Information for surgeons regarding virtual follow-up of surgical patients – 9th March 2020
The current outbreak of the COVID-19 virus has resulted in some changes in Irish hospitals. Up to date information is available on the HSE and HPSC websites. As part of the response to this challenge, a number of hospitals have cancelled or reduced out-patient visits as part of their COVID-19 containment strategy. The COVID-19 virus poses particular risksto the elderly, those who are immunosuppressed and those who have co-morbidity. Such vulnerable individuals are advised to avoid contact with infected individuals. Social isolation strategies are also recommended for individuals who have travelled to a high risk area or who may have been in contact with an infected individual.
The susceptibility of post-operative patients to COVID-19 is unknown but many such patients may wish to avoid a hospital visit. Although curtailing out-patient visits may be prudent in many of these circumstances, for patients who are recovering from surgery, a post-operative checkup is an important safety measure allowing complications and other post-operative problems to be identified in a timely fashion. Alternatives to standard follow up practices may be necessary during the period of the COVID-19 outbreak.
It is important to note that this document relates only to FOLLOW-UP of existing patients and not to the remote assessment of new surgical patients. In many surgical specialties, outpatient attendance is an important mechanism of urgent or emergency access for patients with serious benign and malignant conditions and may reduce emergency presentation through the emergency department. Changes to standard practice in these areas require careful consideration by each surgeon, taking into account all relevant factors.
DESCRIPTION OF VIRTUAL OPD
There is evidence that virtual out-patient (VOPD) assessment, especially as a follow up tool, is safe, cost-effective and acceptable to patients. Such “virtual” follow-up can take many forms, whether written, electronic or by phone, and its use has been described in many specialties. Most reported examples of virtual clinics relate to services delivered by registered medical practitioners, although their use by specialist nurses and physician associates is also reported. A consistent and safe standard of care is reported when carefully selected surgical patients are included, with oversight of the protocols, standards and documentation by a senior surgeon. Most evidence points to the importance of availability of all clinical information relating to the patient, including charts, histology and other results, and electronic medical records including radiology. Each patient consulted, whether in person or virtually, results in the same clinical and administrative workload. Easy access to a senior decision maker is important. While good evidence indicates that a virtual service is highly acceptable to patients, less evidence is available supporting the reliability of this practice in identifying adverse post-operative events so caution is advised. Standard face-to-face followup consultation may be preferable for some patients and should remain available when indicated by patient preference or clinical need.
Experience in using virtual follow-up varies between specialties and among surgeons. A number of publications (referenced below) have evaluated virtual clinics, both in Ireland and internationally. The following guidance may assist surgeons in developing local policy, although it is not intended to replace the clinical judgement of surgeons.
USEFUL PRINCIPLES FOR ESTABLISHING A VIRTUAL OPD SERVICE
- Consultant surgeons should define the appropriate follow-up arrangements for patients under their care, bearing in mind that circumstances arising during the COVID-19 outbreak may require adjustments to their standard practice. For some patients, a virtual follow-up may be considered appropriate.
- Where possible, patients should be informed of planned follow-up arrangements prior to discharge from hospital and recorded in their discharge summary. Preferred contact details should be recorded in the patient record.
- Use of existing OPD appointment systems ensures that every patient receives an appropriate follow-up appointment at the correct time. virtual clinics are sometimes run in parallel with standard clinic arrangements to facilitate administration of the clinic.
- Prior to undertaking virtual consultation, all relevant records should be available and reviewed including clinical notes, operation notes, histology and other laboratory results, and radiology.
- The staff member contracting patients should introduce themselves by name and title and should ensure that the patient is able to have a confidential conversation. The option of receiving a call at another time or attending a standard OPD visit should be possible if the patient requests it.
- Contemporaneous notes of the encounter should be recorded in the medical record.
- A letter to the general practitioner and patient should be dictated after the consultation, highlighting the key findings and recommendations. Unambiguous follow-up or discharge instructions should be given. Any necessary follow up tests or appointments should be booked at the time of the virtual consultation.
Armstrong, K.A., Coyte, P.C., Brown, M., Beber, B. & Semple, J.L. 2017, “Effect of home monitoring via mobile app on the number of in-person visits following ambulatory surgery a randomized clinical trial”, JAMA Surgery, vol. 152, no. 7, pp. 622-627.
Browne, C., Davis, N.F., Mac Craith, E.D., Lennon, G.M., Galvin, D.J. & Mulvin, D.W. 2018, “Prospective evaluation of a virtual urology outpatient clinic”, Irish journal of medical science, vol. 187, no. 1, pp. 251-254.
Carlock, T.C., Barrett, J.R., Kalvelage, J.P., Young, J.B., Nunez, J.M., Colonna, A.L., Enniss, T.M., Nirula, R. & McCrum, M.L. 2020, “Telephone Follow-Up for Emergency General Surgery Procedures: Safety and Implication for Health Resource Use”, Journal of the American College of Surgeons, vol. 230, no. 2, pp. 228-236.
Healy, P., McCrone, L., Tully, R., Flannery, E., Flynn, A., Cahir, C., Arumugasamy, M. & Walsh, T. 2019, “Virtual outpatient clinic as an alternative to an actual clinic visit after surgical discharge: A randomised controlled trial”, BMJ Quality and Safety, vol. 28, no. 1, pp. 24-31.
Logishetty K, Subramanyam S, 2017, Adopting and sustaining a Virtual Fracture Clinic model in the District Hospital setting – a quality improvement approach. BMJ Quality Improvement Reports;6:u220211.w7861. doi: 10.1136/bmjquality.u220211.w7861
Lonergan PE, Gnanappiragasam S, Redmond EJ, et al.2019, Write2me: using patient feedback to improve postconsultation urology clinic letters. BMJ Open Quality;8:e000721. doi: 10.1136/bmjoq-2019-000721
Ma, Y., Jones, G., Tay, Y.K., Hunter, T., Holden, D., Rodgers-Wilson, S., Cashin, P., Tan, P.Y. & Croagh, D. 2018, “Post-operative telephone review is safe and effective: prospective study – Monash outpatient review by phone trial”, ANZ Journal of Surgery, vol. 88, no. 5, pp. 434-439.
Meehan, D., Balhareth, A., Gnanamoorthy, M., Burke, J. & McNamara, D.A. 2019, “Efficacy of physician associate delivered virtual outpatient clinic”, International journal of health care quality assurance, vol. 32, no. 7, pp. 1072-1080.
O’ Reilly M, Breathnach O, Conlon B, Kiernan C, Sheehan E. Trauma assessment clinic: Virtually a safe and smarter way of managing trauma care in Ireland. Injury. 2019;50(4):898–902. doi:10.1016/j.injury.2019.03.046
Ryan, E.M., Rogers, A.C., Hanly, A.M., McCawley, N., Deasy, J. & McNamara, D.A. 2014, “A virtual outpatient department provides a satisfactory patient experience following endoscopy”, International journal of colorectal disease, vol. 29, no. 3, pp. 359-364