Perceptions of telemedicine in specialist outpatient services

Introduction/Aim: COVID-19 has fast-tracked changes to healthcare delivery, including the introduction of a broad range of telehealth services. Work is needed to assess the ongoing suitability of telemedicine for the post-pandemic era. We sought to explore perceptions of telemedicine amongst patients and providers (clinicians and health administrators) who had appointments in cardiology, respiratory, neurology, rheumatology and gastroenterology services in hospital specialist outpatient clinics in Sydney Local Health District. Method(s): Semi-structured interviews explored perceptions of consultations undertaken virtually compared to in-person, seeking perspectives on the benefits, limitations and risks of outpatient telemedicine consultations. The 37 participants comprised 16 patients, 14 specialists, 3 Clinical Nurse Consultants and 4 administrators. Result(s): Patients indicated satisfaction with telemedicine consultations, especially during the pandemic. They valued saving on travel time and costs, and being able to access care from their homes, thereby minimising risk of COVID exposure. The chief disadvantage perceived by patients was inability to receive a physical examination. They noted greater challenges for people with hearing and visual impairments, limited digital skills and/or computer access. Providers' perceptions were more ambivalent. Although telehealth was understood to help meet demands during the pandemic, mis- and under-diagnoses were considered major concerns arising from the inability to perform physical examination. Most regarded telemedicine as an effective tool for review appointments but mentioned an associated increased workload. All participants mentioned the need for relevant education and training, better integration of telemedicine platforms into existing infrastructure and the need for a hybrid model of care. Conclusion(s): Telemedicine played a unique role in meeting patients' needs during the pandemic and its convenience was valued by patients. Clinicians expressed concerns about missed diagnoses, uncertain clinical outcomes, lack of administrative and technological infrastructure. The ultimate test of telemedicine will be its impact on clinical outcomes versus longstanding models of in person care.

COVID-19 management using respiratory supports in the ward, Australian hospital

Introduction/Aim: Acute hypoxaemic respiratory failure occurs often in people with COVID-19 pneumonia, with high need for respiratory support therapies (RST). We aimed to examine the clinical management of COVID-19 pneumonia including use of ward-based RST. Method(s): A ambispective electronic medical record review was conducted at an Australian tertiary hospital for COVID-19 patients requiring ward-based RST between 28/02/2020 and 18/03/2022. Result(s): Of 964 patient records identified, 670 were included, with 61% male and mean age 62 years (SD=19). 344 (51.4%) were unvaccinated, with 120 (17.9%) having >=1respiratory comorbidities. Prone positional therapy was achieved in 63 (9.4%) and recommended in 221 (33%) patients. High flow nasal oxygen (HFNO;n = 243, 36.2%), continuous positive airway pressure (CPAP;n = 131, 19.5%) and non-invasive ventilation (NIV;n = 4, 0.6%) were frequently administered to patients. 120 (49.4%) patients received both HFNO and CPAP. Arterial blood gases were infrequently measured prior to initiation of HFNO (n = 23, 9.5%) or CPAP (n = 25,19.1%). Target saturation aims were documented in 547 (81.6%) patients with a medical prescription for RST in 486 (72.5%). Patients using HFNO/CPAP/NIV had a daily respiratory nurse consultant review 236 (97.1%) with documented RST prescriptions and aims. Medical verification occurred at least once per admission from a consultant or advanced trainee for 213 (87.6%) HFNO patients and 117 (89.3%) CPAP patients. Median usage of HFNO was 2 days (IQR 1-4) and for CPAP 1 days (IQR 0.5-3). The median length of stay was 5 days (IQR 3-8). Clinical escalation with transfer to ICU occurred in 90 (13.4%) patients, with 24 (26.6%) intubated. 44 (6.6%) patients died. Most (n = 424, 63.2%) were discharged directly home without requiring domiciliary respiratory supports. Conclusion(s): Multidisciplinary, ward-based RST was successfully provided to most patients with COVID-19 pneumonia with clear documentation of processes of care. Support for and expansion of ward-based RST models of care should be considered longer term. Conflict of Interest: Nil.

