Telephone triage systems: how to avoid the pitfalls

Telephone triage has been defined as ‘prioritising client’s health problems according to their urgency, educating and advising clients and making safe, effective and appropriate decisions’. It is a complex clinical skill. As GP practices moved rapidly to a ‘total triage’ model, driven by the pandemic, clinicians and other staff may have been thrown into telephone triage without specific training.

Without visual cues and opportunity for physical examination, telephone triage presents a risk of inappropriate management and adverse outcomes, potentially leading to complaints and claims. However, GPs and practices can take steps to avoid the pitfalls and use telephone triage systems with confidence.

Effective telephone triage brings benefits

Telephone triage systems can benefit patients and healthcare providers alike, if they are used well. A majority of GPs surveyed across the UK reported that they increased efficiency. They may be cost-effective and lighten workload, reducing the need for face-to-face appointments and home visits.

For patients, telephone triage may enhance access, facilitating immediate access for urgent care or allowing flexibility for non-urgent care. It may even provide opportunities for patient education on self-care, reducing dependency on face-to-face appointments.

What are the risks and pitfalls?

In ‘Telephone Triage and Consultation – Are We Really Listening?’, published by RCGP, Sally-Anne Pygall provides a ‘how to’ manual for GPs and nurses in primary care. She emphasises: “If it is not performed correctly, it will not yield the benefits, will increase the risks and could significantly increase workload.” One of the biggest risks is delaying or denying a face-to-face consultation when one is needed, but offering an inappropriate face-to-face appointment also risks increasing dependency and using resources needed by another patient.

The manual explains common reasons that telephone triage fails:

• Making assumptions without checking understanding.
• Lack of visual cues causing uncertainty and mistriage.
• Communication barriers – caller difficulties in accurately describing or recalling the history, poorly phrased questioning from the triager, and other communication or language barriers.
• Triage with a third party, especially when they are not with the patient.
• Poor communication due to lack of engagement with the patient.
• Time constraints – this may lead to an untimely conclusion; lack of information gathering; inappropriate outcomes; and poor interaction.
• Patient perception that telephone triage reduces their access to care.
• Patients not liking telephone triage – so they complain or feel dissatisfied as a result.
• Lack of clinician satisfaction and burnout – reducing the motivation to perform triage well.
• Poor documentation. This opens up the risk of legal liability.

If triage does lead to a claim or complaint, Medical Defense Society can provide expert advice.

Tips for effective telephone triage

GP practices can reduce the risk of failures by providing specific guidance and training. The Royal College of GPs (RCGP) offers an online course on Telephone Consultation and Triage Skills and guidance in ‘Remote versus face-to-face: which to use and when?’.

Triagers should guide a caller through a well-defined triage system. Pre-agreed scripts can help staff explain how to access services and what to expect, with reassurance that face-to-face care is available when clinically appropriate. Clear protocols are needed for recognising red-flag symptoms.

Staff performing telephone triage can follow these key points:

• Understand the limitations of telephone triage.
• Know who you are speaking to and check contact details.
• Consider safeguarding, capacity and confidentiality issues.
• Prioritise calls based on urgency.
• Take enough time to gather information and actively listen to the callers’ concerns.
• Recognise patient needs – for clinical advice over the phone or with a face-to-face appointment, or any other mode of consultation.
  • GMC provides a flow chart to help decide when it’s usually safe to treat remotely.
  • When a patient calls repeatedly about the same problem, have a low threshold for a face-to-face appointment or onward referral.
• Jointly agree on an acceptable consultation method with the patient, taking into consideration their needs and preferences, the circumstance, local risks of COVID-19 and national guidance (see updated NHS England standard operating procedures for general practice).
• Direct patients to the appropriate member of the clinical team or other service.
• Set clear expectations for patients: explain the triage process, timescales for call-backs, and what to do if symptoms get worse.
• Provide safety nets: explain when to contact the practice again if a healthcare professional has not been in touch.
• Check understanding of the patient’s concerns. Check the patient has understood advice.
• Keep adequate documentation.

Remember…

GMC’s remote consultation ethical hub reminds clinicians providing services remotely to:

• Follow guidance on consent and good practice in prescribing
• Work within your competence
• Check you have adequate indemnity cover for your remote consultation activities
• Discuss this element of your practice with your responsible officer at appraisal.

Please contact our expert medico-legal team at Medical Defense Society if you need advice or support with legal matters related to tria