Dr Lucy FisherNDUC

Northern Doctors Urgent Care

Demystifying Telephone Triage

L Fisher 2015

Why am I here tonight?

Demystifying Telephone Triage

L Fisher 2015

Why are you here tonight?

Demystifying Telephone Triage

L Fisher 2015

You already know it all

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To promote safe, efficient telephone consultations,

with high patient satisfaction

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Aims

Objectives

At the end of the talk we should have:

1. Clarified what telephone triage and telephone consultations are.

2. Compared and contrasted face to face, and telephone assessments.

3. Reviewed the basic structure of a telephone triage.

4. Considered what elements make for safe telephone triage and consultations.

5. Gained experience in tricky triage situations.

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What’s the difference?

Telephone Triage versus

Telephone Consultation

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Triage is  the sorting of patients according to the urgency of their need for care.

A Consultation is a meeting with a professional or expert for purposes of gaining information.

Telephone Triage versus

Telephone Consultation

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1. Preparation2. Introduction3. Information gathering4. Management/disposition plan5. Ending the consultation/Safety

netting6. Time management7. Record keeping

Similarities telephone cf. face to face

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What went well?What didn’t go well?

A Telephone Triage Call

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Telephone Triage: Basic Structure

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Preparation

Record keeping

Telephone Triage

Introduction

Information gathering

Management plan

Ending consultation

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Telephone Triage: Basic Structure

Preparation

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Introduction Mindmap

Preparation

Introduction

Title and name

Role

Organisation

Caller ID, ask for patient

Patient ID and DOB L Fisher

2015

Information Gathering Mindmap

Information gathering

Consider emergenc

y response

Immediate

Bleeding heavily

Not breathing

Unconscious

Severe chest or abdominal pain

Non –blanching rashFurther brief assessment

After detailed history may still need 999

call

History taking

Open questions

Throw the net wide to establish themes

Closed questionsMay I ask you some safety questions?

eg.PMH, DH , allergies, SH, safe

guarding,Addresses caller’s

concernsIdeas, concerns

and expectationsConsultation

skills

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Information gatheringExamining over the telephone•Can you look at your tummy button?•Please strip your child off to do tumbler test. Please tell me are the legs and hands cold? What colour is the skin?•Please stand on tiptoe, then drop down suddenly onto your heels. Would your child be willing to jump up and down?•I’m going to listen to your breathing. Please put the receiver to your child, so I can listen to their breathing•Talking to assess level of consciousness/ confusion•Will they rouse when you say their name or gently stir them?

Any more?

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Management Plan MindmapM a n a g e m e n t p la n

A p p ro p ria te p la n

Te le p h o n e a d v ic e

G P /n u rs e a p p t

U rg e n t ( x h o u rs )

R o u tin e ( y h o u rs )

H o m e v is it

U rg e n t (x h o u rs )

R o u tin e ( y h o u rs )

G o to A & E

P a s s to o th e r a g e n c y

9 9 9 A m b u la n c e

D is tric t N u rs e

S o c ia l s e rv ic e s

o th e r

M u tu a lly a c c e p ta b le

C h e c k u n d e rs ta n d in g

C h e c k a g re e m e n t

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Ending Consultation MindmapEnding consultation

Safety netting

Specific symptoms relating to differential diagnosis

Specific symptoms relating to deterioration

Follow up with time frames

Where to go

When

And Why

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Safety netting

Safety netting • Symptom specific safety netting advice is a vital part of almost all consultations. It reduces risk, empowers patients and gives them confidence to self manage their conditions, knowing what to do if they feel worse and reduces the likelihood of subsequent complaints. Rather than just say ‘call back if you are worse’, please give specific advice with timescales, based on the clinical condition. e.g. for a teenager with a sore throat, dealt with as telephone advice, mentioning the possibility of breathing difficulties, difficulty swallowing, drooling, etc, and what to do if any of these occur, and how urgently, will be helpful. A completely different set of safety netting instructions would follow a ‘leg pain’ triage. Imagining the questions that you would normally ask, and the red flags that we normally look to exclude, and voicing these, is a good way to help tailor your advice to the scenario in question.

Excerpt from NDUC clinical Guidelines version 1.0 . 2011

Rehearsing some trickier situations. Applying knowledge from guidelines

Role Play

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Case 118 Month old with fever and diarrhoea

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Case 1Which guidelines are useful in assessment

and management?Importance of eliciting ICE on patient

satisfactionEmpowering self care

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NICE CG160: Feverish Illness in Children.

