Transcript Telephone consultations

telephone triage and its use in
general practice
Andy Botherway October 2011
the use of the telephone in
general practice
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Telephones are now a very important tool in our everyday lives.
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There has been a massive increase in the use of the telephone in all areas. Telephone
banking, insurance, shopping and medicine.
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GP OOH services are using it, as is NHS direct.
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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?
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There have been a lot of studies looking into this.
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30% of patients who got telephone advice had originally
requested a home visit.
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However only 25% of these were unhappy with the
telephone advice.
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But 49% of patients would have preferred a home visit....
not necessarily because they needed one!
Concerns and anxieties
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How good are your telephone skills? We have had little formal training in this area.
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It often involves patients we don’t know or have little information about. Eg. OOH
setting.
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Is the data we gather accurate?
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Is it what the patient really wants - how do we manage expectations?
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Do we tend to make premature conclusions?
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Is it the best use of our time?
Telephone vs. face to face
consultations
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Small groups - write down the main differences between a
consultation over the telephone and one that is face to
face.
Main differences....
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Lack of non verbal clues.
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No direct observations.
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No direct examinations.
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No diagnostic tests.
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No smells.
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Active listening.
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Third party consultations.
main differences....
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Often no access to records or prescriptions/drug names.
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Cultural/language problems and accents.
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Hearing difficulties.
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Technical problems, poor line, mobiles.
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Patient and doctor anxieties.
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Assumptions - ‘she’s got tonsillitis again doctor’
advantages of telephone
consultations
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Easy access to advice as circumstances change.
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Time efficient for all parties.
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Patients may feel less guilty/defensive at taking up doctors
time.
techniques and methods
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Initial Assessment
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Hypothesis
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Time stratification
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Reflection
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Social circumstances
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Recommendations
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Summary
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Safety Netting
initial assessment
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Establish to whom you are speaking. Patient, relative, parent or third party.
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Rule out immediate life threatening conditions.
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Consider verbal cues. Speech pattern, speed, volume and articulation.
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Establish reason for call. Why now? What has changed? What is normal?
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Establish reason for call. What makes it better or worse? Past medical history, medications and allergies.
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What do they expect? Remember a good telephone consultation may change these expectations.
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Do not use leading questions. Open or focused closed questions are better.
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Enquire about recent contact with their GP and changes in health/medication.
hypothesis
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Consider hypothesis and most likely differential diagnosis.
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Remember to think outside the box and not to rely on only
the symptoms that the caller/patient says they are worried
about.
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Remember ‘red flags’ and ‘red herrings’.
Time stratification
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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?
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Not everything is appropriate to be dealt with acutely.
reflection
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Reflect the information you have gathered back to the
patient/caller.
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This ensures you have picked up all the relevant
information prior to making a final decision.
social circumstances
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Consider social circumstances and their ability to attend the surgery or OOH clinic.
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Availability of transport, housebound, nursing homes.
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When asking for a home visit remember to ask what are their concerns about travelling.
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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’
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If you are still stuck, shrug off your emotions. Bottom line is CHOOSE YOUR
BATTLES!!
recommendations
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Involve caller/patient in your decision making.
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Discuss outcome with the caller/patient and gain
agreement for decision.
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Explain rationale for the decision you have reached.
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Get agreement on your recommended outcome.
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KISS. (keep it short and simple)
summary and safety netting
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Summarise for the patient shortly and succinctly.
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Check they know whats happening! Directions to
PCC/surgery - bring medications etc.
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Closing statement with 2 messages. What to do if
symptoms develop and what new symptoms to watch for.
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Sound empathetic and not over anxious.
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Always let them end the call.
other tips and pointers
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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.’
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Other resources - peers, pharmacists, toxbase, websites,
BNF etc
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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
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2-3 groups and act out the scenarios. Then discuss how
best to manage them.