By Albert Francis Onde, Clinical Nurse Specialist, National Hospital for Neurology and Neurosurgery & Jennifer Slough, Clinical Nurse Specialist, National Hospital for Neurology and Neurosurgery
MS Intermediate MasterClass 8, 2019
The Multiple Sclerosis (MS) relapse clinic runs once a week with a MS nurse, neurology registrar and neurology physiotherapist, with oversight by an MS consultant. There are four 30 minute appointments for patients to be seen every week in this clinic. It has been running since 2002, and the format of the clinic was last reviewed in April 2018.
The purpose of this clinic is to give patients fast access to steroid treatment for MS relapses. Patients should be assessed before the clinic to ensure that they are suitable for the clinic and for treatment with steroids.
NICE guidelines recommend ‘Rapid Diagnosis and Treatment of relapse’ , and the MS trust guidelines recommend ‘delivering a responsive, high quality and effective service for people who may be having a relapse’ .
It has been recognised that this clinic does not meet the need of our patient group and that it is not being used effectively for the patients who are being seen. Patients have commented that they have to wait a long time to get appointments and it is felt that this is not a preferred pathway for assessing and treating relapses.
Additionally there have been clinic cancellations due to staff absences and we would like to quantify this and the impact it is having on patients.
We therefore designed a two-pronged audit to assess the need of our patient group and to review the use of the relapse clinic over the past six months. This will help to determine how the clinic can be used more appropriately and how the service can be improved for this patient group.
- To determine how many patients are contacting the service via the Neurodirect service with symptoms of a relapse (per week)
- To quantify how many relapse clinics were cancelled during a six month period
- To audit how many patients in relapse clinic were being treated with steroids, and what type of steroids were prescribed
- To determine if relapse clinic appointments were being used appropriately
- To use this data to re-structure the relapse clinic to better meet the needs of patients with MS at Queen Square
We undertook two audits of our service to determine the number of patients presenting with relapses over 4 weeks, and the use of the relapse clinic over the past 6 months.
- Neurodirect audit – we recorded the number of patients reporting symptoms of a relapse via our nursing email service (Neurodirect) over a 4 week period in September – October 2019. This does not encompass all patients during this period having or reporting relapses, however the majority of patients having relapses present to us via this service. We also recorded the wait time to book into the relapse clinic during this time frame.
- Relapse clinic audit – we audited the relapse clinic from May – October 2019, recording the number of patients who attended, if the clinic was over- or under-booked, if any patients did not attend (DNA) their appointments, the type of MS the patients presented with, if they were treated with steroids, and the type of steroids they were treated with (Oral/Intravenous Methyl-prednisolone). We also recorded when the clinic was cancelled.
- Mean of 12.25 (median 13, range 3) patients reporting relapses per week over a 4 week period in September – October 2019.
- Relapse clinic booking 3-4 weeks in advance
Relapse Clinic audit
- 9 out of 26 clinics were cancelled over 6 months (34.6% of clinics) resulting in 36 cancelled appointments
- 45.6% of patients seen in clinic were treated with steroids
- Of those treated, more than half were treated with Intravenous Methylprednisolone (IVMP) vs. Oral Methylprednisolone (POMP)
- 92% of patients seen in clinic had relapsing remitting MS (RRMS)
This has demonstrated that the number of patients presenting with relapses outnumbers the number of appointments we have available in relapse clinic by more than triple. However, it is important to note that not all patients presenting with relapses will need or be appropriate for treatment with steroids.
This has also demonstrated that the current relapse clinic model is not adequate. Patients are waiting up to a month to be seen in clinic. This is being compounded by the clinic slots being used inappropriately and by a large number of cancelled clinics.
The result of 45.6% of patients in relapse clinic being treated with steroids can be interpreted in two ways. In one way, it could be interpreted that patients are being booked inappropriately into the clinic and are not suitable for the relapse clinic as they do not need or are not being treated with steroids. Conversely, it could be interpreted that having a thorough neurological review in clinic is ensuring that patients are not being over-treated with steroids and shows the value of a clinical assessment rather than treating patients following only a telephone review. It is likely that this number is representative of a combination of these two factors.
Additionally, IVMP is being used more than POMP which is not in line with the evidence base  and is not cost effective. This should be considered when redesigning the relapse service.
Conclusion & Plan
These audits have confirmed our hypotheses and demonstrated that the current relapse clinic model needs to be improved. We aim to do this by:
- Increasing the number of clinic slots available
- Improving staff cross-cover to reduce cancellation of clinics
- Implementing a new pre-clinic assessment and patient inclusion criteria to avoid inappropriate appointments
- Educate staff and patients on efficacy of POMP vs IVMP
This new clinic model will be implemented in January 2020 and reviewed regularly.
The structure of the clinic will also change, with the registrar and MSSN seeing the patient together rather than sequentially, to streamline the clinic and reduce repetition, as well as to promote clinician learning.