Remote consulting in the coronavirus outbreak

IF COVID-19 has shown us anything, it’s how resilient NHS staff are in the most stressful situations. Patient demand has probably never been higher across the UK and yet – given how quickly coronavirus has spread – the health service must also contend with the need to reduce the risk of exposure both to staff and patients.

Doctors have little choice but to change the ways in which they normally operate – and one key approach will be increased utilisation of online, telephone and video consultations. Hospitals are actively exploring greater use of video and telephone to consult with patients and manage ongoing care, and where appropriate to reduce unnecessary proximity contact.

NHS England has also sent information to the public concerning planned hospital appointments. It explains that they have asked hospitals to review ongoing patient care. Some clinics and appointments may be cancelled or postponed and patients will be notified of any changes.

Now is an opportune moment to reflect on the benefits of using remote consulting, as well as potential pitfalls. It gives patients access to medical advice, while protecting other patients, staff and clinicians from possible virus exposure – but healthcare staff must be aware of the risks.

Hospitals/trusts/health boards may have their own particular approach to remote consultations but here we offer some general advice.

PROCEDURES AND TECHNOLOGY

• Few hospital clinicians will be accustomed to assessing patients via remote technology. Increased time should be allocated to appointments with peer support put in place. Colleagues experienced at consulting remotely could offer support/supervision.
• Call-back procedures need to be more considered. Patients offered a remote consultation should be given a clear timeframe for the appointment and instructions on how to access and use any relevant system. Ensure also that they have the necessary technology to participate. This will act as a safety net for any technical issues or potential misunderstandings – for example if the patient’s phone number has been incorrectly recorded. Admin staff can help by making sure contact details are correct and clear information has been noted about the reason for their call.
• Ensure that you have clear guidance on pursuing call-backs and how many attempts should be made before recording a failed contact. A consistent process should be agreed and implemented.

THE CONSULTATION

• Remember patient safety comes first. You must be confident that assessment via remote means will be adequate. Establish quickly whether the patient needs further review or examination.
• Stay up-to-date with local health service arrangements to advise and signpost patients. Establish the identity of the patient/their representative, confirm consent where necessary and ensure adequate measures are in place to maintain confidentiality. Record that you have done so.
• Check with the patient that they understand why a remote consultation is necessary at this time and that a face-to-face assessment can be arranged if indicated. If in doubt, check that the patient has capacity to understand the advice you are providing and make decisions.
• 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” in video consultations, i.e. tone/nuance of voice and body language. Individuals may take longer to relax and “open up” more fully about their presenting complaint.
• Record in the patient notes that, due to coronavirus restrictions, the appointment has been via remote consultation. Make an adequate record of information relayed to the patient or carer, including specifics on any safety netting advice and any red flags relevant to that patient.
• Prescribing can be particularly difficult in remote consultations. Checking understanding of dosage, contraindications and other issues can be more problematic. Adequate time is important to ensure safe compliance.
• Be sure to restate the agreed position and any required actions to the patient at the conclusion of the consultation, as 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 better conclude the consultation for the patient, who should be more reassured.

DEPARTING FROM ESTABLISHED PROCEDURES

The GMC has published recent guidance including specific advice on adapting practice to cope with patient demand during the coronavirus outbreak. They understand that special measures may need to be taken to protect your patients and yourself. They say:

“It is likely that, as the situation develops, some doctors will need to depart from established procedures to care for patients.”

Ongoing communication with patients is key in order to reduce uncertainty or resistance to these temporary measures. Significant announcements, such as changing clinic appointments to remote ones, should be conveyed promptly.

LINKS

• GMC: Remote consultations
• GMC: Prescribing guidance
• GMC: Coronavirus information and advice

Alan Frame is a risk adviser at MDDUS