Background

Teleneurology and telephone consultations have long been used in neurology.^{1 2} There is a lack of research data on using remote consultations for new neurology outpatients and only low-level evidence for their use in general practice. Remote consultations provide a mechanism for neurology care during the COVID-19 pandemic. Switching from face-to-face new appointments to remote (telephone or video) consultations allows continued provision of neurological services to patients while reducing hospital footfall; this could limit the spread of COVID-19 and avoid exposing vulnerable patients who attend the clinic to unnecessary risk.

We have built this document using advice from the UK General Medical Council (GMC) on remote consultations.³ However, the GMC’s advice is not wholly applicable in the setting of COVID-19; their safety concerns are mostly mitigated by the fact that we are the patient’s regular healthcare provider, with access to their notes and referral letters. The GMC also makes specific provision for departure from established procedures to care for patients in the highly challenging but time-bound circumstances of the peak of an epidemic.³

Given that the clinical history provides the greatest part of the information that leads to a diagnosis,⁴ remote consultation should be able to help many patients. In general practice, remote consultations were not associated with any statistically significant change in visits to the Emergency Department or any differences in rates of admissions or of patient satisfaction.⁵ However, remote consultations have been linked to more repeated visits: an average of two additional contacts for every 10 patients.⁶ Although a quarter of all patient consultations now occur on the telephone in general practice, there is no evidence base upon which to inform clinician training in this skill.⁷ This paper aims to help neurologists to conduct remote consultations, particularly in relation to the current COVID-19 circumstances, and to help to embed remote consultations as standard practice following the pandemic.

Pre-consultation

The advice regarding who should attend outpatients, social distancing and more stringent infection control measures are being updated frequently as the pandemic develops. This will be subject to further changes, and national guidance needs to be followed. The clinical need for an appointment will need to be balanced against the resources available at the time.

Virtual (telephone or video) consultations should be booked in the usual way, so that the patient, the clinician and the hospital each has a record of the appointments taking place. The patient must be made aware of the time and type of the consultation, with clear instructions on how to join the consultation, and to know that they should be in a quiet place with appropriate telephone or internet reception. It is important to confirm a reliable means of contact with the patient.

Some remote consultations pose particular problems, for example for those patients who have communication or cognitive difficulties. In some instances, it may help to involve caregivers or next of kin, with appropriate consent. Those who speak only limited English will require an interpreter (services are available). Some patients need to come up for a face-to-face consultation in order to be examined; thus, clinicians need access to clinical space to allow examination of carefully selected patients (subject to national guidance in place at the time). A deferred examination in person may represent the best balance of risks and benefits for the patient, a decision that will balance the current COVID-19 risks against the neurological problems.

Follow-up appointments are likely to be easier to run remotely, and some neurologists have used such consultation methods for some time.^{1 2}

Consultation

• A video calling platform is preferred for new patients. However, if video access is limited, then the patient can be contacted initially by telephone before deciding the need for a video consultation or a ‘phone-to-examination’ clinic (see below). Many people, especially the elderly, may be unable to manage a video consultation and need assessing by telephone.

• Headphones or a speakerphone help to allow the clinician to be hands-free and to document the consultation more easily. If using a telephone with a speaker, it is important to maintain confidentiality, such that the conversation cannot be overheard.

• Verify the patient’s details (name, date of birth and location). Check who is with them, as confidentiality issues are no different from the usual face-to-face setting.

• Introduce yourself, including showing your identity card to the camera if the consultation is by video, and explain why the consultation is by telephone instead of face to face and state the time available for the consultation.

• Check that the patient can hear and understand you.

Potential Challenges

• Punctuality. There may be delay to the appointment time. The outpatient appointment needs to be arranged for a time window recognising that other emergencies need to be handled during these unprecedented times.

• Escalating emotions. Try to remain calm and emphasise what you can do rather than what you cannot. Recap the emotions you have heard with ‘It sounds as though…’. Acknowledge the patient’s inconvenience if needed, for example, ‘Thank you for waiting’.

• Examination. Some patients still need to be examined after a remote consultation. Clinicians need a mechanism in place to allow urgent (within a week or less) or routine (‘phone-to-examination’) clinics—see above. Based on evidence from GP settings (6), this may be one clinic every 2–3 weeks.