clinical hub standard operating procedure clinical ... · manchester triage system telephone triage...

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Author Desiree Papadopoulos, Clinical Hub manager

Authorisation Tracy Pidgeon, Head of Clinical Hub Paul Gates, Consultant Paramedic

Authorisation date September 2018

Version 1.1

Related documents VP and Clinical Concern SOP, Use of Taxis OP073, OP023

Applicable to Clinical Hub clinicians

Aim:

To use enhanced clinical telephone assessment to ensure that patients receive a response which is not only safe and appropriate to their needs, but which also ensures the appropriate use of LAS resources. Objective: To provide guidance for clinicians on undertaking clinical telephone assessments and the use of the Manchester Triage System Telephone Triage Algorithms (MTS) to provide the appropriate response to each patient based on their clinically assessed need. To assist clinicians in referring a patient to the right person, at the right time and in the right place to meet the patient’s need.

Background: The Manchester Triage System Telephone Triage Algorithms are a product of the Advanced Life Support Group and are used under license from the publishers Wiley. For ease throughout this document it is referred to as MTS. The LAS uses MTS to augment the triage undertaken by non-clinical staff utilising the Medical Priority Dispatch System (MPDS). MTS is not designed to diagnose. It is intended to guide an appropriate referral decision, disposition or priority upgrade. It is utilised by Clinical Advisors (CAs), Clinical Team Leaders (CTLs), Mental Health nurses or other specialist nurses working in the Clinical Hub. It is a requirement of the license that only registered and trained clinicians can use MTS. Staff should be aware that all telephone assessments are confidential and must be managed in accordance with Trust Policy (TP/009) Access to Health Records and other related Trust and Clinical Hub policies and procedures.

Clinical Hub Standard Operating Procedure

Clinical Telephone Assessment and the Manchester Triage System

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It is expected that the Standard Operating Procedure (SOP) will be followed, however there may be rare occasions when it is not appropriate or Clinical Hub Management give a direct instruction to deviate. These cases must be clearly documented and the principles of (OP/40) Deviation from Clinical Guidelines must be followed. Clinical Advisors should consider discussing with a CTL or Clinical Hub manager before deviating from this SOP.

Basic Principles of Enhanced Telephone Assessment

• All enhanced telephone assessment must be undertaken using MTS. • Clinicians should advise the patient of where they are calling from, their name, grade, reason

for calling and that calls are being recorded and are confidential. • If relevant it would be appropriate to apologise for any delays in response at this stage. • Best practice is to speak to the patient to ensure that the most accurate clinical picture is

obtained and the patient’s individual preferences are accurately communicated. • If the clinician is unable to speak to the patient the reason should be documented and the identity

of the caller recorded. Permission should be obtained from the patient to discuss confidential information. It is recognised that certain groups of patients, e.g. advanced dementia may prove challenging for clinicians to obtain consent and this should be documented clearly.

• Only the patient (1st party) or somebody in the same room as the patient (2nd party) should receive a clinical telephone assessment using MTS. For clarification, 3rd party is someone who has made verbal contact with the patient from a different location; for example voice activated Care Line or a relative at a different address. 4th party is calls from control rooms where no voice contact has been made; for example LFB, London Buses, Care Line alarm activation with no voice contact. 3rd and 4th party are exclusions for MTS assessment, however a contact attempt should still be made in order to obtain as much clinical and safety information as possible; for example any medical history, if the patient is alone, do they regularly or rarely activate their emergency alarm, etc. Additionally, if not already available, a contact number for the patient should be obtained.

• Children aged 15 or younger should not be used as a 2nd party (see Exclusions below).

Functions of Enhanced Telephone Assessment

1. Obtain a full verbal history “Tell me exactly what made you call for help today.”

- Consideration should be given to non-verbal cues; for example shouting in the background, work of breathing (WOB). Note that some telephones filter non-voice ranges, so the fact that you cannot hear background noise does not mean it is not there.

2. Assess clinical need

- Be guided by MTS, the history, non-verbal cues and your previous training and experience. Beware of confirmation bias based on factors such as the original call priority, age of the patient, absence of existing past medical history (PMH), etc.

3. Formulate a treatment plan, educate and motivate the patient to engage with the plan

- Plans should be based on the clinical need of the patient, not service demand. - It is acceptable to tell patients that an emergency resource is not required based on your

clinical assessment. - Develop rapport to motivate non-adherent patients. - Inform the patient of the nature of their problem and your suggested treatment plan; e.g.

referral to a healthcare provider, NETS conveyance, taxi conveyance, advice and self-care. - Be honest about the demand on the service. If busy it is appropriate to use the following:

“Sorry, we are experiencing very high demand and long delays to send ambulances. We do prioritise our most seriously ill or injured patients first.”

- Do not discuss numbers of calls being held, specific time frames for waits or that OP66 has been invoked due to a CAD failure.

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- It is appropriate to give a general timeframe for response; e.g. within 2 to 4 hours for a NONEMERG4.

