Poor adherence to guidelines on early management of acute hot swollen joint(s): an evaluation of clinical practice and implications for training.

BACKGROUND: Synovial fluid analysis is an indispensable investigation to attain a diagnosis in a patient with acute hot swollen joint(s), septic arthritis in particular. A delay in appropriate early management results in serious undesired consequences.

METHODS: We evaluated clinical practice at two teaching hospitals including 81 patients. We analysed medical records, laboratory pathology results and discharge summaries with regard to documentation of joint aspiration, blood cultures, antibiotic treatment and specialist referral. We then conducted a survey of 140 medical trainees to evaluate their self-reported competence at managing the acute hot swollen joint.

RESULTS: We found that synovial aspiration and blood cultures were performed in only 42(52%) and 30(37%) patients, respectively, not in accord with current guidelines. Given trainee doctors are responsible for the early management of acute hot swollen joint(s), our survey reveal low self-reported levels of competence and confidence at managing acute hot swollen joint(s) in 72(52%) and 37(27%) respondents, respectively. Furthermore, 101(75%) trainees indicated a need for more training in joint aspiration. We also report that 13 of 15 hospitals surveyed in London and South East UK do not provide specific training on the management of the hot swollen joint and joint aspiration as part of their induction programme.

CONCLUSIONS: Early management of patients with hot swollen joint(s) to perform synovial fluid aspiration and blood cultures are not being done in accordance with guidelines. We suggest that the medical trainee curricula should incorporate joint aspiration skills as an 'essential procedure', to improve the trainee doctor's confidence and competence at managing acute hot swollen joint(s) to improve adherence to guidelines, and consequently, patient outcomes.