Defining clinical decision making in the provision of audio-visual outpatient care for acute upper limb trauma services: A review of practice.

The Covid-19 pandemic has accelerated the widespread adoption of technology-enabled care in the NHS.1 Moving into phase two of the response, the continuing use of audio-visual technology is expected, where appropriate, to be integral in the provision of safe, quality patient care.2 A clinical need therefore exists to identify when care can be safely delivered remotely using audio-visual technology and when there is a need for in-person contact.  At Salisbury Foundation Trust (SFT), during phase one of the NHS response to Covid-19, the decision to treat upper limb trauma patients in-person or remotely was made using clinical screening criteria. For many patients, audio-visual appointments offered a practical, time efficient way of accessing their reconstructive team for assessment, advice and post-operative care. However, a subset of patients was identified by the team as requiring at least one in-person consultation to minimize perceived clinical risk and to optimize quality outcomes.  In order to understand more fully the challenges and successes of technology-enabled care to date, a national survey of practice across hand units in the UK was conducted. We present here some of our key findings and propose the need to develop nationally agreed screening criteria to determine how and when technology enabled outpatient care can be used in the management of acute upper limb trauma. The results of this survey forms part of a series of projects currently underway looking at the efficacy of audio-visual care in upper limb trauma, including a multicentre observational study. Crown

Dear Sir,

The Covid-19 pandemic has accelerated the widespread adoption of technology-enabled care in the NHS. This has included the use of the Attend Anywhere online appointment system, telephone consultations and web based applications for continued healthcare delivery. This transformation has facilitated a significant reduction in hospital and community based in-person consultations thus reducing transmission of the virus and safeguarding patients and staff. Moving into phase two of the response, the continuing use of audio-visual technology is expected, where appropriate, to be integral in the ongoing provision of safe, quality patient care.

As an early adopter of audio-visual consultation, Salisbury NHS Foundation Trust's (SFT) hand trauma team conducted over 540 patient audio-visual appointments for upper limb trauma patients during phase one of the Covid-19 response. For many patients, audio-visual appointments offered a practical, time efficient way of accessing their reconstructive team for assessment, advice and post-operative care. However, a subset of patients was identified by the team as requiring at least one in-person appointment to minimize perceived clinical risk and to optimize quality outcomes.  A need therefore exists to establish how trauma teams can determine when clinical care can be safely delivered remotely using audio-visual technology and when there is a need for in-person consultation.

At SFT, during phase one the decision to treat patients in-person or remotely was made using clinical screening criteria. These criteria were developed and implemented successfully, but at pace. They allowed the team to confidently assess that, where necessary, the benefit to the patient of an in-person consultation outweighed the risk of attendance. The criteria used included Covid-19 exclusion factors, professional guidelines , and clinical criteria of patient specific considerations, including; injury severity, social risk factors, and mental health considerations. At each appointment, these criteria were reviewed to ensure the care plan remained in the patient's best interest.

During phase two of the Covid-19 response and beyond, proactively determining which patients can be managed remotely and which are likely to require in-person contact to recover function post injury will be essential to the success of upper limb trauma surgery.  In order to understand more fully the challenges and successes of technology-enabled care to date we conducted a national survey of practice across hand units in the UK.  Responses were received from 51 units.

Results from this survey confirmed that prior to the Covid-19 pandemic only 16% of units were offering technology-enabled appointments.  During phase one of the response this rose to 76% for new patient assessment and 82% for patient follow-up. The survey found that 73% of units used criteria for determining whether patients were suitable for technology-enabled appointments, but in agreement with our experience at SFT, 92% had concerns with the use of technology-enabled care overall or for certain patients.

Reasons for concern with technology-enabled appointments and need for in-person consultation included:

Minimising clinical risk: Whilst injury severity was considered the main indicator for an in-person patient appointment offered (96.6%), patients with specific factors such as mental health considerations (39.3%) and social risk factors (25.0%) were more likely to be offered in person appointments.

Specific injury outcomes: Specific injuries were noted to progress more slowly and have poorer outcomes than expected by the team when seen audio-visually. These included high nerve lesions, isolated Flexor Pollicis Longus (FPL) tendon repairs and composite injuries that had resulted in the repair of more than one structure in the same anatomical area. Patient anxiety around outcome (52.6%), a need to physically evaluate the injury (i.e. clinical testing of structures) and bespoke splinting required to optimise outcomes (44.4%) were reported as risk factors in these cases for poor outcomes.

Staff confidence in decision making: A range of factors were observed to contribute to decision making, including the experience level of the team, the unique presentation of the patient and the patient's psycho-social ability to engage in therapy remotely.  A lack of formal clinical decision-making tools and the medico-legal implications of new practice were reported as staff concerns.

Digital transformation is an essential component of the NHS England five-year forward view and the NHS long-term plan. Critical priorities include the development of digital technologies, innovative delivery of audio-visual care and improvement of remote consultation for assessment and treatment. Building on our findings and the emerging pressure to ‘lock in’ the beneficial changes of remote consultation, we propose the need to develop nationally agreed screening criteria to determine how and when technology enabled outpatient care can be used in the management of upper limb trauma. We believe the development of these criteria will ensure that individual care plans remain in the patient's best interest, whilst building on the opportunities for digital transformation. A multicentre observational study is currently being undertaken to determine the wider application of these findings and potential benefit of such a tool.

Declaration of Competing Interest

None.