Teletriage service for two-week wait referrals
In order to more effectively manage the increasing number of dermatology two-week wait skin cancer referrals (150 a week) a teletriage service was developed by County Durham and Darlington NHS Foundation Trust (CDDFT) for all 2-week wait referrals to dermatology and plastic surgery.
The teletriage service required the primary care teams to be able to take good quality photos securely and send them securely via e-RS. Digital solutions were required to ensure that GPs had rapid access to cameras which could securely take patient images and allow easy transfer to the patient record and the e-Referral Service (e-RS), ideally using their own personal mobile device.
The aim was to make the two-week wait triage service accessible for all patients requiring urgent appointments for squamous cell carcinoma and melanoma, and to streamline the patients’ skin cancer referral pathway.
Solution and impact
It was decided that clinical commissioning groups (CCGs) would provide all practices with a dermoscope and access to a secure smartphone app to take photos.
All GP practices were provided with an iPhone 10 with a Heine 20 dermatoscope and bracket.
Practices in CCGs using Consultant Connect technology were provided access to the Consultant Connect PhotoSAF App to download. Each GP was asked to register for a unique account with Consultant Connect using their NHS email address and a unique password.
Subject to patient consent, for each two-week wait referral the GP or other practice staff take three photographs of the lesion (dermoscopic, macroscopic and localising images). The images can then be downloaded to the patient’s primary care record from the Consultant Connect web portal via a secure login and password combination, either by the GP or any authorised member of their team. The three photos are then uploaded into e-RS with the two-week wait referral letter.
All two-week wait referrals made using this pathway are booked into a virtual clinic (CAS) managed by the CDDFT patient booking team. The responsible consultant logs into e-RS every day to check for new referrals. The photographs allow the dermatology team to triage the patient effectively or redirect to plastic surgery or maxillofacial surgery. The dermatology team identifies poor quality images and this data is shared by the Trust with CCGs to identify practices where further training may be required.
Roadshows and time out sessions were carried out across five localities to train GPs and practice staff to use the equipment and take high quality photos. The Trust agreed to change job plans to allow dermatologists adequate time to triage the referrals.
The consultant does the teletriage. If the patient does not need to be seen again, Band 4 administrative support staff (partly funded by CCGs) phone the patients who do not need to be seen after teletriage. They tell the patients about their benign diagnosis so that the patients can be discharged back to their GPs.
The consultant continues to write to the patient and GP. This ensures that there is a formal letter in the notes for an audit trail and for any medico-legal problems in the future.
The Consultant Connect App is also increasingly used by GPs to send images to the Trust via e-RS Advice and Guidance.
The Consultant Connect information governance (IG)-secure platform makes it easy for clinicians to take photos with the Consultant Connect App and attach them to referrals sent via the NHS e-Referral Service. Images and notes are stored automatically in an IG secure cloud (not on the phone). Images and a pdf summary can be downloaded by clinicians or administrative staff from photosaf.com.
The Consultant Connect PhotoSaf app:
- is designed for clinicians to share images
- allows the clinician to add NHS number and accompanying comments to the images
- stores images securely and prevents unauthorised people from accessing the images on the mobile phone
- automatically compresses each image to 5MB or less to comply with e-RS file size limits
Find out more
Dr Maneesha Vatve, consultant dermatologist, University Hospital of North Durham
Any virtual teledermatology 2 week wait pathway will require:
- the use of high-quality macroscopic and dermoscopic images as the ‘reasonable diagnostics’ required to exclude cancer
- a triage outcome that permits the specialist clinician to request to see the patient face-to-face if required
- the facility to communicate directly with the patient and their GP
Outcomes from the virtual teledermatology 2 week wait pathway
The clock can be stopped in 2 ways:
- if the macroscopic and dermoscopic images are taken by a member of the specialist dermatology team (for example, a medical photographer or a nurse), this counts as ‘1st diagnostic test’ so the clock can be stopped at the time the image is taken
- if the images are taken by the primary care team or in a primary care-led community hub and then reviewed by the specialist, the clock stops when ‘an appropriate member of the specialist team’ contacts the patient by telephone, video or face-to-face consultation. Determining who is ‘an appropriate member of the specialist team’ is a decision for the specialist department who have the overall clinical accountability or responsibility for this part of the pathway
For more information, read the guidance: suspected skin cancer 2 week wait pathway optimisation on the Dermatology Future NHS site.
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