Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID- 19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. G Model ARTICLE IN PRESS Reumatol Clin. xxx (xxxx) xxx–xxx www.reumatologiaclinica.org Brief Report Impact of the COVID-19 pandemic on rheumatology nursing consultation夽 Susana P. Fernández Sánchez,a Fermín Rodríguez Muñoz,b Ana Laiz,a,c Ivan Castellví,a,c Berta Magallares,a Héctor Corominasa,c,∗ a Servicio de Reumatología y Enfermedades Autoinmunes Sistémicas, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain b Enfermería de Consultas Externas, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain c Universitat Autònoma de Barcelona (UAB), Barcelona, Spain a r t i c l e i n f o a b s t r a c t Article history: Objective: The COVID-19 pandemic has brought major changes to the model of patient care in Rheuma- Received 7 November 2020 tology. Our aim was to compare the change in the care delivered in a rheumatology nursing consultation Accepted 10 February 2021 before and during the pandemic. Available online xxx Material and methods: Descriptive and observational study. Patient care was registered before and during the COVID-19 outbreak. The variables collected were age, sex, prevalent rheumatic disease, type of visit Keywords: and reason for consultation. Rheumatology nursing Results: 254 consecutive patients were included before the COVID-19 pandemic for 20 days and 251 Activity Outbreak patients during COVID-19 for 10 working days. The mean age was 61 years before and 57 during the COVID-19 pandemic. Of both groups, 74% were women. The most frequently attended pathologies before and during Impact COVID-19 were rheumatoid arthritis and spondyloarthropathies. Scheduled face-to-face visits decreased during COVID-19 (46.5% versus 1.6%), with an increased number of phone scheduled visits (2.8% versus 52.2%) and spontaneous consultations either by phone or e-mail (28.3% versus 45%). The type of scheduled visits during COVID-19 were for stable diseases (20% versus 37%) and monitoring (12% versus 38%). The reason for spontaneous consultation increased during COVID-19 and were mainly doubts regarding prevention measures and treatment optimization (13.8% versus 31.1%). Conclusions: The first wave of COVID-19 brought to rheumatology nursing consultation a global increase in all activities in the number of visits per day, in the number of stable patient controls, in monitoring and answering patient concerns. © 2021 Published by Elsevier Espa?a, S.L.U. Impacto de la COVID-19 en la consulta de enfermería reumatológica r e s u m e n Palabras clave: Objetivo: Comparar el cambio en la actividad asistencial realizada en una consulta de enfermería reuma- Enfermería reumatología tológica antes y durante la pandemia. Actividad Material y métodos: Estudio descriptivo y observacional de 254 pacientes consecutivos antes y 251 Pandemia durante. COVID-19 Resultados: El tipo de visita programada presencial disminuyó durante COVID-19 (46,5% vs 1,6%), aumen- Impacto tando la visita programada telefónica (2,8% vs 52,2%) y las consultas espontáneas a través del teléfono o email (28,3% vs 45%). Las funciones realizadas en las programadas fueron el control del paciente estable (20% vs 37%) y la gestión (12% vs 38%). El motivo de consulta espontánea incrementó durante la COVID-19 sobre todo: dudas respecto a medidas de prevención y optimización de tratamiento (13,8% vs 31,1%). 夽 Please cite this article as: Fernández Sánchez SP, Rodríguez Muñoz F, Laiz A, Castellví I, Magallares B, Corominas H. Impacto de la COVID-19 en la consulta de enfermería reumatológica. Reumatol Clin. 2021. https://doi.org/10.1016/j.reuma.2021.02.003 ∗ Corresponding author. E-mail address: vancor@yahoo.com (H. Corominas). 2173-5743/© 2021 Published by Elsevier Espa?a, S.L.U. REUMAE-1511; No. of Pages 5 G Model ARTICLE IN PRESS S.P. Fernández Sánchez, F. Rodríguez Muñoz, A. Laiz et al. Reumatología Clínica xxx (xxxx) xxx–xxx Conclusiones: La primera ola de la COVID-19 generó en la consulta de enfermería un incremento global de todas las actividades: número de visitas/día, en el número de controles de pacientes estables, en gestión y en la resolución de dudas. © 2021 Publicado por Elsevier Espa?a, S.L.U. Introduction versus 18.4%). During COVID-19 there was a decrease in care to patients with RA and an increase in consultations of patients with The COVID-19 pandemic has become a stress test for health