By Nick Aresti and Bertie Leigh
Published 03 April 2020
Executive Summary
- Our patterns of working will abruptly change with a dramatic shift to virtual consultations for the foreseeable future.
- Regulators have relaxed their rules with regard to the holding of patient data for the duration of the pandemic.
- It remains important to ensure that we take care to protect patient data and that our standards of practice will withstand normal scrutiny once the emergency is over.
- Detailed regulations exist for non face-to-face clinical episodes – but many of these may have to be overlooked to ensure the safety of the most vulnerable members of society.
- Using WhatsApp, FaceTime etc is acceptable although social media should be avoided.
- Microsoft Teams has been made available for free to all NHS staff to communicate amongst themselves.
- Use a large, high resolution screen when reviewing images from home.
- Headsets provide the best audio for patients and clinicians, as opposed to in built hardware.
- Whilst normal protocols will have to be bypassed to roll out non face-to-face services at speed, consideration must be given to data collection and methods to learn from this drastic shift in practice norms.
Introduction
The COVID-19 pandemic has abruptly gripped the world and changed the face of healthcare, perhaps forever. All resources available are being diverted into the expected wave of the coronavirus sequalae, namely severe pneumonia and acute respiratory distress syndrome. The focus of care is centred around ‘flattening the curve’, so that patient numbers requiring hospitalisation remains below the threshold of resources, and of course increasing resources such that the demand can be met. In terms of ventilated beds, it is thought that at best this could be 10 times the current NHS capacity.
What does this mean for Orthopaedics? Flattening the curve also means prolonging it. We are likely to enter a period of months whereby elective services are ground to a halt and emergency and trauma services are changed to compensate for the limited capacity and workforce available. Orthopaedic wards and theatres in acute trusts will turn to makeshift ‘COVID-19 wards’ and ITUs. Specialist and independent services will be asked to share the burden placed on the acute hospitals.
When it ends there will be a backlog of deferred elective or less urgent cases that will mean the Service will be hard pressed for months after the acute pressure ends. For years to come we may have to accept that our society and economy is significantly poorer so that we cannot expect to revert to the ways of doing things that we regarded as appropriate until recently.
Over the coming weeks, elective patients will still require review and trauma patients will continue to present, albeit perhaps in different patterns. Orthopaedic and trauma services must adapt to these huge changes to ensure patients receive the best treatment they can in these troubled times. Furthermore, since the virus spreads through clinical contact, healthcare professionals must limit face to face contact not only with patients, but also with each other. It is not outside the realms of possibility that one infected surgeon may ‘take out’ the whole MSK department in a conventional trauma meeting, leading to a fortnight or more of no surgeons being available to care for their patients.
Non face-to-face (Nf2f) working has been steadily increasing over recent years. Virtual fracture clinics are now the norm in many NHS hospitals and have been shown to improve services significantly. Getting such services off the ground normally takes meticulous planning and negotiations with hospitals, IT services, commissioners and of course patients. It is worth noting that the NHS has been pushing for more virtual consultations, and a national Commissioning for Quality and Innovation (CQUIN) indicator has been set up to incentivise providers to deliver such services. These exceptional times however will not allow for a planning phase and the orthopaedic community will have to abruptly change its way of working.
Here, we provide some insight into how this can be facilitated.
Regulation
The ICO (Information Commissioner’s Office) is the UK's independent body set up to uphold information rights, akin to the CQC of data protection. Their legislative cover includes the General Data Protection Regulation (GDPR). Their rules and regulations are often difficult to navigate and setting up a new service means careful examination to comply. They have however confirmed, that they “won’t penalise organisations that we know need to prioritise other areas or adapt their usual approach during this extraordinary period.” It is still necessary to exhibit care with data sharing, but normal regulations can be temporarily bypassed if required to ensure patient safety. A timescale for this relaxation in enforcement has not been set yet.
The Care Quality Commission has developed an inspection framework for digital primary care providers (Available here). Whilst not all points are pertinent in an orthopaedic setting, the fundamentals are still similar and the document provides useful insight into a safe and effective service.
The GMC has also produced good practice guidance on ‘remote consultations’, (available here). They offer advice as to which types of consultations are better in person or remote. They recommend face to face consultations for a variety of reasons, including when patients have complex medical needs and when you are not the patient’s normal clinician. Unfortunately such patients are often more at risk in a hospital setting, and with the expected high level of absenteeism amongst clinicians, such factors may have to be overlooked.
Legal Considerations
Legally any new pattern of practice is fraught with hazard. Nf2f practice is no exception because it necessarily limits the ability of the clinician to complete the traditional assessment of the patient. Doctors must be careful to adhere to the guidance that has been provided about the circumstances where it will be appropriate. Whilst this guidance is being given when the NHS is facing a crisis and some flexibility in traditional arrangements are being tolerated and even encouraged, these circumstances are likely to last for a longer time than we hope and your actions may be judged long after the emergency is over.
Where patients are treated as part of the NHS the Government has made it clear that NHS indemnity will be available to practitioners under the COVID-19 Act 2020 which went through Parliament last week, even if it was not available before. One of the exceptions under the Act is where doctors have some other cover, such as MDO membership or insurance. The Act should be regarded as a safety net rather than a replacement of the traditional patterns of cover.
However, indemnity is only a small part of the threats faced by practitioners who treat patients inappropriately. They may also be disciplined by their employers or by the GMC and Nf2f is no exception: it contains its own challenges that must be managed effectively. Accordingly it is important to ensure that you adhere to the guidance of the GMC (available here). Here are several areas of particular concern that we wish to highlight.
