Emergency patient encounters
General Practitioner, Hampshire
E-mail: karenaoreilly{at}hotmail.com
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Abstract |
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 TOP Abstract The GP curriculum and...SymptomsCommon and/or important...InvestigationTreatmentEmergency careResourcesPreventionEquipment and drugsEmergency callsEmergency home visitsThe emergency consultationOut-of-hours careReflectionReferences |
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‘It's an emergency doc’. Managing emergency patient encounters in primary care can be both challenging and stressful for GPs. Many problems classified by patients as emergencies in primary care are not, in medical terms, true emergencies. Although this means that you do not always need to summon up your emergency care skills to manage GP emergencies, such cases present their own very special challenge.
True medical emergencies in primary care can present anywhere at any time. The doctor must be able to rapidly diagnose the problem, provide suitable immediate care and arrange appropriate follow up as needed. In primary care, conditions for management of the patient's condition might not be ideal. For example, the patient may be on the floor, the lighting may be poor or the patient may have numerous layers of clothing on. In addition you may find yourself alone and without the support of trained colleagues, or the equipment ideally needed to manage the condition, that is taken for granted in hospitals. Good organization, teamwork, communication and situational awareness are vital.
Becoming prepared to manage these emergency situations is a vital part of any GP's training. This article aims to explore the underlying basic principles necessary to cope effectively with emergency patient contacts in primary care.
Curriculum Statement 7: Care of Acutely Ill People is the main curriculum statement that covers emergency patient encounters. All GPs in training must be able to recognize, evaluate and manage acutely ill patients and provide clear leadership, demonstrating an understanding of the team approach to care of the acutely ill. They should be able to coordinate care with other professionals in primary and secondary care, for example, in making decisions to admit acutely unwell patients and adopt a person-centred approach, respecting patients’ autonomy while recognizing that acutely ill patients often have a diminished capacity for autonomy.
Communication
Common conditions
Management
Out-of-hours cover
Personal perspectives
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Box 1. Knowledge base required for the GP Curriculum
Note: Other investigations are rare in primary care because acutely ill patients needing investigation are usually referred to secondary care.
Providing advice for patients about prevention. For example, for a patient with known heart disease, advice on how to manage ischaemic pain including use of GTN, aspirin and appropriate first-line use of paramedic ambulance.
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Equipment and drugs |
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TOPAbstractThe GP curriculum and...SymptomsCommon and/or important...InvestigationTreatmentEmergency careResourcesPreventionEquipment and drugsEmergency callsEmergency home visitsThe emergency consultationOut-of-hours careReflectionReferences |
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Resuscitation equipment and drugs
Resuscitation equipment is used relatively infrequently. Staff, including GP registrars, must know where to find equipment and be trained to use the equipment to a level appropriate to the individual's expected role. Each practice should have a named individual with responsibility for checking the state of readiness of all resuscitation drugs and equipment, on a regular basis, ideally once a week. Table 1 lists the drugs and equipment needed. In common with drugs, disposable items like the adhesive electrodes have a finite shelf life and will require replacement from time to time if unused. Practices are rewarded with quality points for inspection, calibration, maintenance and replacement of equipment (Management Indicator 7) and for having a system for checking the expiry dates of emergency drugs (Medicines Indicator 3).
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It is important to maintain skills in emergency care by appropriate training. All those in direct contact with patients should be trained in basic life support and related resuscitation skills and should be able to use an automatic external defibrillator. Skills decline rapidly without practice. Regular training using manikins should be preformed every 6–12 months. Knowing how to do it in a classroom setting is not enough. Be sure that you know in your own regular workplace where all the resuscitation equipment is and how it works. Pairing up with another team member and acting out a clinical vignette of a potential emergency can be a good way to familiarize yourself with the necessary protocols and locate where equipment is and how it works.
The doctor's bag
The GP's bag must be lockable and not left unattended during home visits. If left in the car, keep the bag locked and out of sight—preferably in the boot. Consider having a separate bag for drugs and consultation equipment and only get the drug bag out of the boot of the car if it is needed. Keep the bag containing drugs away from extremes of temperature. Exact contents of the doctor's bag will vary according to location and circumstances. Suggested equipment and drugs that you might consider including are listed in Table 2.
