A guide for GPs and their staff on triage at reception

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TRIAGE AT RECEPTION - I Want an Appointment Now!

Everyone who has ever worked behind a GP’s reception desk hears this demand every day. Everyone wants to be seen NOW!

In General Practice, many complaints to the Irish Medical Council result from a patients’ experience of their initial interaction with a practice and especially being denied an appointment when they require immediate attention. While systems to ensure the efficient running of a practice, including how to manage requests for urgent appointments, are important, they should not compromise patient safety. This article examines issues which practices could consider in how they manage and respond to such requests.

 

THE ACUTELY ILL PATIENT

For several reasons, it is important to remember that limited information might be obtained from a patient at the reception desk. Sometimes the patient has difficulty describing their symptoms adequately. Reception Staff should be aware of this - and if a patient appears significantly unwell they should notify the GP / practice nurse immediately, either by phone or instant message – and ensure that the message is received. Practices should agree how reception staff will contact GP / practice nurse in the event of an emergency and all members of staff should be aware of this.

While acutely life threatening situations are rare in General Practice, they are an important event when they occur. All staff must remain vigilant and be aware that General Practice attracts a self-selecting group of patients who may already be suffering significant illness, which can deteriorate rapidly.

Where there is an acute presentation to the practice and the patient is advised to attend elsewhere e.g. another practice / hospital, details of the episode / actions taken should be recorded, and the GPs in the practice notified so they can follow up with a call if necessary.

 

PRACTICE SUPPORT AND TRAINING

Practices should be supportive of reception staff, and all members of the practice team should remain aware of how difficult it is to ‘always get it right’ at reception. In particular, reception staff should be advised to immediately alert the GP or practice nurse if a patient presents to reception about whom they have concerns.

Training for reception staff is important. New members of staff should have an opportunity to learn about practice procedures in caring for people who present to the practice acutely unwell and how to respond if a person requests an urgent appointment. Feedback should be formative and constructive and staff should be given positive feedback in situations where they have responded appropriately. As well as being upsetting to a colleague, harsh words or criticism by the GP may prevent a receptionist from flagging the presence of an unwell patient in the waiting room in the future.

New staff may not understand the meaning of words like ‘acute’ or ‘chronic’ in a healthcare environment and may need assistance in learning the terminology with which we may all be familiar. Furthermore, it might be assumed that all reception staff are aware of the very serious categories of presentations which warrant urgent assessment (e.g. dyspnoea, chest pain, acute severe pain, facial or limb weakness of sudden onset, etc.).

A member of the frontline staff, when faced with a significantly ill patient may panic and inappropriately respond when a patient presents with an acute or life threatening problem. Ongoing training helps remove uncertainty and helps equip staff members with the skills to analyse the level of urgency presented.

 

Some points which your practice may wish to consider

Has your receptionist had some form of training in how to triage patients, within or outside the practice? If so, how long ago and do they need to refresh their knowledge? Can you ensure that appropriate staff have had comparable training and have similar ability in recognising patients with acute illness? Have appropriate practice staff been trained in providing First Aid / CPR?

Some patient groups require special consideration due to their particular vulnerability and all reception staff should be aware of groups such as:

  • Women who are pregnant
  • Children and especially young infants
  • Elderly
  • Patients with chronic conditions: e.g. Diabetes, COPD, mental health disorders
  • Patients with intellectual disability
  • Patients who have language difficulties

 

IF IN DOUBT

In any practice the default position for any member of staff must be ‘If in doubt, ask the GP or Practice Nurse’. An open, supportive and friendly ethos on the practice goes a long way to support patient safety, where communication levels between clinical and non-clinical staff are easy and relaxed.

 

SPARE APPOINTMENTS

A number of spare slots can be kept every day where possible for on the spot appointments, lowering the stress levels of the GP-and the entire practice team.

