Department of Rheumatology, Musgrave Park Hospital, Stockman's Lane, Belfast, Northern Ireland, UK
SIR, Changing medical practice in rheumatology has resulted in fewer hospital admissions and increasing numbers of patients being seen in day-ward settings. The available evidence suggests that this is acceptable to patients and results in similar outcomes to in-patient treatment, with some reduction in hospital costs [1]. The rheumatology day ward in Musgrave Park Hospital, Belfast, opened in 1996. It operates 4 days per week, is staffed for six beds per day, and is shared by five consultant teams. We present an audit of its use during the 6 months from July 2000 to December 2000.
Summary sheets of each admission were completed at the time, and these were then reviewed by the authors. Nine hundred and nineteen day admissions were recorded in the 6-month period, with a mean of 10.8 admissions per day. Rheumatoid arthritis was the primary diagnosis in 43% of cases, connective tissue diseases (mainly systemic lupus erythematosus and scleroderma) in 16%, seronegative inflammatory arthritides (mainly ankylosing spondylitis and psoriatic arthritis) in 16%, osteoarthritis in 10%, vasculitis in 4% and other diagnoses in 11%.
The primary reasons for admission included the assessment and management of complex problems (35%), rheumatological emergencies (10%), multiple joint injections (5%), intravenous infusions other than biologicals (8%), commencement of disease-modifying anti-rheumatic drugs (not including biologicals) (4%), assessment and monitoring of biological treatment (7%), intravenous infliximab (Remicade) infusions (6%), nursing care (11%) and others (14%).
Seventy-one per cent of patients had blood tests, 22% radiological investigations, 16% intravenous infusions, 22% joint injections and 5% intramuscular injections. Twenty-four per cent were seen by professions allied to medicine (mainly physiotherapists and occupational therapists). Infliximab was the commonest intravenous infusion (6%), followed by corticosteroids (5%), prostacyclin (3%) and cyclophosphamide (1%). Thirty-three per cent of patients were reviewed in out-patient clinics and 58% in the day ward itself; 6% were admitted to the ward as in-patients and 3% were discharged.
This audit presents some interesting findings. We have been seeing on average 4.8 extra patients per day above current staffing levels. Despite this, almost half (48%) of the patients were seen within 4 weeks. The mix of diagnoses seen was not unexpected, rheumatoid arthritis accounting for by far the largest single diagnosis. One surprise was the large number of patients being reviewed at the day ward itself. It seems that a number of patients have been reviewed at the day ward rather than in routine out-patient clinics. In some very complex cases this is appropriate management, but for others out-patient clinic appointments would be more appropriate if these were readily available.
Infliximab is already the most common intravenous infusion given. This area in particular has important implications for the future provision of rheumatology services. The use of day-care facilities to administer biological therapies seems to be appropriate and logical. Increasing numbers of patients are likely to receive these in future and this may greatly increase the workload of already busy day-care units. An additional solution to the problem of reviewing some patients in out-patient clinics is to increase the capacity of day-care facilities. For either of these approaches to be successful, measures to increase the numbers of nursing and medical staff, particularly consultants, to cope with the increased demand would be important.
We are now reviewing our day-ward service in the light of these findings. Where appropriate, we are attempting to review some patients in routine clinics rather than the day ward. New funding for biological therapies has prompted moves to open the day ward for 5 rather than 4 days per week. However, our ability to increase the number of out-patient appointment slots and day-ward staff may be constrained by resource limitations.
We would suggest that rheumatology units examine their day-care practice, particularly in the expectation of increasing numbers of patients receiving biological therapies, and plan strategies to cope successfully with the increased workload this may present.
Notes
Correspondence to: A. P. Cairns.
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