Welcome to edition one of our brand new GP Liaison News Round Up - a newsletter designed to keep our local GPs and primary care colleagues up-to-date with all of the latest news from Epsom and St Helier.
A Trust update from our GP Liaison Officer
COVID-19 - the current position at Epsom and St Helier

At Epsom and St Helier, we are currently caring for 151 patients with suspected and confirmed COVID-19. 

375 people have been discharged home or to a care home.

Sadly, 236 patients with COVID-19 have died.
Endoscopy requests and two week rule (TWR) colorectal referrals - an update from Cancer and Clinical Services

In line with advice from The British Society of Gastroenterology (BSG), Joint Advisory Group on GI Endoscopy (JAG) and Intercollegiate General Surgery Guidelines on Gastrointestinal (GI) Endoscopy procedures, the Trust is temporarily cancelling all routine endoscopy procedures until further notice.

TWR cases will be clinically triaged by a Telephone Assessment Clinic (TAC) as normal, booked by the GP through e-RS. The triage will now take account of the faecal immunochemical test (FIT) result provided by the GP. After this, the patient will be triaged by a clinician either for an urgent Endoscopy (where clinically appropriate) or for computed tomography (CT).

Lower GI/FIT for symptomatic patients
 Due to the COVID-19 pandemic, the referral pathway for lower GI TWR referrals has changed. The following mandatory pathways have been agreed by NHS England (NHSE) London Clinical Advisory Group.

All high and low risk patients as defined by NHSE guidelines now need to have a FIT test first except where a patient presents with a rectal or anal mass where these patients should be referred on a TWR pathway as normal. Please see guidance below:

From 11 May 2020 onwards referrals without a positive FIT test will not be accepted and should be treated locally by the GP for 4 weeks. 

  • Only FIT positive results to be referred.
  • Patients with a negative result should be safety netted by the practice.
  • Patients having retrospective FIT tests who have been recently referred on a TWR pathway will not have had any diagnostic intervention and are being retained on the Trust’s patient tracking list (PTL). To ensure that patients are properly stratified during the COVID-19 period, consultants may write to you asking you to dispense a FIT kit to a patient and then inform the consultant of the FIT result. The patient will remain on the Trust’s PTL until it is safe to do so, either based on the FIT value or any other diagnostics.

Action for primary care
  • All practices should ensure that they have enough FIT kits and if fewer than 25, it is advisable to order more. Practices should follow normal procedure and work on the basis that a normal size practice previously would require 1 FIT kit per week, larger practices 2-3.

TWR referrals and appointments

New referral forms
As guidance is updated and pathway changes are authorised, referral forms will be updated to reflect new temporary processes. These changes are being managed centrally by the Transforming Cancer Services Team (TCST).

  • For FIT, practices using DXS (i.e. EMIS) will have their lower Gastrointestinal (LGI) referral form automatically updated.
  • For FIT, practices not on DXS can download the latest version of the LGI form from either of the following IT systems, EMIS, Vision, System One, and uploaded to their practice systems via https://www.healthylondon.org/suspected-cancer-referrals/.
  • The Sustainability and Transformation Partnerships (STP) will update practices as new referral forms become available.

Action for primary care

If you have any Endoscopy queries, please contact:
Mr Ashraf Raja, Endoscopy Clinical Lead via email at ashraf.raja@nhs.net or Justine Braddick, Endoscopy Service Manager at justinebraddick@nhs.net.

If you have any LGI Cancer queries, please contact:
Mr Ashish Gupta, Colorectal Cancer Clinical Lead via email at ashishgupta@nhs.net or Maria Physicos, Cancer Services Manager at maria.physicos@nhs.net.
An update about our Paediatric Radiology Service Provision

 In the unprecedented circumstances caused by COVID-19, our department is not able to undertake all routine imaging.

Surgical emergencies, cancer or other urgent conditions have been and will continue to be accommodated promptly.

Children are more likely to spread the virus because of their habits. Therefore, ideally, children and any family member suspected to have COVID-19 should avoid the radiology department if at all possible.

During this time as we go through the peak of the anticipated COVID-19 cases, we continue to provide appointments for the following indications:

Clinical suspicion of the following:
  • Malignancy
  • Obstructive hydrocephalus
  • Stroke/acute neurology
  • Malrotation or bowel obstruction
  • Intussusception
  • Appendicitis
  • Pyloric stenosis (significant vomiting under 6m of age)
  • Acute blood disorder
  • Acute nephritis/renal tract obstruction
  • Acute hepatitis/jaundice
  • Significant sepsis, abscess
  • Testicular or ovarian torsion.
  • Acute ovarian cyst.
  • Significant GI bleeding
  • Acute hernia
  • Trauma
  • Septic arthritis of the hip or other joints
  • Slipped upper femoral epiphysis
  • Non-accidental injury.

