Remote consultations are likely to endure beyond the pandemic. Here, Dr Jonathan Inglesfield begins a series on how to structure patient contacts via audio and video, starting with potential Covid-19 patients
The coronavirus crisis has led to a rapid change towards the remote consulting model. Such consultations allow us to protect high-risk ‘shielded’ patients from nosocomial infection, to reinforce national messages on reducing social interaction, and of course to protect ourselves and our staff from acquiring Covid-19 from patients.
For some GPs, this might seem to be an imperfect, temporary solution that has to be endured due to an unprecedented situation. But this is a mistake: the overall aim should be to offer the same high-quality service to patients, albeit delivered in a different way, and embed this into your practice for good.
This is the first part of a series, and will explore issues to consider when dealing with potential Covid-19 patients. You may already be doing most of these, but this can provide a useful checklist. Next month, we will cover remote consulting with non-Covid patients.
Consider how you triage
There are two main types of remote consultation: synchronous, where clinicians and patients communicate in real time via phone or video; and asynchronous, such as where email is used to deal with long-term conditions and provide advice on issues like skin lesions, through sending pictures, for example.
There are benefits in promoting the asynchronous model as a first point of contact with the patients, rather than the telephone. A written summary of a patient’s concern is likely to be more useful than a short booking note from a phonecall with reception.
Preparing for the consultation
Various tools have been published to assist in the remote consultation itself. The BMJ infographic guide is useful and could be printed out and laminated.
Specific or closed questions may be such as: ‘Can you climb the stairs without stopping?’
Before initiating the remote consultation, consider whether you will use telephone, video or both. Telephone consultations may benefit from high-quality audio, at the expense of gaining any visual clues. Video can be superb if working well, although its quality depends on the stability of the internet connection.
In potentially complex cases it may be worth planning to use a combination of the two, starting with the telephone consultation. This can be especially helpful with patients new to video consultations who can gain confidence through an initial telephone call. And, it has to be said, for GPs who feel more comfortable with phone consultations.
The box below provides a checklist to consider before the consultation.
Preparation for remote consulting
• Ensure your working environment is professional, quiet and secure. Dress appropriately if planning video calls.
• Review the patient record carefully, especially noting whether they are from a high-risk group or have comorbidities.
• Consider if an interpreter is needed and arrange this.
• Check whether any further information would be useful before initiating the call, such as photographs or further written information and instruct the patient on this. SMS templates may help, such as a guide to submitting photographs via email.
• Consider whether near patient testing will be useful as part of the consultation, such as urine testing, heart rate or pulse oximetry. My practice has a number of oximeters and thermometers available.
• Be clear in your mind what you hope to achieve from the consultation and its likely end points. This will allow you to have a purposeful consultation rather than a poorly directed conversation.
• Make brief notes of the areas you plan to cover, including safety netting, so you do not forget them.
Categorise your patients
It is worth dividing patients in to ‘suspected Covid-19’ and patients with other health conditions.
As we are focusing on suspected Covid-19 patients here, the primary aim of the consultation might be to establish which of the three accepted severity categories the patient falls into:
• Category 1 Severely unwell (admit to hospital).
• Category 2 Needs further assessment and/or safety netting.
• Category 3 Mildly unwell – can safely self-manage at home.
Remember that patients with Covid-19 can be considered to have a ‘biphasic illness’, with a first ‘replicative’ phase and a later ‘adaptive immunity’ phase. The latter phase can in some individuals lead to an exaggerated immune response with rapid clinical deterioration, typically in the second week of illness.
When talking to the patient you may therefore wish to consider where your patient may be in the disease process. If they are in the replicative (early) stage, it can be especially important to underline safety-netting procedures should they deteriorate in the adaptive stage.
A comprehensive summary of the clinical features of COVID-19 and the typical disease process is provided by the RCGP at tinyurl.com/RCGP-covid19.
Determining symptoms remotely
The consultation itself can follow the same pattern as your face-to-face appointments, but beware of the potential pitfalls of remote consulting (see box below).
Common pitfalls of remote consulting
• Ensure you’ve identified and are talking to the right patient.
• If unsure, check where the patient is. Mobile phone use and the demands of lockdown may mean patients are not at home.
• Confidentiality may be an issue in the home. ‘Is this a good time to talk?’ can be a useful opening phrase.
• Surgery visits are an ‘event’ for patients. Ensure they still feel valued remotely, and be aware of the need to talk with an interested tone rather than sounding detached.
• Purposefully start with open questions – the temptation remotely can be to use more closed language.
