30 September 2021
Prompt and aggressive treatment for early inflammatory arthritis makes remission more achievable than ever before. The latest National Early Inflammatory Arthritis Audit shows that East Kent Hospitals University NHS Foundation Trust has 80% of patients in remission at 12 months. To find out how they're achieving these impressive figures, we spoke to Dr Farhan Bari, consultant rheumatologist at the Trust and audit lead for the department, to ask how they manage their service.
Standardising care with a pathway
There are currently seven consultants spread over the three main hospitals which are in Ashford, Canterbury and Margate. The wider multidisciplinary team is made up of six specialist nurses, one advanced physiotherapist practitioner, two OT specialists, a specialist pharmacist and a coordinator.
As a team we cover a population of around 750,000. A couple of years ago we developed an early arthritis treatment pathway which has been instrumental in getting patients into remission. If a patient is seen and a diagnosis confirmed, we have a protocol for everyone to follow. The pathway details what investigations should be done, how often the patient should be seen and by which members of the MDT, the medications to be used, and how to escalate treatment.
The pathway means we’re all working together in the same way with set standards. Even during the height of COVID-19 when routine clinics were cancelled and teams were redeployed, we still held face-to-face clinics for suspected EIA and other urgent cases. This means we’ve been able to continue seeing new patients in-person quickly. With follow-up appointments we’re doing 50% on the telephone and 50% face-to-face while we gradually increase our face-to-face slots.
Treating patients early
Developing the pathway has helped across the MDT to treat and manage patients actively and aggressively. Most of our patients have tried at least two DMARDs by month six and if they're still struggling, we’ll escalate treatment onto biologics as set out in the NICE guidelines. By doing this our patients get into remission quickly and stay that way.
During EIA clinics, we have a specialist nurse working alongside us with MSK ultrasound at the Canterbury site. This means the patient can have an ultrasound straight away while they're with us, speeding up the process. For patients on our EIA pathway, repeat ultrasound scanning helps us to assess disease activity.
Supportive resources
We recruited a coordinator to help support us across all aspects of our service who also supports other specialist conditions and the wider MDT. This role has been crucial to keep an eye on our progress. Whenever a consultant triages a referral as a suspected EIA case, the coordinator ensures the patient is booked in straight away.
In each clinic across three sites, we have dedicated slots for EIA and that’s how we’ve been able to see the patients within the three-week
guidance. These slots are protected and not available to the central booking office, which ensures we can always see referrals quickly. The coordinator is looking at our outcomes daily and ensures we keep accurate records of how quickly patients are being seen. This means any issues can be flagged early.
Taking referrals online
We’ve always had a suspected EIA proforma for GPs to refer to the clinic, but it was hit and miss whether this would come through online or on paper and we experienced delays. We changed the proforma to a complete online assessment. Most of the urgent referrals now come through this one online system, called ERS, which is much easier and quicker.
We ensure that the patients coming through have had the tests we need, so that when we see them, we can confirm a diagnosis as soon as possible and get them onto treatment. Advice to others Recruiting patients to the audit is key as otherwise it’s difficult to know how well you’re doing. In our Trust, it’s a team effort with secretaries, specialist nurses, the audit team, and consultants all inputting data.
We have a weekly MDT meeting where we discuss cases which have been treated with DMARDs but are still active. This means we can jointly come to decisions about escalating to biologics. Early referral and diagnosis, with prompt and aggressive treatment and appropriate follow up, has been crucial for us to improve our remission rates.