{"id":7803,"date":"2020-07-30T17:46:28","date_gmt":"2020-07-30T16:46:28","guid":{"rendered":"https:\/\/www.thinkkidneys.nhs.uk\/kquip\/?page_id=7803"},"modified":"2020-09-04T13:35:27","modified_gmt":"2020-09-04T12:35:27","slug":"birmingham-renal-outpatients","status":"publish","type":"page","link":"https:\/\/www.thinkkidneys.nhs.uk\/kquip\/birmingham-renal-outpatients\/","title":{"rendered":"Renal Outpatients"},"content":{"rendered":"\n<h2 class=\"wp-block-heading\">Learning from one renal unit\u2019s transformation in response to COVID-19<\/h2>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"141\" src=\"https:\/\/www.thinkkidneys.nhs.uk\/kquip\/wp-content\/uploads\/sites\/5\/2020\/07\/Birmingham_left.png\" alt=\"\" class=\"wp-image-7788\"\/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\">Author<\/h2>\n\n\n\n<p><em> Helen Eddington <\/em><\/p>\n\n\n\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<h2 class=\"wp-block-heading\">Summary of beneficial changes<\/h2>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-group\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<div class=\"wp-block-group has-very-light-gray-background-color has-background\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<ol class=\"wp-block-list\"><li>Off-site phlebotomy centres set up with specified \u2018shielding\u2019 times for immunosuppressed individuals<\/li><li>Phone or video clinics were held &#8211; face to face appointments offered if clinically indicated<\/li><li>Video introduced for patient education and virtual home visits enabling us to continue to check homes are safe for home therapies<\/li><li>Virtual clinics to be set up for non-patient contact review<\/li><li>Face to face visits coordinated across all areas of renal medicine and surgery by a small multi-disciplinary team<\/li><li>Renal administration staff allowed extended IT access to allow us to manage our own service more effectively<\/li><\/ol>\n<\/div><\/div>\n<\/div><\/div>\n\n\n\n<h3 class=\"wp-block-heading\">Prior to Covid-19 pandemic<\/h3>\n\n\n\n<ul class=\"wp-block-list\"><li>Our patients attended face to face appointments with\na blood test performed during the attendance. <\/li><li>If changes in renal function were noted this\nwould need to be discussed with patient after clinic via telephone.<\/li><li>The main reasons for this configuration was due\nto wide geographical spread of patients, difficulty in coordinating blood tests\nprior to clinic with no remote centres, and inability to see all of GP results\nwithin our catchment area.<\/li><li>A large number of patients attended out-patients\nat any one time with pooled clinics which led to a significant foot-fall within\nthe hospital. These were held over 5 different out-patient areas during the\nweek.<\/li><\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">In preparation for the Covid-19 pandemic<\/h3>\n\n\n\n<ul class=\"wp-block-list\"><li>All records and results of patients due in\nclinic until July were reviewed by a consultant.<\/li><li>Where appointments could be delayed due to\neither stability of function and low clinical risk this was arranged.<\/li><li>All appointments changed to phone or video\nunless a face to face appointment was clinically necessary.<\/li><\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">During Covid-19 pandemic<\/h3>\n\n\n\n<ul class=\"wp-block-list\"><li>Off site phlebotomy centres were set up in some\nareas and some GP practices were able to do blood tests. <\/li><li>Phone or video clinics were held and only face\nto face appointments offered if clinically indicated. These were all covered by\nour shielding medical staff. <\/li><\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">Post Covid-19 pandemic<\/h3>\n\n\n\n<h4 class=\"wp-block-heading\">Trust\nlevel changes<\/h4>\n\n\n\n<ul class=\"wp-block-list\"><li>The Trust implemented social distancing within\nall outpatient areas and restricted the number of patients that could be seen\nface to face within a 45 minute period. <\/li><li>All staff and patients were required to wear\nmasks; this was implemented prior to the government guidance.<\/li><li>The trust increased the number of patients able\nto attend off-site phlebotomy &nbsp;to enable\nmore activity. There was also an increased number of shielding spaces created\nfor immunosuppressed individuals. <\/li><li>The number of phlebotomy and observation rooms\nhas increased within the main out-patient area to enable social distancing to\nbe maintained though this led to reduced rooms for clinical activity.