Remote working in Nephrology

Review of London kidney teams’ response to COVID-19, March-June 2020

Summary of key themes

  1. Ensure IT infrastructure and space to enable confidential remote consultations
  2. Record consultations and use for training and educational purposes
  3. Use Attend Anywhere to provide opportunities for joined up working involving the MDT, family and carers
  4. Consider evening and weekend remote consultations from home providing a flexible approach
  5. Develop education programmes and information for patients to enable a good remote consultation
  6. Promote patient activation and self-management

Next steps

  • Use the London Networks to develop consensus on remote working
  • Hold a follow up event to define best practice and review progress

Summary of discussions

What worked well?

  • Community phlebotomy services in some areas helped patients stay away from hospital and worked well with remote consultations
  • Flexible working and working from home for clinical staff helps to maintain a better work-life balance
  • Convenience of evening clinics appreciated by some patients and clinical staff
  • Attend Anywhere works well, is easy to use and helps improve MDT working and patient access e.g. family members invited to join consultation, possibly for translation
  • Remote working can promote self-management by patients (if appropriately resourced)
  • Telephone clinics proved relatively easy to set up
  • Trusts experienced lower rates of DNA – may be a function of lockdown
  • Our experiences will inform the rapidly developing science around selection of appropriate consultation setting, which will inform future practice
  • The speed of implementation and roll-out demonstrated a new model for working at pace
  • Remote working has created the need for innovation in the pathways e.g. excellent advice sheets/resource were developed and used for ward teams for breaking bad news over phone
  • Those clinicians who had experience of both telephone and video clinics in general found telephone to be less good, if more easily accessible to all

Key challenges

  • Hospital based phlebotomy does not fit well with remote working – in particular during the peak of the pandemic, many patients were fearful of coming to the main hospital for venepuncture
  • We do not yet have the infrastructure in place to enable blood results to consistently be relayed back to clinical teams
  • Setting up and administrating remote clinics required huge administration support as well as clinical time to work through patient lists
  • Preparation and triaging patients for clinic needs dedicated time
  • Available space to hold a telemedicine clinic and the necessary software and hardware (headphones and web-cams) were not in place to start with
  • Concerns about equity of access to remote consultations and not meeting the needs of certain patient groups
  • At present we do not have a complete understanding of what aspects of care can be delivered effectively in a remote clinic
  • Breaking bad news by telephone is very challenging, but can work with system changes such as clear written protocols, scheduling a follow-up call, and identifying a dedicated contact person in the renal team
  • Forming and maintaining a doctor-patient relationship in a non-face to face is important
  • Efforts need to be made to be holistic in a telemedicine setting. Video consultation platforms such as Attend Anywhere allow for up to 6 participants to take part in a consultation and so with the right resourcing it is possible to continue to provide multi-professional input in a telemedicine clinic
  • Telemedicine clinics have the potential to both lose and gain training and educational opportunities for trainees. Clinicians will need to be imaginative in the way they approach training in non-face to face settings
  • Telemedicine clinics are not intended to fully replace face to face consultations. There is a need to provide a F2F offer to sit alongside a telemedicine clinic, and should be for patients’ to choose
  • Face to Face clinics need to be as COVID-19 secure as possible, respecting Public Health England and NHS London infection prevention and control. Consideration should be given to delivering F2F clinics on non-acute (cold) sites by staff not directly involved in caring for patients with COVID-19

What could we do better?

  • Improve risk stratification, selection and consent of patients requiring F2F
  • Use patient portals such as Patient Knows Best or PatientView for patient self-management
  • We can improve the education we provide to patients to equip them to self-manage their condition better, and also provide the tools to be able to do this e.g. BP monitor, weighing scales, urinalysis technology
  • Provide high quality education for patients and clinical teams on how to use remote consultations effectively
  • Support patients to access video consultations
  • Explore opportunities to work with third sector organisations to support patients to access technology through training and possibly donated hardware
  • COVID-9 secure outpatient facilities allowing better physical separation of staff and patients from those caring for patients with COVID-19. Need more resilience within OPD
  • Better access to community diagnostics whether delivered as a mobile ‘pop-up’ service or geographically dispersed at ‘cold’ sites
  • Improve and standardise the collection of PAM/PROM/Frailty assessments information to enable Shared decision making, guide triaging, and also enable responsive learning and development of risk-stratification and self-management tools