“Fast-tracking” a diagnosis of GCA
J Geraghty, S Maguire, M Medani, D Moneley, P O’Connell
Department of Rheumatology, Beaumont Hospital
Giant cell arteritis (GCA) is an immune-mediated vasculitis of large- and medium-sized vessels occurring in older patients (Usually > 60 Years (1). Symptoms include headaches, malaise, jaw pain raised ESR, and if untreated sudden vision loss occurs in up to 20% of patients (2), making early diagnosis with temporal artery biopsy (TAB) critical (3).Treatment is with high dose corticosteroids which is started immediately diagnosis is suspected. TAB could be a day case surgical procedure but at present the majority of patients are kept as inpatients as the procedure should be done within a week of starting treatment. This results in added strain to an already crowded tertiary care center in addition to exposing patient to hospital borne pathogens.
To document the current route by which patient with a suspected diagnosis of GCA are investigated and determine areas in our current practice that could be changed to improve patient experience, time to diagnosis and decrease the financial burden on the hospital.
A chart review was carried out for all patients who underwent a temporal artery biopsy in the past 3 years in Beaumont Hospital. Data collected included: patient demographics, length of inpatient stay awaiting biopsy and biopsy outcome. From this the mean inpatient wait time to TAB was calculated.
Of the 29 patients reviewed 26 required an inpatient admission. The average inpatient stay awaiting a biopsy was 5.23 days, with the longest wait of 14 days. Only 3 patients had biopsies done as day case procedures over the 3 years analysed.
At present, otherwise well GCA patients are spending on average, 5 unnecessary days in hospital awaiting TAB. A proposed outpatient TAB pathway has significant quality implications for patients by avoiding hospital admissions and improving time to diagnosis, and has financial benefits for the hospital also.
An outpatient pathway proposed by the Rheumatology & Vascular Surgery Department will allow rapid outpatient TAB. Following Rheumatology review, a patient is booked into a reserved weekly day surgery slot. Treatment is started immediately and an ophthalmology review is also arranged if visual symptoms are present. A week post biopsy, the patient is reviewed in the Rheumatology clinic to discuss the results and treatment options going forward. A further audit will be required in time to demonstrate benefits of this new pathway.