A Doctor involved in OOH care may exclusively or mainly deal with patients via the telephone. Different skills are required for this task as there is no direct patient contact, body language is lost and the Doctor will not usually know the patient. Educational events dealing with telephone triage are usually available however the analysis of your telephone skills may be appropriate. It is suggested that you record 10 consecutive telephone consultations and analyse them in the template below. It is probably best to do this on a recording of the consultation rather than “live”.

This exercise would demonstrate learning if changes were made and a further cycle completed. This would be a quality improvement activity.

Opening:

  • Introduction by name
  • Speaks to patient if appropriate
  • Checks demographics

Elicits patients problem including:

  • HPC
  • PMH
  • SH
  • DH/Allergies

- Formulation of plan - Diagnosis and plan documented.

- Check patient understanding – did the patient seem satisfied.

- Advice clearly documented including safety netting.

- Documentation: does the documentation support the triage discussion?

You may download a template here.

OpeningElicited patients problemFormulation of planCheck patient understandingAdvice given clearly and safety nettingDocumentation
Yes full Yes – earache in 3 yr old otherwise well Yes – diagnosis of ear pain analgesia alone Parent agreed with plan of action – advised contact own doctor if appropriate in next few days on listening to the recording parent happy Clear worsening advice given. Yes
Yes but no demographics Yes longstanding abdominal pain in 45 year old man No diagnosis – is awaiting specialist opinion pain no worse tonight – advised analgesia   I seemed a bit irritated that he had called at 11pm about a problem that was present for 3 months Not really satisfied he actually said “no one seems to be able to give me an answer to this pain doctor” and I seemed to ignore this statement No safety netting Yes
Not completely – “hello Mrs X this is the doctor” Yes – feverish child (aged 2). No allergy status Yes – elicited the fact that child reasonably well and that no anti-pyretic administered – advised paracetamol and cooling Yes partially satisfied, concerned re lack of obvious focus of infection but happy to try cooling measures Advised to ring back if fever worse or new symptoms Yes
No – patient very short of breath and more concerned re onward referral Yes – severe SOB in patient with diabetes and pre existing angina. No social history but patient unwell. Yes 999 ambulance Yes Clear advice given re 999 and advised to ring 999 if worse himself. Yes
Yes Yes – 24 year old man with back pain of 2 hours duration – caused by lifting Yes – analgesia I had to issue “stock” co-dydramol as pharmacy shut No – I again seemed irritated with this patient as no analgesia taken before call made Not satisfied-expected visit and “injection” No clear advice as short history. No safety netting Yes
Did not ask if better to speak to the patient Yes - Nursing Home patient with cough, nurse requesting antibiotics Yes – no prescription issued (12 midnight) advised symptoms (1 day cough) did not warrant intervention at present   Sort of – came to agreement with the nurse but she felt antibiotic more appropriate despite lack of systemic upset   Advised verbally to contact GP id worse. Not clear regarding worsening advice . Needed more documentation.
Yes Yes – 6 month baby off food high temp and vomited x1 Yes – I asked appropriate questions to exclude serious illness and base appointment given for 1 hours time Yes – I checked the mums understanding of the appointment and checked that she actually knew where the base was Clear advice about appointment in base and worsening advice while waiting to be seen Yes
No – again I called myself “the doctor” No – difficult telephone call with patient obviously under the influence – not really sure why they rang No – bit of garbled conversation which ended with “well I’m going to bed now” – the patient’s words not mine! Not possible Not sure if patient satisfied. No clear advice but patient put the phone down No. Could have documented what had happened more.
Partially – I introduced my self and discovered that the caller was the patent’s sister but not her name Yes – confusion and falling – had previously due to a chest infection reoccurred this evening. No social history Yes – elicited no current danger to herself and no apparent injury – arranged mobile doctor to call semi-urgently Yes sister aware that doctor would call within next hour or so Satisfaction- Yes – very relieved Clear advice to sister if patient worsens Yes
Yes – recall from earlier – (see above 3rd case) this time I introduced myself but not before the patient asked “are you the doctor I spoke to as they didn’t give a name?” Yes fever worsening no effect with paracetamol and bathing. I elicited a full history of red flag signs (all negative) Yes – to be examined – base consultation very hard as on her own with 2 other children – mobile doctor to visit Yes understands doctor will call later. Patient satisfied as wanted home visit Yes. No safety netting documented. Yes

Reflections on results/exercise

This was a valuable exercise for me and it is the first time I have listened to myself consulting by phone. The first thing that struck me was how difficult it was to judge how I was feeling at the time, the lack of visual input made it difficult for me to judge how appropriately and indeed how seriously I was taking the patients concerns. I have watched video of myself consulting and then because of body language you can get a better idea. The patients must therefore be in a very difficult situation.

30311074I was surprised that I did not introduce myself to everyone (something I thought I did every time). I was happy that I had elicited sufficient information each time to formulate a diagnosis and/or plan and that I had acted appropriately. There were a few consultations that I was obviously a bit short with the patients; this also seemed to be picked up by the patients. This shortness may be appropriate sometimes but it is clear from the recordings that the patients were genuinely worried regarding their problems.

Was disappointed that not clear in documentation in some cases.

Overall I seemed to be able to come to a negotiated settlement and resolution with the patients although the patient with the abdominal pain and the one with the back pain expected more than I could or would do for them.

Do I need to do anything different/learning needs identified?

Firstly the difficulty in gauging the mood of the “doctor” – yes me! The lack of visual stimuli was a problem even though I had performed the consultation. I will in future be more aware of this difficulty and try to introduce more verbal cues “mms, ums and yeas”.

Secondly many of the consultations were shorter than I imagined at the time, I displayed a tendency to dominate the closing section – I used the phrase “that’s OK then Yes?” four times and concluded the consultation in that fashion.

To try to ensure that the patient is truly satisfied with the outcome of the triage.

Overall I am happy with these ten consultations, there is some room for improvement and I will repeat the exercise in one or two years time.