How to carry out remote consultations for people with asthma and COPD
Primary care nurses are having to transform their ways of working to ensure the safety of patients and staff
- New ways of working apply especially to patients needing regular assessment and review
- Nurses should consider using different consultation methods, including phone or video
- Summarise and agree key issues with your patient, agree an action plan – and keep a record
Primary care nurses are having to transform their ways of working to ensure the safety of patients and staff during the COVID-19 pandemic.
And while the focus in recent months has rightly been on the prevention and treatment of the virus, it should not be forgotten that we still have patients with conditions that require regular assessment and review, including people with asthma and chronic obstructive pulmonary disease (COPD).
Crowded waiting rooms in GP practices seem like a distant memory. As social distancing is likely to remain in some form for the foreseeable future, we need to embrace new ways of working, underpinned by a growing body of knowledge and experience.
When a remote consultation may be appropriate
Central to this new way of working is the use of remote consultations, and the aim of this article is to identify the key issues in safely supporting patients with asthma and COPD through use of remote consultations in general practice.
In the early weeks of the pandemic, some patients with severe asthma or severe COPD received a letter telling them they were at very high risk of severe illness from COVID‑19. The letter said they, their families and carers should follow government advice on shielding.
On 22 June, health and social care secretary Matt Hancock announced easements from 6 July for the 2.2 million people in England currently shielding, with shielding coming to a stop at the end of July.
Minimise face-to-face contact to reduce the risk of infection
COVID-19 rapid guidance from the National Institute for Health and Care Excellence (NICE) for people with severe asthma and COPD advised health professionals to minimise face-to-face contact to reduce the risk of infection by:
- Using telephone, video or email consultations whenever possible.
- Cutting non-essential face-to-face appointments.
- Contacting patients via text message, telephone or email.
NICE rapid guidance for severe asthma says that if a patient has a face-to-face appointment, minimise time in the waiting area by careful scheduling, encourage patients not to arrive early and text them when you are ready to see them, so that they can wait in their car, for example.
Consider what sort of consultation is required
The first thing to consider is what sort of consultation is required and what method might be the most appropriate. This may vary according to whether it is an acute consultation or a chronic condition that requires review, and what you actually need to assess.
Telephone triage is common in general practice: it requires an ability to make quick and effective decisions based on what may be considered limited information, without the usual visual cues.
However, if you need to review inhaler techniques and the performance of peak flow or spirometry, a video call may be the better option.
A BMJ article on remote assessments in primary care suggests video calls may be appropriate for patients with co-morbidities, those whose social circumstances have a bearing on their condition, and those who are very anxious. Patients with hearing problems may also prefer a video call to speaking on the phone.
Nurses need to demonstrate that they have used best practice
The Nursing and Midwifery Council Code says nurses need to demonstrate that they have used best practice evidence for any decision or advice given, and that this is accurately and clearly documented. Many GP practices may have already developed protocols to support nurses with these skills, and some have computerised systems to support documentation.
The RCN’s guidance on remote consultations under COVID-19 restrictions covers the triage process and tips for initiating conversations, and is particularly relevant to general practice, community services, extended hours services and out of hours services.
Some patients for whom English is not their first language may need help from an interpreter service.
Using relatives as interpreters can lead to poor-quality care and outcomes
Research has shown that a failure to use professionals, or using ad hoc interpreters such as relatives, can lead to poor-quality care and outcomes for people who do not speak English, or whose English is limited.
This is easier to arrange for face-to-face consultations, but many healthcare providers will have access to services such as LanguageLine, a healthcare interpreting and translation service.
A three-way phone conversation can be time-consuming, so allow extra time for the consultation. RCN guidance on remote consultation advises that you document the use of any interpreting services to ensure the patient understands what is being advised. It says it is also good practice to avoid the use of family members or friends as interpreters, because of the risk of misinterpretation and that you cannot be confident what you are saying is being accurately translated.
A guide to SAFER consultations
We have developed a guide to safe consultations with people who have asthma and COPD, with the mnemonic SAFER to make it easier to recall, standing for start, assess, findings, explain and record.
Establish the reason for the consultation: is it an acute problem or review?
What is the best method of consultation? Phone, video or face to-face in a clinical setting or in a patient's home?
Beginning well is the foundation of a good consultation. Identify yourself – your name, role and place of work, check that you are speaking to the right person, check that you can both hear each other. Ensure confidentiality and privacy and agree on the reason for the consultation.
- Consider that if you are going to be seen you need to dress appropriately
- If using video, ensure your background is not distracting, and that other staff will not keep appearing and walking past you during the consultation
- Consider asking the patient if they have a pen and paper handy so they can make notes of useful resources
- In case you want to check a patient's inhaler technique, confirm they have it with them
Ask about symptoms or change in condition.
Your 'examination', covering colour, respiratory rate, ability to complete sentences on phone, and if appropriate respiratory rate, pulse rate, temperature, chest examination, oxygen saturations, inhaler technique.
What are the patient’s ideas, concerns and expectations?
- Don’t be afraid to change the method of consultation – for example, from phone to video – if one method isn’t working
- If using video, it is feasible to check inhaler technique and peak flow (PF) if the patient has a PF meter
What are the key findings of your assessment?
Do you need to do any other assessment?
Are there any red flags that need acting on promptly? These red flags could include sudden onset breathlessness, haemoptysis, unexplained weight loss, high temperature or new pain.
Summarise and agree key issues with your patient.
Agree on a plan of action.
Safety net – actions a patient should take if their condition changes (highlighting any red flags) and what they should do if they have any future concerns. Arrange a follow-up as necessary.
- Have to hand details of websites or further information on resources that can be useful to reinforce any messages during the consultation
Keep an accurate record of the consultation.
Ensure any referrals are actioned if required.
- Don't forget to look after yourself – factor in time between consultations for a break and to hydrate. The Chartered Institute of Physiotherapy has exercises that can be performed at your desk to help reduce aches and pains from being sedentary
Steve Holmes is a GP, education lead and past chair of the Primary Care Respiratory Society
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