How I...attracted more than 100 patients to a practice stroke evening
Call from an ambulance crew to help at 999 call
Who comes first your patients waiting in the surgery or an afflicted person the ambulance crew want you to look at? Dr Melanie Wynne-Jones discusses
You're in the middle of a busy surgery when the receptionist telephones you. 'I've got the ambulance service on the line; they're waiting at Mrs X's house and want you to attend.'
·Leave your patients and rush to the scene?
·Ask to speak to the paramedic/ambulance person in attendance?
·Ask to speak to the patient?
·Ask to speak to the person who called 999?
·Tell them to take her to A&E?
·Tell them you will visit later?
·Arrange for her to be brought to the surgery for assessment?
·Involve some other service/agency?
Unless you work in one of the more remote areas of the country where GPs have agreed to provide BASICS care or to act as First Responders, the first option is often inappropriate. If Mrs X has something life-threatening such as cardiac chest pain, precious minutes may be wasted while she and the ambulance wait for you to attend, and you are unlikely to have better resuscitation skills than the ambulance officers. If she has a minor injury, and your PCT has not commissioned this as a local enhanced service from the practice, then she will need to attend A&E.
If she is mentally confused, unco-operative or even violent then you are going to be able to do little until you have more information and/or have involved other services; if the situation is already hazardous, then the police should be asked to attend.
You also have a duty to the patients in the waiting room who have booked appointments and may actually be more in need of your medical attention than Mrs X. Relieving the duty doctor of all routine work is not feasible in all practices.
Ask to speak to the ambulance officer on the scene, and locate Mrs X's computer or paper records. You may also need to speak to Mrs X and/or whoever called 999.
·What has happened? (Is it truly an emergency? Why did they call 999 instead of the surgery?)
·How reliable is the story? (Is Mrs X confused, do the witnesses/relatives fully understand the situation or are they trying to precipitate some intervention?)
·What is the background situation? (What pre-existing medical/social conditions may be relevant; can anyone stay with Mrs X, or bring her to the surgery?)
·What is the ambulance officer's assessment of her current condition?
·What do each of the participants think needs to be done and what are their reasons? Is this really an exercise in passing the medicolegal responsibility for her safety over to you?
·Does Mrs X need investigations that can only be carried out in hospital, or a psychiatric assessment? How urgent is this?
·Is Mrs X refusing to go to A&E when it is clearly the right course of action? Does she have capacity to refuse?
·Is a rapid response from social services or the district nursing service more appropriate?
·Will Mrs X be safe if the ambulance leaves now?
·Can you safely make a decision on the basis of the information you have gathered?
By now you should be in a position to judge whether you need to see Mrs X yourself to make that decision, and if so, where and when. You will also need to ensure that everyone else involved understands, and preferably supports, your decision.
Triaging such calls may save everybody's time and wasted journeys; it should also identify the correct management plan. It is usually both safe and efficient, as well as less stressful, and fairer to other waiting patients.
Emergency care practitioners the future?
Calling 999 seems to be increasingly popular, for a variety of reasons that include raised patients' expectations about what constitutes an emergency. These have at least partly been influenced by advanced access, changes in out-of-hours provision, NHS Direct, four-hour A&E target waiting times and television.
Providing an ambulance is expensive, and often not necessary (even when the large amount of trivia and inappropriate calls are discounted); it may also delay care to the more needy.
The Government is piloting the use of emergency care practitioners who will be required to make similar decisions to the one discussed on this page, albeit with much less training and experience than GPs. The aim is to reduce costs and unnecessary transfer to A&E, and is partly driven by another NHS initiative, the changing workforce programme.
·'ECP - right skill, right time, right place' NHS Modernisation Agency
October 2004 www.dh.gov.uk/assetRoot/
04/09/30/88/04093088.pdf Appendix 3 includes extensive list of specific competences.
·Changing workforce programme new ways of working in healthcare. www.modernnhs.nhs.uk/
Melanie Wynne-Jones is a GP in Marple, Cheshire