The coronavirus pandemic has accelerated the move towards remote clinical consultations and no more so than for assessing and reviewing those with asthma. Telephone, text messaging and video-based consultations reduce the need for face-to-face consultations that might increase the risk of infection.
Digital acceleration in primary care
In a speech on the future of healthcare delivered in July 2020, Matt Hancock, the secretary of state for health and social care, said that ‘Coronavirus has catalysed deep structural shifts in healthcare that were already underway’, such as telemedicine (Department of Health and Social Care, 2020). He reported that: ‘In the 4 weeks leading up to 12 of April this year, 71% of routine GP consultations were delivered remotely, with about 26% face to face. In the same period a year ago, this was reversed: 71% face to face and 25% remotely.’ He went on to say that the future for GP consultations should default to teleconsultations unless there is a reason not to.
The British Medical Association (BMA) response has been that patients should be triaged before a teleconsultation is offered (Pulse, 2020). Both the BMA and the Royal College of General Practice (RCGP) have expressed the view that physical appointments will always be a part of general practice, where patients value face-to-face relationships (Pulse, 2020).
Several guides on remote consultations have been published, such as a joint guide between the RCGP, NHS England and NHS Improvement (2020).
A summary of the key points outlined in this national guidance is given in Box 1.
Box 1.Summary of the principles for supporting high quality consultations by video in general practice during COVID-19
- Procure NHS-approved online consultation software
- Complete a clinical safety risk assessment, including checking that, for home-based workers, internet access is secure, encrypted and password protected
- Review and update data protection impact assessment. Ensure that your privacy notice reflects the use of video consultations. Use your existing consultation skills, but remain professionally vigilant
- Communicate well within teams using NHSMail or Microsoft Teams
- General guidelines on conducting a remote examination: visual assessment, clinical questions, observations and documentation.
RCGP, NHS England and NHS Improvement, 2020
Efficacy of remote consultations
Compared with face-to-face consultations in the surgery, a study by Pinnock et al (2003) found that telephone consultations enable more people with asthma to be reviewed, without clinical disadvantage or loss of satisfaction. Shorter phone calls are likely to be an efficient option in primary care for routine review of asthma. A Cochrane review did not highlight any important differences between face-to-face and remote asthma check-ups in terms of exacerbations, asthma control or quality of life (Kew and Cates, 2016).
Many surgeries have adopted new software, such as accuRx (accurx.com) that sit alongside common clinical platforms such as EMIS to make communication between health professionals and patients easier. AccuRx functionality includes text messaging and video consultations and can send out asthma control tests and COVID-19 screening questions.
The importance of the triage process
The Royal College of Nursing (RCN) produced guidelines on remote consultations in May 2020. These guidelines make reference to the General Medical Council's (GMC, 2020) guidance on the importance of good triage, where the decision to offer a face-to-face consultation is made, based on:
- The patient presents with complex symptoms
- There is no access to medical history or patient records
- The person lacks capacity to understand or consent
- There is a need to physically examine the patient
- There is a need to give specific treatment such as an injection
- There is a need to assess the home environment.
The GMC advises that remote consultations can be considered where:
- Straightforward follow up or assessment is needed
- Medical records are accessible
- You have the information to treat available and can prescribe or arrange follow up for prescription if necessary
- The patient has capacity to understand the process.
What can be done via remote consultation?
- Assessing, diagnosing and managing acute respiratory illness
- Routine asthma reviews
- Starting and reviewing/changing treatment.
Based on the RCN/GMC's guidance, the majority of routine asthma reviews could be done remotely and follow up calls to check on response to treatment would also be appropriate, but if a patient is having an exacerbation then they would need triage first.
Advantages and disadvantages of telephone and video consultations for asthma
Telephone triage has been in use for some time in GP surgeries and requires an ability to make decisions with limited information and without visual cues. The pros and cons of telephone consultations, including the use of text messaging, are set out in Table 1.
Table 1. Advantages and disadvantages of telephone consultations for asthma
| Advantages | Disadvantages |
|---|---|
| Quick and convenient | Cannot check/demonstrate inhaler technique, listen to chest, do spirometry or fractional exhaled nitric oxide (FeNo) testing |
| Text integration software like AccuRx that can enable patients to complete an asthma control test (ACT) or be given useful self-management links such as inhaler technique videos | Response rate to questionnaire may be variable |
| Response to ACT can indicate urgency of a follow up consultation – not only to the nurse but also may galvanise the patient into better self care | Harder to build rapport |
| Ability to text links to resources such as inhaler technique videos | Patient may be busy or may have poor phone signal |
| Useful for follow up calls, eg to check response to treatment | Unable to read body language, mood or physical appearance: verbal cues only |
| Remote consultations could be enhanced by the use of telemonitoring, eg using ‘smart’ inhalers to monitor concordance, smart peak flow meters and home spirometry devices such as Spirobank that can send data to surgery | |
| May be more attractive to patients of working age who have trouble making time for traditional appointments |
Telephone triage and responses to screening questionnaires and asthma control tests (ACT) results can then be reviewed, and a decision made about whether a video or face-to-face follow up might be best. The pros and cons of video consultations is set out in Table 2.
