Patients benefit profoundly when clinicians use immediate Advice & Guidance:
- Instant reassurance, avoidance of stress or worry.
- Avoidance of costs and disruption through unnecessary hospital visits.
- Right care, faster.
- Instant reassurance, avoidance of stress or worry.
- Avoidance of costs and disruption through unnecessary hospital visits.
- Right care, faster.
Real-life patient experiences are re-told by clinicians in our videos and in the examples grouped by hospital specialty below.
Telephone A&G – Mental Health
Acute GP Unit Medical Admissions
A patient with a swollen leg had previously presented to the Emergency Department. The symptoms had persisted and the GP was concerned that the patient may have deep vein thrombosis (DVT). She used the Consultant Connect App to contact a GP working in the Acute GP Unit Medical Admissions team at Singleton Hospital. This team of GPs discusses patient cases with the GP making the call. Together, they decide on the best care for the patient and which is the most appropriate clinic or department to send them to.
The GP making the call discussed her patient case with the Acute GP Unit Medical Admissions team and it was agreed that an urgent ultrasound scan was required. She was able to arrange this for the next day. This was a great result for the patient and the scan was also organised for a time when they would easily be able to get transport to the hospital. The use of rapid Telephone Advice & Guidance meant that the patient’s care was expedited.
Dr Holden had a visit from a patient with end-stage heart failure. The patient was adamant that he did not want to go into hospital, for fear of dying there. Dr Holden felt that he should have a very short hospital admission to correct a developing iron deficiency anaemia. Both Dr Holden and the patient did not want an investigation and treatment of the cause, but just for the patient to feel better, so he could get home to die as he wished.
The patient was still in the consultation room when Dr Holden used the Consultant Connect App to speak, without a long wait, with the on-call medical registrar. The patient was able to hear Dr Holden’s admission call and his request for a quick in and out admission. The patient was sent to hospital to receive IV iron that night and was able to go home to sleep and return to hospital the next day for a blood transfusion.
GP contacted the Acute Medicine consultant about a 27-year- old woman who presented with a one-week history of a flu-like illness with a dry cough, vomiting and left sided chest pain. The patient was noted to be pyrexial and tachycardic but had a normal sounding chest and normal O2 saturations. The GP suspected it was either a community acquired pneumonia or influenza and wanted to get an urgent CXR. The GP used Telephone Advice & Guidance to speak to a local Acute Medicine Consultant who “agreed that if the patient attended hospital, they would look at the CXR on PACS and call the patient with the results.”
The patient was prescribed antibiotics in case of pneumonia. “The CXR did not show any initial changes though the radiologist did report signs of possible pneumonia. Using Telephone Advice & Guidance meant the patient was managed in the community avoiding the need for a hospital appointment.”
“A 62 year-old fit and well lady presented with new breathlessness. A routine ECG conducted as a part of investigations showed some slight irregularities. I was uncertain of the significance in relation to her symptoms of breathlessness so used the Consultant Connect App to take pictures of the ECG with patient consent and request consultant review of the trace.”
“The Cardiologist was able to reassure us that this was not a cause for concern and that no further action was required.” The patient also felt reassured. Her breathlessness was monitored and “subsequently settled spontaneously.”
A GP called a consultant on the National Consultant Network regarding a patient with Pericarditis symptoms which were still ongoing two weeks after diagnosis. The GP also informed the consultant that the patient had told him he had taken cocaine. The consultant explained “This changed the complexion of the case and informed him that we needed to be certain that the symptoms were not due to a complication of cocaine which can cause heart attacks and through this an inflammation of the lining of the heart.” The GP was advised to “refer the patient to the local cardiology department” and said that “it felt like a more ‘connected’ approach without the divide between primary and secondary care.”
“A patient with heart failure complicated by a valve prolapse was under my care. Her management was delicate as she has co-existing renal failure that meant it was difficult to balance her diuretics and manage her polypharmacy. I contacted her cardiologist via Telephone Advice & Guidance to get advice when she was unwell. I was able to establish what an acceptable renal function for her would be with the new diuretic regime, and also second-and third-line drugs to try next. Finally, the consultant gave me advice on when she would need admission. I was able to avoid admitting the patient, and she remained in her own home, whilst I adjusted her medication – which is what she wanted. Having a clear plan gave her reassurance and me confidence to manage her when she was more unwell.”
“A GP asking about atrial fibrillation, and general management” for a patient contacted the consultant. The GP did not feel that the patient “needed anticoagulation medication, at least until all the tests were in.” The consultant “informed him that the patient was at very high risk of having a stroke, and whatever the tests showed, they still needed anticoagulation drugs, and that the GP should consider starting today.”
“As the tests could easily take 3-4 months, this protected the patient against a possibly devastating stroke much earlier than originally planned” the consultant explained.”
This was “a good outcome and the GP was pleased with the advice.”
A GP used Telephone Advice & Guidance to contact the consultant regarding a “75-year-old patient who had been taking clopidogrel and had a rash as a result.”
The GP was unsure whether the patient should be admitted to hospital. During the Telephone Advice & Guidance call, the GP explained the history and situation of the patient.
As a result of the immediate conversation between the GP and the consultant, the patient “avoided a referral to the hospital.”
A GP had an elderly patient who had previously been diagnosed with a narrowing on the aortic valve. She was breathless, had fluid retention including swollen ankles and a heart rhythm disturbance which was atrial fibrillation. There was “a very high risk of blood clots in the heart, which can end up in the brain and cause a stroke.” The GP was concerned about prescribing blood thinning drugs as she was unsure about the interaction of the drugs with the patient’s abdominal aortic aneurysm so she called a consultant on the National Consultant Network. The consultant was “able to reassure the GP that the benefit of blood thinners outweighed this risk.” He also advised that “it seemed likely that her breathlessness was caused by a further narrowing of her aortic valve that had put pressure on the heart and resulted in the rhythm disturbance and inefficiency of the heart resulting in fluid retention.” The consultant told the GP that “very early assessment by the local cardiology clinic was mandated.” The GP said “the consultant’s thorough advice was didactic and helped me a great deal in deciding a management plan and to expedite the referral to the anticoagulant clinic.”
