Pims-Ts Mdt - Where Do We Go from Here?

Introduction/Background: Following first reports of paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS) in April 2020, services have rapidly been developed to manage these patients. In our tertiary paediatric rheumatology service a daily virtual PIMS-TS multidisciplinary (MDT) team meeting was set up in January 2021. This meeting facilitates discussions between the tertiary centre (routinely including paediatric rheumatology and infectious diseases/immunology teams) and general paediatric teams in district general hospitals (DGHs) and within our centre. The aim of this project was to evaluate the service and understand general paediatric opinion in order to consider the future direction of the meeting. Description/Method: We looked at a one month period after meetings were initiated and compared it with a one month period a year later (February 2021 and February 2022) to define patient numbers and outcomes. Alongside this we constructed an online survey aimed at general paediatricians to determine opinion of the current structure of the MDT and how it may be developed in the future. The survey was sent to general paediatricians within our own centre and in the eleven DGHs falling within our region. Results were analysed descriptively. Discussion/Results: During February 2021, 19 new referrals were discussed within the PIMS-TS MDT;each referral was discussed for a median of 5 days (interquartile range (IQR) 3-6 days). Of these, 11/19 (58%) had a final primary diagnosis of PIMS-TS and 5/19 (26%) patients were transferred for tertiary care (of whom 4/5 (80%) had PIMS-TS). In February 2022, 14 new referrals were discussed for a median of 2.5 days (IQR 2-5.75 days). Of these, 3/14 (21%) had a final diagnosis of PIMS-TS and 2/14 (14%) were transferred for tertiary care (of whom neither had PIMS-TS). We received responses from 20 general paediatricians covering 9/11 (82%) DGHs within our region plus our own centre. Most clinicians had discussed up to 6 patients in the meeting (9/20 (45%) 1-3 patients;9/20 (45%) 4-6 patients;2/20 (10%) >6 patients). All clinicians felt the MDT helped facilitate appropriate diagnostic work-up and treatment decisions. 18/20 (90%) felt that the meeting helped avoid unnecessary tertiary paediatric transfers. Interestingly, 9/20 (45%) felt that a routine PIMS-TS MDT meant they were more likely to discuss a patient with rheumatology (1/20 (5%) less likely). All clinicians felt the meeting improved care for patients and most felt it increased their confidence in looking after patients with PIMS-TS (19/20, 95%) and was useful for continuing professional development/training experience (19/20, 95%). Considering the future direction of the meeting, all clinicians felt it should be continued but most (16/20, 80%) felt it should be aimed at a wider patient group. 11/20 (55%) felt a later time of day would be more convenient (currently 11am). Over half (11/20, 55%) thought it should be combined with a currently separate meeting for acute COVID-19 patients (7/20 (35%) don't know;2/20 (10%) no). A minority (4/20, 20%) reported difficulty accessing the meeting. Key learning points/Conclusion: As the initial phase of the pandemic draws to a close and numbers of PIMS-TS cases decline this is important data to reflect on how services can go forward into the next phase. While numbers of PIMS-TS cases reduced, the meeting was still wellused and evolved to include patients with other diagnoses. The survey confirms that most general paediatricians believe it improves patient care and would like the meeting to continue but that review of the format may be helpful. Particular considerations are to broaden the scope of the meeting beyond PIMS-TS, revise the timing and consider how to improve ease of access to the meeting for all. Further work will focus on evaluating patient numbers and diagnoses over the full period of the PIMS-TS MDT and adapting the format of the current MDT in response to the feedback received.

Improving safety and efficiency of biologic and DMARD therapy prescribing through development of a multi-disciplinary virtual clinic