sys- systemic lupus erythematosus (SLE), Sjögren’s syndrome and vas- tems worldwide. Studies on its impact on nursing staff throughout culitis (Table 1). the word highlight that it has affected 4 aspects: an increase in The face-to-face programmed type of visit fell significantly work load, in health (with high morbimortality), in a lack of con- during COVID-19 (46.5% versus 1.6%) in the areas of education, pro- tinuous training and in an opportunity where nurses have been able cedures, vaccine review, cardiovascular risk evaluation (P < .001). to provide quality care.1–3 This was not the case in analytical controls (P = .243) and treat- On 14th March 2020, a period of strict lockdown began for ments (P = .723). The non face-to-face—telephone—programmed the Spanish population due to the first wave of the pandemic. All visit increased (2.8% versus 52.2%) and spontaneous telephone or hospital rheumatology professionals had to adapt to this new situ- email consultations (28.3% versus 45%). The most common reason ation, including rheumatology nursing, which has been present in for spontaneous consultations of patients were doubts: on the pro- Spain since 1980.4 The consultation model went from being basi- tection measure against COVID-19, the impact of SARS-CoV-2 on cally non face-to-face and nationally renowned nursing activities5,6 the rheumatic disease, the need for adherence to immunosuppres- were moulded to the requirements of the rheumatology services sant treatments, the dispensation of hospital treatments during and even to the requirements of the hospital itself. Non face-to- confinement, difficulties with dispensation of hydroxychloroquine face nursing care already existed in rheumatology units in Spain and other doubts relating to the difficulty of accessing primary care a long time before the pandemic. This care could be programmed centres. into the nursing schedule, or spontaneously carried out, or given in The functions carried out by nursing professionals in pro- accordance with patient request.7 grammed visits which increased during COVID-19 were stable The aim of this study was to describe and compare the activity patient control (20% versus 37%) and management (12% versus 38%) carried out in a monographic rheumatology nursing consultation (P < .001). The reason for spontaneous consultation (telephonically of long-standing in a university hospital before and during the first or through email) which significantly increased during COVID-19 wave of the COVID-19 pandemic. This was the first study on the were doubts (35 [13.8%] versus 78 [31.1%]) (Table 2). repercussions of COVID-19 in a specific rheumatology nursing con- sultation. Discussion Material and methods Nursing care since March 2020 has clearly been affected by the COVID-19 pandemic. This study shows how the first wave gener- A retrospective, observational study was conducted. The reasons ated an increase in care pressure, a change in the way visits were for consultation of 254 patients from the rheumatology nursing made and in the activity carried out in a monographic rheuma- monographic consultation of a university hospital before COVID-19 tology nursing consultation. The increase in the number of overall were recorded, and of 251 patients during the COVID-19 pandemic. nursing visits made (programmed/spontaneous) per day was due Demographic variables of patients were age, sex and rheumatic to the emergency situation caused by the pandemic, to the situ- pathology. Variables relating to the way in which the activity was ation of risk perceived by the patients (particularly those treated performed were also included: face-to-face or through the phone with immunosuppressants) and the reorganisation of our service or electronic mail, and on the content of the nursing activity offered (rheumatologists from external consultations were transferred to to the patient: 1) programmed in the diary: education, procedures, care for COVID-19 patients). cardiovascular risk control, review of vaccines, analytical control, One study conducted in 2013 by the Nursing Workgroup of control of stable patients, treatments and management and 2) the Spanish rheumatology society (GTESER for its initials in Span- spontaneous consultations/on-demand consultations: outbreak of ish) on rheumatology nursing activity in Spain and another later their disease, side effects from treatments, activation of treatments, conducted in 2019,5,6 