- Only give advice within your scope of practice and current UK clinical practice guidelines. - Ensure that the patient fully understands and engages with the plan.

Challenges to Effective Clinical Telephone Assessment

• Consideration should be given as to whether the patient can discuss their symptoms openly in a public place. Note that some patients may be in a public place specifically to enable this discussion.

• Clinicians should be aware of the inevitable risks associated with enhanced clinical telephone assessment, in particular the loss of visual cues and potential bias.

• Applying the following principles should help mitigate the risks of telephone triage: - Pace the call according to the urgency of the situation. - Remember that the patient also lacks visual cues. Speak slowly and clearly. - Phrase questions in a way that patients can understand, avoiding medical terminology and

jargon. - Avoid leading questions and ask open, not closed questions. - Avoid sounding like you are reading from a script by only asking relevant questions. - Ensure questions are answered sufficiently before moving on.

• To overcome language barriers clinicians should use language line where necessary. The language and the PIN of the interpreter should be documented and any relevant information should be relayed to the ambulance crew if appropriate.

Exclusions for Clinical Telephone Assessment through MTS

1. Where there is no telephone number for us to contact the patient. Consider utilising location history, Summary Care Record (SCR) demographics and internet searches.

2. Children under 16 where there is no responsible adult present. Consider safeguarding and the necessity for urgent dispatch of a resource.

3. 3rd or 4th party callers (see above). 4. Any of the following MPDS determinants/types

- METSBY Police standby

- METC1 METPOL Cat 1 - METC2 METPOL Cat 2 - RVPAGG Act of aggression - RVPACC Aircraft accident/imminent - RVPAI Armed incident - RVPED Possible echo delta - RVPFE Full emergency - RVPAGI Aircraft ground incident - RVPHT Helicopter incident - RVP Request for RVP - SERIOU Serious incident - MAJORA Major incident (auto dispatch) - MAJORB Major incident (manual dispatch) - PLATO Operation PLATO - ACTSHO Active shooter - DECON Decontamination/HAZMAT/CBRN incident - RVPTRA Train stalled/tunnel - SCBUEM SCBU emergency - SCBUNE SCBU non-emergency

Call Selection, Initial Actions and NRRB

• Calls should be selected from the appropriate dispatch group e.g. CDDG for CAT 4 ring backs.

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• Calls must be assessed in time order, with the exception of elderly/vulnerable fallers triaged through MPDS protocol 17 or calls that are specifically highlighted to the Clinical Hub due to concern. These patients should be prioritised for a clinical telephone assessment (see the VP and Clinical Concern SOP).

• Clinicians must press Shift F3 ‘Start of assessment’ to indicate to their colleagues that they are assessing that call (box next to status will show as E).

• Once the assessment is completed they should press Shift F4 ‘End of assessment’ (box next to status will show as F).

• If the patient does not answer make two further attempts approximately 5 minutes apart. Each failed attempt should be recorded by entering NRRB, CHUB in the command line; this ensures that the time of the attempt is recorded in the chronology. Document in the SUPP why the call was NRRB; i.e. VMAIL, MESSAGE LEFT.

• Where possible a voicemail should be left. This should include the reason for the call, a request for the patient to keep the line clear so a subsequent attempt to contact them is answered and a request to call 999 if the ambulance is no longer required.

• If the number is incorrect: 1. Contact the Call Taking Manager (CTM) to have the tape recording listened to and contact

number confirmed. 2. Use location history and SCR demographics for alternative telephone numbers. 3. Consideration should be given to checking local hospitals if you have enough information. 4. Where the patient is reported to be in a public place contact the EOC Watch Manager to

access CCTV if available. 5. If the origin of the call was Care Line they should be contacted to establish if any clinical

information can be obtained and voice contact made with the patient by Care Line. 6. Patients who are not contactable should be transferred back to the location dispatch group.

Consideration should be given to upgrading the priority of call if there is evidence on the CAD of a potential threat to life. Additionally the following patient groups should be treated with caution; mental health patients, under 18s, substance abuse, the elderly, patients who are alone or have significant co-morbidities. The rationale to upgrade or not must be documented in the log.

The determinant used must be one of the following: CHUB1N NO CHUB ASSESSMENT UNABLE TO MAKE CONTACT – CAT 1 CHUB2N NO CHUB ASSESSMENT UNABLE TO MAKE CONTACT – CAT 2 CHUB3N NO CHUB ASSESSMENT UNABLE TO MAKE CONTACT – CAT 3 CHUB4N NO CHUB ASSESSMENT UNABLE TO MAKE CONTACT – CAT 4 The selected relevant priority level of an N determinant should be based on the clinician’s judgement of risk based on the information available on either the active CAD or location history. • Decisions on upgrading NRRB calls should be guided by clinical judgement and discussions

with Clinical Hub managers and CTLs. • Shift F5 should be pressed to revert the call to complete (box next to status will show as C).

