagnosis of OHT or
                                           suspected COAG who have an established management plan can be carried
                                           out by a suitably trained healthcare professional with the relevant skills and
                                           ability to detect a change in clinical status.
                                          Healthcare professionals who diagnose, treat or monitor people independently
                                           of consultant ophthalmologist supervision should take full responsibility for the
                                           care they provide.
                                          Adopt professional/Department of Health guidance to reduce the risk of
                                           transmitting infective agents via contact tonometry or gonioscopy.
                                          Ensure that all machines and measurement instruments are calibrated
                                           regularly according to the manufacturer‟s instructions.

IPG296      Endoscopic                    Current evidence on the safety and efficacy of endoscopic mastectomy and            Acute care only     -
            mastectomy and                 endoscopic wide local excision for breast cancer is inadequate in quantity.
            endoscopic                     Therefore, these procedures should only be used in the context of research.
            wide local excision            The research should include adequacy of resection margins, survival,
            for breast cancer              recurrence or reoperation rates, tumour size and location, patient breast size,
                                           quality of life, and cosmesis.
                                          Research should be conducted only in units specialising in the management of




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                                                                   SHEFFIELD PCT
                                                              Framework of NICE Guidance
                                                                                                                                                    April 2009

Guideline   Title                  Summary                                                                                 Implications      Review     Local
No                                                                                                                                            Date      Action
                                        breast cancer, by surgeons trained in both breast cancer surgery and
                                        endoscopy.
IPG297      Combined bony and          Current evidence on the safety and efficacy of combined bony and soft tissue       Acute care only     -
            soft tissue                 reconstruction for hip joint stabilisation in proximal focal femoral deficiency
            reconstruction              (PFFD) is inadequate in quantity, quality and consistency. Therefore this
            for hip joint               procedure should only be used with special arrangements for clinical
            stabilisation in            governance, consent and audit or research.
            proximal focal             Clinicians wishing to undertake combined bony and soft tissue reconstruction
            femoral deficiency          for hip joint stabilisation in PFFD should take the following actions.
            (PFFD)                     – Inform the clinical governance leads in their Trusts.
                                       – Ensure that parents or carers understand the uncertainty about the
                                          procedure‟s safety and efficacy. They should understand that multiple
                                          procedures may be needed and that the procedure may not result in a fully
                                          functioning limb. Parents or carers should be provided with clear written
                                          information.
                                       – Audit and review clinical outcomes of all patients having combined bony and
                                          soft tissue reconstruction for hip joint stabilisation in PFFD.
                                       The procedure should only be carried out in units that specialise in limb
                                        reconstruction, by surgeons with specialist knowledge of neonatal hip
                                        dysplasias and expertise in limb lengthening procedures.
IPG298      Ex-vivo hepatic            Current evidence on ex-vivo hepatic resection and reimplantation for liver         Acute care only     -
            resection and               cancer raises concerns about the safety and efficacy of the procedure.
            reimplantation              Therefore this procedure should only be used with special arrangements for
            for liver cancer            clinical governance, consent and audit or research. It should only be used for
                                        patients who would otherwise not survive and for whom other treatment options
                                        have failed or are inappropriate.
                                       Clinicians wishing to undertake ex-vivo hepatic resection and reimplantation for
                                        liver cancer should take the following actions.
                                       – Inform the clinical governance leads in their Trusts.
                                       – Ensure that patients understand the uncertainty about the procedure‟s safety
                                          and efficacy; specifically the risks of death or serious morbidity, and the
                                          possible need for liver transplantation. Clear written information should be
                                          provided.
                                       – Audit and review clinical outcomes of all patients having ex-vivo hepatic




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                                                                     SHEFFIELD PCT
                                                                Framework of NICE Guidance
                                                                                                                 April 2009

Guideline   Title                  Summary                                                   Implications   Review   Local
No                                                                                                           Date    Action
                                           resection and reimplantation for liver cancer




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