Introduction to the DMARDS care bundle

Aims of session Introduce the DMARDs Care Bundle Discuss measures, operational definitions and rationale. Discuss data collection process and frequency Discuss ways to involve patients Share resources, challenges and learning The aim of this session is to introduce the concept of care bundles and how they drive improvement , The session should cover: What are they How they work - sharing the experience from SIPC To highlight the care bundle practices will be using and the rationale for it Highlight the frequency and sample size of data collection Demonstrate the data collection process

An Introduction to DMARD bundles

Bundles vs Audits? Can’t always count everything every time Volume may be too high, but high volume is an opportunity to sample Take 5 or 10 notes and check if actions done Less work, but more often 4

Whole is better than the sum of its parts Reliable Care - Care Bundles 4 or 5 elements of care All or nothing Whole is better than the sum of its parts Evidence based Across Patients Journey Creates teamwork Done reliably Small frequent samples This slide notes the key elements of a care bundle 5

All or nothing measures ‘Care bundles’ are all or nothing measures The % of patients who achieve ALL individual measures/get all appropriate care Appropriate when: Each element is important in its own right Patient outcome is improved by ALL measured care being received (the whole is greater than the sum of the parts) Each element should be necessary every time This slide introduced the concept of composite measures “all or nothing” = reliable care 6

Across Patients Journey Reliable Care - Care Bundles 4 or 5 elements of care All or nothing Whole is better than the sum of its parts Evidence based Across Patients Journey Creates teamwork Done reliably Small frequent samples What evidence have we used to form the bundles? 7

DMARDs Care Bundle Appropriate tests are carried out in correct timescale? Has there been a full blood count in the past 12 weeks (AZA) 8 weeks (MTX) as per local guidance?   Appropriate action taken and documented for any abnormal results in previous 12 weeks? If any abnormal results in previous 12 weeks [WBC<4, neutrophils<2, platelets < 150, ALT > x2 normal upper limit (>60)] has action been recorded in the consultation record? Blood tests reviewed prior to prescription? Is there a documented review of blood tests prior to issue of last prescription? Appropriate immunisation? Has the patient ever had pneumococcal vaccine? Patient asked about any side effects following last time blood was taken? Have all the above measures been met? Bundle measures for each of the bundles in the programme were developed, tested and changed throughout the pilot work for the programme 8

DMARD Bundle Appropriate tests are carried out in correct time scale Measure: Has there been a full blood count in the past 12 weeks (AZA) or 8 weeks (MTX) as per local guidance   BSR/BHPR guideline for disease-modifying anti-rheumatic drug (DMARD) therapy in consultation with the British Association of Dermatologists Local guidance should be followed where available Different boards will have different guidelines e.g. Tayside FBC 6 weekly and local guidelines may not exist

DMARD Bundle   Appropriate action are taken and documented for any abnormal results in previous 12 weeks Measure: If any significantly abnormal results occurred in the previous 12 weeks has action been recorded in the consultation record? (ref appendix 1) Need clear definitions of abnormal test results BSR/BHPR guideline for disease-modifying anti-rheumatic drug (DMARD) therapy in consultation with the British Association of Dermatologists Local guidance should be followed where available

Guidelines Multiple specialists initiate these medications Multiple guidelines available (eg BAD, BSR) An agreement!

Local Guidelines A challenge is the number of specialists involved in these drugs , locally and also through tertiary care services 12

DMARD Bundle Blood tests are reviewed prior to prescription    Blood tests are reviewed prior to prescription Measure: Is there a documented review of blood tests prior to issue of the last prescription? No patient should receive a repeat prescription if the monitoring has been inadequate. Good practice

DMARD Bundle Appropriate immunisation Measure: Has the patient ever had a pneumococcal vaccine?   Rheumatology Local Policy, Good practice “across the patient journey” Across the patient journey- preventative care important too 14

DMARD Bundle Side effects Measure: Is it documented that the patient was asked about any new or recent side effects the last time blood was taken for drug monitoring? Recognising the importance of Patient Involvement as per Quality Strategy, The Health Foundation – Closing the Gap  