Manchester Triage System Telephone Triage Algorithms

• When used correctly MTS determines clinical urgency and manages clinical risk. • Its purpose is to use symptoms to identify an approximate time frame that a patient can safely

wait for a face to face (FtF) assessment by an appropriate health care professional (HCP). • MTS is regularly reviewed and the Clinical Hub Managers are responsible for ensuring the

most up to date version is being used. • MTS can only be used by registered HCPs who have completed the approved LAS training

package.

Using MTS for Enhanced Clinical Telephone Assessment

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• Red discriminators (life threatening or serious) should be excluded within the first 3 minutes of the call.

• It is recognised that some discriminators can be excluded without the need for questioning e.g. levels of consciousness can be determined by the ability to have an articulate conversation.

• Red flags are represented by a grey box in the bottom right corner of the MTS card and these should be referred to during the assessment.

• Very occasionally MTS will not have a card for a particular condition. In this case ‘NO SUITABLE MTS CARD’ should be documented in remarks. In this situation the clinician should use their clinical judgement and experience to assess the patient.

• The intention of the assessment is not to diagnose but to identify and prioritise symptoms. Reaching a diagnosis without visual clues, physical examination and tests/vital signs is, in the majority of cases, unsafe.

• If a threat to life (face to face now) is identified ensure that further advice does not delay a response by upgrading the call as soon as possible; this may be before the clinician has completed the conversation with the patient/caller.

• Every clinical telephone assessment must include taking an appropriate and relevant past medical, drug and social history. There may be some minor presentations where further exploration of the patient’s history is unnecessary or in cases of an immediate threat to life where it may be inappropriate. Avoid getting distracted by previous medical history (PMH) that is not related to the primary complaint.

• At the end of a call, appropriate clinical advice and generic worsening advice should be given. Clinicians should refer to the individual MTS card advice boxes. If this varies from the MTS advice then the reason why should be documented.

• Calls which have been clinically assessed and require an ambulance response must be transferred to the controlling Dispatch Group (DG) or NETSDG for a NETS resource.

• All calls where contact has been made (irrespective of whether an MTS assessment could be completed) RBACK, CHUB must be entered in the command line (or F7 function key).This must be followed immediately by the ETR command (or F8 function key); this will reset the welfare ring back time to the assigned priority of that call. These comments will then show in Chronology on the call log.

MTS outcomes

• Clinicians must use their clinical judgment, the nature and urgency of the symptoms, the distance to the hospital, the patient’s social situation, age, mobility, access to transport, and the likely delay for an ambulance attendance to decide how the face to face assessment is most appropriately achieved. This will normally involve a negotiation with the caller.

• Patients that have been assessed through MTS should have the determinant (shows as type on CP) edited to either a CHUB or NON-EMERG profile (appendix 1), or be closed with a Clinical Hub disposition (appendix 2).

• Should the patient be assessed using multiple MTS cards and the assessment concludes with differing acuity levels (FtF Now, FtF Soon and FtF Later) the clinician must base the outcome of the assessment on the highest acuity level.

• The designated time frame begins on commencement of the MTS enhanced assessment not the origin time of the call. However, consideration should be given when profiling a patient that has already waited an extended period. For example; a patient that has waited several hours pre assessment that is deemed by the clinician as NETS suitable should be considered for a within 1 hour or 1-2 hours, as opposed to a within 2-4 hours.

• If no discriminators are identified, blue self-care advice will be indicated. These patients are expected to be a rarity and the majority of patients should have the minimum of a referral. Document the MTS card followed by advice only e.g. MTS 40-ADVICE ONLY.

Documentation

• All clinical telephone assessments must be recorded in the CP event log in capitals (remarks section).

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• If for any reason a telephone other than that assigned to your workstation is used, then that telephone extension must be documented and the reason it was used (this should be very rare). If a patient’s telephone does not accept incoming calls from blocked numbers then use the backup (GPT) telephones on each desk and follow the instructions on appendix 3 for transferring the call to a recorded line.

• All calls are recorded therefore the written record is not designed to replace or duplicate the information from the tape. Written information is predominantly to allow dispatchers, ambulance staff and other members of the Clinical Hub to understand what has happened to the call/patient.

• Records must include the following:

- Presenting complaint

- MTS card/s and final discriminator/s, in numbers (e.g. MTS 22-15 & 27-13)

- Mode of transport and destination (e.g. MOW BY CAR TO CHWES UCC)

- If the patient is alone

- Any relevant exceptions made

- Any clinical, access or other relevant information that is likely to be useful to sector

Emergency Medical Dispatchers (EMD), crews or other Clinical Hub clinicians should be

tagged on the log

- Any refusal by the patient to accept an LAS resource, referral or advice

• Any new information gained in the enhanced assessment that is likely to affect staff or patient

safety must be sent as an urgent tagged message to the crew. Note that there is a 256

character limit in what can be sent to a crew.

