TBA (18A132)

Evaluation of the activity of the Rheumatology department in-patient consult service in a tertiary hospital

Author(s)

Sundanum Sonia, Carey John

Department(s)/Institutions

Department of Rheumatology University College Hospital Galway and Merlin Park Hospital

Introduction

Aside from running a busy outpatient department and participating in hospital medical on-call, Rheumatologists provide an inpatient consult service for referrals ranging from routine to urgent to emergency.

Aims/Background

The aims of our study were
1) To retrospectively assess the number, nature and demographic data of inpatient rheumatology consultations over a period of 2 months
2) To identify the final rheumatologic diagnosis made by the consult team
3) To examine the documentation of the final rheumatologic diagnosis in patients’ electronic discharge summaries (EDS).

Method

Consults are requested by other specialties via an electronic system; the Patient Administration System (PAS).
Consecutive referrals seen by the inpatient consult service from July 1st 2017 to August 31st were recorded on an excel spreadsheet in the Rheumatology shared drive.
The cases were reviewed and the following were recorded: patient’s demographic information, reason for Rheumatology referral, final rheumatologic/musculoskeletal diagnosis, patients offered follow-up in rheumatology outpatient upon discharge, treatment advised, number of patients who required a repeat consult.
The patients’ EDS were also reviewed and documentation of a rheumatology consult taking place during their inpatient stay and the rheumatologic diagnosis made were recorded.

Results

65 patients were recorded in the excel spreadsheet over the 2 month period in 2017; of whom 35 were males and 30 were females with a mean age of 54 years old (age ranged from 18 to 90 years).

A repeat consult was requested on 10% of the above total number of patients during this period of 2 months.The top 5 reasons for referrals in descending order were as follows: crystal induced arthritis (n=17, 26%), polyarthritis in patients with either known or newly diagnosed inflammatory arthritis (n=7, 11%), osteoarthritis (n=5, 7.7%), advise regarding immunosuppressant therapy in patients with underlying rheumatologic conditions (n=5, 7.7%) and finally osteoporosis and advise regarding bone protection (n=4, 6.2%).
10 patients received intra-articular joint aspiration +/- steroid injections.
More than half of the patients seen on consult were offered a Rheumatology outpatient follow-up upon discharge from the hospital (n= 35, 54%).

75% of discharge summaries (n=49) correctly identified that a rheumatology consult took place during the patients’ stay in hospital and 63% of discharge summaries (n=41) had the rheumatologic diagnosis recorded.

Conclusions

The rheumatology inpatient consult service has become busier over the years. This review reflects the variety of rheumatic diseases seen on consult, it also highlights that the most common referral is crystal-induced arthritis.
Gout and pseudogout are conditions commonly encountered in primary care setting and perhaps further education regarding the management of these conditions may be required amongst other specialties.
The consult service helped other specialties to establish or confirm the diagnosis and a treatment plan put in place and over 50% of patients were offered follow-up.

Only 63% of patients had their underlying musculoskeletal/rheumatologic condition recorded in their discharge summaries. While this has slightly improved compared to the previous figure of 59.6% quoted in an audit in 2016, there is further room for improvement. This has potential impact when patients are discharged back to their primary care physicians and also is likely to affect hospital reimbursement.
This needs to be highlighted to junior doctors responsible for writing discharge summaries and further work is needed to educate on the importance of accurately documenting diagnoses on discharge summaries.