Richard Daniels, ST4, Barnet Hospital
In these turbulent times, there have been a few silver linings. One of which is the transformed way in which much of our accepted practice has changed, showing how certain longstanding practices might not be as efficient as had previously been thought.
The stopping of face-to-face outpatient services to restrict the spread of Covid-19 has sped up the establishment of telemedicine clinics in paediatrics and in this guide, we present a guide to getting your own service off the ground as quickly and effectively as possible, to develop a safe and sustainable service that will feed into the future of Paediatrics.
- Risk assess clinic list – who is suitable to be reviewed remotely?
- Routine check up
- Patient would find it difficult to attend hospital – mobility, infection, Autism Spectrum Disorder
- Avoid if:
- Likely to need formal examination
- Difficulty in using technology
- Language barrier/Other communication difficulties
- Parent/Guardian to be contacted in advance to explain process and give a window of time when will call
- Produce patient leaflet and email across with confirmation of date/time to expect call
- Set boundaries for the consultation
- Asking parent to weigh in advance with scales at home
- Test phoneline/video software
- Consider back-up option in event of technological failure
- Select a quiet, private space – well lit, appropriate IT equipment, headset and/or telephone etc
- The most crucial step – Daniels’ First Law. Go to the toilet before starting.
(Law applicable in many scenarios)
- Have a drink and maybe some quick snacks to hand – HALT criteria apply when working remotely too! (Daniels’ Second Law)
- Get all the relevant systems open and running (PACS, EPR etc) before calling the patient
- Review bloods results, last clinic letter, investigation reports etc as appropriate
- Summarise in notes before calling
- Try and revise “red flag“ issues specific to condition
- Think about questions to ask in advance
- Flick through “15 minute consultations” in ADC (ideally before starting clinic)
- Does your hospital have any proformas for this service?
- Call parent & child – introduce self (& others if appropriate e.g. CNS), technical checks (volume, no lag)
- Confirm correct patient – Name/DoB as usual
- Make sure to talk to patient directly if appropriate
- Take & record consent, reiterate confidentiality
- Confirm that you will ring back if cut off
- Be clear and direct with questions – think about how you speak when you use language line compared to your normal everyday pattern of speech
- Recap clinic outcome to family – summarise key points and check understanding
- Say goodbye before closing connection so family know that you will be ringing off
- Dictate letter as normal noting it was telephone contact
- Write note on EPR/paper notes if local hospital policy too
- If no answer, make sure that you have documented the summary to speed up future attempts
- Give family contact details to change next appointment/investigation dates if needed
- Offer Patient/Family satisfaction questionnaire – can you email a link?
- Non-verbal communication is vital and is a casualty of telephone clinics.
- Video-calling gets around some of these issues but requires more equipment and specialised software. It also adds another area of jeopardy with regard to reliability of connection so make so that a back up option (telephone) is available.
- Video calling also offers an option for a “foot of the bed” assessment, for example looking at rashes.
- If assessing by video, minimise time spent with child exposed
- Opportunity to speak to adolescents alone may be more difficult. How can we still have these vital conversations?
- Make sure to keep to time. Parents should know in advance how long appoint will last and you need to stick to it even more so than a regular clinic as they might think you’ve forgotten as they can’t see you popping in and out into the waiting room. Think about putting a stopwatch on the desk.
- Rostering staff – Where are clinics to be run from? Who would be able to run them remotely? Who can support junior staff if no consultant next door. Do appointments need the same duration? Can clinics be run flexibly i.e. for those LTFT? Where would appropriate admin time be provided?
- Equipment required– as a minimum, you will need a phone and computer with access to the appropriate medical software. Specialist remote working software and a webcam may be needed as well for video conferencing. If working in the hospital, is the computer wired into the internet, or are you relying on WiFi like you may be if doing the clinic remotely. Can you test and trust the connection?
- Conversation may feel a little stilted but important to give extra space for the patient to talk
1: Work out what is safe and easy to review remotely as establishing service
2: Test space & technology with simulated clinic appointment. Find those gaps before the real thing
3: Treat as normal clinic preparation in OSCE mode– need to be explicit with everything as losing some non-verbal communication
4: Go to the toilet and make a drink before starting the clinic
5: Be flexible. This is an evolving area of practice so feedback things that work well and that need improvement
Telemedicine clinics are most likely here to stay, offering a lower resource, quicker alternative to the traditional clinic structure, which may be more convenient for some patients, acknowledging there will always been a need for face-to-face consultations for others. This is an evolving area, and best practice will be honed going forward, learning with colleagues from other specialities and disciplines.
Any other tips? Tweet @paediatricfoamed or @ccdaniels65 and we’ll update the guide
With thanks to Dr Vicky Jones (@drvic), Dr Amy Taylor (@paedsdramy), Rachael Greenwood (@RachaelMidsEng), Dr Hannah Baynes (@HLB27), Dr Ilana Levene (@i_levene), Prof Trisha Greenhalgh (@trishgreenhalgh), Dr Victoria Hemming (@vphemming), Dr Tushar Banerjee (@bnrjt07), Sarah Gordon (@timbumbee), Dr Richard Berg (@rbsb) & Dr Lizzie Wortley (@lizziewortley) for their input