• Any rationale that supports a clinical decision must be documented in the log. For example;

HOLDING 230 CALLS PAN LONDON, TAXI ETA 15 MINS, PT ESCORTED BY FRIEND.

Patients that do not require ambulance transport

• Patients that do not require a front line resource should be encouraged to either utilise their own transport or asked if they can arrange their own taxi.

• If booking an LAS taxi, staff must: - Advise the patient that transport home will not be provided - Ask permission to give the taxi firm their telephone number - Advise the patient that the ambulance service will pay for this journey to hospital therefore if

the driver asks for payment then they should refer them to the taxi control • When booking a taxi for a patient journey documentation must include:

- A mobile phone number for the patient

- The taxi booking reference TX=******

- The destination and department i.e. STTOM UCC, MIU, ED or GP surgery

Referral to an Appropriate Care Pathway

• Best practice dictates that the patient should ideally only have to make one phone call to access appropriate care and therefore, the LAS clinician should assume responsibility for the referral of the patient to the ACP (including GP Services).

• This is not the case where appointments are not required for the ACP; for example, a walk in service (refer to NHS MiDoS as required). Clinicians must ensure that the patient will be accepted and that the facility will be open when the patient arrives.

• Where a referral has been made by the clinician a reference number, name of the person taking the patient details and type of referral pathway (i.e. OOH GP service) must be documented.

• Referral to a HCP should ideally be LAS clinician to HCP wherever possible i.e. talk to the GP or Nurse directly to provide the clinical handover.

• In cases where the HCP is unavailable to discuss the patient, the clinician should provide their contact name, CAD number and the Clinical Hub contact number and request the HCP calls back as soon as possible. Ensure all actions are documented i.e. number you called, the person you spoke to and the estimated time the HCP will contact you back.

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• Where an appropriate pathway is considered it should be searched for in MiDoS. This will give information about the suitability of the pathway, and in many cases a non-public number to contact them on. This number must not be given to non LAS staff. If the pathway cannot be found, or if they decline the referral, then the MiDoS feedback system must be used to record this.

Cardiac arrest, imminent childbirth and choking during enhanced telephone assessment

• If during the enhanced telephone assessment the patient is identified as any of the above,

the immediate action of the clinician must be to upgrade the call and ensure the call is in the

correct location DG. Cardiac arrest, imminent childbirth with head out/visible/crowning and

choking with complete obstruction/not breathing/unresponsive must all be profiled as

CHUB1C.

• An urgent tagged message in remarks should state the reason for the upgrade i.e. PT IN

LABOUR AND CROWNING.

• The relevant instructions card within MTS (CPR adult, child, infant or new born) must be

adhered to and utilised as soon as the priority has been upgraded; do not provide ad-lib

instructions.

• A colleague must be identified to contact the CTM (extension 1000 for Bow and 2000 for

Waterloo) for an available EMD to take over instructions from the clinician. Do not put the

caller on hold to ring the CTM as the assessing clinician must give uninterrupted instructions

to the caller.

• The call must be conferenced with the EMD, not transferred due to the risk of disconnecting

the caller. A brief handover should be given to the EMD as to the current presentation, i.e.

BBA with cord around neck. This is so the EMD is aware that it is not a new call and therefore

which stage of their Pre-Arrival Instructions (PAIs) they need to commence.

• The call should be monitored by the clinician for updated information that may benefit sector and attending resources i.e. BBA or CPR in progress by relative. This information must be

sent as an urgent tagged message to the crew and sector advised verbally.

Other life threatening situations during enhanced telephone assessment

• There are instruction cards within MTS for bleeding, fitting and unconscious patients which should be utilised. All pre-arrival instructions are included in the MTS document on the home screen.

Summary Care Records (SCR)

• SCR should be viewed for all patients that receive an MTS assessment and consent must be gained from the patient. In cases of threat to life access consent should be post upgrade.

• On all records accessed with patient consent enter the CAD number in the box shown below. This appears once you have selected the view SCR button and then click the Provide more information about the access (optional) line for the box to appear.

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• It is mandated to view the SCR demographics for all children (under 18 years). Request consent

from the parent or responsible adult with the child. If the parent/adult refuses to consent, view the record as an emergency access. Record the CAD number and reason (i.e. parent refused consent) in the text box on SCR.

• Pregnant females need to have SCR demographics viewed for the presence of a safeguarding flag. Examples include Unborn Baby at Risk and FGM. These flags show on the demographic screen so consent is not needed to view this. Consent must be sought in the normal way to view the full record.

• If a flag is seen it must be opened and read to confirm its relevance to the patient. Note that an FGM tab appears on the record of ALL females under the age of 18.

• All safeguarding concerns must be escalated to the Emergency Bed Service (EBS) via the telephone, not face to face with EBS staff. It is expected that a FtF assessment will follow if you have a safeguarding concern. Where this is not the case the issue should be discussed with a CTL or Clinical Hub or EBS manager and the reasons clearly documented on call log. A call must be made to the destination for any paediatric patient who is conveyed by the parent/responsible adult to ensure that they have arrived. This is irrespective of whether there is a safeguarding concern.

