We are working in a way never seen before. This will bring new challenges and will likely improve efficiency for the future.
GP trainees in particular, but many other more experienced GPs as well, will find themselves thrown into a new world of telephone consulting. For those not working in a triage-based practice, this will bring new challenges.
In-hours triage differs to out-of-hours triage for a number of different reasons and will pose some of its own problems but may make certain things quicker and more efficient.
A large volume of what would have been face-to-face work will now need to be delivered via telephone or online and may prove challenging, particularly as second-day services become more and more restricted.
Consultations encountered in-hours via telephone will include all of the usual things you would see within the surgery, including possible emergencies. These include:
- Acute pathology e.g stroke, ACS, acute abdominal pain, sepsis.
- Breaking bad news
- Assessment suggesting serious pathology that might need to be referred need for urgent assessment
- Discussing primary care test results
- Chronic disease reviews
- Planned reviews for ongoing issues
- Medication reviews
- Discussion of hospital test results and plans
- Care home patient reviews
- Mental health assessments.
- Sick note requests
- Referral requests
- Discussion of multiple chronic symptoms
- Diabetic emergencies.
Pre consultation preparation
Ensure your pre-consultation preparation has been appropriate.
- Do you know the patient? If so, this is likely to make the consultation more efficient.
- Review the problem list.
- Review the last few consultations. Have they been telephone consultations? If so, your threshold for face-to-face consulting maybe lower.
- Review any relevant hospital letters, recent walk in centre contacts, out of hours contacts.
- Review any recent test results
- Review the medication list.
- Do reception notes contain any useful information e.g 'low mood'm ongoing urinary symptoms, etc?
- Ensure you are free from distraction.
- Use speaker or a headset to allow you to type/review records at the same time and to avoid over flexion of your neck.
- Ensure the patient can hear you and that it is a convenient time to talk.
- Try and speak to the patient. Do not assume that you cannot i.e in the case of young children or care home patients. You may well be able to and this will be more useful.
- Take a systematic focussed history.
- Approach this like any consultation so agenda set and apply your open to closed cone of questioning.
- Check 2 pieces of identifiable data if relevant
- Also check where the patient is at the present time.
- Exclude symptoms suggestive of COVID-19. If present and no life-threatening symptoms signpost the patient to 111 as per advice from Public Health England and NHS England.
- Exclude life-threatening symptoms immediately e.g acute chest pain, shortness of breath, abdominal pain, FAST symptoms. These will warrant 999 ambulance referral
- Exclude red flags consistent with significant pathology.
- What are the patient’s fears and what were they hoping would be the outcome of the telephone call? The current crisis may mean some expectations are unlikely to be met so have a common approach to issues that are arising frequently which have been identified amongst your colleagues.
- Enquire about the patients home life – how are their symptoms maybe affecting them at home?
- Does the patient work? if so, what do they do? Are the symptoms impacting them at work?
- Driving may also be relevant.
- Consider safeguarding issues also.
- Ideas concerns and expectations are important and will be ever more so during the COVID19 pandemic.
- How does the patient sound? Are they in pain? Is there any obvious shortness of breath?
- Do they have a BP machine? Can they check their own pulse? Can they check their BM?
- Can parents/guardians of children count a breathing rate? Can they identify recession?
- Some patient may even have a pulse oximeter?
- If this is a third-party consult e.g from a paramedic, can you document a full set of observations including a blood sugar and ECG findings.
- Can the patient email any skin lesions to you via a generic surgery email inbox?
You may wish to convert your telephone call into a video call (if you have appropriate software). This is helpful for observing children, rashes, possible cellulitis, for mental health consultations, or anything you feel having direct observation of the patient would be helpful.
You may need to see the patient directly - ensure you use the appropriate PPE. This is currently not the preferred option, but there are situations where this may arise, for example a gynaecological exam, abdominal palpation, child assessment. If you do this, establish if they have any symptoms of COVID-19.
If so, they will need to be referred to the appropriate service/place in your local area, for example the 'hot hub' if you have one in your area. If they don’t, they should be asked to advise the practice/place they need to attend if they develop symptoms before their appointment.
If the disposition is telephone advice then consider what resources you could provide to the patient e.g PIL via SMS, or links to websites about joint exercises, mental health resources. Careful safety netting will be important at the end of any telephone consultation. Patients should be reassured that they can call back at any point if they still have concerns.
The outcome of your consult may involve referral to another healthcare professional e.g dentist, social worker, district nurse, care navigation team.
You may wish to refer to secondary care and this maybe routine or two-week-wait. Each locality will differ as to what can and cannot be arranged at the present time
You may need to obtain advice and guidance from secondary care in order to resolve the issue in general practice. Some specialties in trusts may have already had this option available before the coronavirus outbreak and others may have set up a system to provide GPs with advice in light of the pandemic. Again, this will depend on your local area so it is a good idea to be aware of what options are available.
This will increase over the next few months and remote prescribing can pose its own problems.
Common drugs that you may start prescribing remotely may include, the contraceptive pill, antibiotics, HRT and mental health medication.
Consider the following:
- The indication for the drug e.g antibiotic. Do you have enough evidence to justify a prescription or would video call help? do you need some preliminary investigations e.g a CRP, a urine dipstick, a blood sugar?
- If it is something the patient has had before, can you justify prescribing it again e.g steroid cream? pain relief?
- Ensure the patient is counselled for any new prescription
- Are there any non-pharmacological options e.g self help, websites, books, online resources
- If a drug is initiated, how do you plan to follow this up?
- If you do not plan to follow up the case then have you provided a careful safety net?
- Does the patient know what you are prescribing and why?
- Does the patient require a dosette? If so how will you set this up?
- If they are self isolating/shielding, how will they get the drug?
- Does the patient know where you will send the drug if using electronic prescribing services (EPS)
- Does the patient know what to do if they develop a problem with the drug prescribed?
- If for a medication review, are all appropriate checks up-to-date and if not, are they needed urgently i.e DMARD drugs or could they wait an extra few months assuming all has been stable e.g BP meds
- Set an appropriate timeframe for the next medication review.
- If a patient is stable, could you consider a 12-month prescription e.g of a contraceptive pill instead of six months?
Ensure it is clear that your consultation has been via telephone and document that there is a current coronavirus pandemic in your notes. If it has been via video link, document this and document that the patient has consented to this.
Ensure your plan is clear and why you have decided to prescribe remotely. Clearly document the safety net you provide and follow up advice.
Any examination should also be documented e.g speaking comfortably in sentences or any values provided by a patient, carer or paramedic.
- Dr Singh is a GP partner and trainer in Northumberland