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First impressions count - triage in reception

High-quality urgent care begins with the first impression. The key player here is the receptionist answering the phone. Dr Diarmuid Quinlan asks: do you rely on common sense, or have you robust procedures to manage emergency situations?

The quality of assessment undertaken by the receptionist, who may be a relatively junior member of staff, is crucial to deliver safe and effective urgent care. The challenge is to correctly identify, and rapidly respond to, the tiny number of patients in whom a delay will result in harm, or possibly even death. Have you identified and discussed these emergency situations? Have you a simple procedure for receptionists to follow when these rare situations arise? To rely on the common sense of receptionists to identify rare situations, and hope they respond appropriately, may pose an unacceptable risk to patients, staff and clinicians. Clinically urgent cases are rare, so learning through experience is fraught with danger for all.

YOUR PRACTICE MUST:

  • Identify emergency situations
  • Rapidly triage these patients
  • Ensure the patient is seen urgently.

TEST YOUR CURRENT SYSTEM

A good place to start is to ask your receptionist:

“What would YOU do if a patient phones the surgery reporting…” Options include telling the patient to:
  • Feeling breathless with chest pain
  • Teenager having a convulsion
  • Pregnant woman with very frequent contractions
  • Adult vomiting blood
  • A baby who is “floppy”?
  • Dial 999 or 112
  • Come to surgery immediately
  • Attend the Emergency Department immediately
  • Transfer the call to the GP
  • Offer a call back later by the GP.

Many doctors hope that their receptionists can recognise and respond appropriately to such situations, but hope is not a reasonable expectation. The location of your practice can influence how you respond to an emergency situation – the appropriate response for a city centre practice may prove fatal in remote rural Ireland. Clear guidance and appropriate training of staff may help prevent a catastrophe in your practice. Perfect preparation prevents poor performance.

Identification and initial management of emergencies by reception staff

This depends on three key components:

  1. A framework to identify emergencies 
    In our practice, we use three easily-identifiable patient groups: adults, children, pregnant women. We use easily-identifiable life-threatening situations: chest pain, bleeding, convulsion. We linked the patient and scenario to a few clear responses. A copy of our triage protocol for non-clinical staff can be viewed here. Please modify this to suit the circumstances in your practice.
  2. Training for receptionists 
    Many practices provide some training, but it may be a distant memory for staff. Learning on the job is unrealistic for rare situations. Consider undertaking an audit of reception staff responses to the life-threatening scenarios already mentioned. Provide training to the receptionists. This can be simply a discussion of “What would you do if...” Repeat the survey and submit this as your audit for 2014. A clinically relevant, patient-centred, emergency care audit – what more could you want?

    As clinicians, we should document all clinical decisions and phone calls with patients. We should encourage our administrative staff to do likewise. If the patient has an adverse outcome, every facet of the case may be subject to intense scrutiny. Clerical staff should document their interaction with patients in these high-risk situations. Who said what, and when, may be a key component in your defence should the patient suffer an adverse outcome. Contemporaneous documentation that the patient was offered an appointment, but declined it, may be very helpful to the GP. Electronic record keeping helps administrative staff make important entries in the clinical record, especially in emergency situations. Encourage your reception staff to document conversations with patients in these high-risk situations.
  3. Analysis and feedback 
    The appropriate management of urgent calls has clear clinical implications – these are important clinical decisions taken by non-clinicians. You are ultimately responsible here. Consider undertaking a formal analysis of the telephone calls/messages you receive. Perhaps you are interrupted excessively, perhaps you are not getting the urgent calls – do you know which happens in your practice?

    Are you a GP whom receptionists fear to interrupt due to your response on a previous occasion? When did you last compliment your staff for skilful management of a seemingly simple phone call? Feedback can help embed good practice, or allow it to wither unnoticed.

    All practices should have a robust policy in place to help receptionists manage emergencies appropriately. Training staff is crucial to make the policy a reality. Encourage receptionists todocument what happened. Periodically analyse how urgent situations are managed in your practice. Use feedback to embed good practice. Successful defence of an adverse patient outcome is dependent on all these factors: policy, training, documentation.

Further information

Dr Diarmuid Quinlan is a GP based in Cork and MPS clinical risk assessment facilitator
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