• All emergency access to records must have the CAD number and the reason for emergency access written in the text box on SCR. The following are examples of when emergency access is warranted: - Patient is in cardiac arrest - Patient is unconscious - Patient does not have capacity - Safeguarding of a paediatric patient. Best practice is obtaining parent/responsible adult

consent, however emergency access is valid if consent is refused or if obtaining consent may put the child at further risk

- Patient is deceased - Unable to make contact and valid clinical concern

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• An SCR code should be documented as a SUPP in all instances of use and this can be as a stand-alone entry: - SCR01 (Information relevant and assisted clinical assessment) - SCR02 (Information irrelevant and did not assist clinical assessment) - SCR03 (No record found) - SCR04 (Unable to access due to IT issues)

Information of Interest (IOI) flagged addresses Where there is a flag against the address, then confirmation must be sought to confirm if the information in the flag relates to the patient being assessed. This information must then be checked and used to inform your assessment. Flags may include frequent caller, palliative care or CMC information. Upgrading Calls

• Clinicians must not upgrade the priority of a call based solely on the time the call has been held. • If a call has been held for a prolonged period every effort should be made to undertake an MTS

assessment. If this is not possible due to the inability to contact the patient/2nd party, then the instructions above in No Reply on Ring Back (NRRB) should be adhered to.

• It is appreciated that at times of high demand clinicians may not have the capacity to contact every patient awaiting a response. During these times it is acceptable to upgrade the priority of a held call based on the information on the CAD or from previous calls to that patient; however, this is the exception and must not be done routinely. Examples of the type of call that may be upgraded without a telephone assessment include: - Cancer patients that are currently undergoing chemotherapy and complaining of symptoms

that could indicate neutropenic sepsis such as fever, vomiting, generalised pain - Overdose patients that have taken a potentially toxic overdose

• In these instances justification for the upgrade must be documented on the log and must include the clinical reason and the number of calls holding across the Trust. For example: UPGRADED, TOXIC OD OF PAR TAKEN WITH ALCOHOL AND PT ALONE, NO CAPACITY TO RB, HOLDING 250 CALLS PAN LONDON. • ONLY a CHUB*N determinant must be used.

Cancellation calls

• If a cancellation is received for a Cat 4 call in CDDG the CANCEL call must be duplicated to the original; the two CADS should not be closed independently without duplication.

• If the cancellation in CDDG is for an original CAD in sector, transfer the C4 CAD using the command TE G/**DG to the controlling sector DG for the EMD to duplicate and close.

• The call handling EMD will have cross referenced the call and this will show in Chronology as an XREF.

• To duplicate calls, utilise one of two methods: - On the CANCEL call select the NEARBY button if highlighted in orange, select the original

CAD and select DUP. This will close the cancellation and show the information on the original CAD in Remarks. or

- In the command line type DUP #**** #**** and press ENTER. The first CAD number typed must be the oldest timed CAD and the 2nd CAD number typed the cancellation, which will be closed once ENTER is pressed.

• If the clinician is confident that closing the call is clinically appropriate the original call will need to be closed with a SHIFT + F9. Use CANCEL BY THE PATIENT from the drop down list. Do not use the Chub disposition 5012 (False alarm/not required) as no patient contact has been made.

• Instances where a cancellation would not be appropriate to accept include mental health patients threatening suicide and possibly paediatric patients where a FtF with a clinician has

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not been sought by the patient/parent, i.e. MOW to a facility. In these cases, attempt to undertake a clinical telephone assessment using MTS or if unsuccessful discuss with the sector EMD for a FtF LAS response, which may include a solo resource if there are no crew safety concerns.

Duplicate calls • If the Cat4 call in CDDG is a duplicate call for an original CAD in sector or a duplicate call for a

higher priority call in sector, transfer the duplicate call to the location DG using the command TE G/**DG. Clinicians must only duplicate two or more calls held within the DG we control; CDDG.

• It is vital that only two or more calls for the same patient are duplicated. Be aware of two different patients in close proximity to one another; for example, in a block of flats or in a care home. In these instances the location history button and/or nearby button may be highlighted orange. This is not confirmation that the two or more calls are for the same patient.

• Check chronology for the XREF, matching origin telephone numbers, patient gender, age, name if documented and update diagnosis in the comments field for confirmation. If it is not possible to absolutely confirm that secondary calls are for the same patient do not duplicate the calls but transfer the CAD to the controlling DG and advise the sector EMD or Area Controller that you cannot confirm the two or more CADs are for the same patient.

• When duplicating calls the oldest timed call must be kept open. The highest category priority (i.e. Cat2) will be maintained when calls are duplicated. Utilise one of the 2 methods listed above to duplicate the calls.

• Additionally, the determinant/type of the newer CAD must be manually edited on the original CAD. Once duplicated select the edit function and change the determinant/type to that of the newer CAD.

