ENT Telephone Clinics During the Coronavirus Pandemic: An Analysis of 400 Telephone Consultations at a District General Hospital

Abstract

Background:

The COVID-19 pandemic led to the introduction of telephone consultations in order to provide specialist health care remotely. This study analyses the outcomes of ear, nose, and throat (ENT) telephone consultations.

Methods:

Retrospective analysis was undertaken of 400 ENT telephone consultations.

Results:

All 2-week-wait neck or face lump patients underwent imaging and 78% were successfully discharged. 80% of vertigo patients and 100% of 2-week-wait throat symptom patients were offered face-to-face consultations. All primary hyperparathyroidism patients were managed remotely, being discharged, or with telephone follow-up. The majority of routine referrals were managed without the need for face-to-face consultation.

Conclusion:

Vertigo patients and 2-week-wait throat symptom patients should be offered a face-to-face consultation in the first instance. For patients with neck or face lumps, initial referral for imaging may improve patient flow and facilitate safe discharge. It is appropriate to continue with telephone consultations for all other patient groups.

Introduction

The COVID-19 pandemic has presented numerous challenges for the National Health Service (NHS). ¹ Ear, nose, and throat (ENT) as a specialty has been particularly adversely affected due to its aerosol-generating procedures that can increase disease transmission and put the clinician at risk. ² In response to the pandemic, ENT services in NHS hospitals have fundamentally changed the way they function, with cessation of elective surgery and focus on the maintenance of emergency and cancer services. The ENT outpatient clinic services also underwent significant modification, with the introduction of telephone consultations.

Prior to the COVID-19 pandemic, otolaryngology was yet a new specialty in the use of telemedicine. ³ Studies showed that telemedicine was suitable for diagnosis of middle and inner ear disorders and sinonasal pathology, but not so effective in laryngeal or external ear pathology that usually required a face-to-face examination. ^4,5 Telemedicine was also demonstrated to be helpful in reducing health care costs and in-person doctor visits. ^6,7 It was also advantageous in the delivery of health care to remote populations. ^8,9

During the pandemic, the use of telephone consultations has been instrumental in maintaining elective outpatient activity as well as access to a specialist. It has also assisted adherence with social distancing rules by reducing the footfall in hospitals and waiting areas. ¹⁰

However, telemedicine in otolaryngology has its own unique challenges. As a highly practical specialty that relies upon the routine use of microscopes and endoscopes to aid disease diagnosis, ¹¹ questions are raised about the overall effectiveness of telephone consultations in management of ENT pathology. With new coronavirus variants under investigation ¹² and the threat of further outbreak still possible, it is likely that challenges faced by health care services will continue much longer than anticipated, with telephone consultations to be the norm for the foreseeable future.

This quality improvement project analyses the patient outcomes after ENT telephone consultations. From our results, we make observations and recommendations to facilitate improved patient care and further service enhancement, which can be utilized by other institutions. This is the first time that this topic has been explored in the literature in detail.

Materials and Methods

Permissions were obtained from the hospital audit department to undertake this project. Ethical approval was not required as this study did not change patient management. Patients (both adult and pediatric) undergoing telephone consultations in ENT clinics between the months of August 2020 and November 2020 were identified and included in this study. Both new and follow-up patients were included.

The ENT telephone consultations at our institution are undertaken by 5 consultants, 5 trust-grade registrars, 2 core trainees, and 2 advanced nurse practitioners. The clinics were categorized into rapid access (emergency) clinic, 2-week-wait (cancer pathway) clinic, consultant clinic, and middle-grade clinic. The outcomes of the consultation were whether the patients were given a face-to-face appointment or telephone appointment or whether they were referred for diagnostics, discharged, or unreachable. All patient data were accessed and analyzed from use of patient electronic records.

Results and Analysis

In all, 400 ENT telephone consultations between the months of August 2020 to November 2020 were identified and analyzed. Of these, 231 of these were new referrals and 169 were follow-up appointments, making the ratio of new referrals to follow-up appointments 1.4:1. Out of the new referrals, 38% (65 patients) were 2-week-wait referrals on the cancer pathway.

Of the 2-week-wait referrals, 51% (33) were patients with neck or facial lumps. All these patients were referred for imaging (ultrasound scan neck) following their telephone consultation, with 78% being discharged after imaging showed normal findings or nonmalignant pathology. This left 22% of patients who, after imaging, remained on the cancer pathway for fine-needle aspiration of the neck lump and further investigation.