&nbsp; <\/li><\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">Departmental\nchanges<\/h4>\n\n\n\n<ul class=\"wp-block-list\"><li>As consultants were released from the emergency\non-call rota the appointments that had been delayed were re-reviewed. <\/li><li>The only area to open was the main out-patient\narea which left no space for a substantial proportion of our clinic\nactivity.&nbsp; Therefore coordination of all\nrenal medicine and surgery clinics was required to allow services to resume and\nto relieve any backlog. This over-arching coordination was performed by a small\nmulti-disciplinary team which included lead consultants, managers and\nadministration staff and ensured activity fell within the foot-fall restrictions\nand numbers of rooms available.<\/li><li>Room and time allocation was split between key\nareas of transplant, CKD, a combined GN, vasculitis and lupus group and renal\nsurgery. This allowed each group to book patients face to face within their\nallotted times. We started face to face activity slowly though this has\ncontinued to increase. Where areas did not require the face to face activity\ndistributed this was then reallocated to other areas and continues to be\nreviewed.<\/li><li>Where possible face to face visits were\ncoordinated across all areas of renal medicine and surgery to limit visits to\nthe hospital. For example pre-dialysis patients underwent Hep B vaccination and\nblood tests while attending vascular access appointments, or clinic\nappointments were performed while patients attended the infusion suite for\nimmunosuppression. This requires ongoing input from the multi-disciplinary\nteams to ensure we limit our requests for patients to leave their home and\nrelieve some pressure on off-site phlebotomy.<\/li><li>There was a large clinic back-log however we\nwere also aware we needed to ensure the workload was manageable by staff still\nrecovering from managing the first Covid-19 peak. The post-covid consultant\non-call rota differed to the pre-covid rota and junior staff were not released\nfrom in-patient activity for some time. This lead to a reduction in the number\nof medical staff free to cover out-patient activity despite the need to cover\nall delayed appointments. Some consultants increased their contract activity to\nenable this to occur.<\/li><li>Large numbers of administration changes were\nrequired for us to implement our \u2018new\u2019 service. There were initial difficulties\ndetermining which patients required phone\/video or face to face appointments\nand also difficulties to ensure the face to face rules were not breached. To\novercome this we set up new face to face clinic codes which were only for the\nset time spaces and limited to the maximum of each clinic. The phone clinics\nwere limited depending on the number of medical staff available to ensure the\nworkload was manageable. Any changes to the out-patient times, codes and\nnumbers initially had to be implemented through the trust IT service. As all\ntrust departments were asking for changes renal administration staff were\nallowed extended access to allow us to manage our own service more effectively.<\/li><li>We are in the process of implementing a new\nservice to perform a virtual review of stable patients who will undergo blood\ntests at remote phlebotomy centres.&nbsp; The\nresults will be reviewed at an MDT with a consultant and specialist nurses and\nif all stable a letter will be sent out to inform the patient. If there are any\nconcerns the consultant can phone the patient and plan further management. We\nenvisage that these virtual appointments will be used across all aspects of our\nrenal medicine service and will alternate with a patient contact appointment.\nAs a safety net patients will also be provided with a phone number to contact\nus if they have developed a relevant new medical issue so we can convert all\nvirtual appointments to phone or face to face as required. This service will\nfree up clinic capacity and can also be run safely through any further Covid-19\npeaks if necessary. In future we would like to utilise digital tools such as an\nelectronic PROM to enable patients to report clinical change and submit data\n(such as home BP readings or community blood test results)<\/li><li>Video has been used for patient education and\n\u2018virtual\u2019 home visits and enabled us to continue to check homes are safe for home\ntherapies. There are advantages to all modes of consultation and we foresee\nthat the future of our service will incorporate a mix of all modes in the long\nterm. <\/li><\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">Challenges and proposed solutions<\/h3>\n\n\n\n<ul class=\"wp-block-list\"><li>Patient feedback has been mixed in this time of\nuncertainty. The majority of patients prefer to have their results available to\nallow a more focussed consultation and find phone clinic much easier to handle\nwith their work or home life. However there are other patients who really enjoy\nthe face to face contact. The video consultations have had some technical\nissues so have been used less, though we expect these to become increasingly\nutilised in the future.