All imaging requests are vetted and examinations rescheduled according to clinical need.
 
All the routine follow up urinary tract scans for bladder problems, non-specific abdominal pain, suspected gastro oesophageal reflux and uncomplicated musculoskeletal scans have been, and continue to be, deferred. Children who have their first urinary tract infection and have not had a previous renal tract ultrasound are continuing to have their scans arranged appropriately depending on the severity of their associated systemic illness.

Neck scans for adenopathy can only be undertaken if acute pain, redness, fevers and suspected abscess is indicated. All other suspected enlarged nodes will only be scanned after hospital clinician evaluation or telephone consultation with a paediatric radiologist. 

The hip ultrasound service is providing appointments within nine weeks of birth so that orthopaedic evaluation and treatment can be started before ten weeks.

However, the following patients have a more significant increased risk of late dislocation or significant dysplasia:

  • Clinically dislocatable hips
  • Following breech delivery
  • Family history.

These patients will still have a first scan before four weeks where possible. All patients in harness and in follow up at the moment will continue to be scanned but more immediate decisions will need to be taken in cases where further follow up or prolonging treatment would normally be the case.

All dental work has had to be cancelled unless an emergency however individual cases can still be discussed with one of our radiologists.

We hope you can understand why we have had to take these difficult measures. Our aim is to ensure that children with a non COVID, significant illness, still receive appropriate imaging during this challenging time.

We would also like to provide reassurance that our paediatric imaging departments at both our main sites provide isolated areas to minimise risk to our patients and relatives.

Both sites have dedicated waiting areas and facilities to separate the paediatric workload from the rest of the hospital.

Staff members wear protection and there is sufficient room for a child and a single parent to be adequately separated from others during their attendance.

Below are some contact details to assist you in contacting the service:

  • St Helier Paediatric clinical support: 020 8296 3032 Dr Liam Woods /Dr Alaa Witwit /Dr Val Cook  
  • Epsom Paediatric clinical support: 07584 165515 / 01372 735 5248 Dr Miriam Khalil
  • Appointment queries: 020 8296 3872. St Helier / 01372 735 5248 Epsom
  • Management queries: 020 8296 3010. Mrs Kaye Shah, Paediatric x-ray superintendent

All other queries please contact:

A message from Dr Kirsty Watts, Consultant Paediatrician and Paediatric Allergy Lead, Epsom Hospital only

Please be advised that the Epsom Paediatric Allergy Service has been temporarily moved to an Advice and Guidance service whilst we focus on supporting the acute service during the COVID-19 pandemic. We apologise for any inconvenience during this unprecedented time.

We will be maintaining and reviewing the waiting list for existing referrals; this includes those with upcoming appointments. We will also be offering advice and guidance for potential new referrals. We will of course inform you once the service is back to business as usual.

To support you in the interim period, we would advise safety-netting patients with potential new allergies. Please find below some information, which I hope you will find useful. There are further reliable resources available from the British Society for Allergy and Clinical Immunology (BSACI), Allergy UK and the Anaphylaxis campaign. I have also attached a summary sheet which you can use to signpost parents to these resources.
 
Indications for adrenaline auto injector (AAI) – from BSACI

“Patients at risk of anaphylaxis that should be considered for long-term provision of an adrenaline auto-injector includes:

  • Those who have suffered a severe systemic reaction where the allergen cannot be easily avoided – This may include a cough, hoarse voice or wheeze if developed after food with additional oral / skin symptoms, even if on this occasion the symptoms resolved without escalation or with the use of salbutamol if asthmatic.
  • Those who are allergic to high-risk allergens, for example nuts with other risk factors (such as asthma), even if the reaction was relatively mild
  • who had a reaction in response to trace amounts of allergen/trigger
  • with continuing risk of anaphylaxis (e.g. food dependent exercise-induced)
  • with idiopathic anaphylaxis
  • with significant co-factors (e.g. asthma in food allergy, raised baseline serum tryptase).”
 
Emergency action plans

Please provide a written emergency action plan for all children with a potential food allergy; these can be downloaded from the BSACI website:

Training for AAIs including sourcing dummy devices can be obtained from:

 
Parent information sheets

Patient information can be easily downloaded from the following websites:

These websites contain very useful information regarding signs and management of allergies including anaphylaxis, and dietetic guidance to support allergen avoidance.