The remainder of the 2-week-wait referral patients were patients with throat symptoms (hoarse voice, dysphagia, odynophagia, sore throat), all of whom required face-to face follow-up for flexible nasoendoscopy. Figure 1 outlines the 2-week-wait patient cohort journey. Figure 2 illustrates the outcome for 2-week-wait neck/face lump telephone clinic outcomes.

Figure 1.

Outline of the 2-week-wait patient cohort journey following ear, nose, and throat telephone clinic consultation. Patients with head and neck complaints referred to imaging and patients with throat complains are given a face-to-face follow-up for endoscopy.

Figure 2.

Illustration of the outcome of 2-week-wait head and neck patients following a telephone consultation, demonstrating that the majority patients are discharged after imaging.

The largest cohort of patients requiring a face-to-face appointment following a telephone consultation were those with vertigo (80%). This was followed by patients with ear complaints (52%) and nose complaints (51%). Twenty-four percent of those with throat complaints (non 2-week-wait) required face-to-face follow-up. Within the subgroup of people with ear complaints, 37.5% had symptoms of hearing loss or tinnitus, in the absence of a surgical history or infective symptoms. Of these, 68% were booked in for face-to-face ENT consultation and audiology, the rest being discharged. All patients, whether new or follow-up for primary hyperparathyroidism, were managed remotely, with none being booked for further face-to-face consultations, but some having ongoing telephone consultation follow-up.

Overall, there were 231 new referrals for ENT telephone consultations. Figure 3 illustrates that only 50.4% of those new patients required an initial face-to-face appointment, the rest being safely discharged, offered investigations, or offered a telephone follow-up. With regard to follow-up patients undergoing telephone consultation, further face-to-face appointment was required for 54%, with the rest being discharged or offered ongoing telephone follow-up. Only 24 (6%) patients were unavailable or unreachable for their telephone consultation appointment.

Figure 3.

The outcomes of ear, nose, and throat telephone consultations for new referrals.

Discussion

Physical distancing has been critical for many health providers to limit the spread of COVID-19 and ensure patient safety. Many departments have relied on methods of delivering care remotely wherever possible. Therefore, it is critical to analyze and determine the efficacy of virtual consultations and establish best practice.

Various studies have looked into patient acceptance and satisfaction of telephone consultations. ¹³ Although face-to-face appointments are considered the norm, telephone consultations have been widely accepted by patients as an alternative during the pandemic and, in some cases, have been reported as a desirable alternative to outpatient visits (negating the need to take time off work, avoidance of transport issues, and bypassing waiting time in clinics). ¹⁴ However, shortcomings of telephone consultations have also been reported in the literature, including limitations in interpersonal communication, diagnostic challenges via telephone, suboptimal connection line, and negative patient preconceptions. ¹⁵

For many clinicians, telephone consultations have been a new experience. Being able to carry out a structured, effective, and safe consultation over the telephone can be challenging, especially in ENT where many patients have hearing or speech difficulties. Several institutions have published tips for telephone consultations to aid doctors in structuring their consultations. ¹⁶

With regard to 2-week-wait clinics in our department, all head and neck lump patients are referred to imaging after initial telephone consultation, and 78% of those patients are discharged after imaging. This shows that sending patients to radiology first allows for a faster diagnosis (by missing out the step of seeing an ENT clinician in clinic) and that this can optimize patient flow and facilitate safe discharge of the vast majority. This may, therefore, be a useful strategy that can be adopted long term within ENT departments. However, it may have the downside of increasing workload for radiology departments by having a higher volume of patients having 2-week-wait imaging inappropriately.

The low yield (22%) of abnormal pathology in 2-week-wait neck/face lump patient referrals demonstrates that effective triaging should be undertaken for these patients. The ENT UK has developed a robust head and neck cancer risk calculator to stratify patients with high-risk cancer ¹⁷ who can be seen face to face or low-risk patients who can be offered a telephone consultation or have their appointment postponed to after the pandemic pressures have settled. Undoubtedly, clinical judgment too should be used in conjunction with any decision-making tool. ¹⁸

In our department, all 2-week-wait patients with throat, voice, or swallowing problems were offered a face-to-face appointment for flexible nasoendoscopy after their initial telephone consultation as examination of the nasal cavity, oropharynx, and larynx is important in diagnosis and management planning. It may, therefore, be prudent to omit a telephone appointment for this subset of patients as it may only pose a delay in diagnosis.

