SKILLS & LEARNING
THE DIETETIC VIRTUAL CLINIC: IMPLEMENTING A HOSPITAL SERVICE Alice Lunt, RD Cardiorespiratory Dietitian, Royal Brompton Hospital, London
Alice is an active member of the British Dietetic Association and Treasurer for the BDA’s Critical Care Specialist Group. She is also Health Advisor for the British Lung Foundation.
For full article references please email info@ networkhealth group.co.uk
Since March 2017, there has been a Royal Brompton virtual dietetic service and this article takes a look at how it has been implemented and the ongoing improvements being made to the service. The Royal Brompton Hospital, London is part of a cardiorespiratory tertiary trust and, therefore, patients can be local, national or international. The geographical implications mean it is often impractical for patients to be seen by a dietitian outside of their hospital admission. We have not been able to provide a dietetic outpatient service to adult cardiac or respiratory patients. From the clinicians’ perspective outpatient clinics have not been possible due to limited room availability, especially if we were to link with other appointments. In March this year, we introduced a virtual dietetic service based on ‘Telehealth’, a digital way to interact with patients within the hospital dietetic service. Telehealth uses technology, such as telephone, email, Skype or websites to support clinical healthcare, including health promotion, disease prevention, diagnosis or therapy.1 The term
‘telehealth’ is gaining momentum, but published evidence is limited in the field of dietetics and in the UK. Nevertheless, positive patient experience and compliance have been reported in rural Canada and Australia.1,2 A Cochrane review of 21 chronic disease studies and telehealth reported positive results for quality of life, efficiency, acceptability and cost effectiveness, together with improved clinical results in heart failure and diabetes.3 It was reported in 2014 that 76% of the GB population use internet on a daily basis4 and with telehealth no longer a new concept, NHS England is becoming more aware of its potential use; an example being a Clinical Commissioning Group (CCG) commissioning for quality and innovations (CQUIN) 2016/17 target is based around telehealth to support patients and colleagues, with financial rewards if achieved.
Figure 1: Results from a cross-sectional service evaluation at the Royal Brompton Hospital into the use of telehealth Would like dietetic input after leaving the ward:
skype 4%
phone 63%
email 33%
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SKILLS & LEARNING
Telehealth uses technology, such as telephone, email, Skype or websites to support clinical healthcare, including health promotion, disease prevention, diagnosis or therapy. ACCEPTABILITY ASSESSMENT
In early 2016, a cross-sectional service evaluation was carried out in the Royal Brompton hospital to consider the potential use of telehealth by the target audience (43% aged over 65 years old and 87% aged over 45 years old). It was reassuring to find that 64% would want ongoing dietetic input following discharge and the majority (62%) would prefer a form of telehealth for ongoing communication (see Figure 1). On further questioning, there was found to be a preference for phone (63%) rather than email (33%) or skype (4%). From the practical side, 83% reported having access to scales at home. Summary of key stages of implementation process: 1. Clinic set up on Lorenzo booking program 2. Development of supporting admin materials 3. Clinic trial then launch with ongoing reflection and improvements 4. Promotion 5. Outcomes data analysis CONSIDERATIONS AT EACH STAGE IN THE PROCESS
1. Clinic set up on booking program Gaining support from the hospital information technology team and outpatient manager was essential to enable this aspect to be possible, as this is not an area or even a computer program that adult dietetics have previous experience of. We considered the following: • allocation of name of clinic and lead consultant; 38
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• time allocation and clinic template; • allowing time for admin; • suitable room to ensure confidentiality, minimal background noise, as well as phone signal and internet access, but not as formal as a clinic room; • laptop with suitable programs and access; • telephone consultation; • smart card, computer program access and training. 2. Development of supporting admin materials For the clinic to run, supporting resources needed to be developed. Local and national resources were found by an intranet search and used as a point of reference for developing tailormade resources including: • referral criteria relevant and appropriate for adult dietetics; • referral forms which are quick, concise and provide useful information to enable prioritisation; • clinic appointment letter for new and follow-up appointments; • outcome letters for new, follow-up and DNA (did not arrive) appointments following clinics, uploaded, as well as send to referrer, patient and GP (Electronic notes); • generic email with multiple access; • feedback form; • excel spreadsheet for monitoring referrals and booking; • printable information and sample delivery services to support dietary advice provided.
