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Camden MSK - developing a pragmatic clinical stratification tool to decide upon telephone, video or face to face consultation at point of triage.

Following cessation of usual out patient community MSK services due to COVID 19 pandemic, all CATS appointments were initially conducted by telephone. Video consultation came online after 3-4 weeks, but was found too complex to switch to mid conversation for most patients and clinicians, and was therefore reserved for use as a follow-up appointment after initial telephone consultation where visual assessment was deemed necessary. This therefore increased the usual demand for follow-up appointments. In addition a very small number of patients required face to face clinical assessment (in PPE of course).

Evaluation of the first few weeks of telephone consultations identified a slightly elevated investigation rate (by percentage) - in all likelihood at least partly due to the limitations of telephone consultation, and an increase in defensive medicine for safety reasons. It is possible other factors e.g. stress and anxiety were also involved due to the context, concurrent part redeployment to critical care, weekend working etc.

In the short term almost all consultations will be remote, however in the medium/long term we expect the reintroduction of routine face to face consultation. The permanent addition of remote consultation media offers service efficiencies due to working from home options and reducing the estates burden - a very significant issue in central London, improved patient experience due to improved access and convenience. It is imperative that these are used appropriately. At present a few consultations are video first, but these decisions are uncommon, ad hoc and this scattered/unpredictable behaviour increases the administrative workload.

The development of a consultation medium decision tool which is an addition and complement to existing triage criteria, ensures the most efficient and sustainable service. IT hardware and connectivity limitations mean video consultation is not always an option so clinics where this is required must be planned for, as must face to face assessment clinics, whereas telephone is theoretically available anywhere. That is not to say many clinics cannot contain a mix of some/all media. The criteria will therefore minimise follow-up appointments required, ensure the most appropriate outcome from CATS appointments  - getting it right first time, optimal investigation and onward referral rates, and optimise patient experience. Patient choice and the availability of IT hardware and connectivity will of course also be taken into account - hence the pragmatic nature. 

What is needed to sustain the change?

Audit of pre and post change investigation rates, onward referral rates, follow up appointments. Possible changes to consultation medium decision tool as part of audit cycle.

Improved IT hardware and infrastructure - webcams, sufficient bandwidth

Stakeholder engagement with permanent addition of remote consultation

Appropriate patient information for all types of consultation including explanation of decision on consultation type

What is your region?

London

edited on Jul 13, 2020 by Kyle Beacham
Public (9)
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Rashida Damanwala Jun 3, 2020

A new and challenging way of working but also with long term benefits and flexibility as a positive outcome. Developing a Decision making tool/ guideline with scope for clinical discretion would be key in the long term success of remote consulting for all parties concerned.

Reply 3

Nilesh Jawale Jun 3, 2020

This is great Paul!

Reply 1

Judith Dawson Jun 3, 2020

We have had a very similar experience in Salford - I would be interested to determine whether you have noticed that there are patterns of clinical scenarios where video first would had added value ??

Our local experience of telephone consult only has largely been well received by patients during Covid- as 'something is better than nothing' -but most when asked would still prefer F2F v virtual.

Reply 3

Paul Kidman Jun 4, 2020

Thanks Judith, agreed - telephone appts are broadly accepted at present, and the majority have not expected/wanted F2F, but that is changing and pts are increasingly confident in travelling, attending hospital/health centres etc so I suspect some will be less happy to accept a virtual appt as time goes by.

We are a single point of access for all MSK (Physio, CATS, ortho, rheum, pain, spinal neurosurgery, podiatry) so routinely get complex referrals; in our limited experience the value seems to be from clarification of key objective features whcih can be self - assessed with instructions and might alter outcome of the appt eg loss of shoulder LR, hip MR, neural deficit, visual inspection of deformity eg tib post dysfunction, etc. From a non-clincial perspective the tech savvy shielded/isolated patients also really like it presumably due to the human contact.

Making the determination comes down to the specifics of the clincial question/issue on the referral and anticipating whether video first will avoid need for video FU. Referral quality is an issue (we have been working on it for ever) and it is not always possible to avoid the need for video FU, or even the odd face to face (rarely obviously).

Reply 2

chris mercer Jun 8, 2020

This sounds great Paul- as you say it ius dependent on the quality of referrals- how have you cracked that nut?

Reply 0

Paul Kidman Jun 9, 2020

I certainly wouldn't claim to have cracked it!
We have worked hard to improve referrals through GP engagement, have seen an improvement anecdotally and rejected fewer referrals which is a good sign. We are fortunate in that we have data sharing agreements so can review health records to find more detail if not included in referral which probably covers up some of the issues (although this is time consuming so is not routine practice).

My plan is to accept (as we currently do) that referral quality is a long term project, and triage decisions therefore carry significnat margin for error already - there will therefore be a need for video FU regardless. What we want to see is the decision making tool evolve via audit cycle so that need for video FU is mninimised. It probably is the cost of doing business in the short term. Long term hopefuly some improvement to referral quality can be made as technology evolves to improve the referral interface.

Reply 0

Judith Dawson Jun 9, 2020

As we move closer to FCP we won't have any prior referral information and so will face greater uncertainty -probably first line should be tel triage for all?

Reply 0

Paul Kidman Jun 10, 2020

We don't have FCP here and there is no appetite for it at present - multiple reasons (although I would be in favour).

We are expecting to increase self referral access which will raise the issue you describe, but there will remain a high volume of GP referrals and we need to reduce F2F FUs as much as possible. I'm hoping a tool will facilitate that. We are planning for self referrals to hopefully be via a medium which will still provide sufficient info for triage into virtual vs F2F in many cases. Fingers crossed!

Reply 0

Greta McLachlan Jun 11, 2020

Status labels added: Choice, Collaboration, Community Care, Effective Team Working, Health & Wellbeing, Information Sharing, Integration Of Resources, Patient Activation, Patient Selection, Referral Pathway Redesign, Technology (Software/ Apps), Telephone Advice, Video Consulting, Horizon 1

Reply 0

Greta McLachlan Jun 12, 2020

Status labels added: Infrastructure, Investment In Technology, Pathway Redesign, Shared Decision Making, Staff & Patient Collaboration, Telephone Consulting, Upskilling Of Staff, Virtual Consulting

Reply 0

Greta McLachlan Jun 12, 2020

The idea has been progressed to the next milestone.

Reply 0

Greta McLachlan Jun 12, 2020

The idea has been progressed to the next milestone.

Reply 0

Kyle Beacham Jul 9, 2020

Status labels removed: Choice, Collaboration, Community Care, Effective Team Working, Health & Wellbeing, Information Sharing, Infrastructure, Integration Of Resources, Investment In Technology, Pathway Redesign, Patient Activation, Patient Selection, Referral Pathway Redesign, Shared Decision Making, Staff & Patient Collaboration, Technology (Software/ Apps), Telephone Advice, Telephone Consulting, Upskilling Of Staff, Video Consulting, Virtual Consulting

Reply 0