telephone triage and its use in general practice

Andy Botherway October 2011

the use of the telephone in general practice

• Telephones are now a very important tool in our everyday lives.

• There has been a massive increase in the use of the telephone in all areas. Telephone banking, insurance, shopping and medicine.

• GP OOH services are using it, as is NHS direct.

• It is argued that a high proportion of calls to GPs can be dealt with over the phone. This can save doctors and patients a great deal of time.

Do patients like it?

• There have been a lot of studies looking into this.

• 30% of patients who got telephone advice had originally requested a home visit.

• However only 25% of these were unhappy with the telephone advice.

• But 49% of patients would have preferred a home visit.... not necessarily because they needed one!

Concerns and anxieties

• How good are your telephone skills? We have had little formal training in this area.

• It often involves patients we don’t know or have little information about. Eg. OOH setting.

• Is the data we gather accurate?

• Is it what the patient really wants - how do we manage expectations?

• Do we tend to make premature conclusions?

• Is it the best use of our time?

Telephone vs. face to face consultations

• Small groups - write down the main differences between a consultation over the telephone and one that is face to face.

Main differences....

• Lack of non verbal clues.

• No direct observations.

• No direct examinations.

• No diagnostic tests.

• No smells.

• Active listening.

• Third party consultations.

main differences....

• Often no access to records or prescriptions/drug names.

• Cultural/language problems and accents.

• Hearing difficulties.

• Technical problems, poor line, mobiles.

• Patient and doctor anxieties.

• Assumptions - ‘she’s got tonsillitis again doctor’

advantages of telephone consultations

• Easy access to advice as circumstances change.

• Time efficient for all parties.

• Patients may feel less guilty/defensive at taking up doctors time.

techniques and methods

• Initial Assessment

• Hypothesis

• Time stratification

• Reflection

• Social circumstances

• Recommendations

• Summary

• Safety Netting

initial assessment

• Establish to whom you are speaking. Patient, relative, parent or third party.

• Rule out immediate life threatening conditions.

• Consider verbal cues. Speech pattern, speed, volume and articulation.

• Establish reason for call. Why now? What has changed? What is normal?

• Establish reason for call. What makes it better or worse? Past medical history, medications and allergies.

• What do they expect? Remember a good telephone consultation may change these expectations.

• Do not use leading questions. Open or focused closed questions are better.

• Enquire about recent contact with their GP and changes in health/medication.

hypothesis

• Consider hypothesis and most likely differential diagnosis.

• Remember to think outside the box and not to rely on only the symptoms that the caller/patient says they are worried about.

• Remember ‘red flags’ and ‘red herrings’.

Time stratification

• If the caller or patient needs to be seen face to face how quickly is this required. 999, urgent visit, GP practice today tomorrow or next week?

• Not everything is appropriate to be dealt with acutely.

reflection

• Reflect the information you have gathered back to the patient/caller.

• This ensures you have picked up all the relevant information prior to making a final decision.

social circumstances

• Consider social circumstances and their ability to attend the surgery or OOH clinic.

• Availability of transport, housebound, nursing homes.

• When asking for a home visit remember to ask what are their concerns about travelling.

• Consider ‘manipulative escalations’. ‘we both want what’s best. we have better diagnostic facilities down here.’ ‘you would be seen more quickly down at the surgery’

• If you are still stuck, shrug off your emotions. Bottom line is CHOOSE YOUR BATTLES!!

recommendations

• Involve caller/patient in your decision making.

• Discuss outcome with the caller/patient and gain agreement for decision.

• Explain rationale for the decision you have reached.

• Get agreement on your recommended outcome.

• KISS. (keep it short and simple)

summary and safety netting

• Summarise for the patient shortly and succinctly.

• Check they know whats happening! Directions to PCC/surgery - bring medications etc.

• Closing statement with 2 messages. What to do if symptoms develop and what new symptoms to watch for.

• Sound empathetic and not over anxious.

• Always let them end the call.

other tips and pointers

• Signposting. Establish rapport with the caller, introduce yourself and advise them on the direction the call will take: ‘I am going to ask some questions in order that we come to the most appropriate outcome.’

• Other resources - peers, pharmacists, toxbase, websites, BNF etc

• Use visualisation - use the patient or caller as an extension of our senses. Remember that describing things can be difficult over the telephone.

scenarios and role playing

• 2-3 groups and act out the scenarios. Then discuss how best to manage them.