I will never forget the day

Introduction: I would like to present a poem I have written about my experience of being part of the multidisciplinary team at a remote district general hospital on the day that a COVID-19 patient was retrieved for ECMO. Main Body: I will never forget the day It was late in the month of May It started in the usual way A handover with our patient lists We gathered, doctors, nurses, therapists And discussed a patient with COVID-19 infection And his clinical deterioration. He was a man of about fifty Usually well and pretty healthy Brought in by ambulance to A&E With oxygen saturations of eighty And quickly escalated to NIV. Three days alternating CPAP and high flow But progress was extremely slow And by the morning of day four He couldn't cope any more Sixty was his respiratory rate So the decision was made to intubate. He was given every treatment known Antimicrobials, paralysis and prone Epoprostenol and dexamethasone So brittle was his gas exchange with any small position change And even on APRV His FiO2 reached seventy. His only chance of salvation Was extracorporeal membrane oxygenation As the retrieval team began their journey ICU and theatre staff worked closely Nurse, consultant and operating department practitioner Helped move the patient into theatre Still proned, too unstable To even transfer to the table We waited in personal protective gear For the ECMO team to appear. From London arrived the ECMO specialist Her registrar and perfusionist A quick briefing, roles allocated, The patient was swiftly cannulated, With the largest lines I'd ever seen! And established on the ECMO machine It was a truly inspiring scene. Switching infusions, monitoring, ventilation, Ready for patient transportation But during the preparation He went into fast atrial fibrillation Requiring electrical cardioversion Amiodarone and magnesium. Sinus rhythm was restored But it was an insult he couldn't afford Increasingly hypotensive he became Chest compressions, adrenaline, all in vein, And to a difficult decision we came All agreed as a team Time to switch off the machine. I will never forget that day It was late in the month of May A life lost in a tragic way But something I can honestly say Never prouder have I been Of every person in that team We gave our all, we did our best In peace may our patient rest. Conclusion: I would like to dedicate this poem to all my ICU and theatre colleagues who shared this experience with me and, if given the opportunity, present it alongside pictures of them in their PPE as they were that day.

A MIXED METHOD STUDY TO EVALUATE THE MEDICINES OPTIMISATION PATHWAY FOLLOWING VIRTUAL OUTPATIENT CLINICS

Aim In March 2020, COVID-19 triggered an NHS directive to reduce face-to-face consultations and adapt to virtual clinics. 1 Hospital pharmacies, each with their own model of care, quickly innovated to ensure patients received their medication safely. The aim of this study was to evaluate the provision of medications optimisation for paediatric patients following virtual outpatient consultations (VOC) and explore potential improvements for future implementations. Method This was a mixed method study using quantitative data;which reviewed medications sent to patients in red, amber, and green categories2 and qualitative data;using patient feedback, to evaluate the processes in three London hospitals. Pathway mapping (PM) sessions, with multidisciplinary team involvement, were conducted across these hospitals to identify areas for improvement and analyse gaps in services. Virtual PM sessions were attended by 30 representatives across the multidisciplinary team including: pharmacists, nurses, consultants, pharmacy technicians, post room attendants;and general, operational, and project managers. Semi-structured questionnaires were used to conduct one to one telephone interviews with patients' families. A separate topic guide was used to interview General practitioners (GP) and primary care network (PCN) pharmacists. The audio recordings were transcribed as 'intelligent verbatim' and analysed using Nvivo. Braun and Clarke's six phases approach was used to conduct an inductive thematic analysis.3 To improve the rigorousness of the study, more than 50% of the transcript were double coded.4 As this was a service evaluation, ethics approval was not necessary. The project was registered with each hospital's clinical audit department. Results The three process maps were analysed and potential improvements for the medicines optimisation pathway were assessed by a paediatric pharmacy subgroup using ease-impact matrix. Potential improvements include: exploration and use of Electronic Prescription Service by secondary and tertiary care, improving communication through Information Technology systems between prescribers and hospital pharmacists, and the creation of a transparent standard operating procedure regarding medication supply following VOC. Seventy-one patients' families across the sites were interviewed between January-May 2021 to reflect on their experience of receiving medications following a VOC. Four GPs and one PCN pharmacist were interviewed in May 2021 to assess on the impact of VOC on primary care. Key reflections from themes generated include the convenience of receiving medications from hospital pharmacies following VOC, satisfaction of the current process, including medicines packaging and medicines information provided to patients and their families. Other reflections included limitations of the current process and its implication on patient safety. Medicines information helplines and education provided by pharmacists were regarded by patients' families and GPs as a valuable attribute. Conclusion Patients' families appreciated the current model of care, however patients' families and primary care healthcare professionals have identified both challenges and suggestions for improvement in delivering the current model. Future research should focus on a mixed mode of integrated care with green and amber medications2 prescribed directly to community pharmacies with clinical screening and counselling conducted by hospital pharmacists.