Introduction/Background: We identified that the system for prescribing biologic and DMARD therapies in paediatric rheumatology at Royal Manchester Children’s Hospital (RMCH) was slow, often causing repetition of work and delays in timely access to repeat and new prescriptions. We created a multidisciplinary team (MDT) virtual clinic involving specialist nurse, pharmacist and consultant to allow for an efficient and safe “one-stop shop” process to review all repeat and new prescriptions. The aim of the VBC was to improve efficiency and communication around prescribing, reduce time to commence new therapies, and ensure more robust oversight of therapeutic drug monitoring and patient safety. Description/Method: Approximately 400 patients currently receive prescriptions via homecare systems for subcutaneous biologics and disease modifying antirheumatic drugs (DMARDS) under the care of the RMCH paediatric rheumatology service. These patients require close monitoring and timely repeat prescribing to ensure safe management.Historically, a prescription request list was sent from pharmacy homecare team to rheumatology specialist nurses, who would review patient records, print prescriptions, and organise a weekly meeting with the responsible consultant to review and sign the prescription. Prescriptions hand delivered to the pharmacy homecare office would await pharmacist verification and submission to the homecare provider. Any pharmacist queries emailed to the nursing team required review, and queries would need to be dealt with by nursing or medical staff, introducing multiple opportunities for delay into the prescribing process. This multi-step process created numerous hours of administrative burden due to silo-working and poor communication.Rheumatology nursing, pharmacy and medical personnel worked together to secure funding approval for a new virtual biologics clinic (VBC), where repeat and new prescriptions would be reviewed weekly by these core team members. For each patient, the diagnosis, indication for therapy, relevant blood results, clinical parameters (e.g. age, weight) and other pertinent factors are reviewed. If screening identifies no barriers to supply, the prescription is signed by the consultant, checked and countersigned by the pharmacist, who submits completed prescriptions to the pharmacy homecare team the same day. BlueTeq forms are completed by the pharmacist or consultant during the VBC, reducing funding risk and ensuring national commissioning framework requirements are followed.Where issues are identified e.g. inadequate screening prior to starting biologics or abnormal blood results, management plans can be formulated and actioned in a timely manner.A clinic letter is generated for each patient discussed, informing the patient, GP and consultant of the outcome of the meeting and actions. Discussion/Results: The first VBC took place in February 2020 and remains a weekly occurrence. The clinic takes approximately one hour to complete with around two hours of preparation time (checking relevant results and generating prescriptions). An average of 15 – 30 patients are discussed each week. To our knowledge we are the only UK paediatric rheumatology centre to run a VBC in this manner.Initial staff perception has been that therapeutic optimisation has been achieved in an efficient, timely manner. Consideration of updated weight and age at each review has allowed doses to be increased and identified opportunities for patients to switch to more suitable or better tolerated devices (e.g. moving from etanercept vials to pre-filled syringes or pre-filled pens).MDT working, sharing of skills and knowledge, has also made it easier to update prescribing guidelines and standardise practice.Prescription generation prior to the VBC has allowed a move from a reactive to proactive approach. Forecasting of when new prescriptions are due ensures that prescriptions are signed (and any issues dealt with) before request from the homecare provider, reducing the risk of patients running out of medicines and uninten ed breaks to treatment.Improved communication within the MDT prevents duplication of work, enabling time savings to carry out other duties.The clinic letter generated ensures that families know their child’s prescription has been issued, along with communication around changes to therapy, which has reduced telephone calls to the department.The VBC rollout coincided with the RMCH biosimilar switch of adalimumab. Expedition of transition to a biosimilar improved Trust cost savings. The VBC facilitated the introduction of use of subcutaneous tocilizumab, reducing need for day-case attendance and reducing use of intravenous tocilizumab which was in demand as a COVID-19 rescue medicine. Key learning points/Conclusion: The VBC has improved efficiency of prescribing, facilitated robust monitoring of patients and has streamlined the process of prescribing, freeing up time for staff to complete other duties.An additional, unanticipated benefit has been the recognition of safeguarding concerns. Through reviewing each patient’s record before issuing prescriptions, we have identified patients who have been lost to follow-up (a particular concern since the COVID-19 pandemic) or repeated non-attendance at appointments. Early recognition has allowed rapid escalation and resolution of issues.Completing BlueTeq requests during the VBC has reduced delays in initiation of therapies and minimised NHS England funding challenges. Consultants have an improved understanding around commissioning criteria and alternative funding options, should NHS funding not be available for certain indications and patient cohorts.We continue to evaluate the VBC. We plan to audit the service, collecting data on time from decision to commence a treatment to starting the new medication, as this is an area we feel has significantly improved with the introduction of the VBC. It is essential to gain feedback from patients and families on their experience of commencing treatments, ease of obtaining repeat prescriptions from homecare and communication of therapy changes.All three members of the MDT are vital for the efficient running of the VBC and all contribute different expertise. At present the same consultant attends each VBC, future developments may be to rotate this among all the consultants in our team. We could invite trainees to attend, as the clinic provides significant learning opportunities including reviewing indications for immunosuppressant therapy, safe prescribing and interpretation of blood results.As the Trust moves to an electronic prescribing system in autumn 2022, it is hoped that the prescribing system will become even more streamlined, allowing for electronic signatures and consolidating systems to ensure data is easily accessible.

