DATE: 23/3/11 / Page 6 of 6
www.bhamcrs.co.uk e:
Rheumatology helpline 07595552782 / REVIEW DATE: March 2012
PROTOCOL FOR PATIENTS WITH INFLAMMATORY ARTHRITIS ATTENDING NURSE LED CLINICS
COMMUNITY RHEUMATOLOGY SERVICE (CRS)
Vitality Partnership/Healthworks Consortium
The community rheumatology service has been established since July 2009 and is provided by a gp with special interest, nurse consultant and visiting consultant rheumatologists . It is expected that across Vitality partnership and Healthworks consortium that approximitely 36 patients will be newly diagnosed with inflammatory arthritis per annum. These patients will require ongoing life long care for their inflammatory joint disease.
The National Audit Office, Services for people with rheumatoid arthritis 2009) report identifies that patients delay in presenting to their GP with inflammatory joint symptoms the community rheumatology service increases awareness and accessibility to specialist musculoskeletal assessment. When inflammatory arthritis has been diagnosed and communicated to the patient, the patient should receive early information, support and treatment (Musculoskeletal Services Framework 2007; NICE 2009;18 week commissioning pathway for inflammatory arthritis 2009; National Audit Office, Services for people with rheumatoid arthritis 2009).
It has been shown that patients forget 50% of the information they have been given, even about simple procedures (Feber 1999). Many patients are reluctant to ask questions (Audit Commission 1993) and lack of education can cause uncertainty, anxiety and stress. The Kings Fund report on patients’ and health professionals experience of rheumatology care (2009) found that patients consistently reported how important access to information on the disease and treatment was for them. The report makes clear recommendations for improvements in information giving at diagnosis and a robust pathway of care especially for those requiring rapid access for disease flare up.
Throughout treatment patients and their families have to cope with a range of problems such as uncertainty, difficulty with activities of daily living and affects on work and social activities. Patients and carers often need a forum to have practical issues dealt with as well as psychological and informational needs met.
The development of community rheumatology nurse led clinics has allowed ongoing rehabilitation for patients closer to home as well as being a safe environment for information giving and psychological support. (Delivering care closer to home, DH 2008).
Nurse Led Clinics:
§ Improve quality of patient care and clinical management throughout the arthritis journey
§ Give patients an overview of their treatment, side effects and facilitate them to adjust to their condition
§ Help identify the individual patient’s needs for additional supportive interventions and facilitation of coping skills
§ Provide an opportunity to discuss psychosocial issues and undertake a nursing assessment and refer for psychological support as required
§ Provide comprehensive patient education packages tailored to the patients needs
§ Signpost patients to a full range of written, visual and auditory education aids
§ Facilitate patient access to the whole team (hospital and community)
§ Provide an accessible point of contact for the patient between appointments
§ Include the family/carers in all interventions according to the patient’s wishes
§ Provide drug treatment management to enhance adherence and improve disease outcome
§ Provide rapid assessment and access to early intervention for disease relapse e.g. joint injections, pain management
§ Teach patients and carers in the self administration of injectable medications such as sc methotrexate as required
§ Provide opportunity to evaluate and audit long term patient outcomes
Criteria for Practice
The role is undertaken by the rheumatology nurse consultant (NC) who is competent in:
§ Consulting with patients
§ Disease activity assessment
§ Musculoskeletal assessment
§ Advanced communication skills
§ Independent and Supplementary nurse prescribing
§ Ordering and interpretation of relevant tests and investigations
§ Providing joint injections
§ Teaching and assessment of patient/carer administration of subcutaneous therapies
§ Additional skills will not be practised until the individual has attended the relevant course and been assessed as competent
Criteria for Patient Attending Clinic
The patients will have a confirmed diagnosis of inflammatory arthritis and will have therapies initiated, titrate and combined at an early stage within the community.
Referral – Patient self-referral, family or carer
§ Appointment system in place – refer to ring help line number 07595557282 or 0121 250 0376 and press option 6 /fax: 0121 523 6163/ or by post for an appointment to be made. For patients who are experiencing increased disease activity (flare up) the NC will triage and arrange for the patient to be seen in the clinic or within secondary care
§ Referrals to members of the multidisciplinary team will be made following the nursing assessment (physiotherapist, occupational therapist, dietician, podiatrist, district nurse etc).
§ Details of how to contact the NC will be reinforced.
Referral – Health Care Professional
§ Appointment system in place as above
§ Ongoing referrals to members of the multidisciplinary team will be made following the nursing assessment.
The Clinic Protocol
The rheumatology nurse consultant will offer a booked appointment system, but within that there will be flexibility. The Template for booking will be as follows: -
5 clinics per week will be held to accommodate patients within heart of Birmingham. Patients who are being seen for the first time will have a 20-30 minute appointment. Follow up patients will have a 15-20 minute appointment. The NC will continue to attend educational events and conferences to keep up to date and network.