Reliable Care - Care Bundles 4 or 5 elements of care All or nothing Whole is better than the sum of its parts Evidence based Across Patients Journey Creates teamwork Done reliably Small frequent samples Multidisciplinary- most practices will need to use doctors, nurse/phlebotomist, and admin to achieve the bundles 16

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Reliable Care - Care Bundles 4 or 5 elements of care All or nothing Whole is better than the sum of its parts Evidence based Across Patients Journey Creates teamwork Done reliably Small frequent samples Reliability is a crucial part of the methodology 18

DMARD Bundle Composite    Composite Have all elements been met for each patient - the ‘all or nothing’ (composite) measure? Every patient , every intervention, every time 19

Small frequent samples Reliable Care - Care Bundles 4 or 5 elements of care All or nothing Whole is better than the sum of its parts Evidence based Across Patients Journey Creates teamwork Done reliably Small frequent samples 20

DMARD bundle 10 patients on Methotrexate or Azathioprine randomly sampled each calendar month 21

DMARD Bundle Data collection Who? When? How? 22

Who will collect the data? Highlight that collecting data is about teamwork - This ties in with safety climate – better involvement throughout the practice will improve results

How long will it take? Not Long! 24 24

Data Collection Process and Frequency We have different mechanisms for data collection and health boards will have the options of: Using a national web-based data collection tool developed by Healthcare Improvement Scotland Inputting data into spreadsheets developed for the bundle Adapt local systems to support data collection For further information on data collection process is available from the SPSP-PC team. There are a number of different mechanisms for data collection, outlined in this slide. Currently a national system is being tested in 2 health boards, and will be rolled out nationally in the Summer 25

DMARDS Collection Template Forth Valley

Data Entry Website

Run Charts – Example of Data

Composite Data Tayside Patient Measure introduced July2011

DMARD bundle 30

Sharing data at board level Newsletters to all practices Presentations to Board Presentations at PLT Sessions/Practice Managers Submission of Committee Papers Different ways to share data 31

Using & Sharing Your Data Not just about collecting data, but about using it Its YOUR data!

“The care bundle was useful because it identified gaps” “You can see week by week, month by month, whether or not you are showing any improvement, we seem to be improving and that’s good”

Reflection Discuss your data What does it show? What have you done to improve your systems? What challenges have you faced? How else might you improve your results/systems? What can you share? 34

Evolution not revolution

PDSA - Improve Compliance of Patients Attending Monthly Blood Monitoring Ensure patients prescribed Methotrexate or Azathoprine attend a monthly review for blood monitoring Patients complying by attending blood monitoring will increase Using a variety of engagement methods Patients engaging 5 Stop repeat prescription until they attend 4 Restrict the amount of repeat prescription available to them to encourage attendance 3 Put a note on patients repeat prescription 2 Send information stating reasons for why it is important to attend 1 Invite patients who have failed to comply by telephone

Achievements

EMIS template (NPT) Improvements in data collection. EMIS (FV) and Vision (Tayside) 38

Vision Guideline

Moved from Paper-Based Recalls to Electronic Recalls Utilising I.T. Moved from Paper-Based Recalls to Electronic Recalls To ensure continuity during locum cover 1 practice developed this message A reminder on the clinical system regarding prescribing of medications was added for the clinicians To ensure GPs check patients bloods prior to Rx re-issue, practices have enforced re-authorisation of one repeat prescription only These are just some of the examples where IT has helped to improve practice systems: Before their involvement in the programme, one practice used a paper-based folder to hold information on recalls. Involvement in this programme prompted the practice to update the system, and they now use an electronic system to manage the recalls, which also generates the patient letters. On practice with single handed GP practice identified issues with the prescribing of DMARDS when the GP was off and a locum was in providing cover. One practice added this message to the clinical system to prompt to ensure that pneumococcal status is up to date and that there are no contraindications. Some practices have forced re-authorisation of one repeat prescription only by the GP rather than allowing printing of scripts by admin staff. This prompts GPs to check patients blood results or order these to be undertaken before issuing a prescription.

Resources www.healthcareimprovementscotland.org/pspc/aspx 42

Resources www.knowledge.scot.nhs.uk/spsp-pc.aspx 43

Care bundles Shed new light on our current practice Act as a catalyst for improvement in care Can lead to increased awareness This slide summarises the positive effects care bundles can have

Questions?