The coronavirus pandemic has resulted in dramatic changes to the delivery of patient care in all health care settings. Primary care has had the biggest shift from previous face-to-face appointments to virtual consultation.
In primary care in the UK, dermatology accounts for 13 million general practice consultations, with 5.5% being referred for specialist advice.1 In these current times, primary care nurses need to feel confident about conducting a virtual dermatology consultation effectively, enabling them to assess, manage and support patient with self-management. Below are 10 practical top tips for a virtual dermatology consultation, from preparation to closing the consultation. But first …
Background
Virtual consulting in primary care and the vision for the future was planned by NHS England pre-pandemic and an implementation tool kit for primary care to conduct virtual consultation was published in January 2020, with the vision:
‘The NHS long term plan contains a commitment that by 2023/24 every patient in England will be able to access a digital first primary care offer. Access to primary care services via online consultations will be a key part of achieving that commitment.’ 2
NHSE have developed a teledermatology roadmap for 2020/2021 to optimise teldermatology triage and guidance as a multi-disciplinary and cross-sector solution for secondary care dermatology referrals.3 This is an important document for changing care pathways, including teledermatology workflows.
How can virtual consulting work for dermatology?
Dermatology is a visual speciality; primary care nurses need to try and see the patient’s skin or use tools to help the patient ‘describe how their skin feels’. Chronic skin conditions can work well with virtual consulting, for example acne, eczema, psoriasis, rosacea and vitiligo.
Acute dermatology and new conditions can be triaged by primary care virtually, for example skin infections, hair and nail conditions. Primary care nurses can conduct virtual joint consultations with their patients and link in virtually with specialist nurses, for example tissue viability, with leg ulcers and wound care.
There are some dermatology conditions which cannot be managed with virtual consultation. Genital examination will always require chaperoned face-to-face consultations, as sending intimate images is not acceptable for the patient. Skin lesions can not be managed with virtual patient examination as dermoscopy is required to identify suspicious lesions and skin cancer. Primary care can provide service by taking a macroscopic and dermoscopic images of the suspected lesion, sending the images for triage of suspected cancer referrals to the dermatologist core member of the local skin cancer multidisciplinary team (LSMDT) or specialist skin cancer multidisciplinary team (SSMDT).3
The tips:
1. Prepare your patient for the virtual consult
There is more preparation required for a virtual than a face-to-face consult. Firstly, ensure the practice and nurse are fully trained and comfortable with the technology for a video consult. Text messaging is useful to advise that this will be a phone call or consult via a video link and a smart phone will be required (or phone connected to an ipad/laptop) with reliable internet connection. Double check the patient can link to a video call – if not confirm the virtual consult will be by phone. Ask the patient to have all their skin treatments at hand, prescription items and anything else they use on their skin.
2. Gather images and assessment information prior to the virtual consult
Every dermatology virtual consult should be accompanied by images, which will need to be taken by the patient with the help of family members. The images will then need to be forwarded, generally via a text system, which will insert the images into the patient electronic notes. Below are some essential points in ensuring clear and suitable patient images – this is essential for a dermatology consult.
- Images should reflect the severity of eczema and recent flare
- Must be in focus (ask someone to take the pictures in a bright light– no ‘selfies’)
- Take an orientation picture (whole arm) – then close up of area of eczema
- Take several images and select the best ones to send
- Make sure image files are under 1MB
- Advise the images will be stored in the electronic referral system (ERS). Explain onward data transfer and storage of images – consent. See the BAD’s Covid-19: Clinical guidelines for the management of dermatology patients remotely. 4
The above are instructions for patient images (adapted from the Primary Care Dermatology Society)5
3. Start with a clear introduction setting out expectations of a virtual consult
The virtual consult starts with sending the video link or making the telephone call. Initiate the consult by saying ‘hello’, establish that the patient can hear you, and for a video call – see you.
Confirm who you are speaking to and ask if anyone else is in the room/or listening in – introduce yourself to everyone (even if off camera) – for a phone call, a speaker phone may be used. Start by asking for verbal consent for the call/video consult. Reassure the patient that the consultation will be similar to a standard face-to-face; and that the call /video is confidential and secure.6 The Psoriasis Association have produced a infographic on ‘Preparing for a virtual consultation’ – access at https://www.psoriasis-association.org.uk/psoriasis-and-treatments/covid-19-information
4. Take a comprehensive history and utilise dermatology assessment tools
Patient history and assessment needs to be comprehensive on a virtual call. A dermatology assessment should be holistic and include discussion on past and current topical skin treatments (see tip 5). Consider sending the patient pre-assessment questionnaires, for example the Patient orientated eczema measurement (POEM)7 to assess physical symptoms over the last week and the Dermatology Life Quality Index (DLQI)8 to assess effects of a skin condition on quality of life – see the box below for more examples. Patients can also be asked pre-consult to keep a diary of symptoms and simple visual analogue scales are useful to assess the extent and severity of skin symptoms: for example, on a scale of 1-10, how red/sore is your skin today compare with last week? Or how itchy is your skin today? Remember to assess for any triggers and ask, ‘what do you think makes your skin condition worst?’; and whether the patient has any diagnosed allergies. Remember to check normal growth and development in children – height, weight and milestones.
