Long delays to see a consultant in outpatients’ clinics is a frustrating – and potentially life-threatening – reality for many patients in the public health system in Ireland.
But one Dublin hospital has found a novel way to reduce outpatient waiting lists by having a virtual clinic in which GPs can discuss their patients with a hospital-based consultant rather than automatically refer them on to an outpatients’ clinic.
The virtual heart failure clinic has been pioneered by consultant cardiologist Prof Ken McDonald and his team at St Vincent’s University Hospital, Dublin.
During this live video link-up, the GP and the consultant can decide what the patient needs most – different medication, continued monitoring in primary care or if necessary an appointment at an outpatient’s clinic.
“A lot of what GPs need can be dealt with through a conversation between the GP and the specialist. It doesn’t require patients to be transported to hospital with a family member taking time off work to bring them,” says Prof McDonald.
There are more than 150 GPs using the service for which a slot must be booked 48 hours in advance
The virtual heart failure clinic is held most Wednesday and Friday lunchtimes in the Heartbeat Trust office next to St Michael’s Hospital Dún Laoghaire. When it first started in 2015, GPs within the St Vincent’s hospital catchment area (south Dublin, Wicklow and north Wexford) could sign up for the service. Then, two years ago, the Health Service Executive opted to include GPs in the Carlow-Kilkenny area. There are more than 150 GPs using the service for which a slot must be booked 48 hours in advance.
“It’s a one-to-one conversation that is better than electronic communication. Other signed-up GPs can listen in to the conversations which can improve their confidence to treat their patients,” says Prof McDonald.
In advance of these virtual meetings, heart failure clinical nurse specialist Caitlin Bryceland gathers all scans, blood test results and medication of the patient so the consultant and GP can have a more informed conversation. In some cases, she can also organise scans or blood tests in advance of the meeting so that this up-to-date clinical information about the patient is available for discussion.
Sitting in on a virtual heart failure clinic meeting, I witness the detailed clinical notes that GPs and the consultant cardiologist have on screen during these conversations. During the video link-up, the GP speaks about how the patient copes on a day-to-day basis and the consultant cardiologist suggests possible improvements in the care. With patient confidentiality in mind, the patients are presented anonymously.
“Sometimes, a GP might be checking if their patient has heart failure because common symptoms such as breathlessness, chest pain or lower limb swelling can be linked to other conditions,” explains Dr Paddy Barrett, consultant cardiologist at the virtual heart clinic. “For example, we would look at whether certain symptoms are a result of chest infections or heart failure, taking into consideration blood pressure, weight, medications and other clinical factors.”
Patients can also be fast-tracked for tests that some GPs don’t have access to.
Following the virtual heart failure clinic, Bryceland sends an email to the participating GP reiterating the questions raised and the advice given by the consultant. GPs can return to the virtual heart clinic to discuss the same patients again and/or new patients.
An audit of the service found that without the virtual heart failure clinic, 65 per cent of GPs would have sent their patients directly to an outpatient clinic, 20 per cent would have sent them to an acute medical unit or emergency department while the rest would have continued managing their patients in their GP surgeries.
One of the most important things we learn is about the difficulties GPs face in the community
Moreover, while GPs are receiving crucial information from the specialists the consultants are also learning about the difficulties faced by primary-care teams.
“One of the most important things we learn is about the difficulties GPs face in the community. For instance, lack of access to specialist blood tests or the [prohibitive] costs of hand-held ultrasound scanners. This allows us to advocate on their behalf to improve access to these blood tests and mobile scanners,” says Dr Barrett.
Some GPs would also struggle to find the time to fit such virtual clinics into their busy days. And, in fact, some cancel at the last minute due to time pressures in their surgeries.
Dr Ronan Fawsitt, a GP in Kilkenny city, has been using the virtual heart failure clinic for the last two years. And while he admits to cancelling on occasion, he sees the virtual heart failure clinic as a crucial part of an approach which aims to treat patients in their homes rather than send them to hospital.
“We are dealing with patients in their 70s, 80s and 90s. If they end up in hospital, it often results in a longer stay and they can come out worse than when they went in – in terms of decreased muscle mass and cognitive decline,” explains Dr Fawsitt.
His heart failure patients now have access to better diagnostics (special blood tests and a mobile cardio echo ultrasound scanner which comes to the GP practice), a clinical nurse specialist in heart failure as well as his improved access to consultant advice via the virtual heart failure clinic. The clinical nurse specialist also helps the patients understand and manage their condition better at home.
“GPs are good at most things, but many of us are a bit nervous about treating heart failure. A lot of knowledge passes between consultants and GPs at the virtual heart failure clinic which means we can improve patients’ treatment plans. I even notice that some of my patients don’t visit me as much because they and their families learn to manage their own condition better with these improvements,” says Dr Fawsitt.
Prof McDonald believes that with adequate funds, the service could be extended to other specialities
With the rise in chronic disease, Dr Barrett sees a greater role for virtual heart failure clinics in the future. “Ultimately, we’d like to see a seamless transition from cardiology outpatients’ clinics and virtual heart failure clinics to the community. GPs could follow up on their patients at a virtual heart failure clinic and then refer them back to [an] outpatient department only if needed,” he says.
And Prof McDonald believes that with adequate funds, the service could be extended to other specialities. He will deliver a presentation on the virtual heart failure clinic at the annual meeting of the American College of Cardiologists in New Orleans, United States in mid-March.