INTERNATIONAL IMPACT OF A CO-PRODUCED TRAINING VIDEO: SELF-EXAMINATION OF TENDER AND SWOLLEN JOINTS FOR PEOPLE WITH RHEUMATOID ARTHRITIS

Background/Aims Patients with rheumatoid arthritis (RA) need support to understand and manage their condition. The COVID-19 pandemic rapidly transformed outpatient clinical consultations from face-to-face towards remote models. This increased the emphasis placed upon self-assessment of joints and disease activity, strengthening the need for patient education materials. We planned to develop a video to support patient research participants to monitor disease activity remotely using the REMORA app. We altered the video's scope and made it open access to meet the need created by changes in service delivery models. Methods A video demonstrating self-examination of tender and swollen joints in RA was co-produced with patients and the multi-disciplinary team. A nurse consultant introduces key concepts, (how to identify and examine tender and swollen joints, which joints to include, etc), coaches a patient through self-examination, and answers key questions. Materials co-produced to support implementation into practice include a joint count manikin and table, an advertising poster, and blogs. Collaboration with international research colleagues has led to the production of a version dubbed in German. Subtitles are available in German and Hindi. Online feedback was sought via a survey. Ethical approval was not required as all contributors acted as equal members of the research team. Results The 15-minute video, supporting materials and survey were uploaded to YouTube in February 2021 [tinyurl.com/REMORAvideo]. 1,000 hits were received in week one, reaching >12,500 after eight months. 20% of viewers are UK-based, 15% from the USA, 10% from India. 26% of views used English subtitles, 0.2% German, 0.1% Hindi. 124/125 people engaging with the 'like/dislike' function on YouTube, 'liked' the video. 48 people fed-back online (26 patients, 22 clinicians). Patient ages were: 18-35(5%), 36-55(62%), 56-75(29%), 76+(5%), the majority of whom were female (19/21[91%]). Before watching, 14/ 17(82%) patients rated themselves as 'poor'-'fair' at self-examination: after watching, the same number rated themselves as 'good'- 'excellent'. 19/21(90%) and 17/21(81%) patients respectively either somewhat or strongly agreed with the statements 'I now feel confident to self-examine for' 'tender' or 'swollen' joints. 19/21(90%) of patients and 13/17(77%) clinicians either somewhat or strongly agreed with the statement that 'the video fulfilled my expectations'. 18/21(86%) patients and 12/17(71%) clinicians would recommend the video. To date, several national organisations have engaged with the video. It supports the BSR ePROMS platform and national audit. The National Rheumatoid Arthritis Society plans to incorporate it into the 'Know your DAS app', and it will contribute to an NHSX playbook of digital best practice. Conclusion This co-produced training video for people with RA, originally intended to support a remote monitoring app, has been well-received, with much wider-reaching international impact than anticipated. This demonstrates the need for materials collaboratively designed with patients to support patient self-management of long-term conditions, in the digital era.

Impact of a community of practice among cancer clinical nurse consultants

Aims: This study aimed to investigate the impact of a 'Community of Practice' (CoP) intervention on stress, burnout, resilience, job satisfaction and mindfulness among cancer clinical nurse consultants (CNCs) working in a large metropolitan cancer centre. The experiences of CoP participants were also explored. Methods : A consecutive mixed methods approach incorporating a one-group pre and post-test intervention design with qualitative interviews was employed. The intervention consisted of six CoP meetings incorporating structured professional development, networking and mindfulness training. The first CoP was delivered in-person with the remainder online due to COVID-19 restrictions. Participants completed validated and reliable questionnaires at baseline data (T0), after the 4th CoP (T2) and after the 6th CoP (T2) with data analysed using descriptive and inferential statistics. Qualitative interviews were conducted online and data were analysed thematically. Results : Thirteen CNCs completed the measures at all three time points and five contributed to qualitative interviews. No statistically significant differences in job satisfaction, burnout, stress, resilience, or mindfulness were observed between measures except for a decline in personal satisfaction from baseline to T1 and a decline in satisfaction with pay between T1 and T2. Across the study period, participants reported fair-to-good overall job satisfaction, high resilience, moderate mindfulness, moderately low stress and low levels of burnout. Five main themes were inductively derived from the qualitative data: Challenges of role;Existing and desired support;Introducing a community of practice;Importance of connection and relationship building;Acknowledgement, support and promotion of role. Conclusion: The CoP brought cancer CNCs in siloed but similar roles together to learn and connect. The CoP was conducted during a global pandemic when nurses faced unprecedented challenges in their roles. Despite this, participants in the CoP were able to maintain their good baseline levels of job satisfaction, resilience, mindfulness, stress and burnout.