Redeployment of staff and refocusing of clinical activities during the height of the COVID-19 pandemic provoked crisis management, rapid service change and unprecedented opportunities for innovation in care delivery. Seeing through the haze of the crisis in March 2020 allowed recognition that there was impending significant risk to patients with pre-existing subacute and chronic illnesses, including large numbers of patients with bone and mineral diseases.

CHANGING AT PACE

Our metabolic bone service, including a fracture liaison service, supports a local population of 1.3 million and offers regional specialised bone and mineral network support to the broader conurbation (~6 million people). Early in the crisis, we risk-stratified patients and procedures, taking into account the benefits of our standard care pre-COVID versus the risks of COVID infection and of delaying our standard care. At pace, we adopted parallel streams of work to support patients locally and also at scale, through working with national organisations. The latter was important to provide standardisation of messaging and to avoid duplication of effort.

We used our databases to communicate with local patients individually by letter, in order to explain their illness in the context of COVID, along with any specific risks and advice. We also provided our rationale and reassurance regarding our adapted plans of care. Additionally, we signposted to other reliable sources of patient-focused information, including our own newly established endocrine–COVID helpline, which proved incredibly popular.

AN ENDOCRINE HELPLINE

Our endocrine helpline was set up to provide general and highly specialised advice and support to patients with endocrine conditions, during weekdays. The helpline, staffed by clinical nurse specialists and a consultant, also received queries from primary and community care colleagues, and from members of the public.

With most endocrine clinics cancelled, the helpline provided patients with a platform through which to access advice and support, including: enquiries on medication/dose adjustment (e.g. calcium dose adjustment in hypoparathyroidism during periods of illness, including COVID-19), prescription management, advice on employment/educational support, and arranging necessary follow-up consultations.

ADJUSTMENTS TO PATIENT CONTACT

We switched all routine face-to-face outpatient activities to telephone/ video calls and rationalised our phlebotomy service to offsite locations. We also dramatically changed our thresholds for ‘routine’ bloods. All new referrals were actively triaged and, where possible, were addressed by advice and guidance. Furthermore, we adopted a ‘forward look’ approach to follow up and partial booking lists, and rationalised follow up and investigations according to clinical need.

We paused all intravenous bisphosphonate infusions due to the high risk of post-infusion systemic flu-like reaction and potential confusion with COVID-19 presentation. Following the end of the first lockdown, and with mass COVID testing being made available, bisphosphonate infusions were reintroduced in August 2020 and offered to both new and existing patients. A clear patient information leaflet was produced and given to all patients, informing them of the potential risk of ‘flu-like’ symptoms and need for COVID testing to rule out the infection.

Delayed denosumab treatment can result in rebound vertebral fractures, and so we adopted novel means of ensuring that patients already taking denosumab received their injections in a timely manner through domiciliary administration (local shared-care protocol), patient self-administration with support from clinical nurse specialists via video or telephone consultation and, if required, hospital administration in a dedicated denosumab injection clinic. DXA (dual-energy X-ray absorptiometry) scanning was paused, as was the primary hyperparathyroidism pathway, including parathyroid surgery. Cases with extenuating circumstances were dealt with on an individual basis.

SHARING GOOD PRACTICE

In parallel to our local service response, we instigated pieces of work (inter) nationally to provide repositories of information for clinicians and patients. Close working links with the Society for Endocrinology,¹ Royal Osteoporosis Society,² NHS England and NHS Improvement, NICE,³ patient support groups (e.g. Parathyroid UK⁴) and through academic publications,⁵ provided a means of sharing good practice while also ‘reality checking’ and learning the views and ideas of others within the field.

LESSONS LEARNED

We now have more efficient systems for triaging referrals, better use of remote follow up, with improved co-ordinated investigations to reduce outpatient ‘visit’ numbers (evidenced by a move towards a one-stop parathyroid service), a ‘direct to infusion’ offer and a proactive endocrine helpline service.

Although one size does not fit all, initial patient feedback is positive. It suggests that, for bone and mineral disorders (where many decisions are based on blood tests and scan results), patients perceive value in avoiding unnecessary travel to hospital with attendant costs and time, when a similar outcome can be delivered by a well-structured and two-way exchange, supported by some form of written communication. However, with rapid introduction of dramatic changes to service delivery, it is important to evaluate effectiveness and value to patients, the public and the care service as a whole, through audit and research. Patient satisfaction, impact of remote consultations and cost-effectiveness should be evaluated systematically.

Our ability to respond to COVID-19 has been borne out of close team working, open communication and visible leadership across administration, nursing and medical spheres. Our continued journey to innovate and refine care for patients with bone and mineral disorders will be shaped by listening to and responding to views of patients and working with patient groups and other stakeholders within our emerging integrated care system.

NEIL GITTOES
Consultant & Honorary Professor of Endocrinology, Head, Centre for Endocrinology, Diabetes and Metabolism, University Hospitals Birmingham NHS Foundation Trust

ZAKI HASSAN-SMITH
Consultant Endocrinologist, University Hospitals Birmingham NHS Foundation Trust

SHERWIN CRISENO
Advanced Nurse Practitioner & Lead Nurse – Endocrinology, University Hospitals Birmingham NHS Foundation Trust

REFERENCES

1. Society for Endocrinology 2020 COVID-19 Resources for Managing Endocrine Conditions www.endocrinology.org/clinical-practice/covid-19-resources-for-managing-endocrine-conditions.
2. Royal Osteoporosis Society 2020 The COVID-19 Hub www.theros.org.uk/healthcare-professionals/covid-19-hub.
3. NICE 2020 Coronavirus (COVID-19) www.nice.org.uk/covid-19.
4. Parathyroid UK 2020 COVID Guidelines www.parathyroiduk.org/resources/guidelines.
5. Gittoes NJ et al. 2020 European Journal of Endocrinology 183 G57–G65.