The GP needed advice on her patient suffering from leg oedema and had known cardiovascular disease and wondered if the patient was experiencing left ventricular failure. The patient’s ECG was grossly abnormal. The GP and her paramedic colleague were unsure whether the changes were acute or due to the patient’s pacemaker, “as there were no previous ECGs on the patient’s record to compare to, which made it much harder to work out if the problem was acute.”
The GP used the Consultant Connect App to send the ECG images via the IG secure Photo Messaging function to a local Cardiologist. The Cardiologist explained, “The GP and patient were worried not so much about the patient’s clinical condition but about the ECG results. I was happy to reassure the GP that the ECG by itself was not concerning.”
A young adult patient presented with atypical chest pain. The GP carried out an ECG, which showed a few unexpected and unexplained features. The GP was keen to discuss the results with a cardiologist, so he used Telephone Advice & Guidance via Consultant Connect. The Cardiologist reviewed the ECG and advised that the patient needed to be referred to the outpatient department for further assessment.
On another occasion, the GP saw an elderly patient who visited him after having stents fitted abroad. The patient’s medication had run out. The patient had had two previous myocardial infarctions and reported 4-5 stents being present, but all medical notes provided to the GP were not in English. Due to the procedures being carried out abroad and the ongoing medication advice given to the patient not matching the local NHS equivalents, the GP was uncertain of the next steps.
The GP used the Consultant Connect service to speak to a Cardiologist. Together, they worked out what medication the patient needed to stay safe in primary care while waiting for their outpatient appointment.
“I saw a 72-year-old patient who had bradycardia, presenting with slow atrial fibrillation. The patient had a history of myocardial infarction, and as their heart rate was at about 50, I was not sure whether they needed pacing. I used Consultant Connect to contact a cardiologist for advice on the patient’s ECG. The cardiologist explained that the patient did not need pacing. This was reassuring as it meant that an urgent referral was not necessary for the patient. The cardiologist advised on the management of the atrial fibrillation which we started in the community.”
A female patient, who recently suffered weight loss, recently visited her GP. The GP examined the patient and found an enlarged liver. Urgent blood tests showed deranged liver function and raised ovarian tumour markers. The patient had a past history of breast cancer and had been discharged a year ago. Clinically the patient had suspected metastases from an unknown primary and the GP was worried about the potential delay that could happen to her investigations due to COVID-19.
The GP used Consultant Connect to speak to a local radiologist to discuss the patient’s symptoms and arranged for her to get an Urgent CT TAP scan in the same week.
Community Mental Health Teams
The consultant received a call about an 80 year old lady who was diagnosed by our memory service with Alzheimer’s disease 3 years ago, but who was not currently under secondary care. Over the past 3 months she has become more forgetful and had developed some paranoid symptoms, believing her neighbours had a spare key, were entering her property when she was asleep, and hiding objects around the house. She was quite distressed about this but through discussion we were able to establish that there were no acute risks to herself or others. The consultant reviewed her medication and did not feel she was on any that were likely to be worsening her cognition.
We agreed she did not meet the threshold for prescribing an antipsychotic at this stage or need a referral to the older adult CMHT at this point, but that she could be referred to us if there is no improvement in her symptoms with the memantine or if the risks increase. Her GP was happy with this plan, and said they had thought this would probably be the treatment plan, but they had found it helpful to check the plan was appropriate, and it gave them confidence in managing the patient going forward.
The GP had a visit from an elderly male patient who had experienced an anaphylactic reaction to the Cholera vaccine when he was young and was told to avoid any vaccines in future. He had not had any vaccinations since then but was quite keen to have the COVID-19 vaccine. However he was very concerned and anxious, wishing to get advice from the immunologists and have allergy tests, if needed.
The GP used the Consultant Connect App to contact a local immunologist from the local hospital and was able to feedback the reply to the patient the same day. The patient felt reassured and was grateful for a quick answer from the expert to his concerns. He was then able to have his COVID-19 vaccine in the same week.
A male patient came to see their GP with a cutaneous horn-type lesion on his upper chest. The patient had a history of fair skin and sun exposure. The GP was concerned that the lesion could be an early Squamous Cell Carcinoma (SCC), so he sent a photo via the app to a dermatology consultant for advice. The consultant agreed that it could be an early SCC and advised a 2ww referral.
“I took a photo of a patient who had a very pronounced rash over the abdomen and limbs. I emailed the dermatology team for advice. They thought it looked like annular psoriasis and recommended treatment. Four weeks later, I got the patient back in. He was able to see before and after photos of himself and was very impressed. With his consent, I later used the photos to present the case at a local GP dermatology meeting. The patient got much better and continues on the treatment.”
A GP saw a patient with a facial rash, which was presumed to be seborrheic dermatitis. As the patient wasn’t responding to standard treatment, the GP used the Consultant Connect App to take a clinical photo which was shared with the Dermatology Team at his local hospital. The advice was to try an alternative rosacea treatment. As a result of using Photo Advice & Guidance, the patient’s condition improved rapidly.
The patient was a child with an itchy body rash and a history of eczema. As the GP was “unsure if this rash was eczema or something else,” she used Photo Advice & Guidance via the Consultant Connect App to take clinical pictures of her patient. These pictures were shared immediately with the Dermatology Team at her local trust. As a result of sharing the pictures, the GP said: “I had a written response from a local consultant dermatologist the very next day. The consultant dermatologist diagnosed the rash to be chronic eczema with lichenification and follicular morphologies and wrote a detailed treatment plan for the patient.”
As a result of using Photo Advice & Guidance: “The patient was provided with the correct treatment plan early on. They did not need to wait for a dermatology hospital appointment – a potential hospital referral was avoided.”
A patient who had developed an “extensive itchy” rash after taking Tamoxifen had called an ambulance and was instructed to stop Tamoxifen and see her GP. After taking antihistamines and seeing her GP, there was no improvement. The GP “was concerned about a medication reaction and started her on Prednisolone. After two days, the rash had not improved. She used the Consultant Connect App to send photos of the rash to a dermatologist” and received a response within 24 hours. The consultant said that “there was no evidence of Erythema Multiforme or Toxic Epidermal Necrolysis and that the rash was in keeping with a drug rash with possible mild DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) but without systemic symptoms.” He recommended continuing Prednisolone “with the addition of a topical steroid and emollient.” The rash was resolved – avoiding a referral.
