Urgent or Not Save

Rheumatologic practice has been turned upside down as a consequence of the COVID-19 crisis. 

Our practice standards have been flipped, such that we are hardly ever seeing patients face-to-face (F2F) in the clinic. The physician’s best clinical tool has become the webcam and telephone. And it seems that our day-to-day goal is keep our patients stable, to get by and wait out this period of uncertainty.  It’s hard to know if we are dealing with a subnormal or supranormal reality. Yet I do believe that this peculiar evolution can and will change rheumatology – in a good way.

First is our obligation to take care of established patients and meet the needs of new patients, many of whom will have serious, mysterious and as yet undiagnosed rheumatic complaints.

Most clinicians have quickly transitioned to remote access evaluations or more established forms of telemedicine, where the nagging question is, “who needs to be seen in clinic or in the hospital with a F2F evaluation?"  After talking to many colleagues, it basically boils down to urgency.  

Our views of “urgent” complaints or disease are likely to overlap, but for many, this seems to be a vague designation with an uncertain algorithm.  This is backed up by many studies looking at referrals that have shown that a minority patients considered urgent at presentation were reclassified and, similarly there are patients with routine complaints who were later declared urgent or emergent.

All patient complaints or symptoms need to be carefully considered for potential underlying morbidity today our patient evaluations should be considered as: 1) Routine; 2) Emergent; or 3) Urgent. In this article I will quickly review those conditions and presentations that should be considered as Emergent or Urgent, as such patients may require more than a telephone triage or video visit.

Routine Evaluation and Care

This category is self-explanatory and would include patients without new complaints or worsening symptoms and may also include symptomatology that can be “routinely” evaluated, observed over time and treated symptomatically.  The listing here includes all content from a rheumatology textbook and takes a fellowship and lifetime of experience to master.

Urgent – Expedited Evaluations – F2F assessments

This could be best described as those conditions that merit immediate attention.  Harrisons Textbook of Internal Medicine says, “There are several urgent conditions that must be diagnosed promptly to avoid significant morbid or mortal sequelae. These “red flag” diagnoses include septic arthritis, acute crystal-induced arthritis (e.g., gout), and fracture.” Notably these conditions are unified in their presentation as – 1) acute and 2) monarticular (or focal) in presentation.

Several studies have evaluated the nature of rheumatology referrals and presentations and in general, have shown that roughly 5% of referrals and patients presenting to rheumatologists will have “urgent disorders or acute inflammatory rheumatic disease. 

• A German study of 103 referrals classified 4.9% as an acute inflammatory rheumatic disease with an urgent indication  Holle JU, et al. Z Rheumatol. 2019 Nov;78(9):832-838
• Hazelwood et al evaluated of the intake and triage of rheumatology referrals to their department of 13 Rheumatologists.  Among 9181 referrals nearly 80% were considered routine (79%), with the remainder being moderate (16%) or urgent (5%).  Hazelwood GS, et al. Arthritis Care & Research, 68: 1547-1553

The evaluation of Urgent complaints or conditions is discretionary but appears to warrant evaluation in 1-4 weeks.  The following list of concerning symptoms or conditions that merit more than routine care should either be seen as a F2F urgent visit or referred to the Emergency Department: 

• Acute monarthritis (septic, non-septic, crystal)
• New trauma or suspected fracture
• Early inflammatory arthritis
• New or worsening polyarthritis (with functional implications)
• Suspected polymyalgia rheumatic
• Fever > 102F
• Bloody diarrhea
• Distal (limb or digital) ischemia
• New focal neurologic complaints
• New spinal stenosis or cauda equina syndrome
• Suspected transverse myelopathy
• Acute anterior uveitis

Rheumatologic Emergencies

These are conditions that, if not immediately diagnosed and manage, will impart a significant morbid or mortal risk upon the individual.  While the assessment of an “emergent” risk is somewhat subjective, I would encourage you to modify this as you deem appropriate.

• Hospitalization or Emergency Department Referrals
• Scleroderma Renal Crisis (HTN, microangiopathic hemolytic anemia)
• Stridor (cricoarytenoid arthritis in RA; subglottic stenosis in Relapsing Polychondritis)
• Seizures
• Lupus patients with seizures, altered mental status, high fever, pericarditis
• Ankylosing spondylitis with spinal trauma, falls
• Inflammatory myositis with  dysphagia, increasing dyspnea, or rhabdomyolysis
• Macrophage activation syndrome
• Catastrophic antiphospholipid syndrome
• Thrombotic events in a Rheumatic patients (MI, CVA, venous thromboembolism)
• Diffuse alveolar hemorrhage
• Acute pneumonitis

Guidelines from Societies and Agencies

NICE

Under NICE guidelines for rheumatic disease patient care considers “urgent access” to be important and states that people with RA and disease flares or possible drug-related side effects should receive advice within 1 working day of contacting the rheumatology service.  A recent NICE audit of UK centers found this criterion was met by 96% of centers. 

ACR

The ACR has several task forces hard at work to serve the needs of the membership. Their efforts can be found here. 

American College of Radiology 

The CDC has recommended that clinicians should reschedule or delay non-urgent outpatient imaging evaluations in order to minimize community spread. Many elective/outpatient procedures can be delayed (Fluoroscopy, upper and lower GI, modified barium swallows, myelograms, arthrograms, joint aspiration or injections, etc.).  Screening studies should be halted (Breast mammography, LDCT, CT colonography, BMD, vascular sonography, Ca++ scoring)

The need for urgent imaging during the COVID crisis should be restricted; CT scans should be considered the most appropriate choice for evaluation of sick hospitalized patients.