• All duplicates must be cross checked with a colleague prior to the duplication being completed.

Closing calls • The only calls that can be legitimately closed without making patient contact are those from a

public payphone. In these cases, 3 ring backs over a period of approximately 20 minutes, should be undertaken with an NRRB command entered for each attempt. If after 3 attempts there is no answer the call can be closed using the Chub disposition 5012 (false alarm/not required).

• Before closing, check that there are no calls in the vicinity of the payphone with a similar presenting complaint; in which case after 3 attempts the call may need to be duplicated to the alternative CAD.

• In instances where patient contact is made and an LAS resource is no longer required; for example, the patient has MOW to a facility for a FtF with a HCP, utilise the same 5012 disposition.

• In instances where patient contact is made and the patient advises they have recovered and no longer require an LAS resource, consideration should be made by the clinician to still undertake an MTS assessment and closure with the Chub disposition 5010 (advice/self-care).

Specific conditions • If a patient presents with any of the following conditions during an MTS assessment, the

following determinant profiles should be assigned as a minimum, regardless of the outcome of the assessment:

- Addison’s Disease = CHUB2C - Chemotherapy/Neutropenic = CHUB2C

• If an MTS assessment is not possible the clinician should assign a minimum Cat2 priority for patients with these conditions.

MPS calls, including patients in police custody • MPS calls received through the CAD link in the majority of cases will be a METPOL determinant

and a Cat 3 priority.

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• METDG, when staffed, will transfer the call to METDG and triage the patient via the MPS officer through MPDS. If METDG EMDs do not close the call, they will transfer the call back to the location DG for a resource to be dispatched. The call will then show with the appropriate MPDS determinant/type and aligned priority category with a METDG flag. At this stage the patient can be clinically telephone assessed using MTS as with any other call.

• If the call is being closed by the clinician the MPS must be advised of the cancellation of the LAS resource and the reason for cancellation, such as taxi to a MH facility. Select shift + F7, use option OTHER and advise of the reason in the free text. Do not use CANCEL as MPS may choose to attend the patient if remaining at home. To contact an officer via their radio dial 611900****** (using the 6 digit ISSI number).

• A clinical telephone assessment should still be attempted on patients in a police custody suite but MTS can only be utilised if the police officer is with the patient. The LAS is contracted to send a resource to custody patients (does not include patients presenting to the front office). Clinicians must not deploy a taxi or request for police officers to convey a patient in custody, regardless of the presenting complaint. If the police offer to transport a patient that is their choice.

111 calls and MTS assessments • The majority of 111 calls passed to the LAS are sent electronically via the ITK link and will have

clinical information documented in the chronology. On occasion calls will be passed verbally and in these instances the clinical information documented in chronology will not be present.

• There are nationally agreed time-frames for ambulance response (appendix 5). • Clinical responsibility remains with 111 until any of the following apply:

- The LAS have arrived on scene at the incident - The LAS have breached the ambulance on scene time assigned to the DX code - An LAS clinician from EOC has made contact with the patient

• If a DX call is to be clinically assessed a complete MTS assessment must be attempted. If a patient has received additional clinical questioning during a NHS Pathways assessment from a clinician (paramedic or nurse) at 111, this can be evidenced by the notes in the chronology and should be taken into consideration. Best practice would be to discuss with the patient what information/plan was established with the 111 clinician. Documented NHS Pathways answers must not be used in place of direct patient questioning.

• DX calls can be contacted and assessed for alternative transport options, regardless of when the call was received into EOC.

• When assessing the patient, do not advise an emergency response is not required as this contradicts the advice given by 111, resulting in poor patient experience. If utilising a taxi conveyance for the patient, explain that this is due to LAS demand.

• On occasion some DX calls post MTS assessment, may be appropriate for an extended time frame and NETS conveyance. If transferring a DX call to NETS DG for conveyance, ensure you have advised the patient of the anticipated time frame.

• If the patient declines transport to a facility and you are providing either self-care advice or referring to an alternative HCP (such as District Nurse), then a full MTS assessment must be completed and documented, regardless of whether the patient spoke to a clinician at 111.

• If a 111 clinician has a clinical concern they will contact LAS and request the EMD attaches a 111 clinical flag. If a dispatch delay has occurred or is anticipated, clinicians must aim to MTS assess these calls within or as close to the allocated time frame as possible.

Governance

• The Manchester Triage group has a requirement that all clinicians who provide enhanced clinical telephone assessment receive a regular audit. The Clinical Hub completes this process in two forms, retrospective quality assurance and peer review.

• Live peer reviews must take place using the LAS peer review form (appendix 4). Each MTS user is expected to have undertaken and received five peer reviews per calendar month. These will be filled in electronically and returned via email to their respective line manager.

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• Managers/CTLs in the Clinical Hub will undertake retrospective quality assurance (QA) audits of each individual’s performance and adherence to MTS procedures and any related SOP’s. This is comprised of four QA audits per individual, per month, which are completed using the LAS MTS audit tool. QA, peer reviews and quantitative performance indicators will be combined to provide feedback to staff working within the Clinical Hub. This is to ensure staff continue to provide safe and effective care and improve the quality of their service.

