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Management of the ENT Consultation During the COVID-19 Pandemic Alert. Are ENT Telephone Consultations Useful?

Objective To describe how the ENT and Head and Neck departments of the HMM and HVC hospitals were managed during the COVID-19 state of alert and to analyse the results obtained to assess the usefulness of telephone consultations in our specialty. Material and methods From March 16, the ENT and Head and Neck departments of the HMM and HVC Hospitals began telephone consultations. Due to the disparity in the actions of the different department members, the decision was made to create a protocol to manage these consultations which started to be implemented March 23. Results During the study period, 1054 patients were attended in the consultations of both departments; 663 (62.9%) were first visits and 391 (37.10%) were successive visits. Twenty-one percent (229) of the consultations could be resolved by telephone, 10.82% (114) required face-to-face care, 57.40% (605) were indicated for an on-demand check-up depending on their disease course, and 10.05% (106) of the patients could not be reached by telephone. Discussion The state of alarm caused by COVID-19 has been a determining factor in how we undertake our care work. In the ENT and Head and Neck departments of the HMM and HVC Hospitals we decided to carry out consultations by telephone as an alternative to the traditional consultation. During this period, we have observed that up to 21.73% of the consultations could be dealt with by telephone. Conclusion The telephone consultation seems to be a very useful tool to attend our patients avoiding the risk of COVID-19 infection during the state of alarm. Furthermore, according to the data analysed and the different studies, it seems a good alternative to the traditional consultation in selected patients.


Introduction
Due to the current emergency healthcare situation we find ourselves in from the new coronavirus (COVID-19) which appeared in December in Wuhan (China), Spain has been in a state of alert since last March 14th. It has been seen that the most effective way of reducing transmission of COVID-19 is social isolation and contact tracing. 1 This has led us to practically stop all our usual care activity, including consultation and surgery, with some exceptions, such as emergencies and oncology.
Despite the measures taken, a significant number of healthcare personnel have been infected in Spain, approximately 25,000. 2 In Wuhan it was observed that the otorhinolaryngologists were amongst the healthcare professionals most affected by COVID-19 due to the close contact with patients we normally have through examinations in the surgery 3 and the high viral load existing in the oropharynx and nasal cavity. 3,4 The extraordinary circumstances we find ourselves in have forced us to adapt. To do so, as already recommended by our Society, 5 in the ENT and head and neck surgery departments (ENTHAN) of the Hospitales Generales Universitarios Morales Meseguer (HMM) of Murcia and Virgen del Castillo (HVC) of Yecla (Murcia) we have conducted a large part of our care work by telephone. This has led to new horizons: are telephone consultations an alternative to traditional consultation? For decades we have observed that telephone consultations are a promising alternative and support for conventional medical care. Although studies published are low level evidence, it appears that telemedicine is effective. In different countries, like the United Kingdom or Australia, telephone consultations are currently being used and it seems that they provide appropriate and easily accessible care. 6

Objective
The aim of this study was to describe the ENT service consultations of the HMM and HVC hospitals during the state of alarm decreed by the Spanish government and to analyse in detail the results obtained to assess the usefulness of this type of consultation in ENT and head and neck surgery.

