P58 A re-audit on the adherence to blood monitoring guidelines in paediatric rheumatology patients on methotrexate, etanercept and adalimumab after the introduction of a blood clerk in the team
Authors: Hunter Eleanor , Cuevas Octavio Aragon 
Published: October 2019

Abstract

Background
A previous audit carried out in 2017 showed that the blood monitoring of patients on methotrexate was substandard with over 60% of patients not being monitored according to guidelines. A positive correlation was found between postcode distance to the tertiary centre and substandard monitoring (those patients living further away showing worse monitoring records). As a result of this audit, a blood clerk was introduced in the team who would be responsible for chasing patients for blood results. This is a re-audit to ascertain the impact of the changes introduced to our service.

Methods
All rheumatology patients being prescribed methotrexate, etanercept and adalimumab were captured using dispensing records. The electronic prescribing software MEDITECHv6 was used to gather data for each patient including demographic data, frequency of blood tests and varicella and measles immune status. Patients were divided into two groups: methotrexate and biologics. These were further divided into treatment starters and maintenance patients. Treatment starters needed to meet the following 6 criteria in order to achieve appropriate monitoring: correct frequency of tests, full blood count (FBC) checked, liver function tests (LFTs) checked, renal function checked and varicella and measles immunity checked. Maintenance patients needed to meet 4 criteria to achieve appropriate monitoring: correct frequency of monitoring, FBC, LFTs and renal function. Potential correlations between substandard monitoring and postcode distance to the centre were explored. Blood clerk intervention rates and their effects were analysed.

Results
216 patients were included in the audit. Overall 76 of them (35%) were appropriately monitored. For all patients on methotrexate and those on maintenance biologics, the main reason for substandard monitoring was a delayed timing of blood taking (50% and 65% of patients respectively). For patients starting on biologics the main factor affecting standard of monitoring was the lack of documentation of varicella and measles immune status (42% of patients). 72% of the patients with inappropriate frequency of blood tests received an intervention from the blood clerk. No correlation was found between distance to the centre and appropriateness of monitoring.

Conclusion
Adherence to monitoring guidelines has not significantly changed after the introduction of the blood clerk, with figures of adequate monitoring very similar to the previous audit (35%). The blood clerk contacts starting patients at 4 weekly intervals if needed, and maintenance patients every 3 months. Bearing in mind the time needed to set up a blood monitoring appointment after a blood clerk intervention, the number of patients with appropriate monitoring raises to 64% in the methotrexate group and 67% in the maintenance biologics group. This shows efficacy of the blood clerk intervention once it happens. Improved guideline adherence may be achieved by bringing forward the blood clerk interventions by 2 to 4 weeks in each patient group.

Conflicts of Interest
The authors declare no conflicts of interest.