THU0588 Management of the Acute Swollen Joint-An Audit of Medical Inpatients

Background Several published recommendations for management of the acute swollen joint exist; the 2006 BSR recommendations for management of the hot swollen joint, and the EULAR/EFORT 2009 recommendations for management of acute knee swelling. Common to these recommendations are that affected patients undergo history taking, examination of musculoskeletal system, blood tests to include full blood count, inflammatory markers and renal function, plain X rays of the affected joint, and aspirationof the swollen joint. Objectives In this audit, we set a standard of expecting management of 90% of patients with acute swollen joints to be in line with these recommendations. The importance of joint aspirationis acknowledged by the fact that knee joint aspirationis deemed an “essential GIM procedure” by JRCPTB (Joint Royal Colleges Postgraduate Training Board) for all registrars training in General Internal Medicine, and competence is “desirable” more junior grades of medical trainees. Therefore, in cases of knee swelling, we documented whether knee aspirationwas performed, prior to rheumatologyreferral. Methods Over 3 months, case notes of medical inpatients referred to the rheumatologyregistrar with acute joint swelling(less than 6 weeks onset) were reviewed. Results 23 patients were identified. History documented in 18/23, examination of joints in 2/23. 16/23 had appropriate blood tests. 5/23 patients had X rays of affected joints. No aspirationof joints other than knees was undertaken prior to rheumatologyreferral. 15/23 patients had knee swelling. 3 had knee aspirationprior to rheumatologyreferral; 1 was done by orthopaedics, and 2 knee aspirationprocedures were done by a renal medical trainee. Median time to rheumatologyreferral was 4 days. Conclusions Lack of awareness of important differential diagnoses may be one factor contributing to the low uptake of appropriate management steps. 2 patients audited were referred with MTP swelling, but on rheumatologyreview, acute knee synovitiswas also present. The acute knee swelling had not been detected, reflecting either lack of full history and musculoskeletal examination, or difficulty in recognizing synovitis. Poor uptake of knee aspirationmay reflect lack of experience or time of seniors on the medical ward to teach joint aspiration. In this audit, knee aspirationsdone by the general medical team were performed by a medical trainee who had recently gained independence in knee aspirationduring rotation on the rheumatologyward. To improve management of acute joint swellingon the medical ward, clinical guidelines are published within the general medical guidance folder of our trust intranet. Rheumatologyregistrars and consultants also undertake supervision for knee aspirationfor medical trainees. A joint model in our clinical skills lab is also available to aid teaching knee aspirationto trainees. References Coakley G, Mathews C, Field M, Jones A, et al. BSR and BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Journal of Rheumatology2006; 45: 1039-1041. Landewe RB, Gunther KP, Lukas C, Braun J et al. EULAR/EFORT recommendations for the diagnosis and initial management of patients with acute or recent onset swelling of the knee. Ann Rheum Dis 2010; 69(1):12-9. Geirsson AJ, Statkevicius S,Vikingsson A. Septic arthritisin Iceland 1990–2002; increasing incidence due to iatrogenic infections. Ann Rheum Dis 2008; 67,638–643 Disclosure of Interest None declared