Advice: How safe is your telephone triage system?

THE coronavirus outbreak has given GP practices little choice but to change the ways in which they normally operate, while also contending with the need to reduce the risk of exposure to both staff and patients. An effective telephone triage system is clearly an essential tool in this new way of working.

The General Medical Council has published a statement outlining how it will support doctors during the pandemic and how it will continue to regulate during this time. The statement recognises that “some doctors may need to depart, possibly significantly, from established procedures in order to care for patients”. The GMC has also acknowledged the need for appointment allocation to be changed to a telephone triage system with the option of remote consultations, which means that good communication with patients is necessary to reduce uncertainty or resistance to what may or not be temporary measures.

We would encourage practices to share with patients any significant changes to existing service arrangements promptly, both through traditional communication channels and also via your social media presence (if applicable), website and electronic text messaging.

While there are well-documented risks in using non-clinical staff to facilitate entry into the triage process, these team members can play an important role when trained appropriately. Practices can manage their risk by having guidance and specific training for reception staff on operating an effective and safe telephone triage system. This will involve clear protocols and guidance for staff on how to prioritise calls based on their urgency, recognising red-flag symptoms, as well as for escalating a request to a clinician where indicated.

Non-clinical staff should never be placed in a position where they are exercising clinical judgment but rather should be guiding the patient through a defined triage process. GPs can help by agreeing on specific questions or algorithms for receptionists to follow.

Non-clinical staff must also be made aware that even casual inferences or ‘chats’ involving symptoms, advice or reassurance can be perceived as ‘medical advice’ by a patient when given in the context of their practice role.

The practice should ensure that a non-clinical staff member is able to seek an immediate opinion from a clinician should this be necessary.

It is a requirement by the GMC for doctors to keep adequate records of any advice they give to patients. This not only helps with continuity of care for the next doctor who is reviewing the patient but also provides evidence of what the patient has been told. The same need to document applies to all staff who have contact with patients.

In addition to written information and communication regarding the practice triage system, the patient should also be told at the start of the process what to expect and what is expected of them in return. This will help educate and reassure that any further information requested from the receptionist is purely to benefit the patient and to ensure they are triaged appropriately.

Examples might include explaining steps in the telephone triage process and timescales for call-backs. The GPs should consider very carefully whether there are any circumstances in which non-clinical staff may signpost patients what to do in the case of worsening symptoms while awaiting a call back from a clinician.

Some patients may be concerned about disclosing personal information to a non-clinical member of staff, so it may be useful to remind them that all practice staff follow the same confidentiality principles.

Once formulated, staffed and managed appropriately, telephone triage can be a valuable system for both patients and the practice, facilitating speedier access to the most appropriate member of the clinical team. The key to a safe system lies in each member of staff being aware of their responsibilities and limitations, and being fully trained and equipped with the knowledge of how to provide an effective and robust service.

Active signposting has also come to the fore in recent years with the intention of reducing unnecessary telephone consultation bookings, recognising that there are occasions when the patient could be signposted to self-help or offered an alternative service. This is distinct from a formal telephone triaging service but also requires reception staff to follow a set of protocols.

Patients who do not require a GP to deal with their query may be signposted by reception staff to other allied healthcare professionals, non-medical staff or an alternative service, such as the NHS coronavirus information hubs. Robust staff training and ongoing assessment is essential to ensure patient safety remains paramount.

How can you ensure the safety and effectiveness of your triage system?

• Triage and call-back procedures need to be structured. Patients requesting a remote consultation should be given a clear timeframe within which they can expect to hear back from a healthcare professional and when to re-contact the practice if they have not been contacted. This serves as a safety net for any technical issues or potential misunderstandings – for example if the patient’s telephone number has been incorrectly recorded.
• Practices should ensure patient contact details are correct and this could mean introducing a process whereby personal details are checked and updated routinely.
• Ensure that those undertaking triage calls have clear guidance on initiating and pursuing call-backs and how many attempts should be made before recording a failed contact. In the current situation it may be prudent to be more flexible and make further attempts to call back than in normal circumstances, especially if your patients have not previously been familiar with telephone triage.
• Manage remote appointment allocation equitably to ensure that the most assertive patients are not prioritised at the expense of others who may actually have more serious problems. This may require further training and awareness-raising for non-clinical staff.

Alan Frame is a risk adviser at MDDUS