Table 2. Advantages and disadvantages of video consultations
| Advantages | Disadvantages |
|---|---|
| Enables emotional and visual assessment: patient may be more relaxed and open in familiar surroundings | Potential marginalisation of patients who are less able digitally or may not be connected to the internet |
| Appropriate for patients with co-morbidities, those whose social circumstances have a bearing on their condition, and those who are very anxious | |
| Patients with hearing problems may be better able to communicate by lipreading or using chat function | |
| Reduced did not attend (DNA) rate: may be more attractive to patients of working age who have trouble making time for traditional appointments | Poor WiFi bandwidth may mean consultations fail |
| Offers window into people's lives which might help explain, for example, why there may be poor concordance with treatment | Problems using technology |
| Ability to text links to resources such as inhaler technique videos and send documents such as personalised asthma action plans | Cannot physically examine the patient |
| Ability to check inhaler technique, measure respiratory rate, help patient measure own pulse rate | Privacy and security issues – patient or clinician could be overheard or patient may use public WiFi |
Video consultation technique
The GMC, RCN and RCGP guidance all contain advice on how to conduct remote consultations safely and effectively (GMC, 2020; RCN, 2020; RCGP et al, 2020; Bostock, 2020).
The main elements can be summarised as:
Starting the conversation
- Introducing yourself
- Checking the patient's identity.
Making reasonable adjustments
- For any disability
- Need for interpreter.
Environment
- Quiet confidential space if you are working at home, where you will not be interrupted
- Checking patient privacy: has the patient given consent for others to be present?
Consent
- Capacity to consent. With children under 16 requiring an asthma consultation, use the Gillick competence principles to determine if the patient is competent for example to make choices about asthma treatment without parental involvement
- Ensure the patient understands what they are consenting to
- Ensure informed consent for recordings or screenshots.
Chaperone
- Appropriately trained
- Visible to the patient.
Check understanding and health literacy
- Some inhaler devices were changed due to issues with inhaler availability early in the pandemic, because of over ordering. Therefore, teaching/checking inhaler technique is vital
- 43% of 16–65-year-olds have difficulty understanding written health material, so videos of inhaler technique may be better than leaflets (Protheroe et al, 2017)
- Use the ‘teach back’ method (NHS Education for Scotland, 2020): ask the patient to describe back to you, in their own words, what has been discussed or the plan/treatment instructions
- Chunk and check: break down information into small chunks with breaks to check understanding in between. Short, regular asthma consultations are better than long ones (NHS Education for Scotland, 2020)
- Use the ICE consulting framework: what are their ideas about what might be causing their asthma problems? What are they concerned about? What are they expecting from you?
Supporting self management
After reviewing control, check and review the patient's personal asthma action plan (PAAP):
- Do you need to make changes, in partnership with them?
- Do they understand daily management, how to identify and respond to signs of deterioration?
If changes are made, a revised PAAP can be emailed or sent as a link by text.
Diagnostic safety netting advice (Almond et al, 2009)
- What to expect – ‘these oral steroids should kick in after x days’
- What to look out for ‘but if you're not feeling better after y days’
- What would I do then? ‘then do come back to me’.
Other points
- Ending video consultations can be hard if the patient has been socially isolated and may want to chat. Use verbal cues – ‘to summarise… okay?’
- Document not only the consultation but record that it was a remote consultation and be specific about how information was obtained
- Keep in mind the Nursing and Midwifery Council (NMC) code – always prioritise people, practice effectively, preserve safety and promote professionalism and trust.
Conclusion
Remote consultations look set to remain a permanent feature of primary care. The evidence so far is that, with careful triage, remote consultations are as effective as traditional face-to-face consultations and could be more resource and time effective both for nurses and patients. They offer opportunity for flexible staff working, but care is needed to avoid clinical isolation.
New software such as accuRx promotes self-management of asthma by enabling patients to do asthma control tests and learn from educational videos. Telemedicine is expanding and in the future things like data sharing from smart inhalers and personal spirometers may enable remote monitoring and potentially better concordance with asthma treatment and better control.
KEY POINTS:
- Research has found that telephone consultations enable more people with asthma to be reviewed, without clinical disadvantage or loss of satisfaction, and with no important differences between face-to-face and remote asthma check-ups in terms of exacerbations, asthma control or quality of life
- The majority of routine asthma reviews could be done remotely and follow up calls to check on response to treatment would also be appropriate, but if a patient is having an exacerbation then they would need triage first
- Remote consultations offer the opportunity for flexible staff working, but care is needed to avoid clinical isolation
CPD reflective practice:
- What are the main advantages and disadvantages to remote consultations for asthma?
- Why is triage important when deciding which patients are suitable for a remote asthma consultation?
- How can you check understanding and health literacy when conducting a remote consultation?