reflected that the most frequently regularly doubts and administrative issues. attended pathologies in the nursing consultations were RA and The data was recorded on a database for statistical analysis. For spondyloarthritis under normal circumstances. Our current data quantitative variables mean and standard deviation were calcu- also confirm that this tendency was repeated both before and dur- lated. Statistical significance level was P < .05. For comparisons of ing the pandemic. We are unaware of the reason why RA, despite proportions, contingency tables were used and for inference the being the most frequent, also reduced its frequency during the Chi-squared test (likelihood-ratio test). For data processing the sta- pandemic. One possibility is that the patients who follow a strict tistical package IBM SPSS 26.0 was used. “T2T” control, regularly, presented with low activity inflammatory diseases and that the duration of the pandemic during the first Results wave (8 weeks, <3 months), did not constitute a major change in their inflammatory status.8,9 We note that the number of patients The 254 patients included before COVID-19 corresponded to 20 who attended with SLE almost tripled (P < .001), and there was an working days (from 16th October to 21st November), whilst the increase consulting regarding Sjögren’s syndrome (P < .001) and 251 patients included during COVID-19 were obtained in 10 days vasculitis (NS) during COVID-19. One hypothesis would be that the (from 23rd March to 3rd April 2020). Mean age of the patients inflammatory load profile of systemic diseases with multi-organ before the pandemic was 61 ± 17 years versus 57 ± 18 years dur- involvement, such as SLE or vasculitis, generated greater fear of ing the pandemic. 74% of both groups were women. The pathologies the virus coexisting with the disease, or also the possible effects treated most frequently before and during COVID-19 were rheuma- of immunosuppressant treatments. However, in SLE and Sjögren’s toid arthritis (RA) (41.7% versus 26.7%) and spondyloarthritis (18.9% syndrome we found that the main reason was due to problems 2 G Model ARTICLE IN PRESS S.P. Fernández Sánchez, F. Rodríguez Muñoz, A. Laiz et al. Reumatología Clínica xxx (xxxx) xxx–xxx Table 1 Descriptive analysis of the sample which regularly attends monographic rheumatology nursing consultation before and that observed ruing the first wave of the COVID-19 pandemic. Before COVID-19 During COVID-19 Variables Mean (SD) Mean (SD) Pa Age (years) 61 (±17) 57 (±18) .053 n (%) n (%) Sex Men 66 (26) 64 (25.5) .919 Women 188(74) 187(74.5) Pb Rheumatological diagnosis Rheumatoid arthritis 106 (41.7) 67 (26.7) < .001 Spondyloarthritis 48 (18.9) 46 (18.4) Systemic lupus erythematosus 10 (3.9) 26 (10.4) Systemic sclerosis 16 (6.3) 13 (5.2) Vasculitis 32 (12.6) 42 (16.7) Sjögren’s syndrome 2 (.8) 19 (7.6) Gout 7 (2.8) 5 (2) Osteoarthritis 2 (.8) 0 Fibromyalgia 0 0 Osteoporosis 11 (4.3) 5 (2) Others 20 (7.9) 28 (11.2) SD: Standard Deviation. a Fisher’s test. b Chi-squared (likelihood ratio). Table 2 Change observed in the frequency of interventions carried out by rheumatology nursing before and during the pandemic. Before 254, n (%) During 251, n (%) Pa Visits programmed Education Face-to-face 61 (35) 3 (42.9) .676 Non Face-to-face 10 (12.7) 15 (6.1) .073 Procedures Face-to-face 18 (10.3) 1 (14,3) .750 Non Face-to-face 2 (2.5) 0 (0) .017 Stable patient control Face-to-face 49 (28.2) 0 (0) .049 Non Face-to-face 2 (2.5) 93 (38,1) <.001 Analytical control Face-to-face 24 (13,8) 0 (0) .154 Non Face-to-face 2 (2,5) 34 (14) .001 Review of vaccines Face-to-face 38 (21,8) 0 (0) .066 Non Face-to-face 0 (0) 6 (2,5) .065 Cardiovascular risk Face-to-face 40 (23) 0 (0) .059 Non Face-to-face 2 (2,5) 0 (0) .017 Treatments Face-to-face 4 (2,3) 4 (57,1) <.001 Non Face-to-face 0 (0) 1 (.4) .453 Management Face-to-face 9 (5.2) 1 (14.3) .379 Non Face-to-face 22 (27.8) 96 (39.5) .058 Spontaneous consultations Face-to-face Outbreak 15 (5.9) 4 (1.6) <.001 Side effect 3 (1.2) 0 (0) Activate treatment 1 (.4) 1 (.4) Doubts 5 (2) 0 (0) Administrative 4 (1.6) 0 (0) Non Face-to-face Outbreak 11 (4.3) 8 (3.2) <.001 Side effect 5 (2) 2 (.8) Activate treatment 3 (1.2) 1 (.4) Doubts 35 (13.8) 78 (31.1) Administrative 14 (5.5) 3 (1.2) a Chi-squared (likelihood ratio). 