Associate clinical professor and consultant rheumatologist at Leeds Teaching Hospitals NHS Trust, Kulveer Mankia, offers his insight of how COVID-19 has affected clinical practice within his department.
Covid-19 impact on continuum of care and throughput in rheumatology
According to Dr Mankia, a significant amount of clinical workload in rheumatology is undertaken in an outpatient setting where there is often a high turnover of patients. Prior to the pandemic, the department held large clinics, which typically included up to 40 patients who were seen every 15 or 20 minutes, with all of them seated in close proximity. As a consequence of the pandemic, all this changed, literally overnight, with routine face-to-face consultations suspended and moved to being largely undertaken remotely over the telephone. A further effect of the pandemic that had an important impact on the running of the service was how many of the clinical staff were re-deployed and Dr Mankia himself was tasked with working as a consultant on a general medical ward for a couple of weeks.
However, although the vast majority of rheumatology consultations were undertaken remotely, it was still possible for urgent cases to be seen in the clinic. Nevertheless, an interesting phenomenon observed by Dr Mankia was the existence of a fear factor among patients, that occurred across all specialties and even led to lower attendance at Accident and Emergency departments. People were simply concerned about catching the virus and, in many cases, newly referred patients were happy to effectively ‘sit it out’ and receive telephone advice from a clinician, rather than visiting the department. However, this has led to increased pressure on certain services. For example, there has been a surge in calls to the rheumatology advice telephone line; this service, usually managed by clinical nurse specialists, has required significant additional support from consultants and other doctors.
Fortunately over the last few months, services have gradually re-opened and Dr Mankia felt that the department has reached a new equilibrium, whereby the stable patients, who under normal circumstances would be asked to attend the department for a review appointment, are instead being managed remotely. With protective measures in place in the rheumatology department, confidence has begun to return and more patients are being seen at the department although several precautionary measures are in place. For instance, those with an appointment are contacted a few days prior to their appointment and asked whether they have any COVID-19 symptoms and are required to wear face masks at the department and seen by clinical staff in full personal protective equipment (PPE). The rheumatology department is therefore divided into areas where phone consultations take place and designated rooms in which patients can have face-to-face consultations. A downside to this approach is that fewer patients can be seen and appointment times have been extended, due to the need for thorough cleaning of the consultation rooms between each patient and to give time to clinicians to change their PPE.
New protocols and guidelines
At the start of the pandemic, Dr Mankia explained how the Leeds Teaching Hospitals NHS Trust developed PPE guidance for clinical staff although specific guidance for patients has evolved over time. Initially, the British Society for Rheumatology (BSR) produced guidance for members, as many patients with rheumatological conditions were prescribed immunosuppressant therapy and were thus presumed to be at high risk from the virus. The consultant body at Leeds developed an algorithm adapted from a risk stratification document originally produced by the BSR and the algorithm is now available on the Leeds Teaching Hospital Rheumatology website. This allows patients to check for themselves as to whether they should be shielding or socially distancing based on their individual circumstances. Interestingly, Dr Mankia noted that the Trust’s guidance has been used by other hospitals and can even be seen on YouTube, although Leeds has been cited as the original source.
While initially most consultations were conducted via phone, some video consultations were undertaken by some staff either in clinic rooms at the department or even from home. This was particularly useful for members of staff, who for various medical reasons, were themselves required to shield. Video conferencing also became the new platform for multi-disciplinary team (MDT) meetings, case reviews and educational meetings.
The pandemic forced a re-think in many areas of medicine and, as Dr Mankia explained, there was an urgent need to triage patients and ensure those with the most urgent cases could access services in a timely manner. For a speciality such as rheumatology, it was case of adapting to achieve a balance that you think will work. For example, some rheumatology care has been delivered remotely provided that staff have access to information such as blood test results. Moreover, the chronic nature of many rheumatological conditions mean that talking to the patient about their symptoms, and any possible treatment-related side-effects, is an extremely useful part of the assessment process. Nevertheless, remote consulting is not perfect and there will be plenty of instances where a patient is having problems or experiencing a disease flare which requires that they are seen and examined due to the obvious difficulty of remotely assessing the extent of joint inflammation.
