Establishing a remote clinical advice service during the COVID-19 pandemic

Problem

Protecting vulnerable medical staff is one of many challenges for NHS hospitals during the COVID-19 pandemic. This resulted in the need to find new roles to accommodate staff unable to continue their usual patient-facing work due to their own personal health, as advised by NHS Employers.¹

Such workforce change came at a time when pressures on acute hospitals were predicted to rise, and pre-existing staff shortages were exacerbated by COVID-19-related illness.^2,3 Loss of workplace identity and social isolation threatened the wellbeing of those affected, and trainees faced uncertainty about how this would affect their education and progression of training.⁴

Potential solution

Six vulnerable registrars and consultants in geriatric and acute medicine at North Bristol NHS Trust (NBT) established a virtual advice service called ‘Ask the Medical Reg’ (ATMR). This service aimed to support patient-facing medical teams and provide a meaningful role for these clinicians during the pandemic.

The scope of the service included:

• provision of senior medical advice to NBT junior doctors and GPs

• supporting GPs and paramedics in decision-making when the benefits of hospital admission are uncertain

• reviewing outstanding investigation results for discharged patients

• ‘silver trauma’ reviews: proactive medical reviews of all patients over the age of 65 years admitted to NBT with major trauma (as the geriatricians who usually provided this service were redeployed to medicine).

Four registrars and two consultants responded to telephone and email requests for medical advice. Consultants provided training and clinical supervision through case discussion, feedback and completion of workplace-based assessments. Two SHO-grade doctors were responsible for following up outstanding investigations and carrying out service data analysis to inform service development.

The service was publicised on the local clinical commissioning group website and via email communication, promotional posters and junior doctor WhatsApp groups. Two outpatient clinic rooms provided an office base for the team. Trust laptops enabled remote access to the Trust clinical systems for out-of-hours work.

The service was accessible via telephone or email 24 hours a day, 7 days a week. Email requests for advice were responded to within 24 hours. All external calls requesting to speak to the medical registrar on-call or the ‘geriatrician of the day’ were directed to our service. A list of silver trauma patients was emailed daily by major trauma practitioners and the ATMR clinicians contacted the relevant inpatient teams to provide telephone advice.

Advice was documented on a standardised record and stored on the Trust computer system. Twice-weekly team meetings facilitated discussion of complex cases and of operational challenges and potential solutions, as well as providing team updates on the rapidly changing inpatient and outpatient services and sharing service data to support service development.

Data collection

Data were collected prospectively, with the exception of data on frailty, which were assessed retrospectively by reviewing the record of advice documentation for the presence of frailty as an explicitly stated issue or a Clinical Frailty Scale score of 5 or more.⁶ If these were not documented, a geriatrician reviewed the patient's electronic medical records to look for markers of frailty. Consultations were categorised into themes including admission decision, management, investigation, ‘silver trauma’ reviews and COVID-19-related queries. Outcomes were defined as decision to admit, admission avoided, face-to-face review recommended, treatment advice, or specialist referral.

A questionnaire to evaluate service user experience was sent via email at the end of week 4. Service utility was assessed using a Likert scale (1=not useful at all; 5=very useful) and whether the clinician would use the service again. Free text boxes were available for comments.

Results

Referrals for clinical advice

During the first 4 weeks of operation, the service received 303 requests for advice. Growth across this period was substantial, with a doubling of the workload from week 1 (mean [standard deviation; SD] calls per day: 7.43 [3.31]) to week 4 (mean [SD] calls per day:14.14 [5.70]). The median age was 71 years (range 19–100; interquartile range [IQR] 49.5–83); approximately a third (38.6%) of patients were frail.

GPs were the most frequent service users, representing 47.5% of all requests for clinical advice. Other service users included NBT junior doctors (32.3%) and paramedics (10.2%). The proportions changed over the 4 weeks, with a falling number of calls for advice from NBT juniors and an increase in calls from GPs from week 1 to week 4 (Fig 1a). This was likely a consequence of internal restructuring of hospital teams improving inter-specialty collaboration and increased publicity of the service within primary care.

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Fig 1.

Calls to the ‘Ask the Medical Reg’ advice line per week categorised by a) referrer and b) theme. NBT = North Bristol NHS Trust.