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The Multidisciplinary Team

Optimal management requires prompt diagnosis, early referral to an experienced MDT working together with families and school, community and primary healthcare providers. The MDT will comprise various professionals including doctors, nurses, therapists, ophthalmologist(s), psychologist(s) and social workers.

Most patients are managed as outpatients. Inpatient care may be needed as part of initial assessment, induction of disease control or as a day case for some therapies (joint injections under anaesthetic or using inhaled analgesia or to receive some immunosuppressive treatments). Parents and children themselves can be supported and offered training to administer medications at home (e.g., Methotrexate as oral or subcutaneous treatments, or some biological therapies as subcutaneous injections). Education and ongoing support from nurses are key to safe home administration. This includes how to manage, store and dispose of needles and syringes. Patients on immunosuppression can become unwell very quickly and families need to know when to seek health care. 

The clinical nurse specialist is central to providing education and support - this will often extend into the local community nursing team and school health nurses. Community and local support is essential for families unable to give treatment themselves at home. Physical therapists work closely with the nurses in their liaison with schools to facilitate integration and performance in school.

The roles of the MDT include the following:

  • Knowledge – making sure families and patient understand the diagnosis and treatment plan.
  • Co-ordination of care – getting treatment started and then ongoing - this may be treatments given at home or on the day case unit (e.g., infusions of corticosteroids, biologics or cytotoxics or joint injections).
  • Support and guidance – helping families when they are worried / concerned.
  • Training – training families or local nurses to give care to child or young person at home.
  • School support – contact with schools / nurseries so that the child is able to fully participate and achieve full educational potential.
  • Supporting children receiving day case treatments involving cannulation or anaesthesia.
  • Facilitate communication between MDT members and families. 

The role of the nurse specialist in the management of rheumatic disease is detailed in pmm for nurses 


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