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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

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

11. Telephone Triage: Basic Structure
L Fisher 2015

12. 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

13. Telephone Triage: Basic Structure
Preparation
L Fisher 2015

14. 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

15. 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

16. 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

17. 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

18. 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

19. Safety netting Safety netting
Excerpt from NDUC clinical Guidelines version
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.

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

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

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

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

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

25. CG84 Diarrhoea and Vomiting in children. Preventing Dehydration
1.3.1 Primary prevention of dehydration
In 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 )
offer ORS solution as supplemental fluid to those at increased risk of dehydration (see ).
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

26. CG160 Feverish Illness in Children. Care At Home
1.7 Advice for home care
1.7.1 Care at home
Advise parents or carers to manage their child's temperature as described in section 1.6. [2007]
Advise 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

27. CG160 Feverish Illness in Children. Antipyretic interventions
1.6.1 Effects of body temperature reduction
Antipyretic 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
Tepid sponging is not recommended for the treatment of fever. [2007]
Children with fever should not be underdressed or over- wrapped. [2007]
1.6.3 Drug interventions to reduce body temperature
Consider using either paracetamol or ibuprofen in children with fever who appear distressed. [new 2013]
Do not use antipyretic agents with the sole aim of reducing body temperature in children with fever. [new 2013]
When 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

28. CG160 Feverish Illness in Children. Safety netting
1.7.2 When to seek further help
Following 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

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

30. 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

31. 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

32. 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

33. 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

34. Any Questions?
L Fisher 2015

35. 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