Safe telephone triage

Telephone-based triage systems in medical and dental primary care practices are here to stay.

Having proved effective in helping to maintain healthcare services during the pandemic, triage systems are now seen as crucial in managing the growing strain on primary care.

An effective triage system should ensure patients are signposted to the most appropriate care, either within the practice (face-to-face or via callback) or to an outside service, such as a community pharmacist.

This should allow GPs and other clinicians more time to focus on complex or urgent cases.

NHS England recently announced funding to enhance telephone access for patients to GP surgeries to “tackle the 8am rush and reduce the number of people struggling to contact their practice”. Plans call for the wholescale replacement of old analogue phones with modern digital systems so patients never get engaged tones but instead are placed in a numbered queue and offered the option of an automated call-back.

This means practices will be required to have an effective triage system in place to prioritise patients who require urgent care and advice, and also to advise patients with non-urgent issues on when or how they can see a GP, or whether they would be better suited accessing another service or online advice.

How can practices ensure triage systems are safe and effective?

Protocols for safe triage

Reception staff play a key role in triage processes and increasingly their job titles are being changed to care navigator or patient care coordinator. Their role in gathering information from patients and signposting appropriately based on this information is essential in effective triage systems.

There are well-documented risks in using non-clinical members of staff to facilitate entry into the triage process and efficiently directing patients to the most appropriate member of the clinical team. Common risks include:

• patients unable to access the service despite multiple attempts
• patients with existing health issues being triaged inappropriately
• important symptoms not being recognised.

A safe triage system will have clear protocols and guidance for staff on 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 making clinical decisions but rather should be guiding the patient through a defined triage process. GPs and dentists can help by agreeing on specific questions or algorithms for staff 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 (or third party calling on someone's behalf) when given in the context of their practice role and this should be avoided.

Staff should emphasise to the patient that the reason they are being signposted is to provide the best care for their particular issue. Should staff have doubts about how best to signpost a patient they should feel confident and able to access clinical support. This can depend on the “culture” within a team around the availability, accessibility and approachability of individual doctors and nurses. Any system of work is only as good as the individuals who work with it, or against it.

Patient expectations

Patients 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 signposted appropriately.

Examples might include explaining steps in the telephone triage process, timescales for call-backs and what to do in the case of worsening symptoms, including what services are available outside of normal practice hours and how to access. Consideration should also be given to patients who are unable to receive telephone calls during working hours and who may require alternative arrangements.

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

Adequate record keeping

A common pitfall in triage systems is failing to record specific advice provided to a patient. Even if a patient is scheduled to be seen in person later that day for a full consultation don’t be tempted to delay making notes on clinical advice provided. Should a patient’s condition change and they later dispute that they were given specific advice, adequate records will be important in any legal defence.

The GMC and GDC make it clear that doctors and dentists must keep adequate records of any advice given to patients for continuity of care. It is helpful for non-clinical staff to adopt the same process and document the information given to patients, including signposting and any safety netting advice.

Key points

• Offer support and training to staff to optimise triage processes and safety for patients.
• Always be available to assist colleagues and staff if there are doubts about ways to direct a patient's care.
• Keep records of all advice given to patients during an initial triage assessment.
• Follow regulatory guidance to ensure best practice when consulting (including remotely) and delegating responsibility, and in record keeping.

Kay Louise Grant is a risk adviser at MDDUS