PIMS-TS MDT – where do we go from here?

Introduction/Background: Following first reports of paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS) in April 2020, services have rapidly been developed to manage these patients. In our tertiary paediatric rheumatology service a daily virtual PIMS-TS multidisciplinary (MDT) team meeting was set up in January 2021. This meeting facilitates discussions between the tertiary centre (routinely including paediatric rheumatology and infectious diseases/immunology teams) and general paediatric teams in district general hospitals (DGHs) and within our centre. The aim of this project was to evaluate the service and understand general paediatric opinion in order to consider the future direction of the meeting. Description/Method: We looked at a one month period after meetings were initiated and compared it with a one month period a year later (February 2021 and February 2022) to define patient numbers and outcomes. Alongside this we constructed an online survey aimed at general paediatricians to determine opinion of the current structure of the MDT and how it may be developed in the future. The survey was sent to general paediatricians within our own centre and in the eleven DGHs falling within our region. Results were analysed descriptively. Discussion/Results: During February 2021, 19 new referrals were discussed within the PIMS-TS MDT;each referral was discussed for a median of 5 days (interquartile range (IQR) 3–6 days). Of these, 11/19 (58%) had a final primary diagnosis of PIMS-TS and 5/19 (26%) patients were transferred for tertiary care (of whom 4/5 (80%) had PIMS-TS). In February 2022, 14 new referrals were discussed for a median of 2.5 days (IQR 2–5.75 days). Of these, 3/14 (21%) had a final diagnosis of PIMS-TS and 2/14 (14%) were transferred for tertiary care (of whom neither had PIMS-TS).We received responses from 20 general paediatricians covering 9/11 (82%) DGHs within our region plus our own centre. Most clinicians had discussed up to 6 patients in the meeting (9/20 (45%) 1-3 patients;9/20 (45%) 4-6 patients;2/20 (10%) >6 patients). All clinicians felt the MDT helped facilitate appropriate diagnostic work-up and treatment decisions. 18/20 (90%) felt that the meeting helped avoid unnecessary tertiary paediatric transfers. Interestingly, 9/20 (45%) felt that a routine PIMS-TS MDT meant they were more likely to discuss a patient with rheumatology (1/20 (5%) less likely). All clinicians felt the meeting improved care for patients and most felt it increased their confidence in looking after patients with PIMS-TS (19/20, 95%) and was useful for continuing professional development/training experience (19/20, 95%).Considering the future direction of the meeting, all clinicians felt it should be continued but most (16/20, 80%) felt it should be aimed at a wider patient group. 11/20 (55%) felt a later time of day would be more convenient (currently 11am). Over half (11/20, 55%) thought it should be combined with a currently separate meeting for acute COVID-19 patients (7/20 (35%) don’t know;2/20 (10%) no). A minority (4/20, 20%) reported difficulty accessing the meeting. Key learning points/Conclusion: As the initial phase of the pandemic draws to a close and numbers of PIMS-TS cases decline this is important data to reflect on how services can go forward into the next phase. While numbers of PIMS-TS cases reduced, the meeting was still well-used and evolved to include patients with other diagnoses. The survey confirms that most general paediatricians believe it improves patient care and would like the meeting to continue but that review of the format may be helpful. Particular considerations are to broaden the scope of the meeting beyond PIMS-TS, revise the timing and consider how to improve ease of access to the meeting for all.Further work will focus on evaluating patient numbers and diagnoses over the full period of the PIMS-TS MDT and adapting the format of the current MDT in response to the feedback received.

