Crisis Management of AHP Out-Patient Services

By Fraser Ferguson @FraserAHP

The Covid-19 pandemic will have a consistent presence in the Allied Health Professions (AHP) outpatients landscape and health and social care across Scotland. It will be a rapidly moving picture so ensure you keep up to date via the Scottish Government pages.

This blog is intended to be a starting point in the wider discussion about thinking about the steps required in reaching a new normal. It has an MSK focus but the key pillars of change can be applied to most AHP outpatient teams. AHPs should be thinking now about being the drivers, steering how their services look and work in this new climate.

Introduction

In this current pandemic all NHSScotland services have to explore how they are going to deliver the safest care for patients, in the safest environment for their staff. Going back to the old normal is not an option.

During the Covid-19 crisis some practices and services have been started, some stopped and some let-go. Some of these have been out with your control, because of wider pandemic management e.g. around social distancing. But others have been from the direct impact of AHPs adapting and evolving to deliver the best they can within the current resources such as telehealth.

Whatever has started or stopped or been restarted will not have been without anxiety or apprehension, but there has also been achievements as years of resistance has crumbled almost overnight.

How we used to work

AHP MSK teams have become used to being in close physical proximity to their patients. Being able to see everyone face to face and to touch and move problematic areas is part of your DNA. However, it is becoming evident that a return to how AHP MSK outpatient departments functioned in the pre Covid-19 arena is not going to happen. Neither are citizens of Scotland with MSK problems going to go away. In fact there will be some who have worsened during the current crisis. Conditions will have become more chronic. There will be some, where serious pathology or cauda equina syndrome will not have been able to access normally available primary care services. The demand on AHP MSK services is going to huge.  AHP MSK teams will have to review the services they have been offering during this crisis and decide quickly what they are going to stop, (re) start and let-go in the months and years ahead.

…A roadmap to the new normal

This guide to Musculoskeletal (MSK) sets out some parameters around how MSK outpatient services require to plan and work differently in the NHS in Scotland now Covid-19 has made us redefine the new normal. Resuming AHP MSK outpatient services in the safest and most effective way within the existing pandemic crisis will support staff, benefit patients and support redirection from emergency departments providing the best MSK journey for all.

It is by no means exhaustive but it aims to provide support in some key areas and these things won’t fit for everyone; however the overall aim is about reducing traffic to protect the most vulnerable, protect all patients and protect MSK staff.

Digital by default

…NHS NearMe:

Changing away from everything being face to face is daunting. Daunting for staff and daunting for patients. With change though comes opportunity. And the evidence so far is building to show remote assessments are welcomed.

With that in mind..aim to only see patients face to face when there is no alternative. NHS NearMe should be your first option for all new patient consultations. You could consider a telephone consultation as an alternative. NHS NearMe is a preferred option since using it enables you to see the patient, which is crucial in helping you gather the whole clinical picture.

If you feel a patient would benefit from a face to face assessment ensure that you use this remote consultation to gather as much of the history as you can. This will mean that the face to face consultation will be shorter and enable you to focus on the key physical assessment.

More information here on NES or at NHS NearMe web site

To support your remote consultation look at the nationally developed & endorsed resource

…Follow up appointments :

For all follow up appointments protect all patients, especially vulnerable groups by doing all that can do remotely, NHSNearMe, telephone, with visits to the department as a last resort. Consider some form of remote observation of progress, like featured on PhysioTools.

…MS Teams :

MS Teams should be the first option for staff meetings and 1-2-1s.

Just because unnecessary face to face meetings should be avoided it doesn’t mean interaction, discussion and stimulation cannot occur. Facilities in MS Teams allow for this. Encourage staff of all grades to get involved in this. It should not be left to managers to have to set up nor moderate. You can set up a department one and then have speciality or invited team channels. Use this amazing opportunity to not just enhance your remote consultation skills but your professional skills too. Not withstanding its impact on the environment with reduced travelling for everybody.

NearMe and MS Teams should be used for complex case reviews – clinic appointments, orthopaedic reviews. Lead the way with your non-AHP colleagues by advocating this approach; it is your safety at risk  If colleagues are hesitant then support them in what is now the normal way of working. Click on the image below for more details.

Do as much remotely as you can & in advance

…Only seeing face to face when there are no other options available.

Take time to plan in advance your interaction with the patient. It may well be that you use the advanced planning to gather as much of their initial medical history as you can…make advanced triage the cornerstone of this. This will mean your face to face time with patients will be reduced as the subjective history will be a review rather than a start from scratch. Any forms you might normally get patients to complete in the department, get these completed beforehand, either via NearMe or email.

