COVID 19 crisis: Rapid development of remote rheumatology medication clinics

Penford, R.; Wren, E.; Mackay, K.

Background: We used to initiate DMARD(s) and Biologic therapies via nurseled shared medical appointments (Group clinics) and could see up to 30 patients per week, with a maximum of 6 patients per group. We did this to start patients on their medications efficiently and safely and to manage the increase in workload. However, with the onset of the COVID 19 pandemic, we had to stop these clinics immediately, but, we did not have capacity to start everyone on their medications in a timely manner by telephone. Telephoning each individual took > 9 hours per week, whereas previously it took 3-4 haours. Objectives: We wanted to start patients on their all rheumatology medications safely and efficiently (within 10 days). Methods: By April 2202, we had organised the filming of 10 short healthcare videos to give patients all the information they required to start a range of DMARDs and biologics. We developed a new protocol (fig 1);patients are asked to view the relevant video, contact our department to confirm they understand the safety monitoring, risks, potential side effects, dose increases etc. As soon as they confirm by email they are happy to start treatment, a prescription is generated and emailed to the hospital outpatient pharmacy, where it is dispensed and delivered to the patient's home. We send a follow up reminder letter about blood test monitoring etc (copy to GP) and a 'shared care agreement' to GP. They are given the option to have a telephone clinic appointment with a specialist nurse if required. Results: Of those requiring DMARDs, 62% reviewed the video, completed the checklist and confirmed by email they were happy to start treatment, within 24-hours. 88% had completed within 7 days. Over half the patients (56%) were starting DMARDs for the first time, of those 8% requested a telephone consultation to discuss treatment further with the Rheumatology nurses. Of the 44% of patients already taking a DMARD and due to start a second medication 24% required a telephone clinic appointment. As this is a new service, we asked for feedback, receiving replies from 34%, all scoring between 9/10 and 10/10. We have released > 7 hours of specialist nurse time for telephone/helpline clinics. Conclusion: The development of digital / remote medication clinics has been a success and we will continue with this approach. We have limited face-to-face appointments, started patients on rheumatology medications more quickly and efficiently than previously (but maintained safety), allowed the nursing staff time to spend more time working in our telephone clinics and have had excellent patient feedback. Although, we are aware, this is at a cost of no peer-to-peer interaction, which has been of value in the past.