Chronic urticaria

We frequently see children with recurrent / chronic idiopathic urticarial. In children who are otherwise well investigations are rarely required, and most are managed well with regular cetirizine. For more information including patient advice sheets please see:

Allergic rhinitis

Please refer to the ARIA guidelines for the management of allergic rhinitis:

If commencing a regular antihistamine, please prescribe a non-sedating antihistamine such as Cetirizine (suitable from two years). If prescribing a steroid nasal spray please ensure adequate instruction is given or it will be ineffective. There are many available YouTube clips demonstrating a good technique:

Milk allergy

Most infants with milk allergy do not require a referral to secondary care. The iMAP guidelines including useful resources such as a milk ladder suitable for non-IgE allergy can be found https://gpifn.org.uk/imap/ .
Should you require any specific advice, please use advice and guidance within e-RS. If you would like to speak to a member of the team please call 01372 735 735 ext 6922 Monday-Friday 8am to 6pm.
An update from Mina Deved, Head of Radiology

As the situation regarding COVID-19 changes on a daily basis, we would like to share some guidance about routine GP radiology routine requests:

1.       Jubilee Health Centre radiology service: Due to current staffing shortages and reconfiguring of staff rotas we are planning to close the radiology walk-in service at the Jubilee Health Centre site for the foreseeable future. Please send urgent patients only to the walk-in service at both Epsom and St Helier sites for X-rays.

2.       With regard to imaging for patients with symptoms that may overlap with COVID-19: There is no indication for chest X-ray in patients with suspected COVID-19 beyond any direct clinical care. As recommended in the Public Health England COVID-19 interim guidance for primary care patients with any suspected features, which may be considered possible for COVID-19, should be isolated if well enough to stay at home or if severe then directed to appropriate emergency care.

For any patients with respiratory symptoms who are well enough to be managed in the community, our recommendation is for empirical management with appropriate clinical follow-up and review if an X-ray is required at a delayed time interval. This is very important to avoid cross infection and to try and contain virus spread. There is no role of chest X-ray in diagnosing COVID-19.

3.       All routine imaging requests : We are in the process of deferring all routine booked radiology investigations and are currently not booking any routine investigations. This measure has been put in place to protect the public and staff members from both transmission and ensure services are redirected appropriately to emergency, urgent and suspected cancer investigations. You should consider whether the radiology investigation will have a direct impact on patient care in the coming weeks with appropriate clinical safety netting.

Currently following routine investigations suspended:

  • Direct Access radiology investigation for US, CT pancreas, MRI head, MRI spine, MRI knees.
  • Routine Ultrasound guided injection service
  • All routine Dexa scan service.
 
We will update on any relevant important changes that develop in the interim, as provision will be assessed regularly.
 
If you have any queries, please contact Mina Deved, Head of Radiology, at mina.deved@nhs.net .
A message from Hayley Beale, e-RS Lead in the Outpatient Booking Centre, with regard to daily e-RS worklists
 
Please be advised that due to the COVID-19 pandemic you may experience an increased volume of outpatient referrals being returned to practices with advice for management in primary care. This will be reflected in your daily e-RS worklists.

Additionally, the e-RS team is continuing to make every effort to notify GP practices of returned referrals by phone or email, but please be aware that some referrals may be returned outside of this process directly from a clinician to your worklist.

If you have any queries, please contact the GP hotline 020 8296 3541 or via email at esth.ers@nhs.net .
A message from the Anticoagulation Service

In response to the COVID-19 pandemic, we have made changes to the provision of anticoagulation services in our hospitals. The aim of this is to reduce the risk of exposure of both patients and staff to COVID-19 infection whilst ensuring the delivery of safe anticoagulation treatment.
            
  • Telephone clinics are being provided for all new patients requiring anticoagulation.
  • Initiate Direct Acting Oral Anticoagulants (DOACs) instead of warfarin unless contraindicated.
  • Majority of patients on warfarin have reasons not to be on DOACs but should switch if possible.
  • Issue 12 weeks supply of DOACs with a telephone follow up at six weeks for South West London patients and four weeks supply to Surrey patients to be followed by telephone consultation on their ‘due to stop date’.
  • Initiate warfarin in patients with mechanical heart valves. However, low molecular weight heparin (LMWH) to be used if initial monitoring is going to be difficult and patient or a family member living with them is able to administer the injection.

General patient support

  • Give all patients telephone advice as well as written information to support the discussion
  • Patients at the end of their duration of anticoagulation to be reviewed with a telephone clinic before stopping.
  • Clinical Nurse Specialists are available to address anticoagulant related queries from secondary and primary care during working hours 8.30am-6pm Monday-Friday on 020 8296 2815.
  • Patients over 70 and other at risk individuals with unstable International normalised ratio (INRs) to be tested as required and followed with telephone advice.
  • Retest patients with stable INRs in 12 weeks.
  • Stable domiciliary patients to be monitored with longer intervals up to 12 weeks. Most of these patients have district nurses and carers for other reasons.
  • Using NHS volunteers to transport at risk patients with unstable INRs who otherwise would have had to use public transport.

In addition to the above we would like to remind you that our Advice & Guidance service via e-RS remains open and we would very much encourage you to use this service if you have any concerns. 