In our department, the largest cohort of patients requiring face-to-face consultations were vertigo patients. As a complex pathology requiring thorough neuro-otological examination, with curative interventions like the Epley maneuver possible in clinic, it is not surprising that 80% of vertigo presentations required face-to-face evaluation. Our recommendation would, therefore, be to offer face-to-face appointments for vertigo patients rather than telephone consultation, to prevent diagnostic and therapeutic delay.

Some patients with ear complaints (52%), nose complaints (51%), and throat complaints (24%) also required face-to-face examination. This may be because ear complaints may require microscopic examination, nose complaints may require flexible nasoendoscopy, and throat complaints pose diagnostic challenges in the absence of a detailed examination of the oropharynx and larynx. Regardless, these percentages demonstrate that the majority of these patients can be managed remotely. Therefore, we suggest that continuation of telephone appointments for this subset of patients is appropriate.

Within ear complaints, we demonstrate that 68% of patients with hearing loss or tinnitus are being booked for face-to-face ENT consultations with audiology input. Depending on service availability and departmental pressures in individual institutions, we propose that new referrals with hearing problems with noninfective symptoms and no surgical background could be referred to audiology first in order to reduce delay in diagnosis and preserve clinician appointment slots for more complex patients.

A particularly interesting finding is that all primary hyperparathyroidism patients are being managed remotely or having telephone follow-up, with none being booked face to face. This may be because a physical examination is often not needed in this cohort of patients, their symptoms can be accurately assessed over a telephone consultation, and their calcium, vitamin D, and parathormone levels can be monitored remotely. We, therefore, recommend that telephone appointments are extremely suitable for these patients.

Cost–benefit analysis studies have shown that telephone consultations in the ENT outpatient setting reduce the need for in-person attendance, report that nearly half of telephone follow-up patients were discharged over the phone with a direct saving of approximately £30 per patient having a telephone follow-up. ¹⁹

Studies looking into telephone consultations from primary care to ENT services have shown to reduce visits to accident and emergency (A&E) and reduce health care costs significantly. ²⁰ There is no doubt that telephone consultations will remain in a post-pandemic setting and creating a telephone consultation program within specialties would prevent A&E visits and improve resource allocation. ²¹

In response to diagnostic challenges posed in ENT telephone consultations, various teleotology systems have been utilized to improve diagnostic accuracy via the telemedical pathway. The implementation of telescopic referral has been reported to be feasible and acceptable. ²² Extended use of technology in ENT telemedicine consultations could benefit diagnostic accuracy as well as have potential educational benefits. Further studies are required to establish the position of teleotology and its impact in health care delivery in the NHS.

Strengths of our study are the large patient numbers analyzed, which increases the validity of the results and increases its generalization to the wider population. Limitations of our study were that we did not explore patient satisfaction with telephone consultations, nor were we able to find out whether the patient attended their general practitioner or emergency services (perhaps at a different institution) as a result of unavailability of face-to-face appointments. We also accept that the study can be limited by variations in interindividual practice between clinicians.

Conclusions

The ENT telephone consultations are and will continue to be an effective way of delivering specialist care, especially in the response of expected backup in demand for elective activity following the resolution of the pandemic to reduce the forecasted gap in service provisions. Our study demonstrates that ENT telephone consultations are well attended by patients, safe and effective, with added benefits of reduced delay in access to imaging in 2-week-wait head and neck cancer referral patients and ability to safely discharge patients without a face-to-face consultation. However, we also show that telephone consultations are limited in usefulness for pathology such as vertigo or 2-week-wait referrals for throat symptoms.

The ENT services require to continue with the adoptable approach in response to the pandemic. In conjunction with clinician education, telemedicine pathway systems, structured consultation, and implementation of teleotology technologies may accomplish positive impact on service provision in otolaryngology in the years to come.

Summary Points

• 2-Week-wait patients with throat complaints should be given a face-to-face consultation rather than telephone appointment in the first instance to reduce diagnostic delay.

• Vertigo patients should be given a face-to-face consultation rather than telephone appointment in the first instance to allow neuro-otological examination and possible curative intervention in clinic.

• 2-Week-wait head and neck patients may benefit from radiological evaluation after telephone consultation and most can be safely discharged without face-to-face ENT assessment.

• Effective triaging of 2-week-wait referrals may allow for a more suitable subset of patients to be given an initial face-to-face appointment.

• Telephone consultations are a suitable initial point of contact for patients with ear, nose, or throat symptoms and primary hyperparathyroidism.

• Patients with hearing loss with noninfective symptoms may benefit from being seen by audiology rather than ENT to prevent delays in care.