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Virtual clinics a vital link in Diabetes in Pregnancy service at UMHL

Yvonne Moloney, Registered Advanced Midwife Practitioner, University Maternity Hospital Limerick: “Video calls are an excellent way of providing care and accessing the patient visually in the community."

(LIMERICK: Tuesday September 22nd)

THE Diabetes in Pregnancy service at University Maternity Hospital Limerick (UMHL) has served mums and mums-to-be throughout the COVID-19 pandemic, thanks to innovative ‘virtual clinics’ that provide convenient access to health services at a time when social and physical distancing remains so central to minimising the threat to public health of the coronavirus.

A virtual clinic is one in which the patient and clinician interact in real time, via a video link or phone call instead of the traditional face-to-face appointment. Across the country’s public hospitals, there has been significant investment in facilitating these appointments, and growth in the specialties across the system, and UMHL is no exception.

Staff and patients of the Diabetes in Pregnancy Service at UMHL are using the ‘Attend Anywhere’ video platform and telephone calls to conduct a total of 92 virtual consultations every week. At a time when visiting our sites continues to be restricted, the technology is enabling the Diabetes in Pregnancy service alone to host four Gestational Diabetes clinics every week (with a total of 24 patient ‘slots); one weekly clinic in Insulin Initiation (with 6 patient slots); while also allowing for 20 scheduled calls for 2 RAMP-led telephone clinics, as well as up to 5 additional RAMP-led telephone clinics with some 28 telephone slots.

UMHL has been using the telephone for distance consultations since 2002, scheduling contacts with patients on the IPMS system to provide a more structured service. The Attend Anywhere video platform has been use since May 2020, as part of UL Hospital’s Group’s strategy for resumption of services by using virtual clinics as a safe means of contact and consultation for patients.

Among service users there was some initial uncertainty about virtual clinics, and this was soon offset by an appreciation for the practical benefits from not having to arrange travel to and from hospital for the clinics, and for the safety of attending a clinic in their own personal space.

Karen O’Brien, a schoolteacher living in Cappamore, County Limerick, approximately 30 minutes’ car journey away from the hospital, has Type One diabetes and has a son aged two-and-a-half years. Currently attending the Diabetes in Pregnancy Service at UMHL for her second pregnancy, she says she finds the virtual clinics much easier to organise and fit into her life than the face to face consultations she had to organise during her first pregnancy.

“I feel much safer, obviously, during the pandemic, and I find it great for my work because I teach, and it can be difficult to organise times for the clinics. It’s much easier to schedule a virtual clinic for a time to suit you. It only takes about 15 or 20 minutes to organise, and you’re done until your next clinic. It’s great. It’s definitely much more convenient,” Karen said.

“In the past, I would have had to go for a consultation after school, so it could be after 3.30 before I would get to the hospital, and perhaps as late as 7.30 before I got out. What happens now is, I get a letter in the post as usual, but as well as the date and time, there is also a link. When the time comes, you log onto that link, there is a short logging on process, and you are through to your doctor or nurse more or less straight away,” she explained.

“I have a Flash monitoring device, and because of that, they have all my charts and everything online, and they can see the results, and they talk you through your results, you get the opportunity to talk about any difficulties you might be having, and it’s all done in 15 or 20 minutes,” she said.

“It’s just the same as going to a regular clinic, really, except that it takes all the inconvenience out of it,” she said.

Deirdre Flannery from Nenagh, Co Tipperary, has a two-year-old daughter and just two months ago gave birth to a baby boy. Deirdre, who has had Type 1 Diabetes for 34 years, admitted that she was initially a little bit concerned because with virtual clinics, urine, blood and blood pressure cannot be tested.

However, she said there was no doubt that she felt much safer to have the virtual option available. “During the pandemic, I certainly would not like to have to go into hospital regularly, and come into contact with loads of other people. Also, I found the whole thing incredibly straightforward. In work I was a secretary, so I would have been used to computer systems, but the whole logging in process is very easy. It’s very simple for anyone to access.”

The other major benefit for Deirdre has been the minimised organisation and logistics. “All you really need is about 15 minutes to yourself, compared with, if it was a hospital appointment, possibly needing a half-day, or sometimes even the full day, to organise things. The virtual clinics are incredibly handy from that viewpoint,” she said.

“Overall, not only is it very simple to use, it is also very secure. I know that some people might have issues with going online, but it’s all very secure. You receive your own individual, time and date sensitive access link to the video call you will have with one of the team, and that is it. I have had no problems with it or concerns about using it,” Deirdre added.

