1. Introduction to the DMARDS care bundle

2. 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

3. An Introduction to DMARD bundles

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

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

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

13. 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

14. 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

15. 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

16. 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

17. 17

18. 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

19. 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

20. 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

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

22. DMARD Bundle
Data collection
Who?
When?
How? 22

23. 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

24. How long will it take?
Not Long! 24 24

25. 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

26. DMARDS Collection Template Forth Valley

27. Data Entry Website

28. Run Charts – Example of Data

29. Composite Data Tayside
Patient Measure introduced July2011

30. DMARD bundle 30

31. 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

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

33. “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”

34. 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

35. Evolution not revolution

36. 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

37. Achievements

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

40. Vision Guideline

41. 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.

42. Resources 42

43. Resources 43

44. 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

45. Questions?