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An expert’s experiences

In this step we hear from an expert pharmacist practitioner Neil Karia and his experience conducting remote consultations and safety netting.
My name is Neil, and I’m a GP practise-based pharmacist. I’ve been in my current role for four years. I have a wide range of responsibilities. The main responsibilities I have is in the management– the clinical management of long-term conditions, mainly asthma, COPD, heart failure, and diabetes. And within my practise, I lead on diabetes.
As a practise, we generally used to do a lot more telephone consultations in comparison to other practises. So the way our system generally worked is we would– a clinician would treat a patient on the phone. And if we felt that it was warranted that the patient be seen face to face, we would then make that decision based on the conversation that we had. So we had a lot of experience when it came to remote consultations. So when COVID-19 came about and GP surgeries closed their doors, we were probably in a better position than most with regards to remote consultations.
So everything I’ve been doing since the lockdown and we closed our doors has been via remote consultations. And that involves my general chronic disease management reviews, but also the management of acute problems. And I think both have their challenges during a remote consultation, but I think it’s probably been a bit more trickier when dealing with acute problems associated with disease management. So, for example, if somebody is having an exacerbation of their asthma, they’re obviously in a normal setting. Face-to-face, we would be able to do peak flow readings, kind of on demand, chest oscillations, respiratory rates.
And not only is that not available, but even if we can make it available via instructing patients to do certain observations or checks and prescribing things like peak flows, we’re relying on instructions for them to do it correctly. So it’s been very challenging. And I’ve say I’ve learnt a lot with regards to remote consultations more than I have done in my whole career as working as a pharmacist. So I would define safety netting as– it’s a piece of communication, verbal or written between a health professional and a patient.
And I think generally it informs the patient of the steps or actions to take if they develop further complications in relation to the problem they’re presenting with or indeed if they develop new complications to a new medicine that’s been prescribed or indeed related to their pathology. So safety netting should be an integral part of all health professional patient consultations and interactions, but I think it’s of absolute particular importance when the barriers to communication, which remote consultations face are present. So it’s very important that in safety netting that you should ensure that the patient has access to future lines of communication when needed. And it should involve very clear and appropriate documentation I think.
And that not only allows continuity of care, but it also very much so protects the patient– protects not only the patient, but clinician further down the line.
As remote consultations often eliminate the physical examinations, which are needed to form a clear diagnosis of what’s going on, it’s very important that a patient has a clear, clear communication and really understands how to recognise worsening red flags about their ailment and what to do, who to contact in response to those red flags and indeed if there are even yellow flags, what steps to take, do they defer. And I think because of that barrier opposed, it’s clear that within a face to face communication, you can gain so much more. The patient can gain so much more from you as a clinician, and you can gain so much more from the patient by non non-verbal cues body language.
So I think safety netting is so important to not only safeguard the patient, but also in protecting the clinician as well. And often, as we’ve already spoken about, sometimes you’re relying on a patient to, for example, measure their temperature or measure their blood pressure and pulse often using equipment which may not have been calibrated. And we do these things, because it’s convenient for us in this current time for a patient to measure their blood pressure with maybe a machine that they have bought. So I think the uncertainty of the accuracy of the data being given to us makes it even more paramount that very clear safety net instructions are given and very clear documentation takes place.
And I think it’s very important more than ever that you ensure that a patient really understands the safety netting advice that’s been given. So I believe you always should be backed up in writing where possible, but also with tactics like getting the patient to repeat back to you the safety netting information is very important.
So I will always outline any red flags, which may be associated with a particular problem that I’m safety netting about. And I make sure those red flags are clear and specific. I will make sure a timeline is also included and also what to do, who to contact, how to contact in response to if those red flags are identified, and this also includes out of hours information as well, the same goes for yellow flags, which who to contact, what timeline, who to contact if the surgery or we are not available.
So as I said, I think a timeline and being specific is really important. So for example, if you’re talking about a cough that a patient has, then you can say, if your cough doesn’t clear up in two weeks, then please book an urgent appointment to see us. So yeah, we’ve given specific instructions with a timeline. I think that’s important. One thing I found really useful with safety netting is providing written information. So when I do my heart failure reviews, luckily we’ve got very good communication with local hospitals. And the specialist pharmacist there have given me a load of resources.
So heart failure we have like a traffic light system, which is important to give to the patient as a safety netting tool, because it details for them what to do if you’re feeling more breathless or feeling more tired or you’re experiencing or your weight is increased by a certain amount. And it clearly outlines who to call, what to do, what steps and actions to take. So I think this is if you’re able to back up what you’re saying via written information. I think that’s so important when safety netting, especially remotely.
I think documentation is very critical. So often I’ve seen people– other clinicians with safety netting advice and it’s just saying patient has been safety netted. And I don’t think that’s appropriate, because firstly if that patient was to call back and speak to another clinician, you don’t exactly know what safety netting information has been given. Also, if in a negligence claim, if something were to happen would that really be suitable for you to cover you? I’m not really sure it will. So clear accurate precise documentation with maybe a note outlining with the patient has the capacity and understands what information has been given. I think it’s very, very important.
I’ve already mentioned backing up verbal safety netting with written or visual advice. So for my asthma reviews providing an asthma management plan is a great way. So I always discuss verbally with patients what to do in response to worsening asthma symptoms or worsening peak flow, but also we ensure that they have an asthma management plan and if possible, even videos. So we’ve been sending a lot of videos on techniques and what have you. So all different types of tools, which are available, should be utilised in your safety netting when it comes to promote consultations in particular.
So again, I think being specific about the advice you’re giving a patient with timelines is very important to try and make it as direct, as clear, as simple as to follow.
I’ve already mentioned providing a clear pathway depending on what’s happening. So if it’s an urgent red flag, are we advising them to contact the ambulance service, or if it’s less severe, what does less severe mean? Are we asking them to contact NHS 111? So make it very clear the advice that’s being given and what pathways and communication channels they have.

In this step we hear from an expert pharmacist practitioner talking about his experience conducting remote consultations and safety netting.

Neil Karia is an experienced GP Practice Pharmacist. During the interview Neil explains how to define safety netting for the patient and the clinician and why it is important.

As you watch, make notes on the what kind of safety netting advice you should always give to the patient. These notes will help with your case study in the next step.

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Conducting Remote Consultations and Triage

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