6 Modifications to usual care

6.1 Advise patients to shield, following UK government guidance on shielding and protecting people defined on medical grounds as clinically extremely vulnerable from COVID-19. Refer to the British Society for Rheumatology's risk stratification guide to identify patients for shielding in England. [amended 31 March 2021]

6.2 Refer to the British Society for Rheumatology's risk stratification guide to identify patients who should self-isolate or maintain social distancing at their discretion. [amended 31 March 2021]

6.3 Make policy decisions about modifications to usual care at an organisational level. When deciding what services should be stopped or continued as things escalate, refer to table 3. [amended 31 March 2021]

6.4 Continue core services, including:

  • rheumatology department advice lines (for general rheumatology, connective tissues disease and metabolic bone)

  • essential parenteral day-case treatment

  • blood tests for drug monitoring

  • on-call services for urgent patient review (both new and follow up)

  • delivery and support for patients on new injectable treatments. [amended 31 March 2021]

6.5 Maintain a robust on-call service for cross-consultant referrals that is available all the time, teaming up with other NHS trusts if necessary.

6.6 In tertiary centres, maintain specialised rheumatology networks and virtual multidisciplinary team meetings to discuss the management of complex disorders and to ratify high-cost drug use.

Primary care and the community

6.7 Use rheumatology department advice lines, run by staff with appropriate knowledge, to provide professional advice to primary care and community colleagues about all patients. If available, use an electronic advice and guidance service for GPs.

6.8 The ARMA specialist guidance on urgent and emergency musculoskeletal conditions requiring onward referral supports primary and community care practitioners in recognising serious pathology that needs emergency or urgent referral to secondary care. When prioritising urgent and emergency musculoskeletal referrals to secondary care, refer to table 3. [amended 31 March 2021]

6.9 In musculoskeletal services, prioritise rehabilitation for patients who have had recent elective surgery or a fracture, and for those with acute or complex needs (including carers). Focus on enabling self-management in line with NHS England's COVID-19 guide on restoration of community health services.

Outpatients

6.10 For urgent new referrals from primary care for suspected inflammatory arthritis, suspected autoimmune connective tissue diseases and vasculitis (including giant cell arteritis), generally offer a face-to-face appointment unless the patient requests an initial phone or virtual consultation. [amended 31 March 2021]

6.11 For urgent follow ups (such as for ongoing and new flares, and for treatment adjustment after monitoring), think about using phone or virtual consultations followed by a face-to-face appointment, if needed. [amended 31 March 2021]

Day care

6.12 Prioritise day-case attendance based on the urgency of a patient's condition (for example, for new or ongoing flares, relapses, intravenous induction treatment).

Inpatients

6.13 Maintain rheumatology ward cover, and an out-of-hours on-call service if possible, to:

  • provide advice on immunosuppressive drugs

  • carry out assessments of rheumatological and COVID‑19 disease status

  • enable early discharge.

Table 3 Escalation matrix according to prevalence of COVID-19 and associated available hospital resources [amended 31 March 2021]

Level of pressure on service

Medium (intensive care beds start to be in short supply, still reasonable number of hospital beds)

High (no intensive care beds, theatre pods being used, very low hospital beds, capacity increased by emergency discharges as per mass casualty plans, elective operating stopped) or

Very high (as for high but also reduced capacity for emergency surgery)

Outpatient clinics: all services

New patients:

Continue as usual.

Follow up:

Suspend non-essential face to face follow-up visits and change to virtual/telephone appointments.

Postpone long-interval (at least 6 months) face to face follow ups and change to virtual or telephone appointments

Adjust templates to minimise waiting times in department.

Option for telephone or video consultation instead of face-to-face consultation, unless absolutely necessary to see face to face.

New patients:

Cut all but urgent clinic attendances.

See new patients with suspected inflammatory arthritis including autoimmune connective tissue disease and vasculitis face to face.

Consultant to triage other urgent new patients to determine whether they need to be seen face to face or virtual or telephone appointment would be appropriate.

Follow up:

Give urgent patients only the option of a face to face appointment and other patients should be given a virtual or telephone appointment

Suspend routine face to face follow up appointments and change to virtual or telephone appointments

Outpatient clinics: patients on conventional disease-modifying antirheumatic drugs, JAK inhibitors and biologicals

Post or use home delivery for oral systemic drugs or provide FP10 prescriptions for readily available drugs.

Prescription duration should be extended to 3 months.

Maximise blood tests out of hospital where local resources allow.

Schedule appointments to avoid patients waiting for treatments.

Maximise use of home care administration.

On a case-by-case basis, determine whether patients could reduce any of their medication.

On a case-by-case basis, determine whether patients could reduce any of their medication.

Consider frequency of blood monitoring appointments and whether they could be reduced in patients with stable disease who have established treatment.

Day-care units

Screen patients to check whether treatment could be deferred, for example, in a patient whose condition is stable and who is on regular rituximab infusions.

Switch intravenous infusions to subcutaneous injections where available, for example, tocilizumab and abatacept.

High: Screen patients to check whether treatment could be deferred, for example, in a patient whose condition is stable and who is on regular rituximab infusions.

Very high: Screen patients to determine benefit versus risk with any delay in treatment.

Denosumab must not be deferred (consider administration in the community) but zoledronate could be deferred up to 6 months.

Rheumatology advice lines (consider providing extra cover from home by nurses needing to self-isolate)

Key resource:

Prompt response needed.

Key resource:

Prompt response needed.

Management of disease flare:

Have a lower threshold for issuing acute prescriptions if appropriate, for example, colchicine for gout or prednisolone for a rheumatoid arthritis flare.

Consider using an FP10 (using postal service from outpatient pharmacy, if possible).

On-call service (hospitals where rheumatology out-of-hours on-call service is not available currently, should consider implementing an on-call rota)

Ensure good liaison with acute services and be involved in managing rheumatology conditions in patients admitted with coronavirus.

Consultants who need to self-isolate but are otherwise well could provide a second on-call service, deliver remote consultations (subject to an appropriate trust policy being in place) and give advice on the phone.

Ensure good liaison with acute services and be involved in managing rheumatology conditions in patients admitted with coronavirus.

Consultants who need to self-isolate but are otherwise well could provide a second on-call service and give advice on the phone.

Very high: In case of a significant number of consultants off work, consider liaising with a nearby hospital on-call service and use a virtual regional multidisciplinary team meeting facility.