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Telehealth triage and clinics for outpatients - the new norm?

Wanda stelmach from northern health talks through the challenge of maintaining outpatient clinics during covid-19.

Disclaimer

The Challenge:

(00:00:41) How to maintain outpatient clinics during COVID-19 and determining the level of urgency for patient care.

The Solution:

(00:01:31) To maintain outpatients whilst maintaining social distancing amongst patients and staff, Northern Health cancelled all face-to-face clinics and started telephone triaging and clinics:

  • All non-urgent referrals were deferred
  • A risk questionnaire was developed to screen new patients and determine appropriate outpatient appointment timeframes and determine whether a face-to-face appointment was required.

The Impact:

(00:05:26) There have been rapid changes in systems and roles. Both physicians and patients have quickly changed their behaviours and have been more accepting of using telehealth. Patient management has also changed, with both physicians and patients more open to embracing a 'shared patient care' model.

Prof George Braitberg

wanda stelmach

Wanda Stelmach is a General and Breast Surgeon with over twenty-five years’ experience in public and private health in the northern suburbs of Melbourne. She has been a full-time surgeon at Northern Health for ten years and the Divisional Director of Surgery, Peri-Operative Services and Endoscopy Services for six years.

Her interest in patient and staff quality and safety developments, as well as health service innovation have led to her involvement with RACS Directors of Surgery, VASM, PMCV, RMIT, NEMICS, BreastScreen Victoria, VPCC/SCV, as well as, DHHS HRT working groups. She is a co-opted member of the Kilmore & District Hospital Governance Board Sub-Committee and a member of the Morbidity & Mortality Committee.

She is also engaged in teaching at undergraduate level at the University of Melbourne Northern Health Medical School as she believes that not only should the younger generation be supported with their clinical learnings but they should also have an understanding of the health service they will inherit as the next generation of doctors and be active players in improvements within the health system. Her personal philosophy is that we are never too old to embrace change – or to be the innovators of change!

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Video transcript

Melanie Hay:

Welcome to another episode of Connecting Clinicians, our COVID-19 clinical governance challenge series. Today we're welcoming Ms. Wanda Stelmach, who is Divisional Director of Surgery at Northern Health, and is also a general and breast surgeon. Today Wanda, will share with us the challenge that they've faced in maintaining their outpatient clinics, the implementation of telehealth triage, and also whether this could possibly become the new norm for them at Northern Health. So, Wanda, thanks so much for joining us today.

Wanda Stelmach:

(00:00:41) Thank you, Melanie, thanks for the introduction. So when the restrictions came in, the challenge we faced was a lot of our infrastructure and outpatient rooms were converted for COVID activities, as well as the need to keep social distancing. And as everyone is aware, outpatients are very crowded, both for patients and staff. The other challenge was that our clinics were undifferentiated, that is we have a spread of patients in different stages of their treatment, new patients, postoperative patients, and patients with various follow up visits. So we don't have clinics dedicated to a particular care plan, but we had to change what we did very quickly to protect ourselves and the community.

(00:01:31) So the immediate solution we put in was to cancel all face-to-face clinics and instigate telephone clinics for the majority of patients. Converting to telephone rather than video was necessary as our health service didn't have video link set up. Also we deferred all non-urgent referrals; these are new patients that we hadn't seen. The risk there was hidden as there's only so much information you can get from a referral letter and it's hard to work out what risks you are missing.

So having brought that in and running for the last few weeks on a mixture of telephone clinics and some face-to-face, we're at a point where we're about 80% telephone clinic and 20% face-to-face. Where to from here? So what is here going to be like, it's probably going to be this way for two years, at least, and we're looking at ideas, how can we run clinics and look after our patients safely. I think a rule for the next few years is going to be social distance; that has to govern all our activities and the quandary for us is our infrastructure doesn't allow easily for social distancing, unless you see fewer numbers of patients.

So we believe that video and telephone clinics are part of our lives and that face-to-face will be decreased. The feedback we have had from some of our patients and clinicians, those that have been lucky enough to be involved in video consults, is that video is a much better modality than telephone because you get subtle cues from seeing a person that you lose over the phone. So we are increasing our capacity to have video clinics, however, we still need to determine how, from the referral letter, we can determine the risk of missing a serious diagnosis.

Triaging based on letters with minimal information leads to a risk, and if you use the example of PR bleeding, how can you know that a PR bleed is a result cancer or a result of haemorrhoidal bleeding? So we are looking at developing a risk stratification questionnaire which will help us determine the urgency of an appointment for new patients. And the idea is that a clinician (and that can be either a medical clinician, even a junior member of staff, or a nurse the liaison officer) will ring the patient and go through a number of questions that leads to a score being developed, and based on that score, the outpatient appointment timeframe will be determined, whether it's within two or three weeks, within four to six weeks or longer.

At the same time we can gather all the relevant investigations that the patients had, so that these will be available for the clinician speaking to the patient on the day of the appointment. We're also trying to determine whether we can, from this scorecard, determine whether a face-to-face is important and therefore an examination is important, or whether a video appointment is appropriate. Following this we'd like to audit our results, because we have to have a validity for this questionnaire, we have to be able to reassure ourselves as surgeons, our GPs, and our patients, that the timeframes we allocate to them are appropriate. There is no no-risk strategy, but we have to minimize the risk.

(00:05:26) So the impacts and the insights. Well firstly, how quickly the systems within the hospital have changed. So clinics have gone to different sizes, roles have changed, e-meetings are there to maintain functional teams and functional clinics, and they've worked really well. What we have yet to determine is the ratio of face-to-face telehealth, and also how the federal and state health departments will support the future in this new post-COVID health era.

We've also discovered how quickly physicians can change their behavior. They're more accepting of electronic communications, more accepting of decreased number of follow up clinics, happier to share the management of the patients with their colleagues. And finally, how quickly patients have changed their behaviour. Again, they're more accepting of electronic communications, they're more accepting of a clinician rather than ‘their’ clinician looking after them, and they're more accepting of decreased presentations to clinic.

Melanie Hay:

Thanks, Wanda, for joining us today and for sharing those insights and the challenge that you're facing at Northern Health. We'd also just like to, honestly, take a moment to really thank you for all the work that you are doing and for that of your colleagues, so thanks very much.

Wanda Stelmach:

Pleasure. Melanie Hay: If you would like to take part in connecting clinicians, then please reach out. There's such value in sharing these type of insights in a timely manner so others can learn and share that experience. Our email address is info@aicg.edu.au. So before we say goodbye, Wanda, is there a final note that you'd like to share with your fellow clinicians, both here and in New Zealand?

Wanda Stelmach:

(00:07:12) So I think the important insight for all of us is that we can change, but we have to be flexible, we have to be willing to look at ideas outside of what is normal for us. And certainly for a clinician like myself, with 20 years plus standing, I have work out how to change my way of thinking about health system, as do my colleagues.

Melanie Hay:

On that note, until next time. Stay safe and Kia Kaha.