OOH Training for GPStRs

• Practical aspects of working in OOH setting• Consultation models F2F• Computer records• Telephone consultations• Red Eye• Palliative care• Controlled drugs• Confirmation of Death• Mental Health• Audit

Plan

Time and Record Keeping

• Allocation of shifts• Any swaps to be informed to me for Kingston

&SMPCT and To Dr Fernandes for Croydon• Arrive on time with your folder• Learning needs from your trainer• Your learning needs – discuss with ES• E-PORTFOLIO

Confidentiality

Time management

• We all working to achieve quality standards

• We work as a team to get to the standards

Use this opportunity

• Ideal setting for practicing for CSA• All patients have one problem• Aim for 10 min consultation

Referring a patient as a medical or surgical emergency or to the community services e.g. arranging Out of Hours district nursing.

Dealing with a death, contrasting an expected death with a sudden death and the personnel and services involved.

Problems of terminal care managed by Out of Hours provider.

Psychiatric problem dealt with Out of Hours e.g. a risk assessment/ MHA section.

Commentary on a management/organisational issue

e.g. arrangements for Out of Hours care for Christmas/ Bank holiday weekend, a local flu/meningitis outbreak.

Critical Event and complaints report (if relevant).

Assessment of competence

Record Keeping

• For your own learning

• Keep all the comments by the Education supervisor – bring it back with you !

• Keep a record of patients seen/triaged/visited/referred

• Record any significant events

Record Keeping

• On line clinician• What you write is what GPs get• Medication and allergies recorded• MIC patients – dispense only –list in pack• If GP f/u make sure patient know and

notes say so and give a time for this• If there is some thing important you want

GP to know then inform the service leader who will fax your consultation

Child protection

• Any issues please discuss with your education supervisor and should contact duty social worker at the same time , before patient leaves the consultation room

Consultations

Eighty-year-old was furious as she came out of the consulting room. Her complaint: "The doctor examined me and said, `Why should you worry about it at your age?‘

If Doctor didn't want to treat me, he should have kept quiet. I'm not coming here again."

Consultations

Primary Care• Open access• First point of contact• Varied, unsorted and

multiple problems• Patient initiated• Shorter time for

consultation

Secondary care• Restricted access• Contact only by

referral• Symptoms pre-

packaged• Single and usually

identified problem• More time

Consultations- different modelsone – the future GP

• Problem presented• Problem examined• Problem defined

• Solution proposed• Solution examined• Solution implemented

Consultations- different modelstwo - Byren and Long

• Doctor establishes relationship with patient

• Doctors discovers the reason for the patients attendance

• Doctor conducts an examination

• Doctor and patient considers the condition

• Doctor and occasionally patient details treatment

• Consultation terminated usually by doctor

Consultations- different modelsthree – Stott and Davis

• Management of presentation problems

• Modification of help-seeking behaviour

• Management of continuing problem

• Opportunistic health promotion

Consultations- different modelsfour- Pendleton’s Seven Tasks

1.Define the reason for the patient’s attendance ,including:The nature and history , their cause, the patient’s , concerns andExpectations , the effect of the problem

2.Consider other problems :Continuing problems

3. choose with the patient an appropriate action for each problem4.Achieve a shared understanding of the problems with patient

5.Involve the patient in the management and encourage patient to accept appropriate responsibility

6. Use time and resources appropriately in the consultation in the long term

•7.Establish or maintain a relationship with the patient which helps to achieve the other tasks

Consultations- different modelsfive - Middleton

Patient Agenda Doctor’s agenda

Negotiated plan

Consultations- different modelssix - Neighbour

• Connecting

• Summarising

• Handing over

• Safety-netting

• Housekeeping

Medical Model of Consultation

The majority of symptoms brought to GP have no clear identifiable specific cause or treatment

Recognising that a problem is functional or medically unexplained and so lies outside the medical model, does not mean we have failed to diagnose and it does not lead to therapeutic nihilism

It is a positive indeed crucial step towards appropriate management

The aim of management is salutogenesis

(is a concept that focuses on factors that support human health and well-being rather than on factors that cause disease)

Consulting skillsThe 5 e questions?

Effect of symptoms How is this affecting you?

Emotions surrounding it How do you feel about it?

Patients own Explanation for it What possible causes crossed your mind?

Patients Expectations of consultation Where do you think we might go with this?

Epitasis- the point just before the climax of a play at which the plot thickens

What made you decide to make this appointment?

Patient Enquiries Is there anything you want to ask me?

RED EYE

• Not Painful

1. Blepharitis

2. Conjuctivitis

3. Subconjuctival Haemhorrage

• Painful with Normal Vision

1. FB

2. Corneal Abrasion

3. Episcleritis

• Painful with reduced vision

1. Acute Glaucoma

2. Iritis

3. Scleritis

4. Corneal Ulcer

Urgent Care Audit

• An Out of Hours Audit Toolkit has been produced to monitor and improve out of hours services. It is an independent toolkit produced by experienced clinicians who have first hand knowledge of commissioning and providing

out of hours services.