If you have any further queries please contact the anticoagulation hotline on 020 8296 2815 and 01372 735170 or via email at est-tr.anticoagulation@nhs.net.

The consultant Haematologist covering the laboratory can be contacted via switchboard on 020 8296 2000. 
An update from Hannah Crease, Senior Sister, Eye Clinics

W ith the daily evolving COVID-19 pandemic we would like to update you with guidance on how patients can seek assessment for acute eye problems or be referred by GPs or Optometrists.

The acute eye service at St Helier Hospital remains available for genuine emergencies between 8.30am-4.30pm Monday to Friday, however we are no longer accepting walk-in patients and all patients are now required to have an initial telephone assessment prior to attending.

Please see the guidance notes below:

  • Patients, GPs or Optometrists should ring us on 020 8296 3817.
  • History will be taken by a triage nurse along with the patients contact details.
  • The triage nurse will either make a decision themselves or pass details to the duty Ophthalmologist who will ring the patient to assess whether they can be given telephone advice, be provided with a prescription or be advised to attend the acute eye unit to be seen face to face.
  • Patients attending face to face will be assessed for signs and symptoms of Covid-19 and have their temperature taken prior to being seen.
  • Relatives will only be allowed to accompany patients if there are extenuating circumstances such as dementia, learning disability or they are children. Only one relative or carer will be permitted.

Please note that GPs and Optometrists can still refer to the acute eye service via email at Est-tr.acute-eye-referral@nhs.net

The out-of-hours Ophthalmology service continues to be based in Moorfields at St Georges Hospital.

Further updates will be sent as and when changes occur.
If you have any queries please Contact Sister Hannah Crease on 020 8296 3817 or by email at
A message from the Cardiology Walk-in ECG service during the COVID-19 pandemic

Please be advised that due to the COVID-19 pandemic and in line with Department of Health (DOH) recommendations, the walk-in ECG service can only accommodate patients who have an urgent clinical requirement for an ECG. This is to support the department to reduce the risk to staff and patients of exposure to COVID-19.
 
In view of this, please only refer patients to the service who have an urgent clinical indication for ECG.

Contact the Department prior to attendance
It is essential that urgent patients who are referred to the walk-in clinic telephone the service first to agree an attendance time. This is to ensure that the department can stagger arrivals and manage the risk of potential infection appropriately.
 
When you agree to refer your patient, we would be grateful if you could ensure that the patient is aware of the importance to call the department, prior to attendance, on the contact details below.

Epsom Hospital
01372 735349

St Helier Hospital
020 8296 2575

If you have any queries please contact Luke Bonner, Cardiology Service Manager on 020 8296 2621/ mobile 07826 922576 or via email at luke.bonner@nhs.net.
A message from Claire Berry, Advanced Nurse Practitioner (ANP) and Unit Manager for the Ambulatory Care Centre (ACC) at St Helier Hospital, with regards to referring patients into the ACC during COVID-19
 
*Please note this service is about to have a name change to Same Day Emergency Care (SDEC).*
 
Please be advised that despite the COVID-19 pandemic, the Ambulatory Care Centre at St Helier Hospital is still open and accepting referrals and as of 8 May 2020 the service will be available over the weekend and bank holidays accepting referrals between 10am-4pm.

Please note, we may ask you to send your patients to the Emergency Department (ED) or directly to the Medical Assessment Hub if we feel the patient is not appropriate for the ACC
Please see below some simple guidelines to assist you with your referral.
 
Direct referral criteria from General Practitioners to the ACC
Is the patient presenting with a medical problem? For example: unresolved urinary tract  infection/chest infection, cellulitis, giant cell arteritis, deep vein thrombosis, decompensated heart failure, pulmonary embolism, headache (list not exhaustive).
Is the patient over 16 years old and not presenting with a chronic condition, alcohol misuse or a mental health condition?
Is the patient independently mobile or if in a wheelchair, able to self-transfer without assistance?

If the answer is yes to any of the above, please call the Ambulatory Care Centre 07975 233233 or bleep 255 to discuss a referral. The current core hours are 8am-6pm Monday-Friday.
 
General exclusions
More appropriate for another speciality (can be discussed with ACC via the ANP/PA or consultant if unsure)
Intoxicated or requiring acute psychiatric input
Complex physical, cognitive or psychiatric needs requiring supervision
Active diarrhoea or requiring isolation due to any other infectious disease/illness
New acute confusion
Cardiac chest pain
 
If you have any queries regarding referral, please contact the ACC on 020 8296 4342 (for general enquiries only, not for referrals) or via email at Claire.berry12@nhs.net
That’s it for this edition of the GP Liaison News Round-up. If you have any feedback or ideas for our next edition, please email us at est-tr.gplo@nhs.net .