1. GP AUDIT PROJECT DR C BHATTACHARJEE (GP) AND DR W BENHAM (GP REGISTRAR) YEAR: 2009-2010 SUNNYBANK MEDICAL CENTRE Wyke, Bradford

2. IMPROVING PATIENTS AND DOCTORS SAFETY – A DILEMMA IN PRESCRIBING DMARDS (DISEASE MODIFYING ANTI RHEUMATIC DRUGS) IN GP PRACTICE A SECONDARY TO PRIMARY CARE INTERFACE AUDIT

3. REASON FOR CHOICE 1. DMARDS are used to treat patients with rheumatological conditions 2. Treatment is initiated by the secondary service care providers. 3. All Drugs are potentially toxic 4. A local guideline monitoring protocol has been implemented 5. It has been noticed that patients are told to collect scripts from the surgery even though blood monitoring is done in the hospital 6. This can lead to a potential medico-legal problem The rheumatology department at the Bradford hospital trust takes the responsibility for the prescription and monitoring of the drugs for the first three months of the therapy. Thereafter a shared care is initiated with the general practitioners

4. CRITERIA CHOSEN Search: Literature searches covered the Cochrane library, embase and medline databases A minimum database should include – regular monitoring through blood test and alteration of medications accordingly On the basis of evidence, our chosen audit criteria are: 1. To establish what percentage of the patient population is having regular monitoring in the form of blood tests 2. To identify the number of patients whose monitoring has been missed and why 3. Follow up SunnyBank protocols

5. STANDARDS SET In an ideal world there should be 100% satisfaction. Practically it is not possible; hence the following standard was set: 95% OF THE DISCHARGE LETTERS SHOULD MENTION THE DETAILS OF THE DMARDS AND FOLLOW UP PROTOCOLS 95% OF THE PATIENTS SHOULD HAVE BLOOD TESTS PRIOR TO THE PRESCRIBING DMARDS IN THE PRACTICE THE TIMESCALE FOR REACHING THE STANDARDS WAS 6 MONTHS, FROM JULY 2009 TO JANUARY 2010.

6. PREPARATION AND PLANNING Firstly I discussed my audit topic relating to how to improve the quality of our practice and gathered their opinions Secondly I contacted medical defence union and their opinion was that the prescribing doctor will be clinically responsible for any mishap After discussion, I generated the following view to setting up my audit: My audit will be about looking at the current practice of monitoring the patients after they are seen by the hospital consultants A new template will be created in light of the first data collection The second part of the audit cycle would highlight whether these new monitoring policy would be an improvement on the previous.

7. FIRST DATA COLLECTION No of patients on DMARDS:57 Monitoring done:31 (only in hospital) No Monitoring:23 (40.35%) 1st primary survey in the practice showed that nearly all GPs were dissatisfied with the lack of monitoring. July 2009

8. CHANGES IMPLEMENTED GPs were generally unsatisfied with the current policy particularly not being able to see the blood results prior to issuing the DMARDS. General consensus was that all patients must have regular blood monitoring if they are to collect DMARDS scripts from the practice Therefore the practice decision was: that all patients who are on DMARDS will be contacted and requested to have blood tests in the practice rather than in the hospital should they decide to collect the scripts from the practice. To explore the possibility of installing ICE (on line pathology results) system through PCT in our practice for viewing the blood reports

9. SECOND DATA COLLECTION January - 2010 No of patients on DMARDS:57 Monitoring done:53 No Monitoring:4 (2 refused to come and 2 were not contactable) Implementing ICE system in the practice: IT dept of both PCT and hospital trust were contacted Final outcome was – implementation is not possible due to clinical governance issue

10. COMPARE FIRST AND SECOND COLLECTION WITH STANDARD

11. CONCLUSIONS DMARDS are invaluable to patients with inflammatory arthropathy Current systems lead to bypassing the blood monitoring in the practice may result in increase level of risks to the patients and doctors. Stringent monitoring implementation should improve the quality of the patient which may reduce the number of complaints. A burning issue for all – should we refuse prescribing DMARDS if patients do not have regular blood monitoring – still to solve!

12. Strengths of the audit were: This audit demonstrates that a clear, legible and well-constructed policy on blood monitoring of patients who are on DMARDS can be written. The high response rate to the phone calls suggests that this subject is important to patients and gps. The audit findings were a tool enabling a useful change to be made which was welcomed by all practice doctors The main limitation of my audit is its small scale: The number of the patients is limited to 57 It has been carried out from one particular practice Suggested future improvement: Implementing ICE as standard in all practices