A patient came to see the GP “with a rash on their knees and feet, which was being treated as if it were psoriasis but was not getting any better.” The GP “took photos of the rash via the Consultant Connect App and sent them to an NHS dermatology consultant for advice. The dermatologist was able to diagnose the rash as lichenified eczema and steroid cream was suggested”. The rapid service meant that “the dermatologist was able to provide the correct diagnosis and the correct treatment. Within 3 days the patient’s rash had settled”.
“My first Photo Advice & Guidance query via Consultant Connect generated a management plan response in 1 hour. 3 weeks later, when I needed further advice, I could re-open the original consultation with my next query which was answered by the same doctor half an hour later”.
“My second Photo Advice & Guidance query generated a management plan response within 24hrs, and so far, the patient has not needed a follow-up with myself or dermatology since”.
A patient came to see the GP suffering with a rash. The patient had coeliac disease and the GP was wondering if the rash was dermatitis herpetiformis. The GP sent a photo via the Consultant Connect App to a local dermatologist who came back and confirmed the rash was in fact pompholyx. She was able to call the patient back within 5 minutes to confirm the correct diagnosis and confirm the management plan.
The GP comments that she has found PhotoSAF useful on multiple occasions for “documenting skin lesions.” She takes a picture of the lesion in question, adds relevant notes and then adds it “to the patient’s medical record so that other clinicians can see what I was seeing at the time the photo was taken.” She has “found it most useful for patients with lesions where there is patient concern about change. This is because the original photo and a repeat one can be easily compared, which I find can be more compelling than verbal reassurance alone.”
Dr Goyal, a GP in Birmingham, recently saw a patient who had suspected severe hand dermatitis. Dr Goyal recognised some of the symptoms, as she has experience of working in dermatology. To ensure her initial thoughts of the patient’s condition were correct, she used Photo Advice & Guidance, via Consultant Connect, to send photographs and notes to an out-of-area NHS Dermatologist, on the National Consultant Network (NCN).
Diabetes and Endocrinology
“I recently contacted an endocrinology consultant for advice on dosing of levothyroxine for a pregnant patient with hypothyroidism. The patient had a history of complications during past pregnancies and was anxious that her thyroid condition was adequately managed. The consultant was able to provide advice on adjusting the dose relevant for the patient during pregnancy and advise on the intervals of when to repeat her blood tests. Being able to speak to the consultant directly and during my consultation with the patient meant that I could reassure the patient there and then.”
“I was unsure if the patient should be started on insulin or oral hypoglycaemics. Usually I would manage Type II presentations myself, but admit children or teenagers presenting with Type I to Paediatrics. The patient was anxious to do something about the situation and wanted answers from me straight away. The Diabetes and Endocrinologist understood the difficulty, defining this type of Diabetes, and was able to start the patient’s management the same day through the Diabetes Nurses in the hospital clinic. Admission was never indicated, but a referral to outpatients would have taken some weeks at least. It felt good to have the management started within a few hours of the diagnosis. This was a great result.”
“I was able to reassure both the GP and patient that the fluctuations were likely caused by patient-initiated changes to lifestyle, which the GP subsequently confirmed after reviewing practice nurse notes, and so didn’t need to consider any scans for the patient to exclude malignancy.”
Dr Goyal saw a patient who “had a lump in their neck and was worried about cancer”. To help manage the patient’s worries about the risk of cancer, Dr Goyal used Telephone Advice & Guidance, via Consultant Connect, to speak directly with a local Endocrinology consultant. The consultant helped Dr Goyal manage the risk of cancer because she was able to explain to the patient “that there are investigations they could do, to get more information”.
“A patient was in the podiatry clinic in the community. They were just having a review but were found to have deteriorated significantly. The podiatrist was able to upload some photographs and do a quick history.”
The photos were reviewed and “the patient then got transferred urgently to the Vascular team at University Hospitals Coventry and Warwickshire NHS Trust (UHCW). That was all done via Consultant Connect. What could have happened is the patient could have been sent in [to a SWFT hospital] for an assessment and then transferred to a UHCW hospital but, by looking at the photographs, we were able to completely bypass that.”
An 88-year-old patient was “found to be profoundly hyponatraemic (causing bradycardia and dizziness).” He had “recently undergone tests to investigate retinal artery occlusion.” Urea and Electrolyte results came back late from the lab. Using Consultant Connect’s Telephone Advice & Guidance service, the GP was able to immediately contact a consultant at Queen Elizabeth University Hospital to discuss the follow up options. The patient was “seen at the Department for Medicine for the Elderly the following day where appropriate investigations were performed, and his medication was reviewed.” The GP says that “this avoided a late evening admission as [she] could discuss the patient’s current functional status with the consultant planning the follow up (which was very prompt).” As a result of using Telephone Advice & Guidance, an “unnecessary admission” was avoided.”
A consultant received a call about an elderly patient, living on her own at home. She was known to have Chronic Obstructive Pulmonary Disease, but had recently become more breathless. The patient complained of weight loss and a poor appetite and explained she had been collapsing at home. She had recently been seen in the Emergency Department, but they felt that she wasn’t improving. “We arranged an urgent Outpatient Clinic appointment, which she attended. We were able to assess her, with access to her medical records and previous investigations. Blood tests, an ECG and lying and standing Blood Pressure were checked and advice with regards to changes to her medication was given. We were able to liaise with other services involved in her care. This enabled the patient to get the assessment and support she needed without an emergency admission.”
An elderly patient had become anaemic but was not symptomatic enough to merit an acute admission to hospital. The patient did not tolerate oral iron supplementation. The GP was able to quickly discuss the symptoms with consultant and agree that reviewing as a non-emergency was most appropriate option to help the patient and that an IV iron infusion was needed. The consultant advised that a morning appointment would be best for the patient as it would be quieter and therefore meaning less risk of COVID-19 exposure.