The Audit Criteria based on the ‘Consultation’

CRITERION RATIONALE

1 Elicits REASON for telephone call or visit

Clearly identifies main reason for contactIdentifies patient’s concerns [health beliefs]Accurate information e.g. demographics in CH’s

2 Identifies EMERGENCY or serious situations

Asks appropriate questions to exclude [or suggest] such situationsAppropriate use of ILTC protocols

3 Appropriate HISTORY taking (or algorithm use)

Identifies relevant past Medical History / Drug History [including drug allergy]Elicits significant contextual information (e.g. social history)

4 Carries out appropriate ASSESSMENT

Face-to-face settings - appropriate examination carried outClinician on telephone - targeted information gathering or algorithm use to aid decision making

5 Draws appropriate CONCLUSIONS Clinician face-to-face/ telephone – makes appropriate diagnosis or differential / or identifies appropriate “symptom cluster” with algorithm useCH – makes appropriate prioritisation CH - streams call appropriately

6 Displays EMPOWERING behaviour Acts on cues/beliefsInvolves patient in decision-making Use of self-help advice [inc. PILs]

7 Makes appropriate MANAGEMENT decisions following assessment

Decisions are safeDecisions are appropriate (e.g for face-to-face / A&E referral)

8 Appropriate PRESCRIBING behaviour Generics used [unless inappropriate]Formulary-based [where available]Follows evidence base or recognised good practice

9 Displays adequate SAFETY-NETTING Gives clear + specific advice about when to call backRecords advice given (worsening instructions)

10 Develops RAPPORT Demonstrates good listening skillsCommunicates effectively [includes use of English]Demonstrates shared decision making

11 Makes appropriate use of IT / Protocols / Algorithms

Adequate data recordingFace-to-face/phone/CH Use of IT tools where available/appropriateClinician on telephone – appropriate use of support tools/algorithms

Calls for Reflection [CfR]

The proportion of calls designated as CfR has now dropped to 5.4%; this reflects well on everyone

However some underlying themes persist:

•failure to record t/bp/p in abdominal pain and SOB/chest pain

•pulse oximetry should be recorded in many cases now

failure to assess abdo pain fully in history-takingosite/radiation + ?recurrentoassociated bowel/urinary symptomsomenstrual/contraceptive details in [potentially] sexually active women

M19 advised 0120Symptoms: irregular heart beat, heart racingTriage/Advice Notes: sudden onset of irregular heartbeats with chest discomfort No hx of heart/chest problemsNo cough, temp, D&V or rash Not on any medications. Her girlfriend and mother with him ambulance to A&E

COMMENT - this record is too brief when giving phone advice only and doesnt justify decision for A+E - nor is it clear who was organising ambulance No indication of when symptoms started, whether still present - did you ask anyone to count or tap out rate - no PMH taken or whether smokes/drinks, whether SOB or faint

F49 seen at homeSymptoms: p/t surgery 10 days ago laparoscopic procedure for gallstones, also large polyp found in stomach, being referred for this ,re admitted to hospitalafter vomiting for several days, last week, sent home , and still not well , today has felt much worse with vomiting again , also bleeding on wound areafrom post op surgery , feeling shivery , and very unwell on some meds, very worriedTriage/Advice Notes: patient had surgery a laparoscopic cholecystectomy and also has a large polyp three days post operative had vomited was taken toSt Helier hospital was admitted for two days now has started vomiting again with slight bleeding ,patient had vomited thrice patient very worried andconcerned p/;h cholecystectomyConsultation Notes: had lap cholecystectomy 10 days ago. making reasonable recovery.developed vomiting today no vomit for 4hours. No diarrhoea. boyesterday. no abdominal pain.t 37.6 abdomen soft. slight ooze from umbilical site. drinking well.vomiting ? nora virus. advised to drink and see GP if no better. has u/s scan arranged

COMMENT - reasonable history spoilt by failure to record medications, whether BO or any other PMH, no note if patient has any support or is aloneHaving made the effort to visit examination findings of 't 37.6 abdomen soft. slight ooze from umbilical site.' somewhat disappointing Suggestionminimum would include p/bp, whether any redness etc around wound or abdo distension/tenderness and BS You have noted a fever but no attempt toexplain, persistent vomiting post lap chole in 49yr old requiring admission is hardly a common occurrence Absence of tachycardia and hypotension wouldhelp reassure nil serious occurring intra-abdominally; also act as a baseline for a colleague who made need to review or medico legal defence ifsubsequent adverse event were to occur