Growing up in rheumatology: An Evaluation of a Young Adult Rheumatology Service

Introduction/Background: Young people with juvenile onset rheumatic disease are treated in paediatric centres until they are required to transfer to an adult centre. Transitional care is a process which begins in early adolescence and prepares young people for this change. There is a rapidly evolving evidence base to support transitional care for young people with long term health conditions with European rheumatology-specific guidance available. The third stage of transitional care, i.e. that which follows transfer to adult care, however, is the least researched. Description/Method: The aim of the study is to evaluate rheumatology service provision for the third stage of transition, i.e. young adult rheumatology provision, at a large NHS trust. A retrospective case-note review was conducted. Relevant patients were identified from young adult rheumatology clinic lists from 2017 to 2022. Of note, no clinics took place during the COVID 19 pandemic lock down in 2020 and transfer of patients during that time was postponed until face to face clinics resumed in adult practice. Patients were assigned study numbers and data was then collected from clinical letters, general correspondence and other annotations uploaded to the Electronic Patient Records (EPR). Patient records searched included those up to 24 years old on current adult rheumatology clinic lists. Discussion/Results: 86 patients (79.1% female, n = 68) were identified. The mean age at transfer was 17.1 years with 53.4% having inflammatory arthritis (n = 46). 59.3% (n = 51) had more than 1 diagnosis. 64% (n = 55) had no other named specialties involved in care at transfer. The median number of medications at transfer was 3, range 0-11. Of those taking medications, 86.7% (n = 72) were self-managing these.59.3% (n = 51) had a transfer letter. 29.1% (n = 25) had a transfer summary completed. 14% (n = 12) had no transfer documentation. Transition readiness checklists were identified in 41.9% records (n = 36). At the time of transfer, copy clinic letters were addressed solely to parents in 4 (4.7%).Young people had attended a median of 5 appointments (range 1-12) in the 12 months prior to transfer. 59.3% (n = 51) attended more than 50% of these appointments independently. 26.7% (n = 23) did not attend between 1-2 of their scheduled appointments in the 12 months pre-transfer.The mean duration between last paediatric and first adult appointment was 4 months (range 1-12). 47.7% (n = 41) did not attend at least one appointment in the 12 months post-transfer, with 23.3% (n = 20) not attending 3 or more appointments.67% (n = 58) of the final paediatric letters covered at least one of 11 psychosocial topics, with a median of 2 topics covered (range 1-5). In the first adult clinic letter a median of 3 topics (range 1-7) were covered in 82.6% (n = 71) letters.Around the time of transfer, disease activity was addressed in only 18 patients (20.9%) with a median score for Physician Global Assessment of 0 (0-10). 36% of patients (n = 31) had a CHAQ score documented, median score 0.5 (0-1.875). 29.1% (n = 25) had pain scores recorded, median 16, range 0-87. Self-reported wellbeing scores were recorded for 23.3% (n = 20), median 16.5, range 0-75. Key learning points/Conclusion: We describe a cohort of young people recently transferred from paediatric rheumatology care with the majority having inflammatory arthritis, being female and being on medication. A third had other specialties involved thus requiring greater coordination at the time of transfer. Transitional care preparation appeared effective with the majority seeing professionals independently prior to transfer, self-managing their medication and in receipt of clinic letters copied to them rather than their parents. Documentation of transitional care is important for multidisciplinary care but was sub- optimal with less than half of the records having transition check lists and a minority with formal transfer documentation. With limited clinic time and a childhood onset disease, a brief summary of relevant information including previous medications tried is important for the adult team and core to current transitional care guidance.The time between last paediatric and first adult appointment has been reported to be important in transitional care and it was reassuring to see this was a median of 4 months. There were higher rates of non-attendance in the young adult clinic compared to paediatrics which could reflect this wide range for continuity and will be an important area for future attention to ensure engagement of young people and the avoidance of lapses in care and potential disease flares. Disease activity was poorly documented in the peri-transfer period however, so it is difficult to comment on prevalence of uncontrolled disease at this time.Documentation of routine psychosocial screening was better post transfer but may reflect that these appointments are essentially a new patient appointment and therefore reflects the adult team getting to know the young person.This service evaluation has therefore identified areas of good transitional care practice as well as areas for improvement in this service and will be a useful baseline for future development.