Figure 2: Patient referrals - reason for referral
3. Clinic trial run, then full launch a fortnight later Since introducing the virtual dietetic service at The Royal Brompton back in March this year, ongoing reflection on ways in which to improve the service has been important. The following changes have already been implemented to overcome barriers identified: • We have sought a dial code to enable calling mobile phones without going through switchboard which was causing delays. • We have started to keep a record of phone numbers with the clinic bookings to optimise efficiency. • Initially appointment booking letters needed to be written manually, whereas now the computer system can produce these automatically following appointment booking. • We have adjusted the laptop settings to stop it logging out or locking the screen during the consultation. This enables documentation directly on to electronic records rather than using paper. • Our referral process is being reviewed to use an electronic program as used for bloods requests, rather than the current electronic form which is then emailed. • Skype has proved difficult due to information governance; the trust has Skype for business; however, this is challenging to use, even for interviews. • We now seek patient consent to email letters, as currently posting takes additional time and resources.
4. Promotion The ongoing feasibility of the clinic is dependent on referrals and, therefore, the following promotions have taken place to raise awareness of telehealth dietetic clinics: • Announcement to multidisciplinary team via email and during meetings. • Involvement of key stakeholders throughout the process including physiotherapists, consultants, dietitians. • Electronic referral and criteria link on intranet via simple search. • Ongoing informal verbal reminders and via patient letters. • Informed CQUIN team to support the NHS England funding bid. • Linked with hospital marketing and communications resulting in promotion article publication in monthly bulletin which is emailed to all and printed versions distributed around the hospital. 5. Outcomes data analysis It is still very early days following the initiation of the clinics and, therefore, this has not been formally assessed or monitored, but this is crucial going forward to ensure sustainability and feasibility. General observations so far: • There have not been any DNAs. • Works for dietitian, MDT and patients, with positive feedback to support this. • Outcomes data being collected includes source of referral, reason for referral, weight changes, BMI changes and transplant www.NHDmag.com July 2017 - Issue 126
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SKILLS & LEARNING Table 1: Feedback from colleagues and patients Patient feedback
Healthcare colleague feedback
Extremely likely/likely they would recommend this service to friends and family.
“That’s brilliant. It is great that you are planning on offering weight loss management advice as well. This will also certainly help to close the loop for the COPD cohort."
There was adequate time. “I look forward to our next telephone call.” The clinic is Excellent/Good.
The call was clear and they were able to understand what was being discussed.
The letter prior to appointment provided adequate and clear information.
The session was useful.
listings (as some referrals are needing to reduce weight to be listed for transplant), hospital admissions or lung function. Figure 2 shows a breakdown of patient referrals. FEEDBACK
Feedback from colleagues and forms posted to patients following initial assessment of the virtual service has provided reassuring, useful and consistently positive feedback (see Table 1). SUSTAINABLE FUTURE
Going forward, there will be ongoing reflection, changes, promotion and efforts to optimise cost-effectiveness including: ongoing promotion; • outcomes data to show effectiveness and sustainability; • optimisation of efficiency and cost effectiveness; • local guideline to support training of dietetic colleagues;
“This is fantastic news! From an outpatient perspective, we desperately need a weight loss service. This could go hand in hand with other ideas we are developing.”
“Everyone I have mentioned this service to have said that it is a brilliant idea and have been very happy to be referred. I think the fact that we are a tertiary centre means that the idea for a virtual clinic is a brilliant way to support our patients and I hope this is something that will only grow in the future.”
"From a clinician point of view, I think the forms are very quick and easy to fill out."
• support of other disciplines internally or external, with setting up virtual clinics if needed. A similar service has already been initiated in other areas of the trust following our implementation of the virtual clinic; • extending to offer Skype when local information governance guidelines allow; • conference abstract submission. It has been rewarding to follow on from patients and colleagues requesting a virtual dietetic service to actually implementing the service this year. To date, the referrals continue to arrive, together with positive response to the new service, making it likely to continue. With supportive colleagues and some new resources virtual clinics can be a useful resource for adult dietetics to utilise. It may not be suitable, or its use in isolation may not be appropriate for all specialities in dietetics; however, this positive experience for all involved shows it has a place.
Any questions or for further information do get in contact. Email: dietitianclinic@rbht.nhs.uk 40
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