• Non-verbal clues are often taken for granted in the surgery but commonly heighten awareness of potentially sick patients, such as breathlessness when a patient walks a short distance from a waiting room. Even if consulting by video, be aware of this potential knowledge gap.
As in any consultation, your aim is to discern a pattern and the symptoms of the patient’s condition, and try to gauge its severity. It is worth noting that many patients do not follow a typical pattern of Covid-19 disease. Patients can, for example, present initially with gastrointestinal dysfunction, and the absence of a common symptom such as fever does not exclude the diagnosis. Common symptoms include:
• Dry cough.
• Sore throat.
• Loss of smell.
• Nausea or diarrhoea.
The next key issue to determine is the severity of the patient’s symptoms. In Covid-19 the key factor is the severity of any breathlessness, including on exertion. Open questions are helpful in this respect, such as: ‘How is it affecting you?’ or ‘How are you managing with it?’ This allows the patient to describe the impact of their illness and, together with the history, should mean you can start to place the patient in one of the severity categories.
Specific or closed questions may be helpful next, such as: ‘Can you climb the stairs without stopping?’, ‘Can you walk around the garden?’ or ‘Are you able to sleep through the night?’
After concluding the history, it is important to undertake an examination. Formally separating the history from the examination in a remote consultation will encourage you to make an objective assessment leading to clear and unambiguous notes – and avoid the consultation just becoming a chat. This is the point at which you may wish to switch from telephone to video consultation if you are using both.
It may be worth using as an SMS template to send to patients on completion of a call
The examination should be as objective as possible, again mirroring an examination in the surgery. Objective parameters to record include:
• Appearance, colour, hydration (video).
• Ability to sit, stand, walk with/without help (video/audio).
• Level of consciousness/confusion (video/audio).
• Temperature (video/audio).
• Breathlessness including respiratory rate (video/audio).
• Pulse (video/audio/near patient testing).
• Oxygen saturation (near patient testing).
Consider red flags or use the NEWS2 score (see RCGP document), although note the caution over its lack of validation for Covid-19.
Accepted red flags in Covid-19 include:
• Severe shortness of breath, and/or sats ≤94%.
• Tachypnoea ≥20 in adults.
• Tachycardia ≥100 in adults.
• Confusion or reduced consciousness.
• Other red flags for acute respiratory disease or sepsis.
You should now be able to place the patient in one of the three severity classes, which was our planned endpoint for the consultation.
Category 3 patients may be reassured, with appropriate safety netting; category 1 patients need 999 admission to hospital.
For those in category 2 there will need to be consideration around careful safety netting or precautionary hospital assessment. This will depend upon a number of factors, including the patient’s comorbidities, social support, and location. You may feel more confident to monitor a normally fit and well individual with good social support in an urban setting with good access to healthcare, but less comfortable if the patient is comorbid or isolated.
After the consultation
Do not be afraid to take some time for ‘professional reflection’ when consulting remotely. One advantage of remote consulting is that you can simply advise the patient you need to verify some details and will call them back. If using a combination of telephone and video, you can inform the patient you will be closing the video link and will phone back shortly.
As the recent controversies over resuscitation have shown, it is important in complex cases to establish the patient’s wishes in case of potential hospital escalation, and check the presence of an advance care plan or DNR documents.
In all patients, safety netting is vital. The RCGP document includes safety-netting advice, and it may be worth using as an SMS template to send to patients on completion of a call. Personalised safety netting can be added, including details of relevant metrics, such as: ‘Your oxygen level is currently 96%. If this falls to 94% seek immediate medical help.’ This can also be useful for paramedics and others who may later attend the patient.
Next month, we will be considering non-Covid cases, and the best way to remote consult with them.
But in the meantime, it is worth keeping in mind the basics. When remote consulting with patients with medical conditions other than COVID19, you are likely to follow a similar pattern to that described above. The following are examples of patients who might need to be seen face to face:
• Patients with abdominal pain.
• Patients with abnormal rectal or vaginal bleeding or discharge.
• Patients with cognitive issues or complex comorbidity.
• Patients in whom important physical metrics are needed but have been difficult to obtain remotely (such as heart rate in children).
• Patients who have suffered trauma.
• Patients whom you feel less confident to assess remotely because of limitations in technology (such as video being unavailable).
This does not mean that remote consultations should not initially be carried out in these groups of patients, but it does mean you should consider a lower threshold for converting the remote consultation to a face-to-face one.
Dr Jonathan Inglesfield is a GP partner in Surrey