Quality statement 1: Referral

Quality statement

People with suspected persistent synovitis affecting the small joints of the hands or feet, or more than 1 joint, are referred to a rheumatology service within 3 working days of presentation.

Rationale

Rapid referral of people with suspected persistent synovitis is important to avoid delay in diagnosis and increase the likelihood of early treatment initiation. Given the potentially devastating effects of delayed diagnosis in terms of joint damage and quality of life, people with these symptoms and signs should be considered to need urgent action.

Quality measure

Structure: Evidence of local arrangements for people with suspected persistent synovitis affecting the small joints of the hands or feet, or more than 1 joint, to be referred to a rheumatology service within 3 working days of presentation.

Process: Proportion of people with suspected persistent synovitis affecting the small joints of the hands or feet, or more than 1 joint, who are referred to a rheumatology service within 3 working days of presentation.

Numerator – the number of people in the denominator who are referred to a rheumatology service within 3 working days of presentation.

Denominator – the number of people with suspected persistent synovitis affecting the small joints of the hands or feet or more than 1 joint.

What the quality statement means for each audience

Service providers ensure systems are in place for people with suspected persistent synovitis affecting the small joints of the hands or feet, or more than 1 joint, to be referred to a rheumatology service within 3 working days of presentation.

Primary care professionals ensure that people with suspected persistent synovitis affecting the small joints of the hands or feet, or more than 1 joint, are referred to a rheumatology service within 3 working days of presentation.

Commissioners ensure they commission services that enable people with suspected persistent synovitis affecting the small joints of the hands or feet, or more than 1 joint, to be referred to a rheumatology service within 3 working days of presentation.

People with suspected persistent synovitis (inflammation of the joints) affecting the small joints of the hands or feet, or more than 1 joint, are referred to a rheumatology service within 3 working days of first reporting the problem.

Source guidance

NICE clinical guideline 79 recommendation 1.1.1.1 (key priority for implementation).

Data source

Structure: Local data collection.

Process: Local data collection. Contained within the British Society for Rheumatology National clinical audit for rheumatoid and early inflammatory arthritis.

Definitions

Timeframe derived from expert consensus.

Symptoms and signs of persistent synovitis include persistent (not resolving within 3 or 4 weeks) pain, swelling, heat, early morning stiffness lasting more than 30 minutes and often recurring after longer periods of rest, and loss of function of the affected joint. Occasionally the joints may also be red, but this is unusual. The person may also have systemic symptoms of inflammation, which include malaise, fever, sweats, fatigue and weight loss.

Any person with suspected persistent synovitis of undetermined cause whose blood tests show a normal acute-phase response or negative rheumatoid factor should still be referred urgently as they may still have rheumatoid arthritis.

A rheumatology service comprises a specialist multidisciplinary team, all of whom have expertise in managing rheumatoid arthritis. The team is led by 1 or more consultant rheumatologists and includes nurse specialists, physiotherapists, occupational therapists, podiatrists and orthotists. It has access to supporting specialties including orthopaedic surgery, psychology, radiology with rheumatological ultrasound and MRI experience, and may also have rheumatology doctors in training.