West Suffolk Hospital Bury St Edmunds
West Suffolk Rheumatology team: Spring 2010
In 2003 we set up an Early Arthritis Clinic (EAC) to minimise delay from onset to treatment and to get the best response as soon as possible. If we had a mission statement it would be “early referral, early treatment, early remission”. Over time we changed our way of working and put together a service very like the 2009 NICE clinical guidance on RA with frequent patient contact for early arthritis patients.
Our experience shows that rheumatology units can implement the NICE model of RA care with little extra investment and without being swamped under the extra workload. Patients with other conditions have not been displaced and follow-up patients still have good access.
General outline of the department
The team has four nurses, three consultants, a registrar, five secretaries and a nurse admin support worker; only four of us work full time. Recently we increased the number of clinics held in the main hospital and started new clinics in three community hospitals and a GP surgery. We have bought an ultrasound scanner and are training staff to use it in clinic. Other services such as occupational therapy and physiotherapy are available.
To get best results we want to see people and start effective treatment as soon as possible after the start of symptoms. To make this happen the whole team regularly reviews practical aspects of care including new ways of working, best treatments, how to assess response and when to change treatment. We have designed an overall “treatment plan” which is routinely followed. Doctors and nurses can share the care of RA patients in the clinic, seeing patients and adjusting treatment according to the same plan.
The RA “patient journey”
GPs are encouraged to refer immediately at first suspicion of inflammatory arthritis without delaying for tests. Our EAC secretary books an appointment, usually within 2 weeks, and sends out a blood-test form (including Rheumatoid Factor and anti-CCP) with a questionnaire covering symptoms and disability. At the first visit the doctor makes a full assessment with any X-rays or extra blood tests needed during the clinic. If the diagnosis is not clear we have rapid access to ultrasound etc. We assess activity using Disease Activity Score (DAS28) at each visit. The patient is offered a nurse appointment in the same clinic, or later that week so treatment can start immediately. We explain that Methotrexate is the “anchor” drug for most patients and should be used whenever possible, and that the aim of treatment is remission. Usually we offer a combination of Methotrexate starting at 15mg/week with Hydroxychloroquine with a short course of steroid tablets to give rapid relief. Patients are encouraged to call the nurses if there are concerns at any time.
Five weeks later there is a pre-booked telephone consultation with a nurse rather than a hospital visit to check on progress. The nurse reviews medication, checks blood tests, and answers any questions. The dose of Methotrexate is usually increased to 20 mg, and other treatments discussed. A patient survey showed very high satisfaction with the telephone clinic.
After another five weeks the patient is reviewed in clinic by the nurses with DAS28 scoring. If not in remission or well controlled, the patient is offered additional treatment. The patients are then seen every five weeks by doctors or nurses, with assessment of progress and activity during every visit. When Methotrexate tablets cause side effects or are not effective, we offer it by self-injection at home. About 300 patients use this treatment, which is safe, effective and convenient.
I found the Early Onset RA Clinic professionally run giving me an accurate diagnosis of my condition whilst allowing me enough time with the staff to talk about my concerns. A reassuring approach with regards to the drug treatment followed and I am able to lead a relatively normal existence coupled with ongoing advice via phone or email to a member of staff to discuss any issues that may arise with my condition."
Because we continually assess patients’ progress we can identify early those who are not responding well enough for more intensive treatments such as anti-TNF. Preparation in advance with TB screening, education and medical review etc means that we can prescribe anti-TNF treatment without further delay.
When patients have stable disease with remission or acceptably low activity we offer yearly appointments. This Annual Clinic was designed to meet the standards set by the British Society of Rheumatology and NICE and cover the whole impact of RA including psychological problems, work related issues, general medical health etc.
Our patients tell us that they would like to be seen quickly if they “flare” so we are setting up a “same week” rapid access clinic for them.
NICE guidance on RA advises treatment early in disease with “tight control” – that is frequent assessment of activity and escalation of treatment for active disease. At the West Suffolk Hospital we believe we have shown this can be done by changing the way we work without the need for major investment.