Traffic lights

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NICE CG84 Diarrhoea and Vomiting in children under 5.

Assessment

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CG84 Diarrhoea and Vomiting in children.

Preventing Dehydration

1.3.1 Primary prevention of dehydration1.3.1.1In children with gastroenteritis but without clinical dehydration:continue breastfeeding and other milk feedsencourage fluid intakediscourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk of dehydration (see 1.2.1.2)offer ORS solution as supplemental fluid to those at increased risk of dehydration (see 1.2.1.2).

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CG160 Feverish Illness in Children.

Care At Home

1.7 Advice for home care 1.7.1 Care at home 1.7.1.1Advise parents or carers to manage their

child's temperature as described in section 1.6. [2007]

1.7.1.2Advise parents or carers looking after a feverish child at home:

to offer the child regular fluids (where a baby or child is breastfed the most appropriate fluid is breast milk)

how to detect signs of dehydration by looking for the following features:

sunken fontanelle dry mouth sunken eyes absence of tears poor overall appearance to encourage their child to drink more fluids and

consider seeking further advice if they detect signs of dehydration

how to identify a non-blanching rash to check their child during the night to keep their child away from nursery or school while

the child's fever persists but to notify the school or nursery of the illness. [2007]L Fisher

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CG160 Feverish Illness in Children.

Antipyretic interventions

1.6 Antipyretic interventions 1.6.1 Effects of body temperature reduction 1.6.1.1Antipyretic agents do not prevent febrile

convulsions and should not be used specifically for this purpose. [2007]

1.6.2 Physical interventions to reduce body temperature

1.6.2.1Tepid sponging is not recommended for the treatment of fever. [2007]

1.6.2.2Children with fever should not be underdressed or over-wrapped. [2007]

1.6.3 Drug interventions to reduce body temperature

1.6.3.1Consider using either paracetamol or ibuprofen in children with fever who appear distressed. [new 2013]

1.6.3.2Do not use antipyretic agents with the sole aim of reducing body temperature in children with fever. [new 2013]

1.6.3.3When using paracetamol or ibuprofen in children with fever:

continue only as long as the child appears distressed consider changing to the other agent if the child's

distress is not alleviated do not give both agents simultaneously only consider alternating these agents if the distress

persists or recurs before the next dose is due. [new 2013]

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CG160 Feverish Illness in Children.

Safety netting

1.7.2 When to seek further help

1.7.2.1Following contact with a healthcare professional, parents and carers who are looking after their feverish child at home should seek further advice if:

the child has a fit the child develops a non-

blanching rash the parent or carer feels that the

child is less well than when they previously sought advice

the parent or carer is more worried than when they previously sought advice

the fever lasts longer than 5 days the parent or carer is distressed,

or concerned that they are unable to look after their child. [2007]L Fisher

2015

Case 242 year old man with sore throat

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Case 2Do you go back for the notes?Did you ask to speak to the patient?

(explanation)Differential diagnoses and discriminating

questions

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GP NotebookEpiglottitis• The symptoms of epiglottitis usually develop

quickly and rapidly worsen. Symptoms include:• a high temperature (fever) of 38C (100F), or

above,• a severe sore throat,• difficulty and pain when swallowing - most children

will refuse to eat due to the pain,• difficulty breathing,• breathing that sounds abnormal and high pitched,• the skin takes on a bluish tinge (cyanosis),• voice sounds muffled, and• drooling saliva.

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NHS choices symptom checkerSymptoms of epiglottitis The symptoms of epiglottitis usually develop quickly and get rapidly worse, although they can develop over a few days in older children and adults. Symptoms include: a severe sore throat difficulty and pain when swallowing difficulty breathing, which may improve when leaning

forwards breathing that sounds abnormal and high pitched (stridor) a high temperature (fever) of 38ºC (100.4ºF) or above irritability and restlessness muffled or hoarse voice drooling

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Did we achieve our Objectives?

At the end of the talk we should have:

1. Clarified what telephone triage and telephone consultations are.

2. Compared and contrasted face to face, and telephone assessments.

3. Reviewed the basic structure of a telephone triage.

4. Considered what elements make for safe telephone triage and consultations.

5. Gained experience in tricky triage situations.

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Any Questions?

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Thank you

Please return all case scenarios and completed evaluation forms

to me

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