We avoided an unnecessary ED attendance and a probable hospital admission, we reduced our travel impact, and we collaborated with our Primary Care, Hospital, and Health and Social Care colleagues to provide a very patient centred plan.
“I saw an elderly 80-year-old patient who was waiting for a hip replacement. The operation was cancelled by the anaesthetist because the patient’s sodium level was low, and they were slightly anaemic. I carried out initial investigations, but couldn’t find a cause.
I used Telephone Advice & Guidance, via Consultant Connect, to speak to an elderly care consultant. The consultant explained that anaemia is not a contraindication and that the patient could be transfused. I arranged further investigations for the cause of the low sodium level, or hypernatremia. I was then able to refer the patient back to orthopaedics for their operation.
Being able to get this type of advice quickly improved the care of the patient. Without the service, it may have taken three months for them to see a consultant, and by that time, the patient could have been presenting with new clinical conditions. Using the service was a good experience for myself and the patient.”
“Recently, during a weekend shift, I attended an elderly male who was in severe pain due to a large swelling in his groin. Through hearing the patient’s past medical history and my examination, I was concerned that he was suffering from a strangulated hernia. Our current guidelines require us to take all surgical cases with the exception of Abdominal Aortic Aneurysm to Perth Royal Infirmary in the first instance for assessment. I used Telephone Advice & Guidance to raise my concerns that it would be detrimental to my patient to have him taken to Perth Royal Infirmary for assessment only then to be transferred on to Ninewells Hospital for the immediate attention his condition required.
Through my immediate discussion with the senior consultant at Ninewells Hospital, we agreed to bypass Perth Royal Infirmary and transfer my patient directly to Ninewells Hospital which helped to speed up his treatment.”
A paramedic used Telephone Advice & Guidance to speak to an A&E consultant about a patient experiencing what had “the potential of a stroke mimic.” The paramedic thought the patient was experiencing Bell’s palsy. Using Telephone Advice & Guidance allowed him to speak to an A&E consultant who was able to talk him through a few simple steps to confirm his suspected diagnosis. Telephone Advice & Guidance gave both the paramedic and the A&E Consultant the confidence that the best pathway for the patient would be to be referred to their local GP rather than needing to undertake a journey to hospital.
“The patient was happy that the outcome meant a local appointment with their GP as opposed to an 80-mile round trip to hospital.”
An Ambulance Technician recently attended a female patient in her 40s, who had tested positive for COVID-19 a few days prior to her 999 call. The patient had been monitoring her oxygen saturations continuously, with a pulse oximeter and was concerned that they were low.
He used Prof-to-Prof Advice & Guidance via the Consultant Connect App to contact a local consultant to discuss the case. After a full assessment of the patient, all documented observations were within normal parameters and there were no acute changes to the 12 lead ECG, and she had normal air entry in all fields on auscultation, the Ambulance Technician had no concerns that the patient was significantly unwell.
Following Scottish Ambulance Service guidance on COVID-19, the patient did not fall into the at risk of deterioration category and there were no red flags identified. As the patient was only suffering from mild symptoms, she was deemed to be suitable to remain at home.
“The patient had started to purge again, so I did some basic blood tests, to ensure, amongst other things, that this hadn’t resulted in any electrolyte abnormalities. As part of those tests, I got some very abnormal and unexpected thyroid function results back, which suggested some pituitary dysfunction and considering her history of taking anabolic steroids, I was concerned about her hypothalamic-pituitary-adrenal axis. I called an Endocrinologist via Consultant Connect to discuss the most appropriate investigations and how quickly we needed to request these. He was fantastic and gave a very clear action plan and advice. It was so quick, and I was able to reassure the patient, set up next day investigations and ensure that she was safely managed and followed up.”
The GP saw a patient with symptoms from enlarged saliva glands. The patient was already known to the local ENT team, but their symptoms had worsened. The GP wanted to know how to manage them in the short term and was able to speak to an ENT consultant for advice. This made the GP more confident with the management plan and reassured the patient that he had sought specialist advice.
The GP saw a patient, who had consistent symptoms of Benign Paroxysmal Positional Vertigo (BBPV). The GP had already “performed three Epley manoeuvres”, which did lead “to partial improvement in her symptoms” and was beginning to consider referring the patient to ENT.
The GP spoke to an out-of-area NHS consultant, who was able to give recommendations and advice, on what to try next before considering a referral to hospital. The consultant explained that the patient should try home exercises (Brandt-Daroff) regularly for four weeks.
“A patient had on-going problems following amoebic dysentery abroad, protracted diarrhoea despite treatment and negative stool cultures. I was sure he didn’t need an urgent scope, but not sure whether steroids should be used, or if I should refer him in. The consultant suggested the use of a further course of metronidazole and refer in if still having problems. Both myself and the patient felt reassured that he could get access quickly to a consultant opinion.”
A patient presented “with obvious inflammatory bowel disease.” It was not clear what the best course of action was, and the GP was unsure whether to start the patient on steroids. He used Telephone Advice & Guidance (via Consultant Connect) to speak to a gastroenterologist from his local hospital. The gastroenterologist provided advice and recommended commencing the patient on steroids in addition to an urgent outpatient clinic referral. This avoided an acute admission – a much better result for the patient. Both the patient and the GP were satisfied by the use of Telephone Advice & Guidance.
GP Advice Line
“A lady with nausea had called 999 around 11pm. She had been fully assessed at home by the Paramedic crew who were unsure how to manage her care. Her vital signs were stable, blood glucose normal, she had no abdominal pains or vomiting, her examination findings were reassuring and she had been feeling nauseated for around 24 hours. On taking the details, she was on lithium for bipolar disorder. The call handler was going to refer the patient to call 111 for urgent home review as was unsure what to do.”
“A brittle asthmatic, who was shielding, had taken an overdose of ibuprofen. The paramedic on scene was able to advise me that there was not a risk from the amount of ibuprofen, as it was not within the toxic range. However, they were concerned that an asthmatic had taken ibuprofen and that may trigger an attack. They had ascertained that the patient had taken ibuprofen previously with no reaction.”