• Any complaint raised will also be subject to QA against the audit tool. This QA will support any investigation and/or reflective learning process and feedback will be undertaken with the member of staff.

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Appendix 1 – Clinical Hub determinants

Response Profile

MTS outcome

Description Resource

type Priority Measure

CHUB1 FtF now POST CHUB ASSESMENT AEU &

FRU/MRU C1

Mean <7 mins 90% within 15 mins

CHUB2 FtF now POST CHUB ASSESMENT AEU C2 Mean <18 mins

90% within 40 mins

CHUB3 FtF soon POST CHUB ASSESMENT AEU C3 90% within 120 mins

CHUB4 FtF later POST CHUB ASSESMENT AEU C4 90% within 180 mins

CHUB1C FtF now POST CHUB ASSESMENT

CLINICAL CONCERN AEU &

FRU/MRU C1

Mean of <7 mins 90% within 15 mins

CHUB2C FtF now POST CHUB ASSESMENT

CLINICAL CONCERN AEU C2


CHUB3C FtF soon POST CHUB ASSESMENT

CLINICAL CONCERN AEU C3 90% within 120 mins

CHUB1V FtF now POST CHUB ASSESMENT

VULNERABLE FALLER AEU &

FRU/MRU C1

Mean of <7 mins 90% within 15 mins

CHUB2V FtF now POST CHUB ASSESMENT

VULNERABLE FALLER AEU C2


CHUB3V FtF soon POST CHUB ASSESMENT

VULNERABLE FALLER AEU C3 90% within 120 mins

CHUB1M FtF now POST CHUB ASSESSMENT MENTAL HEALTH PATIENT

AEU & FRU/MRU

C1 Mean <7 mins

90% within 15 mins

CHUB2M FtF now POST CHUB ASSESSMENT MENTAL HEALTH PATIENT

AEU C2 Mean <18 mins

90% within 40 mins

CHUB3M FtF soon POST CHUB ASSESSMENT MENTAL HEALTH PATIENT

AEU C3 90% within 120 mins

CHUB4M FtF later POST CHUB ASSESSMENT MENTAL HEALTH PATIENT

AEU C4 90% within 180 mins

CHUB1N FtF now NO CHUB ASSESSMENT

UNABLE TO MAKE CONTACT AEU &

FRU/MRU C1


CHUB2N FtF now NO CHUB ASSESSMENT

UNABLE TO MAKE CONTACT AEU C2


CHUB3N FtF soon NO CHUB ASSESSMENT

UNABLE TO MAKE CONTACT AEU C3 90% within 120 mins

CHUB4N FtF later NO CHUB ASSESSMENT

UNABLE TO MAKE CONTACT AEU C4 90% within 180 mins

NONEMERG1

FtF soon NON EMERGENCY

TRANPSPORT WITHIN 1 HOUR

NETS C4

NONEMERG2

FtF later NON EMERGENCY

TRANPSPORT WITHIN 1 – 2 HOURS

NETS C4

NONEMERG4

FtF later NON EMERGENCY

TRANPSPORT WITHIN 2 - 4 HOURS

NETS C4

14

Appendix 2 – Clinical Hub Hear and Treat dispositions.

5008 Deceased, no LAS attendance

5010 Advice/self-care

5012 False alarm/not required – stop code

5021 Referred to own GP/ OOH GP

5022 Referred to D/N

5024 Referred to Social Services

5027 Referred to Specialist team

5028 Referred to Palliative team

5031 Referred to Mental Health team

5099 Referred to other

5121 Referred to Pharmacy

5124 Referred to RAD

7021 Taxi to GP/OOH GP base

7025 Taxi to ED

7026 Taxi to UCC/MIU/WIC

7028 Taxi to Hospice

7031 Taxi to MH facility

7099 Taxi to other

8021 MOW to GP/OOH GP base

8025 MOW to ED

8026 MOW to UCC/MIU/WIC

8028 MOW to Hospice

8031 MOW to MH facility

8099 MOW to other

15

Appendix 3 – Procedure for calling back patients who do not accept anonymous phone calls.

The instructions below outline the procedure for transferring calls from “Non Recorded” to a “Recorded”

line.

There are 2 types of “Non Recorded” phones in use in the Clinical Hub

GPT phone:

1. Call the patient using the GPT phone (dial 9 for an outside line)

2. Introduce yourself to the patient and explain that you need to transfer the call to another line.

(Explain that the line will be silent for a few moments).

3. Press the top right button (indicated by the red arrow in the image above)

4. Dial 7900 followed by the extension number of the Clinical Advisor who will be doing the MTS

assessment.

