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Triage in general practice

Triage in general practiceDr Mark Dinwoodie, MPS Head of Member Education, takes a look at different models of triage for general practice

The concept of triage is nothing new. The word ‘triage’ comes from the French verb ‘trier’, which means ‘to sort’. Napoleon’s surgeon-general was the first to institute battlefield ‘triage’. As the number of patient contacts in general practice steadily rises and the nature of healthcare becomes increasingly complex, it is perhaps not surprising that many view triage as a way of safely managing increasing demand while also meeting patients’ understandable desires for a timely response to their requests for urgent healthcare. Telephone triage and telephone consultations aim to improve access to care.

The purpose of triage is to ensure that the patient is referred to the appropriate clinician for the appropriate level of care within an appropriate period of time. The initial phase of triage is often undertaken by patients themselves. Many will have reflected on their condition and considered who they feel they need to see and in what timeframe. Others will have consulted with friends, neighbours, relatives or work colleagues.

Many practices use experienced practice nurses/nurse practitioners to undertake the role of triage, usually by telephone, for requests for urgent or same day appointments. They assess the patient’s symptoms and concerns, and then agree with the patient how these needs might best be met by giving telephone advice or a face to face appointment, along with an indication of the appropriate urgency.1

Telephone triage

Small scale studies have shown that telephone triage is acceptable to patients.2A Cochrane review of telephone consulting and triage in 2009 found only nine studies that met its criteria and these showed that telephone triage and consulting reduced immediate GP face-to-face consultations and home visits and that approximately half of the calls could be dealt with on the phone.3However two studies showed an increase in later consultations suggesting simply a delay or postponement. The evidence base may be enriched by a study currently underway to evaluate usual (non-triage) care, computer supported nurse-led triage, and GP-led triage for patients requesting same day appointments in general practice, assessing outcomes in terms of workload, cost, safety, patient satisfaction and health status.4

Develop a practice based triage protocol which clearly outlines the steps of the triage process and the roles and responsibilities of those involved

There are important consultation skills needed to triage safely and effectively manage telephone consultations, which are highlighted in a previous MPS article.5 To help ensure reliability and consistency in terms of the triage assessment, decision-support software systems have been used predominantly by out-of-hours service providers and more recently by some practices. They inevitably have a balance between sensitivity and specificity for correctly identifying problems requiring urgent attention and can take longer.6

Challenges of triage

Some people would argue that clinical triage is one of the most challenging aspects of clinical practice and so should be undertaken by those with the most clinical experience. A number of initiatives and practices report a range of benefits in offering GP triage and telephone consultations to all calls from patients requesting GP appointments, in effect “total triage”.

When considering introducing a triage system to your practice, it’s worth reflecting on the purposes of triage, the potential benefits and risks involved, and until more evidence is available, adopting the type of triage that meets the needs of your patients and the practice.

Inevitably, triage overlaps with issues such as patient access, capacity and demand, telephone and appointment systems, skill mix, “Duty Doctor” role, patient demographics and staffing levels and should be considered in conjunction with these.

Identify red flag symptoms that should prompt an urgent response by reception staff

What matters when patients contact their surgery with an urgent need is whether they can get through, whether they will be correctly identified and whether they will be seen or dealt with quickly.7

An important point to make is that triage and telephone consulting are not synonymous. For example, while patients or their carers may request telephone advice for an acute problem, it is dangerous to assume that this automatically means the problem can be appropriately managed by a telephone consultation. Though they may occur in the same phone call, the triage and consultation components should be distinct, otherwise there is a danger that the triage part becomes overlooked. 

Undertaking triage

The usual starting point for triage is for the receptionist to establish the patient’s assessment of the degree of urgency. Establishing information as to the nature of the problem, severity, duration and particular concerns can help prioritise the urgency with which they need to be seen or action taken and this information can be passed onto the relevant clinician who may subsequently deal with the patient.

Ensure that any staff member, including reception staff, document full details of the call in the patient's clinical notes

Patients sometimes find receptionists asking them questions about their condition as unnecessarily intrusive, something that can be resolved with a sensitive approach and an explanation as to why the information is helpful to ensure that they receive appropriate and timely assessment, ie, signposting the triage process. The discussion can also help establish patient preferences and any choices available in the triage process, eg, a phone call back from a duty clinician or an urgent appointment.

