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Mastering telephone triage

For many registrars the only route to obtaining out-of-hours experience will be in a call centre – Dr Alvin Bodner gives some pointers on what challenges this throws up

For many registrars the only route to obtaining out-of-hours experience will be in a call centre – Dr Alvin Bodner gives some pointers on what challenges this throws up

Providing medical services in the NHS has always been a continuing 24-hours-a-day responsibility. It has become a political issue and a matter of concern for patients as GPs have opted out of traditional out-of-hours work. With the new GMS contract and the handing over of out-of-hours responsibility, we have seen adverse publicity in the media and complaints from patients or relatives.

Because GP principals nowadays can opt do little or no out-of-hours work, the only route to obtaining experience for registrars is by sessional work in call centres under supervision of trainers - trainers who themselves may work sessions infrequently.

Registrars may have little previous experience of out of hours telephone triaging yet find themselves having to work for the first time in call centres with minimal training or supervision in receiving and handling patient concerns over the phone. Often the training is very inconsistent,and can vary across different regions in the UK.

The RCGP has produced an audit toolkit which relates the best standards of out-of-hours care, which is worthwhile reading.

Registrar difficulties

Registrars new in post often feel insecure in an OOH environment because:

• They are within a different working environment which is outside of the familiar workplace

• They are initially unfamiliar with the IT software and possibly different hospital communication systems and telephone numbers

•Communication process requires different skills for a number of reasons:

- No direct eye-to-eye contact and few cues other than human voice and conversation

- all judgments based on telephone conversations with patients or relatives

- it is difficult to evaluate home circumstances or severity of symptoms - and therefore decide on the urgency and appropriate response rate

• Acute clinical conditions may be familiar to ex-hospital registrar but in an OOH call centre environment there are no medical records and despite this important management decisions have to be made; the clinical details are often taken verbatim from the patient and many patients may not be particularly articulate and when stressed or concerned cannot give a detailed history

• Patients may be frustrated, worried or angry as situations build up over a period of hours, especially if they can't get hold of their own doctor or are indeed disappointed with their own practice and elect for an OOH consultation; the registrar has to learn to handle these emotions

• Finally, there may be special challenging and difficult scenarios such as psychiatric emergency or a palliative care issue and the issues of what to do or who to contact emerge

Pitfalls

Problems usually occur for the following reasons:

• Failure to think through possible issues and a failure to grasp whole situation

• Confrontational issues with patient or relatives, such as demand for home visit or refusal to come to the call centre when this is appropriate

• Poor record keeping about clinical detail and communication about patient or relatives concerns

Complaints

The most common reasons for OOH patient complaints are::

• Misjudged urgency of the clinical situation and consequent inappropriate response rate by follow-up visiting doctor

• Unsatisfactory attitude of doctor faced with anxious or demanding patient

• Failure to visit the patient

Handy tips

• Read and reflect on the rubric information provided by first contact staff, especially demographic details. This will give social clues, such as living conditions, locality, social risk and so on. Consider the possible issues including a probable differential diagnosis before picking up the phone and addressing the problem. This will help with the line of questioning. Thinking in terms of physical psychological and social issues is a good fall back.

• Then telephone the patient and go over the story again with patient or relative. Clarify description of symptoms and get a feel for the clinical picture in terms of time/duration. Is the condition deteriorating? Carers involved or living alone? Ask about medications. Keep good records of conversation. Ask about current medications /past medical history and recent GP contacts .

• Remember: you are relying on a ‘telephone relationship' so listen to the manner of speech as well as the description of symptoms and think about mobility status, vision/hearing status and mental state (for example, is the patient depressed or suicidal?)

Management

• Use all this information as the basis of the urgency of response following the telephone consultation and make a decision –should there be a home visit or treatment centre consultation? Should you send an emergency ambulance?

• Ask yourself: what does the patient actually want from the telephone call? Is it advice only; reassurance/guidance, medical assessment and social care?

Management possibilities

• Give advice only, by phone

• Safety-netting – tell the patient to ring back if things get worse

• Offer an appointment at treatment centre

• Offer home visit. Give enough information to the visiting doctors to enable prioritisation and convey an estimated time interval for visit to the patient based on your assessment, for example visit within one hour, two hours or urgent requiring an emergency ambulance; have regard for caseload for visiting doctor, especially in winter.

Challenging situations

Psychiatric emergency at home

This is usually urgent and potentially very time-consuming so obtain as much information as possible by phone and assess urgency. Phone the visiting doctor and pass on information directly to him/her so that prioritisation of visits can occur. Include details of past history and psychotropic drugs.

Palliative care – emergency

This is usually urgent and under hospital care. Obtain as much information as possible to enable home care to continue– for example physical, psychological issues, social/care agency input and details of hospital care and pain/symptom relief issues.

Difficult telephone consultations

Insisting on a home visit

Be polite rather than confrontational and reassuring, but record details to allow visiting doctor ot make final assessment.

Frustrated carer

These are often fed up with the ‘system' or the patient. Reassure that care is available. Keep calm/pleasant/reassuring. One may need to alert mobile doctor personally.

Finally remember:

• All telephone call are usually recorded

• Keep full detailed and legible written records of information obtained on phone

• If worried – seek help

Dr Alvin Bodner is an MRCGP examiner and a GP in Rochdale

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