“My patient was facing a delay to a complex gynae surgery decision. This was because the consultant was off work long term. The patient was very anxious the delay would make surgery harder and less likely to be successful. She had been ‘primed’ with a hormonal injection and anticipated a scan to assess changes and to help plan surgery. The gynaecologist understood the situation was complex and time critical and needed to make a speedy clinical assessment in the absence of the colleague. They offered to get the patient re-assessed on the 2-week pathway. The patient was relieved by this and It felt better that the responsibility was lifted off me”.
“A 54-year-old female presented with obvious advanced cancer. The two-week wait (2WW) referral had been done. I tried ringing 2WW but because this line is not staffed by a clinician, I was unable to move the appointment from 14 days and the patient was deteriorating. When using Telephone Advice & Guidance, I was put through to one of the gynaecologists within seconds and they arranged for the patient to be scanned that day and given appropriate follow-up treatment. This would have been an acute admission otherwise. An acute admission was avoided, and the patient was given the care they needed”.
“A young female patient came to visit the nurse as she was suffering from excessive prolonged bleeding whilst using progestogen only pill (POP). The girl was unable to use the combined oral contraceptive pill (COC). The nurse used Consultant Connect Telephone Advice & Guidance service to get rapid advice from a local gynaecologist on the most suitable option for the patient”.
The patient’s midwife recommended that she discussed going on “Acyclovir Prophylaxis in the late stages of her pregnancy with her GP, due to history of recurrent genital herpes”. When the GP saw the patient, she “was well with no symptoms of genital herpes”. Therefore, the GP decided to make a Telephone Advice & Guidance call via Consultant Connect, to discuss the case with a local Gynaecologist. The call proved very useful, as the Gynaecologist let the GP know that the guidance had recently changed, as “research had shown it is better for patients with recurrent herpes, to be on Acyclovir Prophylaxis from 36 weeks”.
“I was the on-call doctor on that day and received some abnormal blood results for one of my patients who had leukemia and was under the care of a haematologist. The patient was undergoing chemotherapy, but the blood results showed a sudden drop in hemoglobin and platelets. I used Telephone Advice & Guidance to contact Haematology and luckily was able to speak to the named consultant for the patient. As she knew the patient already and was able to see the results online, she immediately took over her care and her team contacted the patient and managed everything from there. Had I not used the Telephone Advice & Guidance service I would have had to admit the patient through the Emergency Care Unit (EMU) or Acute Medical Unit (MAU) which would have meant an increased wait for the patient and also going through inappropriate services.”
A GP used Telephone Advice & Guidance to contact a consultant on the National Consultant Network about a patient as they were unsure “which investigations or whether a referral was needed for a patient with a long history of non-specific body pain and a slightly raised kappa light chain level. During the conversation, the consultant explained “that a normal haemoglobin, creatinine and the very slight increase in kappa light chains, in the setting of a normal serum protein electrophoresis meant that this did not warrant a referral.” Instead the consultant advised the GP to “check the patient’s calcium level for completeness and check the serum free light chains in 12 months.”
“I saw a patient with chronic facial swelling of about 6 weeks and I was concerned with the possibility of vena cava obstruction. I spoke with a consultant in my local hospital via Consultant Connect. I wanted the patient to have a chest X-ray urgently but, due to the current COVID-19 climate, I wanted to try to avoid a trip for the clinically vulnerable patient to the Medical Emergency Assessment Unit at the hospital.”
“I saw a patient who had recently been diagnosed with an extensive DVT. She exercised frequently right up until the diagnosis and during my follow-up appointment with her, she mentioned that she was on her way to an exercise class that day. As the patient had only just started on a direct oral anticoagulant (DOAC), I used Consultant Connect to speak to a Haematologist for advice on whether there was a minimum amount of time a person should be on a DOAC before resuming exercise to reduce the risk of thromboembolism. The consultant was really helpful and advised that, although there was very little evidence on this, the consensus opinion was that it was safe to exercise as soon as the DOAC was started as its primary mechanism of action was to stop clot extension. We concluded that the patient could continue to exercise, assuming it was not causing her any symptoms or pain.”
Mental Health Medication
“A GP contacted me about management of a complex psychotropic medication regimen and akathisia in a young man with antisocial personality disorder, anxiety and depression. The patient was taking Aripiprazole which he started for psychosis when using large amounts of illicit drugs. He was also taking Venlafaxine (different daily doses) and possibly Quetiapine. In addition, he was on Procyclidine, Insulin and Ramipril. His diagnosis was anxiety and antisocial personality disorder, ADHD (as a child) and illicit substance use. The patient said he was not on street drugs currently but the GP said he sounded slurry on the phone. He also had diabetes which was not well controlled. The patient had rung the surgery as he was concerned about his jumpy legs and feeling twitchy (akathisia) which had been going on since he came off street drugs 4 – 5 months ago. The patient had been adjusting his own medication – taking Quetiapine on and off every few days. He did not find Procyclidine helpful.”
A GP, who had a patient with depression, called a pharmacist via Consultant Connect. The patient was taking Sertraline but wanted to switch back to Mirtazapine. The reason for this was that it helped the patient to sleep better but the GP was unsure how to handle switching the medication.
The pharmacist was able to formulate “a switching regime that was appropriate for the patient.” This was a great result for the patient who received rapid results and the best possible care.
In this case, Telephone Advice & Guidance was important as the GP was able to get rapid support when they needed it and the patient remained in primary care.
“One of my patients is an 88-year-old who suffers with Trigeminal Neuralgia and takes Carbamazepine. A few weeks ago, the patient collapsed and attended A&E. They found that the patient had low sodium levels and recommended to stop Carbamazepine. After being discharged, the patient’s pain returned and could not be controlled with Opioid Analgesia. This affected the patient’s mood and quality of life. In spite of stopping Carbamazepine for six weeks, the patient’s sodium levels were still low. The patient was then diagnosed with SIADH in their urine and had a plasma osmolality test.”
The GP suspected that the cause of SIADH was the Carbamazepine.