5. The Clinical Advisor picks up the AVAYA phone when it rings.

6. Hang up the GPT phone. The call is now connected to the AVAYA phone, which is a recorded line.

TRANSFER BUTTON

16

Appendix 4 - LAS- Manchester Triage System Clinical Hub Peer Review Form Name:

Event No:

Reviewer:

Date:

Fully achieved or N/A

Partially achieved

Not

achieved

Effective communication - skilled questioning

1. Uses the appropriate agreed scrip & explains the reasons for the call

2. Speaks directly to the patient/ensures the caller is with the patient

3. Elicits relevant history & the presenting complaint

4. Controls the call & the information from the caller

5. Determines relevant extended history (e.g. PMH, medication, social hx)

6. Phrases questions in a way that the caller can understand e.g.

not using medical jargon

7. Avoids use of leading questions (e.g. “you don’t have any pain do you?”)

8. Recognises when to probe about the presenting complaint

9. Ensures questions are answered adequately

Effective communication – Active listening

10. Builds a good rapport, shows respect, empathy, polite manner & addresses

the caller/patient’s concerns in a professional manner

11. Accurately picks up on verbal/non-verbal cues (e.g.

background noise)

12. Demonstrates active listening, but not repeating needlessly

Skilled provision of information & advice

13. Responds appropriately to callers requests for information

14. Provides appropriate information & advice, including emergency care, analgesia,

comfort & health promotion advice where necessary

Skilled use of MTS

15. Appropriate MTS card utilised

16. Moves through MTS logically & efficiently – recognises clinical risk points & does not

delay any response

17. Appropriate outcome reached & correct discriminator elicited

Delivers a safe & effective outcome for the patient

18. Appropriate patient outcome & appropriate use of the PPM

19. Negotiates where it is appropriate & does so effectively

20. Ensures appropriate follow up arrangements where necessary (e.g. GP, considers

safeguarding & vulnerable child or adult referrals)

21. Ensures consent was obtained to access the patients Summary Care Records (SCR)

22. Information gained from the SCR was used effectively and appropriately to enhance

safer alternative care pathway options

23. Provides appropriate targeted & generic worsening advice

23. Ensures the patient/caller understands the outcome of the call & the advice given

24. Documentation in command point is clear, concise & accurate with the discriminator &

outcome clearly identifiable

General comments (ref no. above) Learning needs identified

Fully achieved: Demonstrated to a good/excellent standard or not applicable.

Partially achieved: Any issues identified in this indicator did not affect the overall safety of the call. Not achieved: Issues identified have affected the safety of the call.

17

Appendix 5 – 111 DX dispositions Disposition Description Priority

DX010 Emergency Ambulance Response for Potential Cardiac Arrest C1

DX0101 Emergency Ambulance Response for Potential Cardiac Arrest C1

DX0102 Emergency Ambulance Response for Potential Cardiac Arrest Post Delivery C1

DX0103 Emergency Ambulance Response for Fitting Now C1

DX0104 Emergency Ambulance Response for Major Blood Loss C1

DX0105 Emergency Ambulance Response for Potential Shock C1

DX0106 Emergency Ambulance Response for Respiratory Distress C1

DX0107 Emergency Ambulance Response for Unconsciousness C1

DX011 Emergency Ambulance Response C2

DX0111 Emergency Ambulance Response for Acute Abdomen Pregnant C2

DX0112 Emergency Ambulance Response for Acute Coronary Syndrome C2

DX0113 Emergency Ambulance Response for Anaphylaxis C2

DX0114 Emergency Ambulance Response for Aortic Aneurysm Rupture/Dissection C2

DX0115 Emergency Ambulance Response for Labour Complications C2

DX0116 Emergency Ambulance Response for Major Blood Loss C2

DX0117 Emergency Ambulance Response for Possible Stroke Time Critical C2

DX0118 Emergency Ambulance Response for Potential Shock C2

DX0119 Emergency Ambulance Response for Respiratory Distress Non-Trauma C2

DX01120 Emergency Ambulance Response for Respiratory Distress Trauma C2

DX01121 Emergency Ambulance Response for Septicaemia C2

DX01122 Emergency Ambulance Response for Unconsciousness C2

DX0181 Emergency Ambulance due to Clinical Reasons C2

DX014 Crew arrived before a disposition was reached C2




DX0125 Emergency Ambulance Response (override from non-ambulance disposition) C3

DX0126 Emergency Ambulance Response for Trauma Emergency C3

DX0127 Emergency Ambulance Response for Pregnancy/Labour problem C3


DX0162 Transport to an Emergency Treatment Centre within 1 hour C3

DX0128 Non-emergency Ambulance Response (override from non-ambulance disposition) C4

DX017 Ambulance for Clinical Reasons C4

DX018 Ambulance for Transport Reasons C4

DX016 Non-emergency Ambulance Response C4

DX013 Assistance needed at home due to inability to get off the floor C4

DX0161 Non-emergency Ambulance Response possible Viral Haemorrhagic Fever C4

DX024 Assistance is being dispatched to arrive within 2 hours C4


DX026 Deferred dispatch is being arranged C4


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