The Nurse Led Clinic will allow the NC to:
1. Offer information and support to patients and carers at any stage and as required along the patient journey , in a more informal setting
2. Assess progress to ensure patient has the most effective education and equipment for their stage along the journey
The medical record will be to use the EMIS system ensuring a single patients record when this is Web hosted and until then use the practice an electronic template based system. The information will be conveyed in writing to the patients GP, Rheumatologist, patient and other health professionals involved in the patients care.
Criteria for seeking advice from a GPSI and or Rheumatologist
§ Patient whose disease is not controlled with current therapy to plan forward care (much of this is protocol driven)
§ Patient requires and injection procedure not provided by the NC
§ Patients presenting with complications from dmard therapy e.g. suspected pneumonitis, significant infection
§ Patients presenting with complications from the disease process e.g. digital vasculitis, significant infection, significant protienuria
§ Non specific concerns as assessed by the NC
Outcomes measurement (Ryan et al 2004)
§ The DNA rate for appointments
§ Average waiting time for new and follow up outpatients
§ Ethnic monitoring
§ Patient satisfaction surveys will also be undertaken on an annual basis with key outcomes being fed back to Commissioners.
§ The following specific clinical data will also be available on a quarterly basis:
~Types of rheumatological conditions seen
~Numbers of onward referrals to physiotherapists or orthopaedics
~Numbers of joint injection procedures
~The impact on secondary care will also be monitored on a quarterly basis
through the use of the following formula:
§ Number of patients referred per 1,000 pop per annum versus national rates
~Ensure that all patient records will be maintained and secured in line with
national guidance and local policies (for example, data protection act,
confidentiality, Caldicott guidelines etc.)
~Submit the outcome of the appointment and / or treatment plan to the patients
~GP, GPwSI and or rheumatologist within 5 working days of the appointment
taking place.
§ Submit the following information to the commissioners
~The number of referrals and type of referral received and referral source
~Number of inappropriate referrals
~Number of patients seen for first review
~Number of patients requiring rapid access, e.g. Side effects / increased
disease activity / blood dyscrasia
~Number of helpline calls
~Number of patients discharged from the service and reasons for discharge
~Number of patients referred back to Secondary Care and reason for referral
~Number of domiciliary visits
~Level of nurse prescribing
~Numbers of onward referrals to multi disciplinary team / other specialties
Key Performance Indicators
Service user experience / 20% return of questionnaires / Patient satisfaction questionnaire / NoneAccess / 100% of patients to be triaged within 3 working days (and prior to patient being seen in clinic) / Provider information returns / None
Access / All patients contacted within 1 working day of electronic triage / Provider information returns / None
Access / All patients offered appointment date within 21 working days / Provider information returns / None
Patient safety / 80% of patients seen to have been triaged prior to attendance and seen as appropriate in the community service / Provider information returns / None
Patient safety / Clinicians delivering service governance arrangements lapse / Performance & Governance checks / Service suspended
Data quality / Monthly activity returns not supplied within 5 working days / Provider information returns / 1 month delay in payment
REFERENCES
Audit Commission (1993) What seems to be the Matter: Communication Between Hospital and Patients, NHS Report No. 12 London: HMSO
Delivering Care closer to home: Meeting the Challenge, DoH (2008) http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086052
18 week commissioning pathway for inflammatory arthritis (joint pain) http://author.pathwaysforhealth.org/xpath2007/xeditor/publisher.asp?d_ref=A2C9C53D886F432E96AC327D93BFB245&d_name=&o_mode=0
Feber T (1999) Design and Evaluation of a Strategy to Provide Support and Information for People with Cancer of the Larynx, European Journal of Cancer Nursing, 2(2): 106-14
King’s Fund (2009) Perceptions of patients and professionals on rheumatoid arthritis care www.rheumatoid.org.uk/download.php?asset_id=615&link=true
Musculoskeletal Services Framework (2007) DoH www.18weeks.nhs.uk/Content.aspx?path=/achieve-and-sustain/Specialty-focussed-areas/Orthopaedics/MSF/
National Audit Office, ‘Services for people with rheumatoid arthritis’ (15th July 2009) www.rheumatoid.org.uk/article.php?article_id=680
Neufield K (1993) A Nursing Intervention Strategy to Foster Patient Involvement and Treatment Decisions, Oncology Nursing forum, 20: 631-5
National Institute of clinical excellence (2009) Rheumatoid Arthritis: The management of Rheumatoid Arthritis in Adults http://guidance.nice.org.uk/CG79
Oxford Handbook of Musculoskeletal Nursing (2009) Oliver S (Ed), Homer D, Specialist Nursing Support: The Role Ch 21: p.555-61, Oxford University Press
Royal College of Nursing (2004) Administering subcutaneous methotrexate for inflammatory arthritis: guidance for nurses
Ryan S, Browne A, Home D, Wild A, Hennell S, Homer D (2006) Benchmarking the nurse consultant role in rheumatology, Nursing Standard, vol 20, no 33 p 52-57
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