ABSTRACT
Background/Aims Intraarticular corticosteroid injections (CSI) are used as a short-term treatment for inflammatory arthritis and osteoarthritis. At the outset of the COVID-19 pandemic there was concern regarding the immunosuppressive effect of steroids and the potential risk of COVID-19 infection in patients treated with CSI. There is no universal evidencebased consensus on the optimum dosing of CSI. Nationally there was a mixed response to CSI use during the COVID- 19 pandemic. Early during the pandemic, our Trust advised using only the lowest BNF indicated steroid dose to minimize any potential side effects. Large joints (knees and shoulders) were injected with 40mg of Kenalog compared to 80mg pre pandemic. No previous survey has reported the incidence of covid infection post CSI. The primary aim of this project was to address this gap. A secondary aim was to review the clinical effectiveness of a 'larger' versus 'smaller' steroid dose in CSI. Methods Retrospective data collection was carried out for 107 patients who received CSI during the pandemic. All patients who received CSI within the Trust rheumatology department were followed up with a sixweek phone call. During this consultation the effectiveness of the CSI was considered by asking them to score the effectiveness of the CSI out of 10 (10 being maximum improvement). The incidence of COVID- 19 infection was also recorded. This data was compared to the same data from a group of patients injected with a larger dose of CSI pre-pandemic (n=114). Results The patient reported incidence of COVID-19 infection within 6 weeks of CSI was 1.87%. Patient reported outcomes showed a mean improvement in joint symptoms of 6.97 using 80mg of kenalog, versus 5.02 improvement using the smaller 40mg dose at six week follow up. Interestingly 56% of people injected with a larger dose reported a minimum 8/10 improvement compared to 22% of patients injected with a smaller dose. Conclusion The low incidence of COVID-19 infections following CSI indicates that there is no significant correlation with increased in risk of contracting COVID-19. This study did not collect any data on outcomes of infection but at the time of the phone calls no patients had been hospitalized or died. The incidence of COVID-19 infection was below the national average. Some of the Rheumatology patients injected may have been advised to shield which may have contributed to the lower-than-expected figure. The significantly increased benefit consistently reported by patients supports the use of a higher dose steroid (Kenalog 80mg) versus lower dose (40mg) when injecting large joints in patients with arthritis. It is important to weight up the risks and benefits of CSI but this suggests that we should use the higher dose in clinical practice.
ABSTRACT
Background/Aims Long Rheumatology waiting lists in the UK were further affected by the COVID-19 pandemic;resulting in negative impacts upon the timeliness and efficiency of patient care. The use of Advanced Practitioners within Rheumatology care pathways has been shown to be safe and effective;they can support the Rheumatology workforce and expedite care where patients are appropriately triaged to them. As part of a service provision change in a NHS Trust, an Advanced Practice Physiotherapist (APP) post was funded with the intent to harness these benefits. Initial utilisation of the APP appointments within the Rheumatology provision was found to be low and could be improved. A Quality Improvement (QI) Project was initiated, with the aim to increase APP appointment utilisation to at least 85% over a period of four months, and for at least 75% of these appointments to contain patients who had been appropriately triaged. Methods The 'Model for Improvement' was chosen as the QI approach. The project was led by an APP. Firstly, a stakeholder analysis was performed to identify staff with influence and interest in the project. A root cause analysis found lack of awareness of triaging clinicians and challenges with booking processes as potential reasons for lowerthan- expected appointment utilisation. Change interventions were devised and tested over three Plan, Do, Study, Act (PDSA) cycles. PDSA one developed communication with booking and triage staff to clarify these processes with them. PDSA two educated clinical staff about the APP role, triage criteria and the booking procedures confirmed in PDSA one. PDSA three focused upon sustaining change by reinforcement of the topics established in PDSA two among staff. Outcome measures used were the percentage of available APP appointments utilised per week, and the percentage of these which contained patients who were appropriately triaged. Results APP appointment utilisation increased from a mean of 22% pre-project to 61% during the change intervention period. Sixty-three patients were seen over the 17-week change intervention period;of which 86% had been appropriately triaged. Data showed that 70% of the patients directed to the APP were managed by them (24% discharged and 46% reviewed). Of the remaining patients, 13% were followed up by a Rheumatologist, 12% did not attend and 5% had an alternative outcome such as awaiting advice. Conclusion This QI project led to an improvement in Rheumatology care provision locally. Engagement with support staff, education of clinical staff and implementation of clear standard operating procedures improved the utilisation of the Rheumatology APP resource. Results suggest that the APP role was effective locally in managing appropriately triaged patients, without a negative effect on patient care or other services. Continuing to improve utilisation will support management of the Rheumatology waiting list and improve patient care.