ABSTRACT
One of the many logistical challenges facing our dermatology department during the COVID-19 pandemic was how to continue safely the systemic monitoring of dermatology patients on immunosuppressive medication and retinoids. The majority of these patients in our tertiary referral centre are entirely monitored by the hospital, with general practitioners having little/no capacity to manage shared care. Lack of ability to carry out routine face-to-face appointments acted as a catalyst for the service to evolve rapidly, from all monitoring appointments being clinician led to a structure whereby stable patients had at least one annual clinician review with regular monitoring appointments in between. We have created, assessed and adapted a new system for patients and staff. At the onset of the pandemic, to explain the new system to them, patients were contacted by letter and telephone. Initially, doctors made entries into patients' electronic notes to state which tests/follow-up they required. This was laborious, often missed and needed to be filled in for every visit. We therefore created a standard online proforma to check patients medication details/required tests, which could be updated easily. Although all clinician-led reviews remained with the patients' original team, blood/monitoring results for all patients were reviewed by one of four consultants as a planned activity and prescriptions were issued for home delivery if the results were satisfactory. Patients also completed a form each visit stating if they wanted to highlight any issues with their medication/condition to their doctor. Qualitative data were collected from patients and staff through a pre- and postchange questionnaire 6 weeks after roll out. The pre-proforma questionnaire identified concerns such as nurses' lack of confidence in which tests were required, prescription duplication/ error and patient confusion, particularly not being able to collect prescriptions on the day of monitoring, which resulted in some patients temporarily running out of medication. The post-electronic proforma questionnaire demonstrated a useful and easily accessible resource for the staff, which - on the whole - reduced workload. Although some patients struggled to adapt, the majority were satisfied. The COVID-19 pandemic has forced sudden changes in practice, but, in our experience, this can result in safe, more efficient and sustainable new ways of working. We demonstrate a system whereby patients can receive regular hospital monitoring without seeing the doctor at each visit. This is important when considering service provision throughout the ongoing pandemic and - given that consultant time is limited and costly - in considering future structuring of dermatology services.
ABSTRACT
One of the many challenges facing the department during the COVID-19 pandemic was how to provide follow-up safely for Mohs surgical patients. With the need to practice social distancing and avoid unnecessary face-to-face (F2F) follow-up, we felt the system could be improved to ensure patient and staff safety. We created, reviewed and adapted a new system to follow-up on patients. We designed a questionnaire that was sent out to patients 3 months postprocedure. This included questions on aesthetic and functional outcomes, and postoperative complications, including bleeding and infection. Recording these outcomes is a requirement for all Mohs surgical patients, outlined by the British Society for Dermatological Surgery. Information collected via the questionnaire allowed us to identify those who required further follow-up and those who could be discharged. A patient was felt to be suitable for discharge if they reported no postoperative complications, their scar bothered them 'a little' at most and they had no functional complications besides paraesthesia. Otherwise, patients were invited for medical photography and an appointment was arranged for them, either by telephone, or if necessary, F2F. Patients were given the option to request a consultation even if they did not meet the criteria for one. Data were collected for 131 patients who had Mohs micrographic surgery between April 2020 and July 2020. Sixty-six per cent did not require follow-up as defined by the criteria. Eighty-nine per cent of patients found the questionnaire 'acceptable' or 'somewhat acceptable'. Feedback from staff has been positive and the questionnaire continues to be our first step in follow-up. Patients are informed of this new format at the time of surgery. Our next step is to identify factors that predict the requirement for review so these patients can have a suitable appointment scheduled. We intend to review the process after the pandemic, as while this approach is considered acceptable in the current climate, we understand that it may be less so once the pandemic is over. We have demonstrated a novel approach to the follow-up of Mohs surgical patients during the COVID-19 pandemic. Our data suggest that two-thirds of postoperative reviews may not be required and propose a sustainable method to identify these cases. This is significant, not only in relation to the pandemic, but in the long term. Appointments should be reserved for a clinical need to ensure efficient use of clinicians' time.