Reception staff should not make any clinical judgment about patients’ needs or attempt to make a diagnosis. If they are involved in preliminary triage or prioritisation they should follow a clear protocol with algorithms and be supported to default to a safer option of speaking to a clinician if unsure or if the patient is unhappy with a proposed plan. 

Algorithms and protocols

Algorithms and protocols will need to be tailored to individual practices. Many practices have adopted a traffic light system or a range of standard actions for patient reported symptoms and groups of patients so as to appropriately prioritise the response for the receptionist. These actions might include: call 999; advise the patient to attend A&E; interrupt clinician straightaway; speak to clinician as soon as available (within 15 minutes); make appointment today; make an appointment tomorrow or make routine appointment. Actions should be based on likely patient symptoms rather than diagnoses. A list of potentially life-threatening symptoms, eg, vomiting blood would therefore be in the “call 999” box or “interrupt clinician straightaway” depending on practice preference. An animal bite might be in the “make appointment today”. These issues are discussed in more detail in MPS’s publication The GP Compass.8

Safety netting advice should always be given when triaging urgent requests, ie, seek medical help sooner if there is deterioration in the patient’s condition or increasing concern.

Documentation

Detailed documentation of the telephone assessment is vital. It is important that the medical records include enough detail to justify the proposed management and to demonstrate that appropriate management of the patient’s problem can take place without the need for a face-to-face consultation, where necessary.

Ensure clinicians have access to up to date clinical information and guidelines
References
  1. Baylis D (2012), Nurse telephone triage, Your Practice, Vol 6, Issue 2 (2012)
  2. Gallagher et al (1998), Telephone triage of acute illness by a practice nurse in general practice: outcomes of care, Br J Gen Pract. 1998 Apr;48(429):1141-5
  3. Bunn F et al (2004), Telephone consultation and triage: effects on health care use and patient satisfaction, Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD004180. DOI:0.1002/14651858.CD004180.pub2
  4. Campbell JL et al (2013), The effectiveness and cost-effectiveness of telephone triage of patients requesting same day consultations in general practice: study protocol for a cluster randomised controlled trial comparing nurse-led and GP-led management systems (ESTEEM), Trials. (2013) 4;14:4. doi: 10.1186/1745-6215-14-4
  5. Males T (2015), Risk of telephone consultations, Practice Matters, June (2015)
  6. Males T (2007), Telephone consultations in Primary Care; a practical guide, Royal College of General Practitioners (ISBN 978-0-85084-306-4)
  7. Primary Care Foundation, Urgent care. A practical guide to transforming same-day care in general practice (2009)

Tips on introducing a triage system

  • Involve staff and obtain patient views
  • Map out the existing journey for a patient wishing to have an urgent/same day appointment to identify bottlenecks, delays, duplication, omissions and risks
  • Develop a practice based triage protocol which clearly outlines the steps of the triage process and the roles and responsibilities of those involved
  • Consider whether algorithms or a decision support system would be helpful
  • Identify red flag symptoms that should prompt an urgent response by reception staff
  • Ensure clinicians have access to up to date clinical information and guidelines
  • Ensure that staff receive appropriate training on communication and listening skills before commencing the role and that it’s undertaken in a confidential location
  • Ensure that staff practise within own limitations and competence
  • Ensure that any staff member, including reception staff, document full details of the call in the patient's clinical notes
  • Ensure that the triage system is audited, monitored and evaluated as to its use, effectiveness, efficiency and safety
  • Ensure that there are adequate appointments available for patients, following triage, that require a face to face consultation.

CPD for your ePortfolio and revalidation

To help you collect the information you need for appraisal and revalidation, we have developed an online module to support this article.

The module should take no longer than 30 minutes and will provide you with 0.5 CPD credits; further CPD credits can also be claimed after completing the reflective notes.

What to do next…

Once you have read the article, simply go to www.mps.org.uk/practice-matters where you will find a link to our online learning platform.

You’ll need your membership details to register and log on.

Once logged on the module will be highlighted on the home page.

You can complete the module at a time that suits you and download your certificate of completion and any reflective notes.

4 comments
  • By Sheila Wheeler on 03 May 2018 03:44

    SAFETY OF CLINICAL AND NON-CLINICAL DECISION MAKERSIN TELEPHONE TRIAGE: A NARRATIVE REVIEW  Full article in PubMed. Wheeler, Greenberg, et al.