Material and methods
Together the ENT and head and neck departments of HMM in Murcia and HVC in Yecla provide service for a population of 314,431 inhabitants.
From March 16th 2020 onwards we began to carry out telephone consultation, only attending consultation for oncological or emergency service patients. However, since there was a fair amount of disparity in how to proceed by different members of the departments, we decided to create the following protocol, giving specific instructions on dealing with telephone consultations, which began to be applied on 23rd March: 1 All patients with hospital and outpatient consultation appointments would be contacted by telephone the day before the appointment by administrative staff, assistant nurses and/or nurses, to inform them that they should remain at home and the following day they would be called by the clinician for consultation. If the patient insisted that a visit was essential, it was reported they should be called first thing in the morning or the clinician was consulted. 2 On the day of the appointment, the clinician would ring each patient and complete the consultation form, specifying: A The reason for consultation, which would begin with ''telephone consultation by'' and would then specify the cause of the consultation. B Physical examination: if the patient finally did not go, ''not carried out'' would be stated. C The remaining fields (personal history, allergies, diagnosis and treatment/recommendations) would be filled in as standard. D During the process the patient would be given the necessary explanations, informing them of the most probable course of their condition and telling them that if this differed, they would be given an appointment for consultation after the state of alarm was over, or if symptoms worsened, they could go directly to the outpatient department. E If necessary an electronic prescription would be given. 3 Those patients who it was estimated required faceto-face consultation, were given an appointment the following day (one day after the original appointment) with intervals of 15 min between appointments. 4 Due to the type of examinations to be made, otorhinolaryngologists are particularly exposed to contagion, and at all times we will therefore follow correct recommendations on protection.
5 The patients suspected with being infected by COVID-10 and who require ENT examination will previously be referred to the emergency services to rule out COVID-19 infection.
From 23rd March to 17th April (18 working days) we collected the following data to analyse the usefulness of telephone consultation: number of first visits, number of successive visits, number of consultations resolved over the phone, number of patients who required face-to-face attention, number of patients who were to request appointments depending on the evolution of their condition and number of patients who we were unable to locate by phone.
We considered that a consultation resolved over the telephone was when we were able to resolve the problem which the patient consulted us about without the patient having to go for face-to-face consultation, either by discharging them or treating them with posterior review if necessary, to assess the result (e.g. the patient who has clear clinical symptoms of allergic rhinitis and we treat with intranasal corticoids). The patients who were referred for subsequent care on demand were those who were given a suspected diagnosis from their stated symptoms and to whom standard evolution of their condition was explained and/or treatment was guided and who were given further appointments if a worsening or persistence of symptoms ensued.

Results
During the study period in the consultations of both services 1054 patients were attended, of whom 663 (62.9%) were on their first visits and 391 (37.10%) were on successive visits (Tables 1 and 2). 21.73% (229) of the consultations were able to be resolved over the phone, 10.82% (114) required faceto-face consultation, 57.40% (605) were to request review depending on the evolution of their condition and 10.05% (106) of patients were unable to be located by phone.  The patients who attend consultation face-to-face presented with acute pathologies (epistaxis, complicated infections of the ENT region, new blood vessel formations, etc.) or oncological pathologies.

