Demystifying Telephone Triage Dr Lucy Fisher NDUC Northern Doctors Urgent Care L Fisher 2015

Demystifying Telephone Triage Why am I here tonight? Gp partner at Elsdon Avenue at Seaton Delaval I have worked for NDUC for 11 years I am clinical supervisor, for registrars and new starters I give the telephone triage educational talk for the registrars and in educational meetings for sessional GPs I am on the call review team L Fisher 2015

Demystifying Telephone Triage Why are you here tonight? What are you hoping to learn ? Ask 5 people to give their answers L Fisher 2015

You already know it all L Fisher 2015 Here is a grandmother sucking an egg I’m not going to tell you anything you don’t already know What I would like to do is: 1) give you a structure: have a path that you keep coming back to , even if the caller leads you off. 2) and rehearse using some useful guidelines: what information to gather to : reach a safe decision about management/ disposition : safety net effectively L Fisher 2015

Aims To promote safe, efficient telephone consultations, with high patient satisfaction What are you hoping to learn ? Ask 5 people to give their answers L Fisher 2015

Objectives At the end of the talk we should have: Clarified what telephone triage and telephone consultations are. Compared and contrasted face to face, and telephone assessments. Reviewed the basic structure of a telephone triage. Considered what elements make for safe telephone triage and consultations. Gained experience in tricky triage situations. What are you hoping to learn ? Ask 5 people to give their answers L Fisher 2015

Telephone Triage versus Telephone Consultation What’s the difference? I have been asked to speak about in hours telephone consultations Discuss with the person next to you for 2 minutes what is the difference between triage and consultation L Fisher 2015

Telephone Triage versus Telephone Consultation Triage is  the sorting of patients according to the urgency of their need for care. A Consultation is a meeting with a professional or expert for purposes of gaining information. I have been asked to speak about in hours telephone consultations ( merriam webster dictionary definition) Yourdictionary definition So triage is the sorting and if you give telephone advice, that’s the consultation L Fisher 2015

Similarities telephone cf. face to face Preparation Introduction Information gathering Management/disposition plan Ending the consultation/Safety netting Time management Record keeping Review starting point for attendees. Ask them to come up with break down of these areas. Examination? L Fisher 2015

A Telephone Triage Call What went well? What didn’t go well? L Fisher 2015

Telephone Triage: Basic Structure L Fisher 2015

Information gathering Preparation Record keeping Telephone Triage Introduction Information gathering Management plan Ending consultation mind map developed by me from Pat Feeney’s work Reason for this: to have a path that you keep coming back to ,even if caller leads you off, and info at your finger tips L Fisher 2015

Telephone Triage: Basic Structure Preparation L Fisher 2015

Caller ID, ask for patient Introduction Mindmap Preparation Introduction Title and name Role Organisation Caller ID, ask for patient Patient ID and DOB Preparation Reading patient record reason entered for call by reception: alerts, problems, meds, practice notes, recent consultation entries/ letters saying clearly who you are, gives time for patient to orientate themselves, patient will feel more comfortable to talking to you. Asking caller who they are, allows to ask for patient, reintroduce yourself to patient, time to build rapport. L Fisher 2015

Information Gathering Mindmap Consider emergency response Immediate Bleeding heavily Not breathing Unconscious Severe chest or abdominal pain Non –blanching rash Further brief assessment After detailed history may still need 999 call History taking Open questions Throw the net wide to establish themes Closed questions May I ask you some safety questions? eg.PMH, DH , allergies, SH, safe guarding, Addresses caller’s concerns Ideas, concerns and expectations Consultation skills L Fisher 2015

Information gathering Examining over the telephone Can you look at your tummy button? Please strip your child off to do tumbler test. Please tell me are the legs and hands cold? What colour is the skin? Please stand on tiptoe, then drop down suddenly onto your heels. Would your child be willing to jump up and down? I’m going to listen to your breathing. Please put the receiver to your child, so I can listen to their breathing Talking to assess level of consciousness/ confusion Will they rouse when you say their name or gently stir them? Any more? L Fisher 2015

