A nurse-led telemedicine service: sharing good practice
Letham is one of the largest villages in Scotland, with a population of almost 3,000, 30% of whom are over 65 years of age. While there is no medical practice or pharmacy within the village, there are at least eight GP surgeries in the surrounding area, the nearest being six miles away.
Home visits from these practices are carried out only on request, and as public transport is limited, attending the practice for a routine appointment can be an onerous task, especially for elderly people and those with young children. The only permanent on-site health-care facility available to all residents in Letham is the community nursing service offered by NHS Tayside. This supports two permanent nursing staff who offer hands-on community nursing and health visiting on weekdays.
Increased demand for services
The built area is continuing to expand to meet the needs of Letham’s growing population. This has increased the demand for health-care services, adding to the existing workload of the primary-care practitioners, especially those based at the Green Street surgery in Forfar, who currently care for 65% of older people in Letham.
This situation prompted the GP partners at the Green Street surgery to re-evaluate the services offered to clients in Letham and explore new and innovative ways to provide local patient-centred care to the villagers. With the consent of the nursing staff, a pilot project was established in May 1998, linking the nursing treatment room at the local sheltered housing complex in Letham with the Green Street surgery using video-link technology.
Setting up
This pilot, facilitated by funding from the then Tayside Health Board, aimed to test the feasibility and effectiveness of a primary-care-focused telemedicine service in this remote rural location. The technology chosen – the VC7000 video-conferencing system – used equipment made redundant after an unsuccessful local development that had attempted to link an out-of-hours nurse-led service at Forfar infirmary to the on-call GP’s home.
The current interactive, real-time consultation service is done through an integrated services digital network (ISDN2) line. The equipment includes a video display screen, microphone, keyboard, loudspeaker, telephone handset and camera unit that enables pictures and sound to be transmitted and received simultaneously. This set-up, outdated by today’s technological standards, is enhanced by the addition of a hand-held camera that enables nurses to provide detailed close-ups for the GP if needed. Lessons have also been learned from the previous attempt to use video links in Forfar, such as the need for a permanent set-up and a robust infrastructure within which to operate the VC7000.
Nurse-centred telemedicine
During the pilot period, which was initially limited to residents of Letham’s sheltered housing unit, a 30-minute interactive video-linked session was held each week. Each of these involved up to four patients, who had previously consented to the remote consultation and were accompanied by a nurse. She set up the video-link equipment and supported the patients and the GP by providing reassurance to the former and assisting with the examination as and when requested by the latter.
The remote consultation process in Letham adheres to what has been coined “nurse-centred telemedicine” (Gerrard, Grant and Maclean 2000). In this, the nurse acts as the primary provider of “hands-on care” and the doctor adopts a solely consultative/guidance role. By contrast, in “doctor-centred telemedicine” technology enables communication between the primary medical provider in a rural/remote area and specialists normally located at a central (urban) health-care institution.
It is argued (Gerrard, Grant and Maclean 2000) that the nurse-centred service is a much more viable model of operation, compared to the doctor-centred one, as most teleconsultations are likely to involve non-life-threatening or routine situations and thus fit with the level of competencies offered by general nurses in the community.
Feedback
To evaluate the effectiveness and appropriateness of the pilot, it was decided that, after each teleconsultation, an “in-house”-designed questionnaire would be completed by patients, doctors, nurses and students.
The feedback from the questionnaire not only supported the continuation of the video-link service, but also prompted the establishment of a new drop-in nurse-led clinic. This now provides the ideal opportunity to assess and provide care to patients and, at the same time, “filter” or triage appropriate candidates for a teleconsultation.
Those deemed likely to benefit from prompt rather than urgent medical attention are asked to come back later in the week and have their medical consultation over the video link. The nursing team leader in Letham has constructed a referral protocol that governs the process that determines whether a consultation with the GP is necessary. It also serves as an operational framework for all other nursing staff, helping to optimise the effectiveness, efficiency, continuity and consistency of the service.
Evaluation
When an external evaluation of the telemedicine service was carried out in 2000 (Macduff and Wesy 2000), users were highly favourable and unanimously agreed that it should become a permanent feature of the health-care service provision in Letham. The recording of such high levels of patient satisfaction was a cardinal factor in the decision to continue this service in the village beyond the pilot stage and up to the present day.
Recently, it has been expanded to include mothers requiring postnatal follow-up for routine care or specialist intervention including for postnatal depression. We are also currently looking at the benefits of providing remote palliative care to patients from secondary care.
Quality time
As noted in recent policy papers, using technology to bridge the distance between care providers and service users is an effective way of supporting patient-centred care.
Nursing staff in Letham have found that the video link not only provides a more holistic and convenient service, reducing the number of vulnerable patients that have to travel to visit their GP, but it also means that the nurses themselves now have quality time to discuss other matters with the GP. Using the telemedicine service has also motivated them, increased their job satisfaction, and enabled them to continue their professional development and keep their skills and knowledge up to date, so complying with Nursing & Midwifery Council (NMC) requirements.
The good news for Scotland is that a Scottish Centre for Telehealth is being established in Aberdeen, and the lessons learned in Letham could now be implemented on a national scale.
For a full a full list of references and the latest results of the telemedicine audit, contact the author Sylvia Harvey
Sylvia Harvey DNTL/HV