    Patient safety is a persistent problem in telephone triage research; however, studies have not differentiated between clinicians’ and non-clinicians’ respective safety. Currently, four groups of decision makers perform aspects of telephone triage: clinicians (physicians, nurses), and non-clinicians (emergency medical dispatchers (EMD) and clerical staff). Using studies published between 2002-2012, we applied Donabedian’s structure-process-outcome model to examine groups’ systems for evidence ofsystem completeness (a minimum measure of structure and quality). We defined system completeness as the presence of a decision maker and four additional components: guidelines, documentation, training, and standards. Defining safety as appropriate referrals (AR)– (right time, right place with the right person), we measured each groups’ corresponding AR rate percentages (outcomes). We analyzedeach group’srespective decision-making processas a safe match to the telephone triage task, based on each group’s system structure completeness, process and AR rates (outcome).  Studies uniformly noted system component presence: nurses (2-4), physicians (1), EMDs (2), clerical staff (1). Nurses had the highest average appropriate referral (AR) rates (91%), physicians’ AR (82% average). Clerical staff had no system and did not perform telephone triage by standard definitions; EMDs may represent the use of the wrong system. Telephone triage appears least safe after hours when decision makers with the least complete systems (physicians, clerical staff) typically manage calls. At minimum, telephone triage decision makers should be clinicians; however, clinicians’ safety calls for improvement. With improved training, standards and CDSS quality, the 24/7 clinical call center has potential to represent the national standard.  

    Research is still rife with confusion, misrepresentation and lack of complete, high quality systems in telephone triage.  Independent, peer-reviewed studies of structure, process and outcomes are still needed.

  • By Dr. Chris Morrell on 31 January 2018 02:45 This fails to refer to a number of more obvious limitations/objections. 1. Even in face-to-face consultation, the clinician often has painfully little time to consult patient history and elicit real cause of a visit. He/she often relies on previous experience of that patient. If patients are distributed randomly on the day of a visit (i.e. without being allowed to book an appointment to see a doctor who knows them) all this is lost. If outcomes are not to suffer as a result, GPs will need an increase in the time allotted to each visit. Thus, in this respect,  triage practice is wasteful of clinical resources. 2. From the patient perspective, triage takes confidence away from the GP system. It has been considered a reasonable expectation for a patient to see a particular doctor, even if the wait for an appointment is a long one. This practice has been the established norm for a great many reasons; a female patient may want to see a woman doctor and vice versa; a child may have confidence in the 'family doctor' but not in a stranger; an elderly patient with multiple chronic conditions should not be expected to go through a long patient history with any accuracy in the short time allowed (here an under-informed GP incurs the risk of poor combinative drug treatments); a patient with psychosomatic aspects to a physiological complaint is liable to be missed completely other than by a GP that he/she has consulted before (underlying psychological problems, according to one recent study, account for a third of GP visits); cultural knowledge of a particular patient group may be essential to effective GP consultation and is likely to be an expertise restricted to a single member of a GP practice; likewise expert knowledge and experience of certain conditions such as cancer, diabetes. This list is not exhaustive. If, as the 2014 study showed, triage costs are not lower than conventional GP practice, and do not result in a lower workload for GPs, it is difficult to see what can persuade GP practices to introduce an impoverished service to patients. GPs have a contract of service to perform, and it is in the nature of any contract that both parties must be satisfied by the terms agreed. At the very least, patients have a right to have a proposed change explained to them, and to express their opinion on any proposed change.
  • By S Williams on 26 May 2017 01:04 funny how things develop a life of their own!  Our practice recently started telephone triage- leave details and a GP will phone you back.  Flaw in the system- after a certain number of calls are taken and the call-back list is 'full', and a recording is put on saying no more calls will be accepted that day. Voicemail and email are also not available to the patient. So all the good systems described in this article about signposting etc, do not get a chance to come into play, and patients are denied even initial contact with a human being.  
  • By Tobias Armstrong on 25 January 2016 11:48 It's so interesting to me that there's so much that goes into a simple doctor's visit. From the patient side, you literally just walk in and get taken care of, but there's so much to take care of from the clinic's side. Next time I go in for an appointment, I'm going to try and pay a little more attention to see how much is going on behind the scenes. Thanks for the article!
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