COVID-19 impact on delayed clinical visits in diabetic retinopathy patients

Purpose : The COVID-19 pandemic created an unprecedented setback for diabetic retinopathy (DR) patients receiving routine anti-vascular endothelial growth factor (VEGF) injections. In this retrospective clinical study, we assessed visual and anatomical outcomes of “late follow-up” appointments cancelled or rescheduled during an 11-week quarantine period from March 15th- June 1st, 2020, due to the urgency to limit non-emergent clinical visits. This study tested the hypothesis that strict frequency of treatment is a requisite for successful therapy. Methods : To meet “late follow-up” requirements, all study patients had appointments scheduled within the quarantine period that were delayed past their previous physician recommended interval, beyond June 1st, 2020. Of the 7042 delayed patients, 5137 returned for examination. 2764 were injection patients, of which 616 were delayed beyond the quarantine period. These 616 patients were subsequently categorized by diagnosis. We then analyzed the electronic medical record (EMR) for 300 eyes with treatment-requiring diabetic retinopathy to establish baseline anatomical and visual status prior to the delayed clinical visit. The EMR of the follow-up appointment was subsequently viewed for comparison. Best-corrected visual acuity (BCVA) and retinal examination findings were recorded from both visits. All eyes received at least 1 anti-VEGF injection prior to March 15th, 2020. Results : 300 eyes were delayed beyond their previously scheduled interval an average of 14.04 weeks. Upon return, 37 eyes (12.3%) had improved BCVA, 169 (56.3%) remained stable, and 94 (31.4%) had worsened. Of the 300 eyes, there was an average of 2.2 lines lost (p=0.03). 29 delayed eyes (9.7%) returned with improved macular edema, 121 (40.3%) remained stable, and 143 (47.7%) had worsened upon examination. Due to vitreous hemorrhage, edema progression in 7 eyes (2.3%) was unknown. 290 eyes (96.7%) remained with non-proliferative DR, while 10 (3.3%) progressed to proliferative DR. 23 (7.6%) returned with new or worsened vitreous hemorrhages. No patients developed a retinal tear or detachment during this period. Conclusions : COVID-19 had a severe impact on routine clinical visits. Prolonged frequency of anti-VEGF treatment for DR is associated with increased risk for BCVA decline and negative anatomical outcomes. Effective therapy requires strict compliance with intravitreal injections and routine clinical appointments.

A statewide medical dental integration initiative

Background: Wisconsin has a significant gap to improve access to pediatric oral health care. Only 1 in 5 Wisconsin Medicaid eligible children ages 0-5 years received preventive dental services, in 2018. By the time children in Head Start are 5 years old, half have developed caries. Dental hygienists can now practice in medical clinics without the direct supervision of a dentist due to the 2017 Wisconsin ACT 20 legislation. As 80,000 children ages 0-5 enrolled in Wisconsin Medicaid in 2018 had a medical visit, but no dental visit, a medical dental integration model offers the opportunity to leverage medical visits to incorporate oral health care. Methodology: Utilizing a modified version of the Institute for Healthcare Improvement's Breakthrough Collaborative Model, the Wisconsin Medical Dental Integration (WI-MDI) project aims to: 1) Expand access to preventive oral health services;2) Reduce the prevalence of caries experience and untreated dental caries;and 3) Develop a financially sustainable model for integrated oral health care that redefines how preventive oral health care is provided to children. This three-year project started in January 2019 with the creation of an Advisory Council composed of representatives from multiple healthcare systems, federally qualified health centers, professional associations, and state agencies. The WI-MDI driver diagram (Figure 1) was created to assist clinic teams in implementing system changes required to integrate oral health into primary care. Data is collected in Life QI, an online quality improvement platform used to assist with project oversight to both track and analyze improvement data. Discussion: Six Advisory Council meetings have occurred to date with the partnership growing over time (N=15-20 partners). Clinical team's readiness to implement the MDI model was assessed through their identification of readiness to proceed with each of the drivers (Figure 2). A yearlong Learning Collaborative started in October 2019, with two learning sessions to date, and five monthly Collaborative calls addressing primary drivers clinics were not ready on yet (yellow/red colors). Three federally qualified health clinics (FQHCs) are currently participating with dental hygienists integrated into their medical teams. Participants engagement has been enhanced through a complementary stipend from a dental partner. Conclusion: Recruitment of healthcare systems to engage in this Project has taken longer than anticipated, however, intentions to adopt the model remain high. System changes necessary to incorporate a new provider into primary care delivery revealed several key barriers: incorporating dental documentation into existing medical records, updating billing systems to bill dental codes, investment of hiring new staff, and greater challenges for large systems' acceptance compared with FQHCs. Due to COVID-19 pandemic, modifications have been made to now include virtual monthly team calls to help systems overcome these barriers with plans to start Learning Collaborative Wave 2 in March 2021.