The COVID-19 pandemic has resulted in immense system pressures for maternity departments across the UK. Pregnant women were quickly recognised as a high-risk group who should be shielding (NHS UK, 2020; Poon et al, 2020), which posed a question around the delivery of routine antenatal care.
In the UK, antenatal care consists of between 7–10 appointments for a low-risk woman throughout her pregnancy, depending on if she is multipara or primipara (National Institute of Health and Care Excellent, 2009; Royal College of Obstetricians and Gynaecologists, 2020).
For high-risk women, this can be double or triple that number of visits to hospital or to their community midwife. With increased specialisation of care, pregnant women may also attend numerous specialist clinics, depending on their risk stratification. They may also need ultrasound scans, blood tests, blood pressure checks or vaccinations. Therefore, the COVID-19 pandemic called for a rapid transformation to virtual antenatal clinics, which aligns with the NHS long-term plan to reduce face-to-face consultations by a third over the next three years (NHS UK, 2019). Virtual antenatal clinics have not been widely explored, but an American study reported high patient satisfaction compared to face-to-face consultations (Pflugeisen et al, 2017; van den Heuvel et al, 2018). In this article, the setting up of an operational virtual antenatal care service in a tertiary obstetric care centre is presented, and recommendations for maternity departments across the UK and beyond are discussed.
Setting up virtual clinics
The centre's approach to setting up virtual antenatal clinics was to imagine what would happen and how, from a patient perspective, when attending for a face-to-face consultation, and then develop systems to ensure nothing would be missed through the virtual clinic approach. This was a quality improvement project with multiple cycles, with each cycle resulting in an adaptation or intervention to refine the process.
The aim was to generate a patient-centred, safe, effective and feasible virtual antenatal clinic. There was already an established, small, obstetric virtual clinic at our centre, which ran once a week and was offered to women who had previous third or fourth degree tear or postpartum haemorrhage. Building on this experience proved immensely beneficial when expanding the virtual clinics to cover all of antenatal care; particularly, the importance of adopting a holistic approach and the value of patient information leaflets.
The virtual antenatal clinics established consisted of a telephone consultation and clinics were conducted in the following specialty areas: general obstetric, perinatal mental health, maternal medicine, prematurity prevention, diabetes, hypertension, renal and substance misuse.
A holistic approach
During the pandemic, pregnant women were often unable to access many of their routine general practice services or community midwife appointments, so the centre endeavoured to resolve as many issues as possible during each virtual consultation. For example, a birth plan would be decided and arranged, blood tests would be organised (by posting out the blood forms and occasionally asking the woman to come into the hospital to have them taken) and all scans were booked well in advance.
Women were also referred to other relevant clinics to ensure continuity of care. Although this meant dealing with anaemia and booking caesarean sections in a mental health clinic, and acting on results that had previously been missed, this was done to ensure the best quality care was provided.
Overcoming challenges
In obstetrics, the pregnant woman keeps her handheld notes, so that they are readily available for each professional she comes into contact with and for emergency situations. This presented a challenge to the virtual clinic, because the last entries could not be reviewed and growth charts and scan reports were not readily available. Instead, professionals were reliant on the electronic medical record and the hospital notes, which is challenging because of the number of gaps present.
Given the General Data Protection Regulation relaxation of guidelines around use of Whatsapp for patient communication with professionals, women at these clinics were given the option of ‘whatsapping’ their scan and growth chart or sending it to a virtual clinic mailbox. This ensured all the relevant information was used to generate management plans.
Not only is there difficulty because retrospective care records cannot be reviewed, but there is also the challenge of ensuring the virtual clinic summary is included in the patients handheld notes, for future healthcare professionals to refer to. To overcome this, a virtual clinic proforma was developed to document the key discussions that took place and the management plan, which was posted to the patient with a request to file it in their notes. A record of virtual clinic proforma was also kept, which could be sent to the community midwife on special request.
This virtual clinic proforma underwent multiple ‘plan do study act’ cycles and resulted in a document that was intended to be pre-filled by a junior doctor with the following information: estimated day of delivery, gestation, risk factors, obstetric history, quick check on need for aspirin or glucose tolerance testing, booking bloods and patient details. Then, the consultant obstetrician would undertake the virtual consultation, by first confirming the details on the proforma with the patient, and filling in the consultation notes and management plan.
