Click here to read part one of my interview 'Apprehensive about delivering Remote Reviews?' to hear about how I built my confidence with remote reviews, the aim of these reviews and the patient feedback I have received on them.
As far as possible I structure Remote Reviews as I would with any face to face review. There are many excellent resources available to support review structure including PCRS- Building blocks of a good respiratory review, the Remote Review website and the Interface Clinical Services Website.
It is worth acknowledging that typically, I do tend to spend a little longer undertaking these reviews than most, but this is allowed as part of my funding. Before completing the review, I try to confirm the diagnosis of COPD by reviewing spirometry readings (<0.7 FEV1/FVC ratio), as well as eosinophil levels and whether the patient has a history of asthma.
I tend to begin my consultations with completion of a thorough patient history. I believe it is really important to give the patient the opportunity to talk about their condition in their own words through the provision of open ended question techniques such as “Tell me about your lungs, 'start from when you were younger' and the first time you noticed any issues with your lungs.”
Once the patient has shared their history I begin by revisiting ' normal breathing' and what physical changes are occurring in their lungs such as emphysema, bronchitis. I believe there are huge benefits to empowering patients to understand their symptoms linking them to the pathophysiology as it helps facilitate better self-management of care.
Within each of my consultations I undertake a COPD assessment test (CAT). This scoring system can be cascaded ahead via email or post but I recognise the benefit of joint completion with the patient during the review as it enables me to ask more detailed questions, for example if someone is telling me about their cough, I like to use that opportunity to ask about the type of cough (dry, productive), consistency, quantity and colour of phlegm (if any) etc.
With COPD non-pharmacological treatments are crucial. If the patient is continuing to smoke, I can reiterate the health benefits of stopping smoking as this is the single biggest thing they can do to improve their overall health. I find it is necessary to repeat this message a few times during the review with a vision that they will become empowered to acknowledge the benefits of stopping smoking. Ideally at some point within the conversation I will have the opportunity to discuss with the patient a direct referral by me to a smoking cessation service who will provide direct contact and support for the patient. I find approximately 80% of my patients who still smoke would like support to help them quit.
During the review I also discuss pulmonary rehab, although due to the current pandemic restrictions in place nationally this is not currently an option. I also to agree to forward them a copy of the British Lung Foundation booklet around COPD and how to keep well. I will always discuss breathing exercises, dietary needs, and the availability of flu and pneumonia vaccines.
Following this I include discussion around the Pharmacological Treatment options. Typically, I choose to offer treatment according to guidelines but will always consult and include patients within this, before choosing a medication. This inevitably involves explaining the different treatment options available to them, the differing types of device and dosing they come in. In most cases patients are very keen to follow the guidelines. Despite this if a patient has a strong preference for another treatment option, I am agreeable to offer this documenting their decision making and reasoning within their clinical notes.
As I have become aware it is impossible to check a patients inhaler technique over the telephone I will always direct them to 'Asthma UK' or 'Right Breathe' websites to offer them approved visual technique tips to help ensure their technique is the best it can be.
Determining Inhaler Change and Follow Up
When determining if a patient needs an inhaler change it is important to look at both the patient’s symptoms and the guidelines. I tend to follow the All Wales and national guidelines as much as possible, as these are very clear, concise and easy to follow.
For the majority of my patient group I am now as confident making Medicine Optimisation changes remotely as I was face to face. I will safety net each and every change with a follow up appointment four weeks later. This provides the patient with reassurance that this change is not something they will just be ‘left on’; increasing both their confidence to try and my confidence to prescribe.
During the follow up I repeat the patients CAT score and compare this with the score from their initial review. It is known that it is unusual with COPD to see a massive improvement in CAT score, however if the patient has been prescribed an optimal bronchodilator, they will usually report that their symptoms are improved and that their exercise tolerance has increased.
The necessary changes to practice delivery due to COVID resulted in a fast change to long term condition reviews. These 'virtual reviews' have been positively received by patients and appear to be offering similar outcomes to historic face to face reviews. This offers the viewpoint that it is potentially unlikely that a return to the 'standard' face to face review 'one size fits all' approach will occur. I expect a blended approach of a 'virtual review' followed up face to face if any serious problems are identified will be the norm of the future.
Three top tips
- Listen to the patient- Ask open questions - this empowers them to share their personal history and story of their symptoms
- Involve the patient in the decision making - Explain the physiological effects vs their symptoms and treatment, empowering them to effectively self-manage their own condition
- Don’t forget non-pharmacological treatments- Address these first – once these are sorted move on to optimising medications