Management Plan Mindmap Appropriate plan Telephone advice GP/nurse appt Urgent ( x hours) Routine ( y hours) Home visit Urgent (x hours) Go to A&E Pass to other agency 999 Ambulance District Nurse Social services other Mutually acceptable Check understanding Check agreement Management plan includes formulating a working diagnosis which includes the most likely diagnosis the most common diagnoses for this presentation and rare but significant ( ie dangerous diagnoses) ( no need to mention rare but insignificant, ie will make no difference to management if diagnose) L Fisher 2015

Ending Consultation Mindmap Safety netting Specific symptoms relating to differential diagnosis Specific symptoms relating to deterioration Follow up with time frames Where to go When And Why Safety netting • Symptom specific safety netting advice is a vital part of almost all consultations. It reduces risk, empowers patients and gives them confidence to self manage their conditions, knowing what to do if they feel worse and reduces the likelihood of subsequent complaints. Rather than just say ‘call back if you are worse’, please give specific advice with timescales, based on the clinical condition. e.g. for a teenager with a sore throat, dealt with as telephone advice, mentioning the possibility of breathing difficulties, difficulty swallowing, drooling, etc, and what to do if any of these occur, and how urgently, will be helpful. A completely different set of safety netting instructions would follow a ‘leg pain’ triage. Imagining the questions that you would normally ask, and the red flags that we normally look to exclude, and voicing these, is a good way to help tailor your advice to the scenario in question. REMEMBER TIME FRAMES: THINGS CAN GET BETTER, WORSE OR STAY THE SAME: GIVE ADVICE WITH TIMEFRAMES FOR EACH SCENARIO. Eg sore throat: if getting better, fine to watch and wait, if staying the same review with own Gp 1 week, if getting worse specifically with pain, recontact when above plan not working, with swallowing, recontact immediately if drooling ie not swallowing own saliva, immediately if develops a rash. L Fisher 2015

Safety netting Safety netting Excerpt from NDUC clinical Guidelines version 1.0 . 2011 Safety netting Safety netting • Symptom specific safety netting advice is a vital part of almost all consultations. It reduces risk, empowers patients and gives them confidence to self manage their conditions, knowing what to do if they feel worse and reduces the likelihood of subsequent complaints. Rather than just say ‘call back if you are worse’, please give specific advice with timescales, based on the clinical condition. e.g. for a teenager with a sore throat, dealt with as telephone advice, mentioning the possibility of breathing difficulties, difficulty swallowing, drooling, etc, and what to do if any of these occur, and how urgently, will be helpful. A completely different set of safety netting instructions would follow a ‘leg pain’ triage. Imagining the questions that you would normally ask, and the red flags that we normally look to exclude, and voicing these, is a good way to help tailor your advice to the scenario in question.

Role Play Rehearsing some trickier situations. Applying knowledge from guidelines L Fisher 2015

Case 1 18 Month old with fever and diarrhoea L Fisher 2015

Case 1 Which guidelines are useful in assessment and management? Importance of eliciting ICE on patient satisfaction Empowering self care L Fisher 2015

NICE CG160: Feverish Illness in Children. Traffic lights L Fisher 2015

NICE CG84 Diarrhoea and Vomiting in children under 5. Assessment L Fisher 2015

CG84 Diarrhoea and Vomiting in children. Preventing Dehydration 1.3.1 Primary prevention of dehydration 1.3.1.1In children with gastroenteritis but without clinical dehydration: continue breastfeeding and other milk feeds encourage fluid intake discourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk of dehydration (see 1.2.1.2) offer ORS solution as supplemental fluid to those at increased risk of dehydration (see 1.2.1.2). I have trawled through clinical knowledge summaries, clinical evidence looking for trial evidence for interventions: VERY LITTLE PROVEN INFORMATION ON MANAGEMENT STRATEGIES FOR SELF LIMITING ILLNESS L Fisher 2015