Physical signs and psychological assessment tools:
5. Ask the patient about past skin treatments and have current skin treatments at hand for the virtual consult
Assessing skin management; and asking questions about current and previous treatment is crucially important in dermatology. Ask these questions by taking the patient’s through their day and find out when they apply emollients and topical treatments and any oral treatment e.g. use of antihistamines and antibiotics. Some good treatment assessment questions to ask are:
- How often do they use emollient and topical treatments (daily skin routine)?
- Where do they use them?
- How much do they apply? What size are the packs?
- Which treatments are effective/have helped?
- Which treatments have not helped?
- Are there any specific concerns with treatments (e.g., topical corticosteroids)?
6. Be aware of ‘red flags’ and if there is any concern arrange a face-to-face appointment
An awareness of ‘red flags’ or deteriorating skin symptoms is very important. Assess for clinical evidence of secondary infection – is the skin sore, wet and weepy with yellow crusting. Is the patient’s skin condition flaring, are there different symptoms, e.g. pain and vesicular blistering may indicate eczema herpeticum – a dermatological emergency, requiring same-day anti viral treatment. Is anyone else in the family experiencing the same skin symptoms? For example, intense itching may indicate a scabies outbreak.
7. Work with the patient on a treatment plan so they can self-manage
An individual treatment plan is essential to help patient self-manage and especially important for chronic long term skin conditions. Remember you may need to involve the patient’s family (with permission) in helping with the treatment plan. Focus on general skin care and prevention of flares, for example, complete emollient therapy (washing and moisturising). It is really important that the patient is given realistic expectation on what to expect from topical treatment, what to apply, where to apply, how long to use the treatment for and when to stop? One example is a two-week treatment burst for an eczema flare, topical steroid matched to the severity of eczema and body area would be used once a day, for seven days and then reduced to every other day.9
8. Utilise ‘talking in pictures’ for patient education, especially for phone consults
A helpful technique for virtual patient education is to ‘talk in pictures’. In dermatology, the ‘brick-wall’ analogy for explaining the differences between normal and dry skin is well-known.10 Other ‘talking pictures’ include a fire analogy for treating eczema, when the flames (inflamed skin) are present an extinguisher (the topical steroid) is needed to stop the fire (acute treatment); which leaves the embers, which need to be dampened down – treatment needs to be reduced or escalated down (sub-acute treatment), until dust needs to be mopped up – dry skin (daily complete emollient therapy)
9. Try to set a review date as best practice for chronic disease management
Plan review appointment depending on severity and treatment expectations, two weeks for an eczema flare, four weeks for eczema/psoriasis management, two months for acne. An initial video consult could be a phone review but do ask patients to send images and complete assessment tools for a thorough review.
10. Always provide a summary of the treatment plan and review plan when consult is closed
Reinforce treatment plan and new prescriptions, and remind the patient to collect from a nominated pharmacy. Recommend the NHS Pre-Payment Certificate (PPC) for working adults. Finally, summarise the consult, ensure the patient understands the treatment plan – if they are uncertain ask them to repeat it back. Inform the patient you are closing the consult, wave on video and say goodbye.
Conclusion
This article and practical tips on virtual consulting in dermatology aims to give nurses clinical confidence in managing patients with skin conditions.
Telephone v video consults
Phone
– Accessible for all – everyone has a phone
– No visual interaction
– No non-verbal communication
– Cannot read body language
– Potentially less effective for holistic care
Video
– Have to have smart phone/webcam
– Visual
– Non verbal communication
– Body language can be read
– More effective for holistic care
References
1. Schofield J, Grindlay D, Williams H (2009). ‘Skin conditions in the UK: a health needs assessment’. Centre of Evidence Based Dermatology, University of Nottingham.
2. NHSE. Using online consultations in primary care –implementation tool kit. Jan 2020. https://www.england.nhs.uk/publication/using-online-consultations-in-primary-care-implementation-toolkit/ [accessed Nov 2020]
3. NHSE. A teledermatology roadmap for 2020-21. NOTP Teledermatology Roadmap 202021. Imperial College. London. Available at https://future.nhs.uk [accessed Nov 20]
4. BAD. COVID-19: Clinical guidelines for the management of dermatology patients remotely. -Patient consent. Available at: https://www.bad.org.uk/healthcare-professionals/covid-19/remote-dermatology-guidance [accessed Nov 20]
5. PCDS. Photography for the patient. Available at http://www.pcds.org.uk/clinical-guidance/photography-for-the-patient-how-to-take-a-good-photograph-of-a-skin-conditi [accessed Nov 20]
6. Greenhalgh T. Video consultations: information for GPs. 2020. IRIHS Research Group. University of Oxford.
7. Charman CR, Venn AJ, Williams HC. The patient-oriented eczema measure: development and initial validation of a new tool for measuring atopic eczema severity from the patients’ perspective. 2004. Archives of Dermatology; 140(12):1513-9.
8. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)–a simple practical measure for routine clinical use. Clinical Experimental Dermatology; 19(3):210-6.
9. National Eczema Society. Topical steroid factsheet. Available at https://eczema.org/information-and-advice/eczema-booklets-factsheets/factsheets/ [accessed Nov 20]
10. Cork MJ and Danby S (2009) Skin barrier breakdown: a renaissance in emollient therapy. British Journal of Nursing; 181 (14): 872-877.