Can you shift from everything or nearly everything being face to face to a mixture of telehealth and face to face, with the emphasis on only seeing face to face when there are no other options available.

Self-care advice

As part of your pre planning before any face to face consultation link in with the patient so they are aware of the MSK pages at NHS inform. If appropriate get them to download MSK Help app before they come in. Both these resources have been nationally developed and endorsed by clinicians in NHSScotland.

Send prepared condition specific information – all in advance.

It might be that your initial remote consultation ends by directing patients to this advice with a short follow up contact to review any issues or misunderstandings with these.

Working outside of the normal department

…The aim of all of this is to reduce unnecessary face to face contacts

Patients should have the least exposure to AHPs as possible. Other than during actual exam follow the 2 metre rule.

Unnecessary contact with patients should be avoided. This protects you and them. Previously, a patient would come to the department for all parts of their rehab. They would often bring a friend or family member. This cannot continue as a matter of routine. For any face to face appointments, make sure you remind patients of this.

…Department changes

As part of your pre planning remind patients of the changes made to the clinic environment as listed below. Give them as much advanced warning of how things will look and operate. It should look and operate differently. Take the time to explain this to them to reassure and educate them.

Remind them about self-distancing and self-isolation rules that will be in place when they arrive at the department.

…Footprint

  • Where possible have a separate entrance and exit. Set out clearly marked pathways for patients and staff to get around the department. This will help maintain social distancing.
  • Plan in advance for appropriate spacing in waiting area. Mark off or remove chairs.
  • Stop patients waiting at reception area to check in or to make a further appointment.
  • How can you work with IT and your eHealth/dHealth leads to create a remote check in. Some hospitals already have this – can existing technology be used to add in AHP appointments?
  • Re-design work spaces to maintain 2 metre physical distancing space between people creating one way walk-through, opening more entrances and exits, or changing seating layouts in break rooms.
  • Make sure clear signage on the floors and walls explains this to staff and to patients
  • If patients can wait outside before their appointment encourage them to do so.

…Outdoors

  • What can be done in the car park without the patient actually being in the department? Yes, weather may impact on this. But could you have a drive through tent? Use outside for handing out basic equipment for rehab?
  • Have a seated area for people who don’t have cars. Again, won’t work for everyone but it should be all about reducing traffic to protect the most vulnerable.
  • You will have to link with appropriate people in your work are for this but in this new norm these changes should happen. Help drive the change (no pun intended).

…Working patterns

For those people who need face to face review think about staggered consulting times. This will give more space in the department for staff and patients. Consider department being open longer during the day and into weekends to accommodate this. Staff should be reminded not to share food and to use their own cups and plates. Sit apart whilst eating or even eating in own cars could be considered.

Consider separate teams who only work with each other – including clinical and non-clinical staff. This means full time staff will always work part of their week from home. So if one team gets sick, the other team doesn’t. And the non- sick team can step up to full time at the department. This will take planning and teamwork to rearrange working patterns.

Safety

…Yours and your patient

  • Your MSK working area has changed and will remain so for the foreseeable future. It is important that you remain safe and keep your patient and your colleagues safe too.
  • Consider having the window open in consulting room if possible. Offer and remind patients to wash their hands when they do arrive in the department and again before they leave
  • Explain why you are 2 metres apart
  • Let patient sees we are doing everything for their safety
  • Ask them to cough in their elbow towards the window before you start.
  • Encourage face coverings during all face to face contact
  • It is unwise to assume patients will remember this. Doing this is a good habit to get into to reinforce its importance.

…Illness and isolation

If patients have any concerns about any potential Covid-19 symptoms you should direct them in the first instance to www.nhsinform.scot/coronavirus  

Remind patients not to attend department in person ever if they should be self-isolating.

…PPE

Regular updates for everyone on PPE usage should form part of your normal departmental working. Reminders of safe procedures and physical distancing should be carried out.

Footnote on data

During the pandemic AHP MSK crisis management practices will have stopped, (re) started and let go. How are you going to measure changes, impact and output? It is likely that your current key performance indicators are not going to as relevant with your new services. They will certainly not be comparable with older services. Your teams’ success will not be measured the same way it was when things were normal so if you don’t count, you don’t count.

Blog idea based upon a series of tweets by

https://twitter.com/LJCarter15/status/1256499940303536136?s=20

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