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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.