Yvonne Moloney, a Registered Advanced Midwife Practitioner on the Service, said that the video calls had proved very successful for a broad cross-section of patients. “Certain patients have engaged very well with video calls, including non-Irish patients, patients who are nervous of becoming infected with COVID-19, patients travelling long distances, patients with child-minding difficulties, and with difficulties accessing public transports. Patients who speak another language and have a friend or family member of their choosing on the video call, which is particularly useful at a time when family and friends cannot join them for appointments at the hospitals. Interpreters can also join the calls if necessary, and if the language barrier poses too great a difficulty on the video call, a face to face appointment can be arranged.”

Some patients use Bluetooth technology to send the readings from their Continuous Glucose meters or Flash Glucose meters to the hospital ahead of their virtual appointments, and while a number of patients have challenges around WiFi speed and their personal IT skills, Yvonne reports that “most patients will find ways around the difficulties rather than travelling to see us”. [See Notes]

Yvonne Moloney is no stranger to service innovation, having led the launch earlier this year of a new ‘Managing Diabetes in Pregnancy’ smartphone app, the first of its kind in Irish maternity hospitals, is enthusiastic at the steady growth in use of virtual clinics, especially since the launch of the video calls. Assessing the first four months of video-based virtual clinics, Yvonne said: “Video calls are an excellent way of providing care and accessing the patient visually in the community."

There are numerous administrative and logistical challenges to be surmounted to ensure the service runs smoothly, and it’s also important to ensure that measurements of blood pressure, testing of blood and urine, and other investigations, are completed ahead of the clinics. “As we become more proficient at doing the clinics and ensuring the patient has these measurements carried out either at antenatal appointments or GP appointments, it will improve.”

“At the end of every video consultation, we make sure the patient is aware of the plan for follow-up on the clinic. Also, we always have a backup process in the event of the call failing. I will phone the patient and help them trouble-shoot the issue. We use GDPR guidelines to ensure the privacy and confidentiality of the consultation. For instance, we use the video platform for group education sessions for up to six patients, but these are for general education of patients, and personal details are never discussed on group calls,” Yvonne added.

Eileen Ronan, Director of Midwifery, UMHL, said “The introduction of the diabetes virtual clinics in UMHL is welcome, as it has given us the opportunity to strengthen our collaboration between service users and staff, to provide a timely and accessible service for all who require this important health information during their pregnancy.”

Associate Clinical Director of Maternal & Child Health Services for UL Hospitals Group, Dr Naro Imcha,said the success of the clinics was testament to the enthusiasm and adaptability of service users, and UMHL’s nuanced understanding of individual needs: “The enthusiasm with which our service users have quickly adopted the virtual clinics is a testament to the resiliency and adaptability of our society. Using technology as a tool for safety and efficacy, UMHL can continue to deliver much needed care without disruption. During such challenging periods, it is also essential to give that extra support to those who require it. Our teams understand the needs of each person and tailor the approach to suit the situation, thereby applying a personal touch even in the virtual clinics.”

Notes – local survey of service users:

In a local survey of service users conducted by the UMHL Diabetes in Pregnancy service, almost a quarter of respondents (23%) rate the virtual clinics as significantly better than face-to-face consultations; more than half (54%) found no difference between virtual and traditional consultations, while 15% felt the virtual experience superior to attending clinics in hospital.

Almost all of those surveyed (93%) felt they were able to communicate everything they wanted to their midwife or doctor during the video link-up, and even though some were less enthusiastic (for example, 7% did not feel they were able to communicate everything they wish to during the clinics, and 8% rated the overall experience poorer), all said they would use the virtual service again.

The service has proven to be successful in helping patients surmounting physical access issues. For example, 73% of respondents said they would have travelled to hospital in their own car, 20% in a relative, neighbour or friend’s car, and 7% on the bus or train. Physical distance from the hospital is also an issue for many. Thirty-five percent of patients surveyed lived between 11 and 20 miles from the hospital, with an equal amount residing between 21 and 50 miles away.

Time saved travelling, and minimised length of wait time were identified as the chief benefits by survey respondents. The ‘wait time’ benefit was ticked by 94% of respondents, and ‘time saved travelled’ by 80%. Other benefits identified included: not having to arrange childcare or care of a relative (60%); shorter wait for an appointment date (54%); greater convenience (54%); saving money (47%) not being dependent on someone for a life (40%); feeling safer and more at ease (40%); not having to bring someone (34%).