Discussion
The pandemic produced by COVID-19 and the subsequent Royal Decree 463/2020 of 14th March, which declared the state of alarm for management of the healthcare crisis occasioned by COVID-19, has led to constraints in performing an infinity of ordinary activities, among which are our care activities.
In the ENT and head and neck departments of the HMM and HVC we decided to carry out telephone consultation as an alternative to traditional consultation and, aimed at facilitating and unifying the activity of different members of the services during this period, we created a protocol for its management.
We chose to carry out telephone as an alternative to face-to-face consultation because it seemed to be the most effective option for providing care to our patients whilst avoiding risk of contagion by COVID-19 both for patients and healthcare staff. Other alternatives we considered were the suspension of all consultations, postponing appointments until the end of the state of alarm and continuing to carry out standard consultation activity. The first option meant leaving patients unattended for an unknown period of time, which we rejected, and the second option was unviable, given the state of alarm in which we found ourselves.
According to the data we collected during the period analysed, we observed that over 20% of consultations could have been solved over the telephone, thereby avoiding inconveniences for the patients, derived mainly from having to go to the hospital for consultation and improving clinical efficiency, and we therefore wonder whether it would be useful in the future to incorporate this type of consultation as part of our healthcare.
Few studies exist to assess the usefulness of telephone consultation as substitutes for face-to-face consultation and the majority are studies conducted in primary care. In a systematic review by Cochrane in 2004 7 they observed that telephone consultation reduced the number of visits to the primary care clinician and that at least 50% of consultations could be managed solely by phone although it was unclear whether the number of subsequent consultations increased. In our case, 21.73% of consultations could be managed by phone, with this percentage increasing in the case of first visits up to 23.98%. However, we cannot yet assess if many of these patients would go back to being attended in the following weeks for the same causes.
In another systematic review, Downes et al. 6 found that there had been a reduction in consultation time per patient by 1.5 min when this was completed telephonically, although these patients then secondarily required to visits of followup more than the patients who were attended face-to-face. In our experience we can also speak about a reduction in time dedicated to telephone consultation compared with conventional consultation. However, we cannot quantify the time per patient although we observed that the total time per telephone consultation was less than the time invested in the conventional consultation, due largely to the absence of examinations. Furthermore, in this systematic review they also observed that when a telephone consultation was made the number of patients who required face-to-face consultation dropped by 39%.
Regarding telephone consultation in our speciality, there were two studies which covered this issue. The first was a randomized controlled study in which patient satisfaction was compared with telephone consultation for follow-up in different pathologies in our area. 8 The authors concluded that the patients to whom follow-up was made by telephone are less satisfied than those who go to for face-to-face consultation. However, this contrasted with their experience. Part of their follow-up consultations are routinely by phone with a high perceived level of satisfaction. They pinpoint that telephone consultation is not appropriate for all patients nor for all diagnoses, and would recommend that the clinician makes a prior selection of patients who would be eligible for this type of consultation. Notwithstanding, in other studies which also measured perceived satisfaction by patients no differences were found between the patients attended by telephone and those attended face-toface. 7,9 In our study we collected the level of satisfaction of patients. However, a high level of satisfaction was perceived by all colleagues who were participating in the telephone consultations, although the current circumstances of healthcare emergency in what we found may induce a bias, since the population were confined at home, fearful about the healthcare crisis and this could have given rise to a higher level of satisfaction in the patients by a clinicians who was interested in their health problems.
Another study focused on the telephone consultation in ENT and head and neck units and was a cost-benefit analysis conducted in patients in review consultation who were offered face-to-face follow-up or phone consultation. 9 The patients who were offered optional telephone follow-up had to fulfil the following criteria: diagnosis of pathologies where treatment outcomes could have been subjectively assessed by the patient (epistaxis, sinusitis, etc., in which the patient's symptoms dictated the need for follow-up); severe pathologies (such as cancer) were ruled out. The authors estimated a saving of 28% in directs costs made from telephone consultation, concluding that telephone followup saved time and money and reduced waiting time so that new patients could be attended for consultation.
Our experience and that of other authors therefore suggest that telephone consultation offers many advantages such as: (1) greater clinical efficacy with higher access to consultations for patients, particularly those who live in rural areas 6 ; (2) an increase in cost-effectiveness, since telephone consultations have to be shorter than conventional ones 10,11 ; (3) greater convenience for patients, who do not need to travel, arrange childcare or ask for time off work and (4) reduction in costs for patients, who save money avoiding transport costs and other indirect costs which are difficult to measure. Some disadvantages also arise: (1) possible increase in consultation after follow-up, 6,7 and (2) greater probability that the patients forget the appointment or that they cannot be contacted by phone. 8 Although one of the limitation of our study was that we did not analyse which pathologies could be exclusively managed over the phone, after the review of different stud-ies we believe that patients and/or pathologies which are viable for telephone consultation are: patients with chronic pathologies; patients who wish to know the results of lab tests, X-rays or biopsies; patients who have been prescribed treatment and who require assessment of the response, and patients who agree to consultation over the phone.

Conclusions
During the state of healthcare emergency in which we find ourselves, telephone consultation seems to be a very useful tool for patient care. It avoids agglomerations in the medical practices, thereby reducing the risk of contagion by COVID-19. Implementation of the protocol described for management of telephone consultations has allowed us to carry out this task more easily and effectively.
According to collected data and different studies analysed, telephone consultation seems to be a good alternative to traditional consultation in ENT and head and neck. In our opinion, and according to different authors, it would be useful to make a previous selection of patients and/or pathologies that could benefit from this type of consultation and the satisfaction perceived by our patients. This would all give rise to an increase in care quality, which is the main aim of our daily practice.

Financing
This study received no specific grants from public sector agents, commercial sector agents or not-for-profit entities.