&nbsp; <\/li><li>To deliver phone or video clinics staff require\na quiet space with no phone-calls or other people in the background. Some\nconsultants are facilitating this by covering these from home or from an\nindividual office space however the majority of consultants work in an open\nplan office and require an out-patient room for this. When the junior medical\nteam join clinic activity they will also require room space. The lack of areas\nhas proved challenging and this will need to be considered in future planning\nif other out-patient areas do not open in the near future.<\/li><li>Our service covers a large geographical area\nhowever the remote phlebotomy sites for the trust cover the closer secondary\ncare catchment.&nbsp; Even within Birmingham,\npatients may require public transport to attend remote phlebotomy centres and\nthose on transport also struggle to be accommodated. <\/li><li>Some GPs have not been able to assist during the\ncrisis and negotiations with GPs are ongoing to help provide services in the\nfuture. Some patients from the extended catchment area have blood tests done\nlocally by their GP however they are not visible on our hospital system. <\/li><li>We are considering a remote \u2018roving\u2019 phlebotomy\nservice which may utilise dialysis units to help facilitate remote blood tests\nin the future.<\/li><\/ul>\n\n\n\n<h3 class=\"wp-block-heading\">Key messages<\/h3>\n\n\n\n<ul class=\"wp-block-list\"><li>Communication and coordination is central to\nsuccess in implementation of changes in practice that affect all\nmultidisciplinary team members. This worked because it was run by a small,\ntight and highly organised team<\/li><li>Within the out-patient area very little has\nremained the same and therefore managing enforced change with a tired or\nstressed workforce has to be managed equitably, clearly and carefully. <\/li><li>Be aware that many changes lead to increased\npressure on administration staff and understanding the issues with booking\nsystems and restraints are required to develop a new process.<\/li><li>Listen to patient feedback. Not all change is\nbad and many of our new adjustments have led to an improvement in aspects of\nthe service.<\/li><\/ul>\n\n\n\n<hr class=\"wp-block-separator\"\/>\n\n\n\n<h2 class=\"has-text-align-center wp-block-heading\"><a href=\"https:\/\/www.thinkkidneys.nhs.uk\/kquip\/hub\/birmingham-learning-covid-19\/\">RETURN TO UNIVERSITY HOSPITALS BIRMINGHAM &#8211;<br>LEARNING FROM COVID-19<\/a><\/h2>\n\n\n\n<hr class=\"wp-block-separator\"\/>\n\n\n\n<h2 class=\"has-text-align-center wp-block-heading\"><a href=\"https:\/\/www.thinkkidneys.nhs.uk\/kquip\/shared-learning-covid-19-outpatients\/\">RETURN TO SHARED LEARNING FROM THE KIDNEY COMMUNITY ON RENAL OUTPATIENTS DURING COVID-19<\/a><\/h2>\n","protected":false},"excerpt":{"rendered":"<p>Learning from one renal unit\u2019s transformation in response to COVID-19 Author Helen Eddington Summary of beneficial changes Off-site phlebotomy centres set up with specified \u2018shielding\u2019 times for immunosuppressed individuals Phone or video clinics were held &#8211; face to face appointments offered if clinically indicated Video introduced for patient education and virtual home visits enabling us to continue to check homes are safe for home therapies Virtual&#8230;<\/p>\n","protected":false},"author":130,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"jetpack_post_was_ever_published":false,"footnotes":""},"class_list":["post-7803","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Renal Outpatients - The Kidney Quality Improvement Partnership<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.thinkkidneys.nhs.uk\/kquip\/birmingham-renal-outpatients\/\" \/>\n<meta property=\"og:locale\" content=\"en_GB\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Renal Outpatients - The Kidney Quality Improvement Partnership\" \/>\n<meta property=\"og:description\" content=\"Learning from one renal unit\u2019s transformation in response to COVID-19 Author Helen Eddington Summary of beneficial changes Off-site phlebotomy centres set up with specified \u2018shielding\u2019 times for immunosuppressed individuals Phone or video clinics were held &#8211; 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