3 G Model ARTICLE IN PRESS S.P. Fernández Sánchez, F. Rodríguez Muñoz, A. Laiz et al. Reumatología Clínica xxx (xxxx) xxx–xxx in distribution of hydroxychloroquine and its management by the there is a need for studies to assess the activity of other nursing pharmacy offices and hospital pharmacies. consultations on a national level. Furthermore, the creation of pro- The impact of the first wave of COVID-19 transformed the tocols and guidelines are essential to reach a consensus on the work nature of care in outpatient consultations. Spanish rheumatology,10 carried out by these professionals on a national level. Infection by nephrology11 and neurology12 services changed their face-to-face SARS-CoV-2 has been proven to be a multi-organ disease, triggered care almost totally to non face-to-face care (telephone or telem- by a virus, which may lead to a severe disease with high morbid- atic). In our study the scheduled visits were carried out non ity and potentially mortal due to thrombosis and/or the cytokine face-to-face, basically over the phone. Non face-to-face sponta- release and respiratory distress síndrome.15 This has completely neous consultation (via phone or email) doubled, probably due to transformed the care profile of our services and specialties. Despite the fact that the service kept the normal nursing telephone num- this, in recent literature there is no exhaustive description of how ber and created a specific email which was distributed by social nursing care in rheumatology has been affected. media (Twitter, corporate web) and by the administrative staff of To conclude, COVID-19 has brought about an increase in care the centre. Also, the service scheduled a pilot plan of synchronized pressure and a change in the type of activity carried out in mono- telemedicine with the Departament de Salut (Generalitat of Catalo- graphic nursing consultations. This rheumatology nursing activity nia), which simplified and prioritized the telematic care process as within the units/services is still in its development phase but it con- a pilot test. tinues to be an essential resource for marinating quality care during Activities such as education were reduced to a quarter thanks the different waves of the pandemic. to different reasons, among which we would highlight that dur- ing the first wave of the pandemic no face-to-face initial visits Financing to the doctor could be made. To resolve this issue, videos were made to reinforce aspects of education such as the administration This Project did not receive any type of public or private financ- technique for subcutaneous treatments of biological therapies or ing. methotrexate. Activities such as procedures (blood extraction, PPD, Shirmer test, questionnaires or treatment administration) and car- Conflict of interests diovascular risk visits decreased almost completely due to the total lockdown of the population. The authors have no conflict of interests to declare. Pallarés et al. described this new form of non face-to-face care as an opportunity to control patients with chronic diseases, under- Acknowledgements lining the favourable reception of it by the patients and enhancing the key role played by nurses for these activities.13 Along these To all those comprising the rheumatology and nursing team of lines, authors like Tornero-Molina et al. consider that rheumatic the Hospital de la Santa Creu i Sant Pau for their confidence and patients may be followed-up and assessed through non face-to- stimulus in rheumatology nursing. To Ignasi Gich for all his help face visits (telemedicine), and achieve a high level of satisfaction with statistical analysis. for the patient and the doctor.10 In our study stable patient con- trol almost doubled through phone consultation, which could have References been to attend to patients who had programmed medical controls but who could not attend them due to medical facility closures. The 1. Lopez MJ, Majo HR. Situación de Enfermería en tiempos de COVID-19: una mirada panorámica. JAH. 2020;3, http://dx.doi.org/10.37958/jah.v3i3.50. vaccines control visits were reduced by a sixth since many analyt- 2. Padilha MI. From Florence Nightingale to the COVID-19 pan- ical tests with serological revision were cancelled. Also, all patient demic: the legacy we want. Enferm. 2020;29:e20200327, vaccination programmes were temporarily cancelled, due to the http://dx.doi.org/10.1590/1980-265X-TCE-2020-0327. reorganisation of infectious disease services. 3. 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