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It is important to check all drugs that you carry in your bag at least twice a year to see that they are still in date and usable. Record the origin, batch number and expiry date of all drugs administered to patients or dispensed to them to take themselves. Drugs given to patients from the doctor's bag should be in a suitable container and properly labeled with
- The patient's name
- The drug name
- The drug dosage
- The quantity of tablets
- Instructions on use
- Relevant warnings
- Name and address of the doctor
- Date
- Warning ‘Keep out of reach of children’
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Emergency calls |
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TOPAbstractThe GP curriculum and...SymptomsCommon and/or important...InvestigationTreatmentEmergency careResourcesPreventionEquipment and drugsEmergency callsEmergency home visitsThe emergency consultationOut-of-hours careReflectionReferences |
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Nearly all requests for emergency care are made by telephone. Surgery staff should be trained to handle distressed callers, recognize serious problems and act appropriately when such calls are received. Where possible, a single number should be provided for patients to access help. If using an answering machine, ensure the message is easily heard and contains clear instructions. Worried patients find it difficult to cope with complicated telephone referral systems or messages.
When taking a call requesting emergency input from you as a GP, appear helpful rather than defensive from the outset. Keep calm and friendly—even in the event of provocation. Worried callers often appear abrupt or demanding. Record the time of the call, date, patient's name, address and a contact telephone number, brief details of the problem and action taken (even if calls are being recorded).
Collect only information you need to decide what action is necessary. Your options are
- to give the patient advice
- to give advice and arrange for a follow up telephone review later on
- to arrange for the patient to come to the surgery (or an out-of-hours centre) for review
- to visit the patient
- or to call for an ambulance to transport the patient to hospital immediately without a GP seeing the patient.
If giving advice, make it simple and in language the patient can understand. Repeat the advice given to make sure that it has been understood. Consider asking the patient or carer to repeat what you have told them. Always tell callers to ring back if symptoms change or they have further worries. If in doubt, always see the patient.
If the patient needs to be seen, collect enough information to decide where and how quickly the patient should be seen and whether extra equipment or help is needed. Ensure that the address is correct, and ask for directions if you are not sure where to go. Try to give a rough arrival time. In some cases, for example, major trauma, large gastrointestinal bleeds, acute stroke, myocardial infarct, burns or overdoses call for an emergency ambulance at once.
If a call seems inappropriate, consider the reason for it. For example, depression might provoke recurrent calls for minor ailments. Take time to politely educate the caller about the reasons why their call is inappropriate. Offer alternative routes through which the caller might seek help, such as a routine booked appointment to discuss health worries or calling NHS Direct for health advice.
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Emergency home visits |
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TOPAbstractThe GP curriculum and...SymptomsCommon and/or important...InvestigationTreatmentEmergency careResourcesPreventionEquipment and drugsEmergency callsEmergency home visitsThe emergency consultationOut-of-hours careReflectionReferences |
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Being prepared
Before you undertake emergency visits, check that your drug box is fully stocked and all items are in date. Check all the equipment that you will be taking with you is operational and ensure that you have a supply of spare batteries. Ensure that you have a portable, quick reference text to refer to for information, such as the Oxford Handbook of General Practice, or Emergencies in Primary Care, and a copy of the British National Formulary or Mimms. Find out which chemists locally have extended opening hours or carry the local pharmacy rota. Collect a list of emergency telephone numbers that might be of use when on call, for example your trainer's mobile phone number and the numbers of local hospitals and social services departments.
If you are providing your own transport, ensure that you have a reliable car with a full tank of fuel. Have a good street map of the area and/or an electronic navigation device to help you to find your way about. Always carry a working mobile phone and a large strong torch in the car.
Safety and security
Doctors, particularly if visiting patients alone, are vulnerable to attack. Before undertaking any home visits, set up your mobile phone to call the police or your base at a single touch of a button. Consider carrying an attack alarm. In all cases, ensure that someone else knows where you are going, when to expect you back and what to do if you do not return on time.
If you are going to a call that you are worried about, either take someone with you to sit in the car or call the police to meet you there before going in. If you reach a call and find that you are uncomfortable, make sure that you can get out. Note the lay-out of the property and make sure you have a clear route to the door if you need to escape.
Doctors may be attacked for supplies of the drugs that they carry. If possible have separate bags for drugs and consultation equipment. Leave the drug box locked out of sight in the boot of the car when doing a visit and only get it out if it is needed.
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The emergency consultation |
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TOPAbstractThe GP curriculum and...SymptomsCommon and/or important...InvestigationTreatmentEmergency careResourcesPreventionEquipment and drugsEmergency callsEmergency home visitsThe emergency consultationOut-of-hours careReflectionReferences |
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When doing an emergency visit, or when seeing a patient as an emergency in the surgery, try to stick to the problem that you have been called about. Take a concise history and examine the patient as appropriate. Make a decision on management and explain it to the patient and any carers in clear and concise terms that they can understand. Repeat the advice several times and consider writing it down as well. Record the history, examination, medication administered or left with the patient, management suggested and advice given for the patient's notes. Always invite the patient and carers to ring you again should symptoms change, the situation deteriorate or further worries appear. Arrange follow up if needed.
