Telephone triaging during the 1st wave of the COVID 19 Pandemic: Outcomes and proposed pathway for managing patients referred for breast pain

ABSTRACT

Introduction/Background• The sudden outbreak of the COVID 19 pandemic led to increased stress on healthcare systems across the globe. They struggled to continue to provide other essential clinical services whilst dealing with the rapid surge of COVID 19 cases. It was therefore essential to optimize patient-centred care safely in a risk adapted environment without compromising outcomes.• We present our experience of telephone triaging of new symptomatic patients referred to a single, tertiary, academic large volume breast unit. Based on our observed outcomes, we propose a novel pathway for management of patients referred with Breast Pain. Methodology• We conducted an audit of patients triaged for telephone consultation at Guy's and St Thomas' NHS foundation Trust, UK between 1st April 2020 to 30th June 2020. Data was collected retrospectively from hospital records following approval from the Trust Audit Committee. Two week wait (2WW) referrals determined to be of low index of suspicion for breast cancer were triaged to telephone consultation. Criteria for low index of suspicion was breast pain, non-suspicious skin changes, bilateral non pathological nipple discharge, gynaecomastia, patients < 30. Patients > 70 were initially offered telephone consultation for risk assessment to avoid potential exposure to COVID19 (shielding of vulnerable cohort). Follow up data was recorded up to October 2020. SResults• There were a total of 685 new 2WW referrals during this time. The total number of patients that were triaged to telephone consultation were 111. The median age of this cohort was 34. There were 105 women and 6 men in this cohort. When classified by symptoms, 47 were referred for breast pain, 46 for suspected breast lumps, 6 for nipple discharge and 12 for other miscellaneous reasons.• The total number of patients that were invited back for imaging or face to face (F2F) consultation or both were 67 (60%).Total number that came back for F2F consultation were 50, out of which 14 were purely for F2F. The total number of patients that came back for imaging were 53, out of which 17 came for imaging only. Total number that came back for F2F and imaging both were 36.• 44 patients were discharged without a F2F consultation or imaging (40%)• F2F consultations (50) when classified by symptoms, 70% presented with breast lump, 14% with breast pain, 6% with nipple discharge, 2% with breast infections and 8% with other benign causes.• Total number of biopsies performed were 9, out of which 2 were cancers and the rest were benign.• There were 3 patients that came back with new referrals after a few months of being discharged following a telephone consultation. They presented with the same symptoms, or their symptoms had worsened or they had new symptoms. However, none of them had any significant finding on F2F consultations or imaging and were reassured and discharged. Conclusion• Our audit (although a small cohort), some published data (Cancer Waiting Times data in the UK comparing 1st 6 months from 2019 with 2020) and literature support the effectiveness of this tool in unprecedented times.• Breast pain is not the most alarming symptom. None of the patients in our cohort with breast pain were found to have any significant finding on imaging or were diagnosed with breast cancer.• Any breast lump or pathological nipple discharge irrespective of age should undergo triple assessment as gold standard.• Our proposal is to design a separate pathway for patients with breast pain as they do not necessarily need a F2F consultation or imaging (can be elicited by the clinician and called only if deemed necessary). This will in turn decrease the strain of 2WW referrals and increased burden on radiology.