This approach proved effective because it meant a large number of patients could be seen in the virtual clinic and the necessary information was readily accessible for the consultant to make an informed decision about the patient's care whilst on the call. This was also a highly effective approach for the remote consultant team, who were undertaking virtual clinics from home and could not access the electronic medical record during working hours because of high usage. Adopting this approach also increased the size of the clinic; 33 patients could have a virtual appointment in one clinic session.
A language barrier presented another issue for the virtual clinics, as Leicester is a multi-diverse patient population. To overcome this, a virtual clinic team member who could speak Gujurati, Urdu, Hindi and Bengali was consistently used. At the start of clinic, it was established which patients would have language barriers so that sufficient time was dedicated to complete their consultation. For other languages, translation services via telephone were used and, if the virtual consultation was deemed unsuccessful by the healthcare professional, the patient would be invited back for a face-to-face appointment.
There was also a problem with a minority of women recurrently not answering the phone for their virtual appointment, despite three or more attempts to contact the patient during the virtual clinic at different time intervals. Closer inspection of the notes revealed there may be several reasons for this, such as not answering the phone to a withheld number because of safety concerns or language barriers. This was particularly the case for the substance misuse clinic, where women preferred to come in to hospital to see their case handler in person and so that important screening tests could be performed. Therefore, at the end of the virtual clinic, the notes of every woman who had not been contactable were reviewed.
‘The COVID-19 pandemic called for a rapid transformation to virtual antenatal clinics’
It would be documented in the notes and the importance of the consultation would be decided based on the patient's gestation and risk factors. If she was low risk or early gestation, a ‘did not attend clinic’ proforma would be sent to her in the post and an appointment rebooked for 1-2 weeks time. If she did not attend again or was high risk, the community midwife would be asked to contact the patient either by phone or in person. This ensured the safety of patients and accounted for the fact that there are often several reasons why a woman may not attend a virtual appointment.
When a patient attends a face-to-face appointment, after the consultation, they would have their clinic outcomes actioned immediately by the clinic coordinator. In the virtual setting, this was managed by a junior doctor, who would organise the investigations on behalf of the patient and then include the dates and details of investigations in the virtual clinic proforma to be posted out. This ensured all clinic outcomes were actioned and avoided delays. This was even more important for the remote consultants, who needed everything actioning, including intrapartum care plans, and paediatric alerts.
A new clinic outcome sheet was developed, which the consultant obstetrician would complete to denote the management plan clearly for the wider team to action. The virtual clinic proforma was also compared to the clinic outcome sheet to ensure the whole management plan was actioned. Decisions around follow-up care were made with the consultant in charge of the clinic and, by adopting a holistic approach to care, this minimised the need for follow-up appointments. Open appointments were offered to women as well. Strict follow-up criteria included the need for scans, blood pressure or urine screens, the patient wanting time to decide about mode of delivery, and third degree tears. This was implemented to reduce clinic sizes, given the system pressures presented during the COVID-19 pandemic.
When patients attend clinics in person, they are often provided with patient information leaflets (PILS) to help them better understand the consultation and to help them make informed decisions. For the virtual clinics, the patient's email was taken during the virtual consultation and the relevant PILS was sent immediately after. The PILS available were also reviewed, and any missing topics were identified by the team. Old leaflets were updated, to ensure accurate information was being provided.
The virtual antenatal clinics presented a big change for the clinical and non-clinical staff alike. It was important to work together to organise the clinics and evolve the systems. Changes made included letting the women know that their virtual telephone appointment would not be at an exact time, but instead would be in a morning or afternoon period. Not giving a specific time was important because women may not answer, they may want a longer or shorter telephone conversation, they may need to send us a scan and there may be a need to call them back, so precise timing was not possible. However, by informing the women of this, their expectations were managed. Also, ways to improve the line of communication between staff were developed, by ensuring that the clinic outcomes sheets were legible and clear.
The evolution of the virtual clinics was made possible because the same virtual clinic team was working full-time. Through a collaborative approach with regular discussion and feedback between junior and senior clinicians, it was possible to make improvements to the process quickly and efficiently. There was also a role for training colleagues who joined the virtual clinic, so that they were aware of the systems and changes from their usual practice. Although new team members were often worried about performing virtual clinics, they quickly adjusted to the new style of consultation.
Conclusions
In the midst of a global pandemic, digitalisation has been instilled into the NHS and made virtual antenatal clinics possible. Having developed a feasible model, ways to make the virtual antenatal clinics sustainable moving forward are now being assessed. The authors hope the insights shared will be helpful for those currently establishing virtual antenatal clinics.