“I used Consultant Connect to get specialist telephone advice about alternative medication to Carbamazepine for my patient. I was connected to a neurologist from outside of our area. He was extremely helpful and informed me that, normally sodium levels improve within 2-4 weeks of a patient stopping Carbamazepine. As the patient’s sodium levels had not improved in that time, the neurologist did not think that the Carbamazepine was what caused their SIADH. So, he suggested referring the patient to an endocrinologist for further investigation.
He also recommended trying Carbamazepine again or Phenytoin as another option. However, he advised me that the side effects for an 88-year-old could be high but that it was also worth a try.
Following a discussion with the patient and their family, we agreed the patient would try Phenytoin. However, the patient had to stop the medication after two weeks due to side effects. With the neurologist’s advice, I felt confident enough to stop Phenytoin and try Carbamazepine again. The patient’s symptoms improved within two weeks, there was no deterioration in their sodium levels and they were subsequently reviewed by an endocrinologist.”
A 45-year-old male patient suffering with cluster headaches came to visit Dr Beasley. He was on the waiting list to be seen by Neurology but was struggling to function due to the pain. Dr Beasley used Telephone Advice & Guidance to speak to a Neurologist for immediate advice and to discuss a pain management plan.
Dr Beasley was able to call the patient back straight away with a management plan and a different analgesic option. “The patient was very appreciative.”
Older Adult / Working Age Adult Mental Health
“I was discussing Consultant Connect with one of my colleagues, a consultant psychiatrist, and he explained that he’d been called one day by a GP who was in a meeting with a patient, and that GP was able to put the consultant psychiatrist onto speakerphone, and they were able to have a three-way conversation about the person’s mental health problems, so it was like having an additional specialist in the room to call on for that ten minute appointment with the GP.”
“I had a patient the other day who came in who needed some medication change in terms of depression. She’d just been started on some antidepressants, she had been breastfeeding and then had experienced some side effects. I wasn’t quite sure about exactly what I should be changing – like going up with the medications, or whether I should actually be looking at changing medications. So I used the app and got directly through to one of my colleagues here at Oxleas, one of the psychiatrists, who was able to give me some really quick advice over the phone. The up-side of that was it gave the mother a lot of confidence that I was able to access expertise in a really quick way.”
“We had a GP who rang us, who was concerned about the fact that somebody was using the A&E as a kind of frontline service, and not going to their GP. They had anxiety, and so when they became overwhelmed they would go to A&E. What I talked through with the GP was how the GP might be able to develop strategies to enable that person to come to him and for him to be able to reassure her that he was going to be able to manage her mental health needs, whilst stopping her from taking up valuable resources in A&E. So I talked with him about things like medication, about groups in the community that might help, and I also spoke to the mental health professional involved who increased their visits, and then we were able to help that person reduce or stop their visits to A&E, with the GP being the main source of management for that person.”
“I recently saw an asymptomatic lady with a small macular hole but good vision. In the past I might have referred her for a routine opinion and she might have waited a couple of months to be seen in HES, worrying in the meantime. In the event, I was able to call her back later that same day to tell her the ophthalmologist had seen the scan and was happy for us to perform another OCT in the community in 6 months’ time unless she noticed any visual change – a much better outcome for everyone involved.”
A patient contacted an optometrist remotely. He “was suffering with chronic eyelid dermatitis.” Unfortunately, his “usual treatment regime was not alleviating his symptoms.” The optometrist used the Consultant Connect App to make an Advice & Guidance call to a specialist.”
“I found the entire procedure very beneficial as it provides immediate access to advice because your call is answered within seconds. It was helpful to talk through the patient scenario with an expert clinician. In this case, I was connected to a hospital optometrist and there was also an ophthalmologist present. Together, they provided me a clear treatment regime to relay to my patient.”
“Over the last 12 months, a patient from our practice attended the emergency department due to foot pain. The patient had an x-ray which confirmed that a bone wasn’t broken and was discharged from the emergency department.
A short time later, the patient returned to the practice with the same issue. The x-ray report identified the possibility of a foreign body in the foot and rather than sending the patient back to the emergency department, Consultant Connect was used to speak directly with a specialist.
The Consultant was able to review the images and quickly organised a repeat x-ray and follow up appointment for the patient. Without Consultant Connect, the patient would have had to go back to the emergency department and would have had to wait to be seen. Going direct to a pre-arranged appointment with a specialist made best use of both patient and hospital time. This meant the patient received the care and treatment they needed in a more streamlined and effective way.”
“I saw a baby who was relatively well. He had a slight cold but the mother was worried. The examination was largely uninformative apart from an oxygen saturation of 82%. I tried different oxymeters but the sats were still low.
I decided to discuss my findings with a paediatrician who immediately told me to send the child in! The child ended up in hospital for four days and was treated for the infection on site. The point is, apart from the low sats, the baby was as good as normal. Using Telephone Advice & Guidance that day was crucial. If I hadn’t had the conversation with the specialist, it’s very likely that the baby would have ended up as a 999 call from home later.”
A young patient came to see the GP suffering with a case of severe constipation and was very uncomfortable. Dr Fitzsimons used Telephone Advice & Guidance to call a local paediatric consultant, who suggested a disimpaction regime and further management plan if that failed.
Using Telephone Advice & Guidance in this way meant that the patient’s condition was treated efficiently without the need to visit the hospital.
I recently answered a call via the outpatient advice line. The patient was a young child who had recently moved from a different country. The child had a rare metabolic disease. The child had been under follow-up in his country of origin and the GP was wondering how best to get him into follow-up within our services. I was able to point the GP and child to the relevant specialists within our health board who had experience of dealing with these rare metabolic conditions. This enabled the GP to refer the child immediately to the right place, avoiding a referral to a general paediatrician (who may not have experience of this rare condition).
A 14 year old was seen by their GP with flu like illness and couple of small palpable neck glands. The GP did the blood test which showed mildly raised alkaline phosphatase and was worried about abnormal liver function. This is not unusual and being the only symptoms from the patient, the consultant advised the GP that no further action was required. The GP was reassured and a referral was avoided.
