1. telephone triage and its use in general practice Andy Botherway October 2011

2. 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.

3. 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!

4. Concerns and anxieties How good are your telephone skills? We have had little formal training in this area. It often involves patients we dont 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?

5. 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.

6. Main differences.... Lack of non verbal clues. No direct observations. No direct examinations. No diagnostic tests. No smells. Active listening. Third party consultations.

7. 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 - shes got tonsillitis again doctor

8. 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.

9. techniques and methods Initial Assessment Hypothesis Time stratification Reflection Social circumstances Recommendations Summary Safety Netting

10. 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.

11. 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.

12. 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.

13. 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.

14. 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 whats 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!!

15. 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)

16. 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.

17. 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.

18. scenarios and role playing 2-3 groups and act out the scenarios. Then discuss how best to manage them.