CG160 Feverish Illness in Children. Care At Home 1.7 Advice for home care 1.7.1 Care at home 1.7.1.1Advise parents or carers to manage their child's temperature as described in section 1.6. [2007] 1.7.1.2Advise parents or carers looking after a feverish child at home: to offer the child regular fluids (where a baby or child is breastfed the most appropriate fluid is breast milk) how to detect signs of dehydration by looking for the following features: sunken fontanelle dry mouth sunken eyes absence of tears poor overall appearance to encourage their child to drink more fluids and consider seeking further advice if they detect signs of dehydration how to identify a non-blanching rash to check their child during the night to keep their child away from nursery or school while the child's fever persists but to notify the school or nursery of the illness. [2007] L Fisher 2015

CG160 Feverish Illness in Children. Antipyretic interventions 1.6.1 Effects of body temperature reduction 1.6.1.1Antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose. [2007] 1.6.2 Physical interventions to reduce body temperature 1.6.2.1Tepid sponging is not recommended for the treatment of fever. [2007] 1.6.2.2Children with fever should not be underdressed or over- wrapped. [2007] 1.6.3 Drug interventions to reduce body temperature 1.6.3.1Consider using either paracetamol or ibuprofen in children with fever who appear distressed. [new 2013] 1.6.3.2Do not use antipyretic agents with the sole aim of reducing body temperature in children with fever. [new 2013] 1.6.3.3When using paracetamol or ibuprofen in children with fever: continue only as long as the child appears distressed consider changing to the other agent if the child's distress is not alleviated do not give both agents simultaneously only consider alternating these agents if the distress persists or recurs before the next dose is due. [new 2013] CG160 Feverish Illness in Children. Antipyretic interventions L Fisher 2015

CG160 Feverish Illness in Children. Safety netting 1.7.2 When to seek further help 1.7.2.1Following contact with a healthcare professional, parents and carers who are looking after their feverish child at home should seek further advice if: the child has a fit the child develops a non-blanching rash the parent or carer feels that the child is less well than when they previously sought advice the parent or carer is more worried than when they previously sought advice the fever lasts longer than 5 days the parent or carer is distressed, or concerned that they are unable to look after their child. [2007] L Fisher 2015

Case 2 42 year old man with sore throat L Fisher 2015

Case 2 Do you go back for the notes? Did you ask to speak to the patient? (explanation) Differential diagnoses and discriminating questions L Fisher 2015

GP Notebook Epiglottitis The symptoms of epiglottitis usually develop quickly and rapidly worsen. Symptoms include: a high temperature (fever) of 38C (100F), or above, a severe sore throat, difficulty and pain when swallowing - most children will refuse to eat due to the pain, difficulty breathing, breathing that sounds abnormal and high pitched, the skin takes on a bluish tinge (cyanosis), voice sounds muffled, and drooling saliva. Epiglottitis The symptoms of epiglottitis usually develop quickly and rapidly worsen. Symptoms include: a high temperature (fever) of 38C (100F), or above, a severe sore throat, difficulty and pain when swallowing - most children will refuse to eat due to the pain, difficulty breathing, breathing that sounds abnormal and high pitched, the skin takes on a bluish tinge (cyanosis), voice sounds muffled, and drooling salvia. L Fisher 2015

NHS choices symptom checker Symptoms of epiglottitis  The symptoms of epiglottitis usually develop quickly and get rapidly worse, although they can develop over a few days in older children and adults. Symptoms include: a severe sore throat difficulty and pain when swallowing difficulty breathing, which may improve when leaning forwards breathing that sounds abnormal and high pitched (stridor) a high temperature (fever) of 38ºC (100.4ºF) or above irritability and restlessness muffled or hoarse voice drooling L Fisher 2015

Did we achieve our Objectives? At the end of the talk we should have: Clarified what telephone triage and telephone consultations are. Compared and contrasted face to face, and telephone assessments. Reviewed the basic structure of a telephone triage. Considered what elements make for safe telephone triage and consultations. Gained experience in tricky triage situations. What are you hoping to learn ? Ask 5 people to give their answers L Fisher 2015

Any Questions? L Fisher 2015

Please return all case scenarios and completed evaluation forms to me Thank you Please return all case scenarios and completed evaluation forms to me L Fisher 2015