“The app allows me to speak direct with specific areas of need. A recent example was the need to contact the Palliative care team for some advice in managing an End of Life patient. I was able to speak very quickly to the Palliative Care specialist and discuss a treatment plan to allow the patient to remain comfortable at home with their family around them.”
An elderly female patient in a nursing home had a fall, which resulted in a scalp wound. The wound had been managed by a staff nurse on site with steristrips but the wound needed further treatment. The nurse had phoned NHS 111 and been directed to the Flow Navigation Hub and told to wait for a call via Patient Connect. Dr Andrew Russell, an A&E consultant at University Hospital Monklands then phoned the nurse to discuss via Patient Connect. The patient would have required ambulance transfer both to and from hospital, so Dr Russell phoned the out-of-hours hub to get the number for the area district nurse.
A patient with a swollen and painful foot contacted his GP. The GP “asked him to send in some pictures.” These images and the patient’s history were uploaded to the Consultant Connect platform and shared with a specialist.
The GP and the consultant were able to decide on “a full management plan with different steps” which was shared with the patient. The GP and the patient “have started actioning this.” The consultant also asked to be kept updated so he could provide further advice as needed.
This was a good result for both doctors and the patient as it meant that the patient could remain in primary care.
Before Consultant Connect was introduced, the nurse used to refer any patients she wasn’t sure how to treat straight to secondary care. However, she now finds Telephone Advice & Guidance a better tool because: “It is faster, efficient, informative & immediate”
A patient came to see the nurse with troubling asthma. The patient was having repeated exacerbations, which were not improving. She used Telephone Advice & Guidance to contact a respiratory consultant to get advice on the correct treatment plan for the patient.
A male patient who had been experiencing rapidly worsening shortness of breath over the last few months came to see the GP. The GP diagnosed pulmonary fibrosis. The patient didn’t need an admission, but he could not have waited months to be seen in a respiratory clinic. The GP used the Consultant Connect service to rapidly speak to a respiratory consultant on the same day, to arrange an urgent appointment for the patient.
I’ve had experience in speaking to both local and out-of-area NHS consultants. A recent example is when I saw a young respiratory patient with a clinical problem that I wanted advice on. I used Consultant Connect to speak to our local respiratory team and was connected very quickly. It was extremely useful and I got an instant resolution to this patient’s management.
Dr Turner was able to support them and provide care in accordance with their wishes, by adding tablet based treatment and having an assessment the next day. Collaboratively, Dr Turner and the GP were able to start “similar management to a hospital setting via support from the community respiratory team”. Dr Turner adds: “I felt we offered patient centred care, whilst sharing perceived clinical risk.”
“I spoke to a Rheumatology Consultant at my local Trust. The consultant reviewed the blood results and confirmed a likely diagnosis of Rheumatoid Arthritis and advised they would most likely give a Depomedrone injection and then consider DMARD.
Speaking to the consultant made me feel confident to continue to support the patient and his wife, and meant they knew what was likely to happen. They had a chance to read preparatory patient information so could make an informed decision regarding starting a DMARD in that first outpatient appointment. It was easy to get through, and a few minutes on the phone meant that we could work in an integrated way across primary and secondary care. Together we were able to deliver good quality care to this vulnerable patient.”
“I saw an elderly gentleman with symptoms suggestive of Polymyalgia Rheumatica, however it was an atypical presentation and I was concerned that I might be missing something (such as underlying cancer) and was not sure whether to initiate treatment or wait for further tests or refer, knowing that a referral could take several weeks. I called the Rheumatology team via the Consultant Connect App and was able to discuss the case in detail with the senior registrar who advised me what tests to organise and when to initiate treatment, as well as a detailed steroid reducing regime. The registrar explained all the things that would have been arranged at the first clinic appointment, so I was able to get the ball rolling before the patient would be able to be seen at the clinic. This was a better outcome for the patient who was able to get the right treatment quickly.”
A patient presented to the GP with symptoms suggesting Giant Cell Arteritis. The GP was able to use Telephone Advice & Guidance on the Consultant Connect App to speak to a local Rheumatologist at Poole Hospital NHS Foundation Trust. The consultant advised on the best course of action. The GP commented that he “can highly recommend” using this service.
Speaking to a consultant was “an excellent, direct, and time-saving way to access timely consultant advice.” Using the app is “the easiest way to speak to a specialist consultant [the GP has] yet to find.” The GP also explained that he called Rheumatology again a week later. This “ensured that the patient had a timely clinic review to consider a temporal artery biopsy.” This was a positive result as Telephone Advice & Guidance allowed the patient to get quick and effective care.
“A patient presented with severe symptoms of back pain, knee pain with effusion, ankle pain and clear evidence of synovitis. The presentation was of an acute flare up of probable seronegative arthritis. The patient had already been referred to Rheumatology and was awaiting an outpatient appointment. The condition had clearly deteriorated significantly and rapidly, the patient was in a lot of pain could barely mobilise and was in significant distress.”
“I saw a patient whose blood tests came back showing very high levels of transaminases as part of his liver function blood test monitoring on methotrexate. The level of transaminases was just above the level at which specialist advice was recommended in order to decide if methotrexate should be temporarily stopped. Previously, I would have had to call the hospital. However, I was able to get through to a Rheumatologist via Consultant Connect who confirmed that is was best to omit the dose for that week and repeat the liver function blood test the following week. This was especially helpful as the patient was very reluctant to stop his methotrexate so being able to provide timely specialist advice and reassurance was particularly important for him. She also discussed the best ongoing management with respect to the repeat transaminase levels which was so useful.”
“A 55 year-old male patient contacted the surgery with recent onset acute lower back pain. During the telephone consultation, I identified red flags in the history that suggested the patient may have Cauda Equina Syndrome and needed an urgent MRI. I contacted the Spinal Team via the Consultant Connect App and was instantly connected with a consultant orthopaedic spinal surgeon. He agreed that the patient required an urgent MRI scan of his spine and gave me advice on how best to arrange this via our local A&E department.”
“I arranged admission of the patient to our local A&E department with a referral letter which included the details of the consultant advice I had received. The patient had an urgent MRI scan which fortunately showed only a slipped disc, excluding Cauda Equina Syndrome. The patient was discharged from A&E later the same day with analgesia.