Key learnings and challenges
Perhaps the most important thing is that the departmental team has worked together and managed to adapt and transform a service that had been established over many years in response to the pandemic. Dr Mankia also believes that the pandemic has highlighted to staff that remote consultations could work for stable patients and that even if the pandemic were to disappear tomorrow, it is possible that remote consultations, for some patients, would remain. However, the long-term implications of such changes on patient care would need to be considered carefully.
One of the more challenging aspects of the pandemic, which has required a lot of thought, has been the modification of practical services such as ultrasound and joint injection clinics. The ultrasound service requires staff to be in close contact with patients for three to four hours per session and was thought to be one of the higher-risk practices in rheumatology. Factors that needed to be considered ranged from the size of the room in which the ultrasound scanner was housed, current levels of ventilation, the need for before and after cleaning of equipment, even down to where patients would have to sit and wait before their scan. While it was relatively straightforward to simply move the ultrasound scanner to another room with sufficient ventilation, appointment times have had to be extended to allow for cleaning between patients.
A further difficulty created for clinicians and patients was that immediate ‘ad hoc’ scans were no longer possible. Whereas in the past, if a clinician felt that a patient needed a scan, this could happen after their consultation; now, all of these requests have to be planned and the department has had to create a new standard operating procedure for the ultrasound service.
Though there has been a clear impact on the number of scans than can be performed at any one time, a further difficulty highlighted by the pandemic has been how staff receive training on use of the ultrasound scanner. Ultrasound training, by its very nature, requires a ‘hands-on’ approach that invariably involves a degree of closeness with a trainer as the trainee needs to be able to read a scan on the screen to interpret the data and has to become familiar with how to operate the machine. During the pandemic, such practical training was no longer possible and is in the process of being re-designed to include a significant amount of online teaching including demonstration videos.
Rheumatology departments also provide joint injection clinics for patients and these have also reduced, although as Dr Mankia found, early in the pandemic, many patients were initially reluctant to visit the hospital and made the decision to try and manage for longer periods of time between injections. Again, this procedure has required a lot of thought because it involves close contact with patients.
Dr Mankia says how navigation through the department has changed radically because of the pandemic and is carefully structured with patients only brought in if they have a specific appointment and that relatives are no longer allowed in the same area. Patients are seated outside the specific room for their appointment and then leave the department. Overall, he feels that face-to-face consultations have reduced considerably and in fact currently, even new referrals are initially contacted by telephone to discuss their symptoms. With access to the GP records, relevant blood tests and the patient history, Dr Mankia felt that a diagnosis can sometimes by made armed with these facts. However, in many cases a physical examination is required and the patient will need to be seen in person.
One of the key learnings from the pandemic has been that the conventional model in which every patient consultation had to be face-to-face may be adapted and clinicians are now very much in tune with new ways of managing patients. Furthermore, there are possible benefits for those patients who are stable and for whom regular blood tests and monitoring are performed, in that they might no longer need to travel to the hospital for some routine appointments.
Regaining momentum post-pandemic
Dr Mankia thought that many of the changes implemented as a consequence of the pandemic could remain in place and that it was not really a question of regaining momentum to go fully back to the old way of working. It was highly probable that the department would continue with some virtual MDT meetings and, as he pointed out, interestingly, more people can attend these compared with the original face-to-face meetings. Both case discussions and academic educational meetings have been successfully delivered via a virtual platform and a proportion of these may continue to be done remotely. He thinks the pandemic has forced the pace of change, not just in rheumatology but in different specialties, as witnessed from discussion with consultant colleagues. Out of necessity, most colleagues in other clinical areas appear to have embraced the new mode of working and patients seem to be adapting to this as well.
Contributor
Kulveer Mankia BMBCh MA (Oxon) DM MRCP PGDip Health Res
Leeds Teaching Hospitals NHS Trust, UK
