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Increased use of Digital and virtual video consultations, pre screening suspected urgent patients from primary care prior to referral to the Trust.

by Michael Dare | May 26, 2020 | in Rheumatology

During the COVID-19 pandemic i am pleased to say not a single day of patient care was interrupted. We continued to provide services and switched from face to face consultations to virtual and telephone consultations within a matter of days. 

We continued to run full clinics of 12-15 patients per day, we continued to offer urgent slots for new PMR patients, new swollen joints and continued to operate a advice and guidance and flare up service with a turn around time of 24 hours. 

We managed to significantly reduce any referrals to the secondary care trust by screening all new patients with a telephone call to ensure they were in fact new connective tissue disease patients or early inflammatory arthritis patients. 

This pandemic has really shown us the value of virtual and telephone clinics. 

What is needed to sustain the change?

What is your region?

No answer chosen

edited on Jul 13, 2020 by Kyle Beacham
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Carol McCrum May 27, 2020

Really helpful outline of your response to the covid circumstance in primary care- could you give more detail on the profession model of who is undertaking the screening of the referrals and share any screening resources/tools /criteria being used to undertake the screening of the referrals for these suspected conditions- thank you

Reply 0

Michael Dare May 27, 2020

Dear Carol Thank you for your comment and i am happy to share this information. We have a very well established Community Rheumatology service which is currently staffed by One Extended Scope Rheumatology physiotherapist, One full time consultant Rheumatologist, One locum Consultant Rheumatologist, One developing Rheumatology ESP and two specialist Osteoporosis nurses.

The screening is being done by the members of staff above and takes the form of a full telephone consultation in which a full clinical history is taken, video consultation is done to examine reported swollen joints, blood tests from primary care are reviewed and limited examination via video consultation are done such as self MCP/MTP squeeze test. If additional urgent bloods are needed these are arranged

Currently our trust (Secondary care) are only accepting EIA referrals based on the criteria attached which we screen for as well as Connective tissue disease which we also screen for in terms of typical symptoms such as positive ANA, raynauds disease, ulcernation, rash, non erosive synovitis and other system involvement depending on the spectrum of CTD.

I think this model has definitely shown us that such initiatives can greatly reduce the amount of referrals that go directly to sec care and i firmly believe by doing this we can really improve on figures such as the AxSpA delay to diagnosis and EIA waiting time and accuracy of patients presenting in the EIA clinic.

We have also seen certain cases F2F such as those suspected for possible PMR with headaches to exclude GCA, angry suspected CPPD joint to exclude septic joint and patients for IA joint injection with a Angry Monoarthropathy rheumatoid Flare with the appropriate PPE.

We have also experimented with taking BASDAI scores, DAS 28 scores etc via virtual consultation although i must admit this was a challenge.

Happy to share any further information

Reply 0

Elizabeth MacPhie May 29, 2020

Really interesting to hear how your service has adapted and agree a vital role played in keeping patients away from hospital and additional layers of screening/triage which I suspect will provide to be a new way of working that would be good to continue with in the future.

We are also a community based service, though our whole service is based in the community so all patients including IA, CTD and vasculitis are managed by our team (consisting of 4 consultant rheumatologists, ESP, 5 specialist nurses, 2 physiotherapists, OT, pharmacist and pharmacy technician).

I feel one point that needs to be acknowledged by community services like ours is that we haven't had any members of the team redeployed to help out our colleagues in acute medicine at the acute trust, which I suspect will be the same with your service. This has meant we have been able to continue to deliver the majority of the service, though the majority of appointments have been by remote consultations. We have continued to see new urgent referrals F2F and urgent FUs and to deliver infusions.

I am mindful that when I speak to many colleagues in the region and wider they have had most of their consultants redeployed to the wards. And the impact of covid-19 has been much greater on their services and the road to recovery will be much more challenging.

Reply 0

Michael Dare May 29, 2020

Dear Dr MacPhie thank you for your detailed reply. Yes your community service seems much more well established and set to see more complex patients. As our service is run by a private provider we see contractually what the trust and CCG want us to see and essentially our role is to:

1. Keep mechanical and chronic pain patients out of secondary care
2. Manage simple inflammatory and Rheumatic disease in house such as simple PMR, Gout, mild Seronegative inflammatory arthritis and Mild AxSpA on NSAIDS.
3. All complex cases like CTD, Vasculitis, EIA etc contractually goes to the trust and we have seen a massive improvement in waiting time for patients especially EIA patients as the trust is not overburdened with patients who shouldnt be in Secondary care Rheumatology to start off with.

We prescribe and manage mostly conventional DMARDS biologics and biosimilars are left with the trust and we have a excellent relationship with the trust so are able to readily refer to the trust and they can refer stable patients to our service. In the past calender year i think we have saved over 2700 secondary consultations which we have safely managed in the community service at many many thousands of pounds saving for the tax payer and resulting in much quicker service for true EIA and complex inflammatory patients within the trust.

We really see the potential of remote consultations for in particular cDMARD and bDMARD reviews as well as reviews of patients with normal results post investigation.

Reply 1

Greta McLachlan Jun 12, 2020

Status labels added: Effective Team Working, Information Sharing, Pathway Redesign, Patient Selection, Prim/Sec Integration, Referral Pathway Redesign, Screening, Technology (Software/ Apps), Telephone Advice, Telephone Consulting, Video Consulting, Virtual Consulting, Horizon 2

Reply 0

Greta McLachlan Jun 15, 2020

Status labels added: Prim/Sec/Com Integration, Triage

Status label removed: Prim/Sec Integration

Reply 0

Greta McLachlan Jun 15, 2020

The idea has been progressed to the next milestone.

Reply 0

Greta McLachlan Jun 15, 2020

Status labels added: Upskilling Of Staff, Workforce

Reply 0

Kyle Beacham Jul 13, 2020

Status labels removed: Effective Team Working, Information Sharing, Pathway Redesign, Patient Selection, Prim/Sec/Com Integration, Referral Pathway Redesign, Screening, Technology (Software/ Apps), Telephone Advice, Telephone Consulting, Triage, Upskilling Of Staff, Video Consulting, Virtual Consulting, Workforce

Reply 0