 

COMMUNICABLE DISEASE

Triage training should include a management system of separating those with communicable illness, whether a child with chicken pox or an adult with the flu, and where space allows they should be directed to a separate waiting area – or perhaps encouraged to sit out in the car until the GP is ready to see them. They pose a significant and unseen danger to other patients who may be immunocompromised – small babies, the elderly and those on immunosuppressant therapy to mention a few.  Most receptionists can recognise that a child with a rash is potentially infective and the signs of influenza are self-evident.   If there is no policy or training a new member of staff may not see infectivity as an issue, so firm leadership and good communication are key to a good system of triage in any practice.

 

NO GP ON SITE

Every practice needs to have an action plan for what the receptionist should do when a patient arrives at the practice, and appears extremely ill. Ensure that the reception staff feel they have the authority to call an ambulance if the situation demands it.

 

DOCUMENTATION

Any requests for urgent attention should be recorded. Where an ‘urgent’ appointment is requested and reception staff consider a ‘soon’ appointment more appropriate, this should be recorded  by the reception staff. If this is not acceptable to the patient or an urgent appointment is demanded, the reception staff should refer the matter to the doctor/nurse.

 

TEMPORARY STAFF

Every practice has a time when the reception is under pressure, there may be unscheduled sick leave or a few people on maternity leave at the same time, necessitating temporary staff covering reception. A printed guide can be invaluable, such as the brief guideline below. Emergencies can happen at the most inopportune times.

 

TRIAGE

Drawing up a definitive triage protocol is difficult. For example, a patient may calmly say they are experience crushing central chest pain while eating a bag of crisps and smiling, while others will say they are ‘grand’ and sit quietly in the waiting room while experiencing a life threatening episode. While all practices have different approaches to triage, some suggestions for drawing up a protocol for patients requesting urgent appointments are addressed below. The word ‘urgent’ has different connotations for different people and this must be borne in mind by reception staff.

 

For the purposes of scheduling appointments, patients can be categorised as follows:

Routine Appointment

Next appropriate available appointment

 

Soon appointment (within the week), e.g.

Patient worried but not in distress

Issue which has been a problem for some time and has no acute features

Repeat of regular medication –running out. (Perhaps a rescue prescription could be supplied until an appointment is available)

 

Review today, e.g.

Severe pain of any kind e.g. acute back spasm/ear infection/abdominal pain

Eye injury

Acute Discomfort e.g. abscess, severe tonsillitis

Sudden swelling of a limb (DVT)

Already saw GP recently but condition deteriorating

Acute injury/accident/fracture

Pregnant woman concerned (minor bleeding, reduced movements uti etc.)

Visual disturbance

Significant Psychological distress

Ill child

Request for Post Coital Contraception

 

See immediately (interrupt GP) or ambulance if no GP on the premises, e.g.

Acute Chest Pain

Acute breathlessness e.g. asthma/pneumonia

Acutely Ill child

Floppy baby

Collapsed patient

Acute facial swelling (allergy)

Weakness of facial features or loss of use of a limb (eg CVA)

 

This is not an exhaustive list of urgent presentations.

 

WHAT GOES ON OUT THERE?

As the GP do you really know how your reception staff manages patients looking for urgent appointments? How do you know that it is being dealt with appropriately? While it is important to trust your receptionist, it is nonetheless important to remember that the GP is ultimately responsible for how the practice is run.

Do ensure that whatever your protocol, all staff members are aware of it and all manage requests for urgent calls in the same way.

 

SOME TRIAGE RELATED QUESTIONS FOR YOUR PRACTICE TO CONSIDER:

 

  • Is there a protocol for triage at reception?
  • If so, is it written down?
  • Can reception staff contact a GP in the practice easily in an emergency?
  • Can reception staff reach a GP who may be off the premises in an emergency?
  • Do you have a warm, supportive and open relationship with your front of house staff?
  • Do your staff think they have a warm supportive and open relationship with the GPs!
  • Have you discussed with staff the circumstances in which to call an ambulance without prior GP approval?
  • If you can’t answer yes to all the above maybe it’s time for another practice meeting or training session.

The contents of this publication are indicative of current developments and contain guidance on general medico legal queries. It does not constitute and should not be relied upon as definitive legal, clinical or other advice and if you have any specific queries, please contact Medisec for advice.


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