First, you need to assess and record the suitability of the patient for this form of consultation, checking that you share a common language or are able to communicate effectively and that the patient has full capacity to understand the issues that are being discussed. They may be being accompanied by a family member or friend and you have to satisfy yourself that the patient wishes to share their confidences as well as being able to act as translator and support. This is of course an obligation that you are very used to discharging in face-to-face clinical practice, but can be harder to discharge and there is a danger that it will be overlooked when the third person cannot be seen.
Second, it is essential to establish that the ailment that is being presented is suitable for this sort of consultation. Where it becomes apparent in the course of the consultation that there may be something more complicated going on, you must not be afraid to make it clear that the patient needs to seek a different sort of consultation. You may be able continue to deal with the simpler presenting problem whilst offering to refer the patient to a different sort of portal for the more complex condition This is analogous to the problem posed by the patient who reveals a condition that is beyond your specialist area of practice in the middle of a conventional consultation.
Third, it is important to make detailed records of the information available at the consultation and the advice given. Whether or not treatment is prescribed, it is essential to record the alternative treatments that were discussed and the advice given about each. This should ideally be contained in an email sent to the patient at the end of the consultation so that you have permanent evidence of the advice that you gave and the fact that it was received by the patient. There is no need to make a duplicate note in the clinical record, just add the email to the file.
Fourth, it is vital to record the safety-netting arrangements. The email should usually conclude with a record of the advice that was given about follow-up and the circumstances that should prompt the patient to return to you or another doctor.
Types of Nf2f interactions
Broadly speaking, Nf2f interactions can be thought of as one of the following:
- Synchronous – where the patient and clinician interact in real time. This will replace clinic appointments and is generally in the form of telephone or video calls.
- Asynchronous – where the patient and the clinician interact at different times. This type of consultation may replace MDT’s – including morning trauma meetings or sub-specialty meetings. This requires more sophisticated conferencing facilities.
Hardware Considerations
IT and estate requirements will likely be diverted to the fight against COVID-19 and there is a high chance that clinicians will have to use their own devices. Thankfully, almost all clinicians use a smartphone (BMJ article on smartphone ownership here). They generally all provide sufficient technology for most Nf2f work. Any risk with their capabilities is likely offset by the reduction in risk to patient safety. Despite that, practical advice may improve the experience for patients and clinicians alike.
Using a headset provides better audio for both the clinician and the patient. It frees up the clinician’s hands for typing and the increased distance between the microphone and keyboard leads to less background ‘typing’ noise.
When reviewing images remotely, screen resolutions make a difference in diagnostic capabilities. For reviewing plain radiographs, the Royal College of Radiologists recommend a minimum of a 3 Megapixels (MP) display with a resolution of at least 2048 x 1536 (Guidance here). Whilst most modern devices exceed the pixel display requirements, the screen resolutions are often less – the larger the screen, the better.
With increasing isolation measures and more people working from home, network issues may reduce efficiency of digital communication. Fail safes should be put in place to combat failures of IT systems.
Software considerations
Discussing specific platforms is outside the remit of this article. We must however consider some important factors when choosing our mediums.
The most important factor is to understand the digital literacy and needs of our patients. Young and active patients are likely to have no barriers to using the technology we choose. There will however be a cohort of patients, likely the oldest, who do not possess the technology or the ability to use it. GMC and CQC regulations are clear on the issues this presents with capacity to consent and patient safety. Given these patients are the most vulnerable, a case by case risk assessment must be made in how to proceed – cancel or delay the appointment, use simpler technology such as phone call, or rely on friends / relatives to assist them.
From the providers standpoint, we must consider:
- Integration of clinical systems into existing trust software
- The operational complexity
- How easy it is to share data
These themes are expanded on further in a useful guide to Nf2f services, produced by UCLP (available here).
Synchronous consultations are likely to be either by telephone or video conferencing such as Skype or FaceTime. Asynchronous encounters require a little more sophistication. Several software solutions exist, including Zoom, GoToMeeting and eTrauma. Points to consider in making the choice include the ability to install and integrate into existing systems, the speed at which this can be done, cost and accessibility from either trust computers or remote locations.
NHS Digital are recommending the use of Microsoft Teams, which is initially being made available through NHS mail, but also eventually to trusts employing their own email systems. This application has been designed to “enable you and your colleagues to send instant messages, make internal calls, share, edit and collaborate on files and documents all in one central, secure location” (further information available here). We would encourage the use of this platform where possible as it will allow for cross trust / regional communication, which may become increasingly important as we are gripped by the pandemic.
There are of course concerns that the increasing use of technology will allow for breaches in data security and patient confidentiality. Whilst the use of personal devices to convey patient information has been largely scrutinised in the past, the NHS has recognised the benefit of doing so in these exceptional circumstances, and have issued guidance accordingly (available here). In summary, the use of mobile messaging, including WhatsApp, FaceTime and SMS is being encouraged. Avoid social media as much as possible.
When working remotely, using a Virtual Private Network (VPN) provides extra security to your own device as well as to patient data. Plenty of VPN solutions are readily available online. Furthermore, avoid using public WiFi, which is not as secure.
Summary
Setting up Nf2f services is challenging and normally requires engagement with all the relevant stakeholders and patient groups. Unfortunately, there is not enough time for the normal avenues. There will be no time for meetings and business plans. Local politics, CCG contracts and CQUIN’s must all wait. We must endeavour to deliver the safest and most effective services for our patients and deal with the potential consequences at a later date, knowing that early intervention saved lives. Where possible, build in failsafe mechanisms and collect data so that when we emerge from this pandemic, we may have jumped ahead in our use of technology.