Remote consulting in a pandemic (dental)

The COVID-19 pandemic created challenges for the dental profession. Practices had little choice but to change the ways in which they normally operate – pausing routine dental care and increasing their use of online, telephone and video consultations

Remote consulting can be used safely, provided clinicians are aware of and manage the associated risks. The government recommends that patients requiring dental care should be offered the “three As”: advice, analgesics, antibiotics. It is a sensible approach that provides access to dental advice while protecting other patients, staff and clinicians from possible exposure to the virus.

Each practice may have its own particular approach to remote consultations but here we offer some general advice. 

• Remote consultations may be held with the patient or someone making contact on their behalf. Establish the identity of the patient and/or their representative, confirm patient consent where necessary and ensure that adequate measures are in place to maintain confidentiality. Telephone consultations can make this difficult so ask basic questions to check identity and record that you have done so. Ensure there is no risk of being overheard in a patient consultation, especially if you are working outside of your usual work surroundings.
  
  
• Record in the patient notes that, due to coronavirus arrangements, the appointment has been via remote consultation. Make an adequate record of information relayed to the patient/carer, including specifics on medications prescribed, safety netting advice provided and any red flags relevant to that patient. Record also if you have signposted the patient to another service or clinician. Where a decision has been made that the patient does not require a face-to-face assessment ensure that the records make it evident that this is an appropriate approach.
  
  
• Explain the limitations of telephone triage to patients, and why a face-to-face consultation is not available.
  
  
• Allow sufficient time in remote consultations to listen carefully to the information provided and to ensure that the individual you are consulting with is clear on what you are advising
  
  
• Be aware of the increased importance of “para-verbal communication”, i.e. tone and nuance of voice and body language. Patients may also require additional time to “open up” more fully on the presenting complaint.
  
  
• Obtain as full a history as possible including detailed medical, social and dental histories, including a history of the current condition.
  
  
• Ideally clinicians will have access to patient dental records. If this is not possible, the notes made should be as detailed as for a new patient. Some patients may not belong to your practice and no existing record will be available. Creating a template can assist in ensuring consistency.
  
  
• If you cannot adequately assess the patient remotely, you should make an appropriate referral or advise the patient on how to seek alternative dental care and record that advice.
  
  
• If a record of the consultation needs to be uploaded to the practice record keeping system at a later date, ensure that a handwritten note is made at the time of the consultation, which can later be transcribed to the relevant system (and the handwritten note then securely shredded). Ensure that the date of the consultation, the date the record was made and the date on which the record was added to the system are clear. Note the reason for the delay.
  
  
• If a patient needs to be referred, ensure that they know what is involved e.g. further triage/assessment, distancing/waiting arrangements.
  
  
• Keep a list of triaged patients to facilitate appropriate follow-up.
  
  
• Prescribing can be particularly difficult in remote consultations. Checking understanding of dosage, contraindications and other issues can be slightly more problematic. Again, adequate time is important to ensure safe compliance.
  
  
• The General Dental Council’s guidance on prescribing medicines allows for remote prescription if there is no viable alternative and it is in the patient’s best interests.
  
  
• The 10 high-level principles of remote consultation and prescribing, developed by healthcare regulators, continue to apply. In the current crisis the key requirement is to make an appropriate clinical risk assessment.
  
  
• It is important that clear instruction is provided on how to take any prescribed medication, and that the records reflect this.
  
  
• Dental practices should liaise with local pharmacies to establish a protocol for remote prescribing.
  
  
• Remember that patient safety always comes first and you must be confident that assessment via remote means will be adequate. Establish quickly whether the patient may need further review or examination and direct them to the most appropriate service if required.
  
  
• Patients may contact the practice from outside the country, especially now with restricted travel. It is important to remember that your indemnity may only cover you for patients you consult with in the UK. When consulting remotely with a patient outside of the UK, it is important to explain to them that for their own safety they should seek advice and assistance from local clinical services. They should be assessed and treated by a clinician locally, who may be able to offer a face-to-face assessment or prescription, if needed.
  
  
• At the conclusion of the consultation, be sure to restate the agreed position and any required actions to the patient. This may be your last chance to ask for clarification and pick up something important (in case you have been “barking up the wrong tree”). It will also be more reassuring for the patient.
  
  
• As the COVID-19 situation continues to evolve so do official guidelines. Check relevant advice as well as local health service arrangements/processes regularly and make sure you can demonstrate that you have kept up-to-date.

Departing from established procedures

The GDC has stated: 

“Expert advice on the clinical aspects of COVID-19 will continue to come from the health authorities of the four nations and we will continue to signpost to this guidance as and when it is updated. But that guidance will inevitably not cover every potential scenario, and therefore, dental professionals will need to continue exercising their professional judgement and weigh the risks in any given situation. They will also need to continue to assess whether they are trained, competent and indemnified to carry out the activity in question.

“However, in the recent joint statement from the healthcare regulators we said that we understand that in highly challenging circumstances, professionals may need to depart from established procedures to care for patients and that should concerns be raised, relevant environmental and human factors would be taken into account.”

Ongoing communication with patients is key in order to reduce uncertainty or resistance to these temporary measures. Significant business announcements should be shared promptly, for example via your practice website, organisational social media channels or through your text messaging service. 

Summary points in remote consultations

• Maintain patient confidentiality in your own workspace at all times. Ensure you are confident the person on the other side of the phone is who they say they are and that it is appropriate to speak with them if they are not the patient.
  
  
• Ensure that the patient is aware of the limitations of telephone triage.
  
  
• Take more time to establish the needs of the patient and to be clear they understand the advice you are providing.
  
  
• Keep adequate records of the consultation and all information given to the patient, including any medication prescribed and safety-netting advice.
  
  
• Consult GDC guidance on remote consultations and prescribing and follow this as much as is possible given the circumstances.

Further guidance

• GDC - Responding to COVID-19: providing treatment in uncertain times https://www.gdc-uk.org/news-blogs/blog/detail/blogs/2020/03/26/responding-to-covid-19-providing-treatment-in-uncertain-times
• RCS COVID-19 Hub - urgent care recommendations for dental specialities https://www.rcseng.ac.uk/dental-faculties/fds/coronavirus/

MDDUS Training & CPD resources: 

https://www.mddus.com/training-and-cpd