Background/Purpose: Diagnostic and therapeutic arthrocentesis and soft tissue injections are routinely performed by Rheumatologists mostly in the outpatient and some in the inpatient settings. There are variations in technique and the dosing of medications used. Our aim was to assess the procedural variability among rheumatologists at a single academic medical center in an attempt to standardize the process using evidence-based medicine when applicable, thereby improving clinic workflow and efficiency.

Methods: An anonymous 2 part questionnaire was completed by 12 rheumatology staff physicians and fellows. The 2^nd part of the questionnaire covered the procedure clinic workflow using the Likert scale which was completed by 7 rheumatology clinic nurses as well. Review of literature was done using the PubMed. Medication information was referenced using www.lexicomp.com

Results: Part 1 of the questionnaire was notable for preference for lidocaine as local anesthetic of choice (Table 1). There was a wide variability in the dose of methylprednisolone and lidocaine used for the knee and glenohumeral intra-articular (IA) injections, trochanteric bursa and trigger finger injections in our clinic.  Part 2 revealed concordance between the physicians and nursing staff regarding delays and inefficiency of the clinic workflow (75% and 86% respectively, were in agreement). 92% of physicians and 86% of nurses agreed that standardization would be beneficial despite 41% physicians and 57% nurses indicating satisfaction with the current clinic workflow.

Review of published literature was notable for the following: Utilization and type of gloves used (sterile vs non-sterile) or sterile vs aseptic techniques varied widely in clinical practice. Chlorhexidine was superior to iodine for skin sterilization. The choice of intraarticular glucocorticoids was largely driven by the training background of physicians, with lack of definitive data to support the use of one over the other. Mepivacaine and Ropivacaine are thought to be less chondrotoxic compared to lidocaine and bupivacaine. Use of direct oral anticoagulants and warfarin with INR <2 do not increase the risk for hemarthrosis.

The next step is to implement the standardized procedure practice within the clinic using the information gathered and follow this with a post implementation survey and practice monitoring.

Conclusion: There are no specific consensus or common practice guidelines such as the use of sterile gloves to perform sterile technique vs aseptic technique, iodine use and use of lidocaine for IA injections as certain practices are not evidence based and depend on previous training and individual preferences. Standardization may help improve efficiency and staff satisfaction and reduce potential errors. There is an unmet need for development of evidenced-based musculoskeletal procedure guidelines in rheumatology.

Table 1