F76 seen at homeSymptoms: on chemo since last Wednesday, developed chest cough, bringing up green sputum, run down, slight DIB PMH - melanomaTriage/Advice Notes spoken with her son. she had chemo last Wednesday for abdominal melanoma. general condition run down in the last 2 days withchesty cough, bringing up green-brown sputum, slightly wheezy.PMH - melanoma, HTConsultation Notes: T 37 RR 14 chest creps left base good air entry alert with familylrti cefalexin 500 mg tds

COMMENT - given underlying malignancy essential to take full PMH/DH [should be routine practice], also social situation should be recorded for elderlyhome visits Respiratory examination should routinely include p/bp/SATs also You have prescribed ABs yet recorded no drug allergy history Cefalexin is not included in Microbiology guidelines for LRTI and there have been safety alerts for some years now not to prescribe on >65s due to high C.diff riskThere is no other clear management plan and no safety-netting

Referrals

• From The Patient Care 24 • From car this records your conversation

at the base• From car arrange ambulance through the

controller giving details • For 999 calls make sure everyone is

aware who is doing this ?patient ? Relative ?or doctor . In life threatening condition YOU should do it

Referrals- MH

GP deputising service contacted by client. Emergency Psychiatric specialist assessment or follow up identified.

Crisis Line 0800 028 8000.GP to provide demographic details and establish if known Trust Patient.

Describe presenting crisis.Crisis Teams/ Crisis Line able to refer to GP deputizing service or NHS Direct for those requiring non A&E emergency physical input

On assessment, if found safe, but not suitable to be at home discuss with duty psychiatrist re bringing to ward for assessment/ admission

On assessment if safe, provide Crisis Resolution and refer to CMHT next working day or discharge to GP. Home treatment Follow up if indicated.

Agree intervention plan. Sharing of relevant information from Trust Database and GP assessment. Arrange assessment time with patient. Initial risk assessment re safety of visit and any back up needed

MH admission

• Contact duty SR / Consultant

• Contact Duty Social worker

• We cannot fill the section forms – social worker to arrange section 12 approved doctor

Palliative care

• Visiting guidelines – always visit-within 2hrs

• Patient Crae 24 has special register

• Aim to keep patients at home –if this is the wish of the patient

• Palliative care drugs stored in Patient Crae 24

Palliative care

• St Christopher's & St Raphael's

• St Christopher's has OOH visiting team

• District nurses normally know the patient

• Please be more sympathetic to the needs of patients and relatives at the time of end of life

Confirmation Of Death

• All visits completed within 2 hrs

• Form to be filled up –yellow copy for patients relatives

• In Croydon / Sutton / all unexpected deaths reported to Coroner

Controlled drugsOnly issue after collecting evidence and till next

working day

List of Drugs by BNF Section [consult if unsure]4.1.1 Hypnotics - includestemazepam‘z’ drugsclomethiazole [Heminevrin]4.1.2 Anxiolytics – includesdiazepam/lorazepamchlordiazepoxide4.7.1 Non-opiate – includes codeine/dihydrocodeine [DHC]cocodamol 30/5004.7.2 Opiates – includesmorphine and other CDscodeine/DHC 30mg or above

ALWAYS FILL THE CONTROLLED DRUG FORM

Controlled Drugs Issued by Croydon Doctors on CallPlease ensure you print all information On . . . . . . . /. . . . . . /. . . . . . . Dr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Issued the following controlled drug. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Amount issued . . . . . . . . . . . . . . . . . . . . . Call Number . . . . . . . . . . . . . . . Patients Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patients address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Post Code . . . . . . . . . . . . . . . . . .Patient’s telephone No. . . . . . . . . . . . . . . . . . . . Patient’s Surgery . . . . . . . . . . . . . . . . . . . . . . . . . .

Date of birth . . . . . . . /. . . . . . . . . . /. . . . . . . . . We requested proof of previous prescriptions: Yes NoWas the prescription issued a: New prescription for the patient Repeat prescription Please furnish the Patient’s Practice with additional information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Signature of Duty Doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date . . . . . . . /. . . . . . . . . . /. . . . . . . . . . . . .

Telephone Advice

• Almost 30 % of calls received end up in advice only

• Must do effective , safe telephone consultation

• OOH pack 1 has detailed consultation models- please read

Telephone Consultation

• Telephone consultations follow the same models as surgery consultations but lack of visual feedback makes building a rapport with the patient more challenging.

Facilitate communication and protect yourself by

• speaking directly to the patient • recording all calls• using a hands-free phone if one is available• listening actively and paraphrasing what you heard• allowing the patient to ask questions• making contemporaneous notes• completing actions from one call before tackling the next• Safety netting

Effective -Telephone Advice

• I

• P

• F

• A

• N

• K

ntroduction - always give your name

resentation of the problem - let patient tell all the problem

urther inquiry - ask sufficient and detailed questions

gree the problem - discuss and agree with the patient the problem

egotiate the options - discuss and agree with patient the management

eep the door open – safety netting – make sure the patient feels comfortable enough to ring back if necessary

Any Questions?