Transcript GPR-OOH-induction

OOH Training for GPStRs
Plan
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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
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
Assessment of competence
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).
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
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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 prepackaged
• Single and usually
identified problem
• More time
Consultations- different models
one – the future GP
• Problem presented
• Problem examined
• Problem defined
• Solution proposed
• Solution examined
• Solution implemented
Consultations- different models
two - 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 models
three – Stott and Davis
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Management of presentation problems
Modification of help-seeking behaviour
Management of continuing problem
Opportunistic health promotion
Consultations- different models
four- Pendleton’s Seven Tasks
1.Define the reason for the patient’s attendance ,including:
The nature and history , their cause, the patient’s , concerns and
Expectations , the effect of the problem
2.Consider other problems :
Continuing problems
3. choose with the patient an appropriate action for each problem
4.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 models
five - Middleton
Doctor’s agenda
Patient Agenda
Negotiated plan
Consultations- different models
six - Neighbour
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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 skills
The 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
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Not Painful
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3.
Blepharitis
Conjuctivitis
Subconjuctival Haemhorrage
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Painful with Normal Vision
FB
Corneal Abrasion
Episcleritis
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Painful with reduced vision
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Acute Glaucoma
Iritis
Scleritis
Corneal Ulcer
Urgent Care Audit
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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
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Elicits REASON for telephone call or
visit
Clearly identifies main reason for contact
Identifies patient’s concerns [health beliefs]
Accurate information e.g. demographics in CH’s
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Identifies EMERGENCY or serious
situations
Asks appropriate questions to exclude [or suggest]
such situations
Appropriate use of ILTC protocols
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Appropriate HISTORY taking (or
algorithm use)
Identifies relevant past Medical History / Drug
History [including drug allergy]
Elicits significant contextual information (e.g. social
history)
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Carries out appropriate
ASSESSMENT
Face-to-face settings - appropriate examination
carried out
Clinician on telephone - targeted information
gathering or algorithm use to aid decision making
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Draws appropriate CONCLUSIONS
Clinician face-to-face/ telephone – makes
appropriate diagnosis or differential / or identifies
appropriate “symptom cluster” with algorithm use
CH – makes appropriate prioritisation
CH - streams call appropriately
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Displays EMPOWERING behaviour
Acts on cues/beliefs
Involves patient in decision-making
Use of self-help advice [inc. PILs]
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Makes appropriate MANAGEMENT
decisions following assessment
Decisions are safe
Decisions are appropriate (e.g for face-to-face / A&E
referral)
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Appropriate PRESCRIBING behaviour
Generics used [unless inappropriate]
Formulary-based [where available]
Follows evidence base or recognised good practice
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Displays adequate SAFETY-NETTING
Gives clear + specific advice about when to call back
Records advice given (worsening instructions)
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Develops RAPPORT
Demonstrates good listening skills
Communicates effectively [includes use of English]
Demonstrates shared decision making
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Makes appropriate use of IT /
Protocols / Algorithms
Adequate data recording
Face-to-face/phone/CH Use of IT tools where
available/appropriate
Clinician 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-taking
osite/radiation + ?recurrent
oassociated bowel/urinary symptoms
omenstrual/contraceptive details in [potentially] sexually active women
M19 advised 0120
Symptoms: irregular heart beat, heart racing
Triage/Advice Notes: sudden onset of irregular heartbeats with chest
discomfort No hx of heart/chest problems
No 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 home
Symptoms: p/t surgery 10 days ago laparoscopic procedure for gallstones, also large polyp
found in stomach, being referred for this ,re admitted to hospital
after vomiting for several days, last week, sent home , and still not well , today has felt much
worse with vomiting again , also bleeding on wound area
from post op surgery , feeling shivery , and very unwell on some meds, very worried
Triage/Advice Notes: patient had surgery a laparoscopic cholecystectomy and also has a
large polyp three days post operative had vomited was taken to
St Helier hospital was admitted for two days now has started vomiting again with slight
bleeding ,patient had vomited thrice patient very worried and
concerned p/;h cholecystectomy
Consultation Notes: had lap cholecystectomy 10 days ago. making reasonable
recovery.developed vomiting today no vomit for 4hours. No diarrhoea. bo
yesterday. 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 alone
Having made the effort to visit examination findings of 't 37.6 abdomen soft. slight ooze from umbilical
site.' somewhat disappointing Suggestion
minimum would include p/bp, whether any redness etc around wound or abdo distension/tenderness
and BS You have noted a fever but no attempt to
explain, persistent vomiting post lap chole in 49yr old requiring admission is hardly a common
occurrence Absence of tachycardia and hypotension would
help reassure nil serious occurring intra-abdominally; also act as a baseline for a colleague who made
need to review or medico legal defence if
subsequent adverse event were to occur
F76 seen at home
Symptoms: on chemo since last Wednesday, developed chest cough, bringing up green sputum,
run down, slight DIB PMH - melanoma
Triage/Advice Notes spoken with her son. she had chemo last Wednesday for abdominal
melanoma. general condition run down in the last 2 days with
chesty cough, bringing up green-brown sputum, slightly wheezy.
PMH - melanoma, HT
Consultation Notes: T 37 RR 14 chest creps left base good air entry alert with family
lrti 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
elderly
home 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 risk
There 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
Crisis Line 0800 028 8000.
GP deputising service
contacted by client.
Emergency Psychiatric
specialist assessment or
follow up identified.
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
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
On assessment if safe,
provide Crisis Resolution and
refer to CMHT next working
day or discharge to GP.
Home treatment Follow up if
indicated.
On assessment, if found
safe, but not suitable to be
at home discuss with duty
psychiatrist re bringing to
ward for assessment/
admission
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 drugs
Only issue after collecting evidence and till next
working day
List of Drugs by BNF Section [consult if unsure]
4.1.1 Hypnotics - includes
temazepam
‘z’ drugs
clomethiazole [Heminevrin]
4.1.2 Anxiolytics – includes
diazepam/lorazepam
chlordiazepoxide
4.7.1 Non-opiate – includes codeine/dihydrocodeine [DHC]
cocodamol 30/500
4.7.2 Opiates – includes
morphine and other CDs
codeine/DHC 30mg or above
ALWAYS FILL THE CONTROLLED DRUG FORM
Controlled Drugs Issued by Croydon Doctors on Call
Please 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
 No
Was the prescription issued a:
 New prescription for the patient
 Repeat prescription
Please furnish the Patient’s Practice with additional information
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Signature of Duty Doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date . . . . . . . /. . . . . . . . . . /. . . . . .
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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
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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
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I ntroduction - always give your name
P resentation of the problem - let patient tell all the problem
F urther inquiry - ask sufficient and detailed questions
A gree the problem - discuss and agree with the patient the problem
Negotiate the options - discuss and agree with patient the management
K eep the door open – safety netting – make sure the patient feels comfortable
enough to ring back if necessary
Any Questions?