Rheumatology patient attendance to the paediatric emergency department

ABSTRACT

Background: A large proportion of patients present to the paediatric emergency department (PED) with non-urgent problems [1]. With growing pressures on services, there is a need to reduce unnecessary attendances. Children with rheumatological conditions may attend PED with flares of their condition or unrelated presentations. These patients may be immunosuppressed due to steroid, disease-modifying or biologic therapy;PED attendance may therefore pose a serious infection risk. Objectives: To evaluate why children with rheumatological conditions attend the PED and whether these attendances are avoidable. Methods: This study was run in Royal Manchester Children's Hospital, a UK hospital with a PED and tertiary paediatric rheumatology services. Patients under rheumatology who attend PED are usually seen directly. A dataset of all patients referred directly to paediatric rheumatology between 01/01/19 and 31/12/19 was obtained from electronic records (n=59). The age, sex and reason for attendence were collected, as well whether they were admitted/discharged. Further data on management was collected from discharge letters for those with joint pain/swelling. Results: This cohort had 36 females and 23 males, with an average age of 11.9 years (range 1-18). 28 were discharged (47.5%) and 30 were admitted (50.8%). One patient left before being seen. The average waiting time was 3.97 hours. Table 1 summarises reasons for attendance to PED and final outcome. The most common reason for attendance was joint pain/swelling (n=14, 23.7%). Of these, nine were discharged with advice on analgesia or steroid dosing and for early review in clinic. There was no documentation on whether there had been any attempt to access the available rheumatology helpline prior to attending PED. Non-rheumatology-related reasons for attendance are also shown in Table 1, and notably include 20 patients with infections, 75% of whom were admitted to hospital. Chicken pox was the second most common reason for attendance (n=5, 8.5%);all patients attending with chicken pox or shingles (n=6) were admitted. Conclusion: Our study shows that attendance to PED with joint pain/swelling is usually avoidable in patients known to paediatric rheumatology services. Appropriate alternative services are needed to reduce hospital attendances;nurse-led helplines are beneficial, but still face some challenges in both availability and accessibility [2]. It is also important that patients and parents are given action plans for acute flares, which would ideally involve early clinic review rather than PED attendance. Our data also showed that patients are spending a long time waiting in PED, which needs to be avoided particularly in the context of immunosuppression. This is especially poignant now in light of the COVID-19 pandemic. Direct referral to rheumatology with non-rheumatological problems likely reflects a desire for specialist advice in the context of complex conditions and medications, for example with regards to infections whilst on immunosuppressive medications, or uncertainty about whether new symptoms are related to the underlying condition. Expansion of helpline services and new approaches such as remote consultations should be explored.