Information for surgeons regarding OPD Triage during COVID-19 Epidemic – 19th March 2020

CONTEXT

The current outbreak of COVID-19 has resulted in significant change in surgical practices in Irish hospitals. As part of the response to this challenge, many hospitals will cancel or reduce out-patient visits as part of their COVID-19 containment strategy. It is most regrettable that a large number of surgical patients will be inconvenienced, and some may be at risk of missed or delayed OPD visits. The duration of disruption to services is difficult to predict.

Due to the disruption, it may be necessary for surgical teams to take a more active role in managing their own waiting lists. Many patients who are booked for OPD over the next 6 weeks have already experienced a prolonged delay. Some hospitals operate a partial booking service where only the next 6 weeks receive appointment dates and others are kept on a waiting list, based on pre-agreed urgent and routine quotas.

Waiting list validation and arranging diagnostic tests before OPD visits may be possible from information on the referral letters if enhanced clerical support is available to facilitate this. Furthermore, for new referrals, departments should consider pooling waiting lists for non-specialist work. It is important to note that this guideline document relates only to the period of disrupted services during the COVID-19 outbreak and every effort should be made to return to normal services at the earliest opportunity. This information does not replace the use of expert surgical clinical judgement on a case by case basis.

PROCESS 1: VALIDATION PROCESS FOR FUTURE OUTPATIENTS ALREADY ON A WAITING LIST AND THOSE DUE TO BE SEEN WITHIN THE NEXT 6 WEEKS

Review the referral letter and any medical records or results available.

Possible Outcomes:

• Enough information to book diagnostics prior to being seen (ACTION: book diagnostic test, and write to patient & GP)
• Enough information, no change to plan (ACTION: reaffirm priority as per Process 2, arrange date for OPD or VOPD. (REF: NCPS guidance on virtual OPD) where available. As much as possible do necessary tests on the day of hospital visits as a “one stop” service)
• Not enough information, no change to current plan (Action: reaffirm priority as per Process 2 and consider if suitable for VOPD. (NCPS guidance on virtual OPD) where available)
• Enough information, does not need to be seen or can be deferred (Action: VOPD. (NCPS guidance on virtual OPD) or advice letter and return of referral to GP).

PROCESS 2: NEW PATIENTS REFERRED FOR AN OPD APPOINTMENT DURING THE COVID-19 RELATED DECREASE IN OPD AVAILABILITY

Arranging diagnostic tests before OPD visits may be possible based on the information in the referral letter, if enhanced clerical support and diagnostics are available to facilitate this. Furthermore, for new referrals, departments should consider pooled waiting lists for non-specialist work.

During this review, the following triage categories may be useful:

Urgent patients are those who are highly likely, in the surgeon’s opinion, to come to harm if treatment does not proceed urgently. These patients should be prioritised for an OPD visit, a phone call or a virtual consultation by a member of the surgical team.

SOON PATIENTS WHO LIKELY REQUIRE CARE WITHIN THE NEXT TWO MONTHS may be suitable for a phone call or a virtual consultation to clarify symptoms. The surgeon should consider whether direct referral for an investigation or the provision of advice to the referring GP could avoid the need for a hospital visit or could manage symptoms while awaiting an OPD review at a future date. Any such actions should be documented in the medical record in a letter to the GP and the patient. (REF: NCPS guidance on virtual OPD) It should be noted that this category may contain a large number of patients and exceed the health system’s capacity to meet demand. Surgeons should try to identify the most high risk patients in this cohort based on their individual and collaborative expert clinical judgement.

ROUTINE PATIENTS WHO CAN WAIT TWO OR MORE MONTHS in the surgeon’s opinion should be listed for a future OPD clinic and the reason for this postponement explained to the patient and referring doctor. As the duration of the COVID-19 outbreak cannot be quantified, such referrals may be pooled and deferred to a future date.

If local circumstances (eg staff shortages or service pressures) do not allow a review of medical records and/or referral letters, a future OPD appointment date should be issued to the patient.

It is important to note that this document relates only to the period of disrupted services during the COVID-19 outbreak and every effort should be made to return to normal services at the earliest opportunity.