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In Conversation with Amjid Mohammed – Calderdale and Huddersfield Foundation Trust

In this guest blog, Amjid Mohammed, Emergency Department Consultant from Calderdale and Huddersfield NHS Foundation Trust, discusses their approach to setting up their Emergency Department remote monitoring project, delivered in partnership with Yorkshire & Humber AHSN as part of the NHSx Regional Scaling Programme.

In the middle of the COVID-19 pandemic, we investigated how clinicians could offer remote consultations. There were a lot of senior clinicians who were isolating – not unwell – but unable to undertake patient facing duties. At the same time, we had many more patients than normal, which led to a mismatch between patients’ needs and service delivery. We worked on a project to allow senior clinicians working from home to be able to help with management of our live emergency department. To do this, we initially used MS Teams. This helped with managing the department needs as well as providing support to juniors.

We had heard of TytoCare, which could allow consultants to see new patients coming in the emergency department and thought we could incorporate it into our workflow. We were seeing patients who were reasonably well, but who still ended up in an emergency department because they couldn’t access healthcare anywhere else. I soon realised that If I could place a patient in front of a remote monitoring device such as TytoCare, so that the consultant at home was able to see them, take their medical history and examine them, we could manage workload better in the emergency department.

We went through a detailed workflow design and ended up with three workflows. We tried to see whether it was feasible, safe, and whether there was any benefit for that consultant working from home seeing patients remotely. Previously, remote monitoring and remote consultations were done in several different areas, and over the course of the pandemic in elective and semi-elective environments as well.

To build and implement the redesigned workflows, we worked with Yorkshire & Humber AHSN colleagues as well as the project management team in the Trust to look at how these could work. We spent a few weeks trying to see how we could make these workflow designs work better:

• First workflow design: the patient comes to the emergency department and registers. Immediately after registration the remote clinician can see that patient on the list, select them for a remote consultation and a healthcare assistant in the department can instruct the patient where to go and assist with the consultation.
• Second workflow design: the patient registers and is triaged in the emergency department. Once triaged we know a lot more information about that patient and how ill they are. They have observations done so that we have a clearer picture of the patient’s needs. The patient then has a consultation with the remote consultant and the healthcare assistant in the department is on hand to assist if necessary.
• Third workflow design: the remote consultant helps manage patients who have already been seen by another clinician and where a second opinion or more expert advice is needed.

Who did we engage with?

We engaged with the technology supplier, TytoCare, who provided some technical training around how to use their device most effectively and how their processes worked. Clinical safety processes had to be undertaken and ratified by safety committees in the Trust to ensure it was the right thing to do for patients and didn’t create more risk or safety issues.

We did some patient surveys and pretty much universally patients were happy that they were seen reasonably promptly in the emergency department and usually by a senior clinician. By using remote consultations, the overall waiting time was reduced, the time to see a clinician was improved and patient satisfaction levels in the consultant group that were being seen was quite high as well. The patient journey in the emergency department can be s fraught, you don’t know when you’re going to get seen, you don’t know who is going to see you, you don’t know the level of expertise. If I can have a consultant working from home who is able to consult  with patients, that in itself provides reassurance for patients.

We also thought if we could see patients who were thinking about coming in or on their way to the emergency department, we could have a bigger impact. So, we tried to engage with the ambulance service, other carers in the community, falls teams, urgent care response teams, care homes, all of whom were potential collaborators on this. If the emergency department consultant can have an influence on the patient’s journey before the patient comes in, then this will help deliver the right patient to the right clinician at the right time in the right place and make much better use of resources by taking emergency department decision-making closer to the patient.

This type of work cuts across traditional barriers and if implemented could revolutionise the care provided to patients. Not all patients are digitally savvy or have access to digital resources, but I think we’ve got to be realistic about it and say, right, if for instance 50% of my patients can use digital solutions, this means I can release more staff resources. I could then better look after the patients who don’t have access to digital healthcare with more focused resources.

Working together is essential if we want to succeed

It’s important that we work together on these matters. The patient doesn’t know and frankly doesn’t want to know when they are moved from one service to another. They just want to be looked after. But there are boundaries in place that have an additional cost, complexity and bureaucracy just because the patient has moved from primary care into A&E and then onto a ward. Every time the patient is handed over to a different service, there is another layer of complexity, and you get another lot of people involved, another lot of committees, another lot of safety information that needs to be ticked off. All this creates difficulties and obstacles in trying to innovate and solve these problems. As healthcare providers we need to consider the patient journey as a whole and not just a small part of this journey.

Sometimes the benefit realisation to an individual part of the service is not tangible to them even though there may be a huge benefit to the patient. When we work in narrow silos, we run the risk of not implementing innovations that can bring huge benefits to patients and healthcare staff. We need to consider the whole of the patient and the whole of their journey and work together to solve the whole of the problem.

I think that’s the conversation we need to have at an integrated care system level. If we all work together and follow the patient journey, it will make the system less clunky, more efficient and much more cost effective. It was challenging trying to deal with other teams outside of the A&E department when trying to implement these types of solutions. One of the lessons I’ve learnt is to remain flexible. I think if you have this rigid view of “I’m going to do this pathway and that’s all I’m going to do”, then you’re not really allowing yourself to see what the technology can achieve for you and your patients.

Having done the proof of concept and pilot study and seen first-hand the benefits of using remote monitoring where appropriate, I think that to become an integral part of the way we work, we need a bigger strategic conversation with the integrated care systems.