I followed the patient up afterwards and he was very grateful for how quickly his problem had been assessed and managed, and this was only made possible with the help of Consultant Connect.”
“A 62-year-old female patient contacted the surgery worried about a skin lesion which had become inflamed over the past 2 weeks. It had brown pigmentation and she was concerned about the possibility that it was cancerous.”
Due to measures put in place during COVID-19, the GP asked the patient to send him photos which he uploaded to the Consultant Connect platform. He received a response within less than an hour confirming his belief that it was “a seborrheic keratosis and no further referral was needed.”
“I was able to reassure the patient that the lesion was not concerning and that a specialist had reviewed the photographs and confirmed this. The patient went away both reassured and pleased with the outcome and how quickly I was able to deal with her concern.”
A patient was concerned he “might have developed changes to a skin cancer incision scar but examination revealed no concerning features.” The GP used PhotoSAF on the Consultant Connect App to take a photo of the patient and later downloaded it so that it could be “reviewed at intervals.” When the scar was reviewed at intervals, the photos “evidenced no change.” The GP was pleased with the use of PhotoSAF as it saved the patient “further anxiety.” He also highlighted that a secondary care referral was avoided – saving time for both the patient and local consultants.
A patient presented with skin lesions that needed to be “reviewed over a period of time to see if there were any changes.” The GP could securely photograph the lesions with PhotoSAF and was later able to download and save them to the patient’s medical record. The photos were compared to the lesions at a later date and it was clear that they had “remained unchanged.” The GP explained that using PhotoSAF meant that a “referral was avoided.”
Another patient also had lesions but was, in this case, housebound. The patient did not want to be referred to hospital but the GP felt that the lesions may be cancerous and so she “wanted advice.” She took a picture using PhotoSAF and, upon downloading it from the secure cloud to her computer, was able to forward it to a dermatology consultant at RUH. The consultant reviewed the image and agreed that it was likely to be a form of cancer. The patient was assured that a referral was necessary and “agreed to be seen by a consultant.” This ensured that the patient got the necessary medical care.
“A patient was advised to see me by another health professional who had noticed a change in one of the patient’s moles. I would have referred the patient to a dermatology clinic had it not been for A&G – possibly even on the fast-track suspected cancer pathway. Not only did this Advice & Guidance service give me the confidence to seek advice, but once I had received a reply from a dermatologist, it also gave me the confidence to reassure my patient. This avoided further anxiety for my patient as well as a referral.”
“A consultant dermatologist replied by e-RS to the image I sent saying “the attached photos are of super quality (thank you).” The dermatologist was able to comment of macroscopic and dermatoscopic features (as I had held my phone’s camera directly over a dermatoscope for one of the images) and to state that the lesion looked benign. The dermatologist suggested for a GP to see the patient again in four months to compare the mole with the images taken via PhotoSAF.”
A patient who was under a nurse’s care was suffering from a leg ulcer which was taking a very long time to heal. The patient “felt that the wound was not healing at all at some points.” They had become “very low in mood as the wound was also malodourous.” By taking photos of the condition, “the patient’s progress was tracked.”
The nurse explained that “the patient’s wound had now healed.” However, before this, she was able to monitor her patient’s condition (over time). The pictures also allowed the patient to “see the progress even if it was slow.” Using PhotoSAF on the Consultant Connect App in this way really benefitted the patient as the nurse said it “improved her mental health.” She also explained that using PhotoSAF, “allowed a detailed handover to her team member for holiday cover.”
A male patient came to see Dr Photiou with a cutaneous horn-type lesion on his upper chest. The patient had a history of fair skin and sun exposure. Dr Photiou was concerned that the lesion could be an early Squamous Cell Carcinoma (SCC), so he sent a photo via the app to a dermatology consultant for advice. The consultant agreed that it could be an early SCC and advised a 2ww referral.
Trauma and Orthopaedics
A GP used Consultant Connect’s Telephone Advice & Guidance service to quickly contact out-of-area Trauma & Orthopaedics consultant Dr Firas Arnaout, about an elderly male patient. The patient had a soft tissue swelling in the thigh and a history of a minor trauma (which the patient assumed was muscle sprain). The lump was getting bigger despite rest. This was a typical but rare case of soft tissue/muscle sarcoma.
A patient who had been hospitalised with biliary sepsis and during recovery sustained an acute back injury came to see the GP. A CT scan confirmed a bony abnormality in the L2 vertebra, but the MRI scan was deferred as the abnormality was too close to the gallbladder. The patient was discharged with analgesia.
However, upon checking the discharge summary, the normal protocol of no scan for 8 weeks after surgery was waived, due to nature of the presentation. The MRI scan confirmed the acute superior endplate fracture of the L2 vertebra. The GP used Telephone Advice & Guidance via Consultant Connect to get a specialist opinion. He spoke to an out-of-area spinal surgeon from Consultant Connect’s National Consultant Network. The GP explained: “The surgeon’s response was comprehensive and clear, and he set out a management plan for the patient.”
A patient’s ultrasound scan had shown an incidental finding of a renal cyst. The GP used Telephone Advice & Guidance to rapidly contact a Consultant Urologist to discuss the best course of action. The consultant recommended that the GP organise a CT scan and that the patient’s cyst was continuously monitored using further ultrasound scans.
The consultant spoke to a GP who required advice on which pathway to refer an andrology patient, who had already tried PDE-5 Inhibitors. The consultant was able to guide the GP on where best to send the patient for specialist care.
“I suspected a patient was developing Peripheral Vascular Disease but wasn’t sure. Measurements at the surgery had been done and were suspicious so I wanted to order further investigations but wasn’t sure which or if admission was needed. I went on the app and contacted the vascular surgical team who suggested that they would do all the investigations in a one stop shop vascular clinic as needed so admission wasn’t necessary unless things got worse and a routine clinic referral was made. The patient avoided unnecessary admission and investigation and had a more convenient one stop shop review which confirmed the diagnosis. The patient was very glad to not have to be admitted to hospital.”
For more information about how we work with commissioners, hospitals & mental health trusts to improve patient care, please get in touch.
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