Admission
When seeing patients as emergencies in the community, it is important to know about the local hospital and social services available and how to access them. In some cases, it is obvious that emergency admission to the hospital services is needed. Find out how admissions are processed in the local hospitals before you start to see emergency patients. Whether to admit or not is your decision, and not that of the doctor in the hospital that you refer the patient to, who has not seen the patient. Do not allow yourself to be dissuaded from admitting a patient if your clinical judgment is that the patient requires admission.
If an urgent specialist review is needed, but the patient is safe at home, then consider arranging urgent outpatient review instead. It is often possible to organize same or next day review of a patient as an outpatient. This option is usually preferable to the patient and is a more cost-effective option. For some acute medical problems, such as suspected deep vein thrombosis or suspected miscarriage, special emergency access clinics are run on a daily basis to avoid unnecessary admissions.
Where a patient cannot stay at home, for example because the carer cannot cope or because the carer is ill, then explore other support options. For instance, contact the duty social worker to provide additional carers in the home or an emergency placement in a care home. If the patient has terminal cancer, consider contacting the palliative care team to arrange for a Marie Curie nurse.
Dangerous diagnoses
In primary care, if a potentially life-threatening diagnosis is suspected, act as if the diagnosis was certain and refer immediately to secondary care. It is better to be wrong and appear overcautious, than miss a treatable condition that might otherwise be fatal. For some conditions, even the suspicion of the diagnosis demands urgent action (Box 2). Problems occur where a doctor has correctly suspected that diagnosis, recorded it but then not acted on the possibility.
Box 2. Dangerous diagnoses
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Referral letters
Good communication is essential when referring patients to other doctors and agencies. Ensure all referral letters include the following:
- Address of the referrer (including telephone number if possible)
- Name and address of registered GP if not the referrer
- Date of referral
- The name, address and date of birth of the patient (and any other identifiers available, for example the patient's hospital or NHS number)
- The name of the person to whom the patient is being referred (or department if not a named individual)
- Presenting condition—history, examination, investigations already performed with results, treatments already tried with outcomes
- Relevant past medical history and family history
- Current medication and any intolerances or allergies known about
- Reason for the referral, that is what you want the recipient of the letter to do. For example, to investigate symptoms or to reassure parents
- Any other relevant information, such as social circumstances
- Signature and name in legible format of the referrer.
Consider using carbonized paper to keep copies of referral letters written remotely from the patient's computerized record. Alternatively, write the letter on the computer linked to the patient's record. Give the letter to the patient to take to hospital or fax or e-mail the letter through to the admitting doctor.
When it is not a true emergency
Requests for emergency consultations for problems that you, as a GP, do not consider to be medical emergencies are common occurrences. In the middle of a busy duty day, such contacts can illicit feelings of irritation. Take a deep breath and try to view the situation from the patient's perspective. Explore what the patient is concerned about or hoped to gain from the contact.
There are many reasons for patients to ask for inappropriate emergency consultations. For example, a parent who has a child who has had meningitis in the past might be very reluctant to manage even minor upper respiratory tract infections in the future without a GP review in the light of that experience. Sometimes patients may be misinformed about what is an emergency. It is a common perception that children with conjunctivitis need an urgent appointment to be prescribed topical antibiotics. The evidence actually suggests that in 80% of cases, the symptoms will clear themselves with no medication within 5 days. Patients with depression or anxiety states may also request emergency consultations for seemingly minor problems, either as a cry for help or because they just cannot cope with the added stress of a minor illness.
For patients who use emergency consultations inappropriately, take time to educate the patient and/or carers about self-management and the use of emergency GP services. Try not to deal with non-emergency problems except with advice as this may encourage the patient and/or carer to inappropriately use the emergency GP service again. Instead, if you can, make an appointment for the patient to come back during routine surgery time to review the problem.
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Out-of-hours care |
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TOPAbstractThe GP curriculum and...SymptomsCommon and/or important...InvestigationTreatmentEmergency careResourcesPreventionEquipment and drugsEmergency callsEmergency home visitsThe emergency consultationOut-of-hours careReflectionReferences |
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OOH is defined as 6.30pm to 8.00am on weekdays, the whole weekend, Bank Holidays and public holidays. Since December 2004, Primary Care Organizations (PCOs) have taken full responsibility for making sure there is effective OOH provision in the UK. Practices can ‘opt out’ of providing an OOH service. The decision must be made for the whole practice and individual doctors within a practice cannot opt out alone. The cost of opting out for a practice is 7% of the global sum. There is nothing to stop practices that have opted out from offering surgeries or consultations within the time periods specified as OOH. These services are paid for through extended opening incentives.
PCOs can consider a range of alternative OOH care providers as long as accreditation standards are met. Only where a practice is exceptionally remote, will the PCO be able to require a practice to continue providing OOH care. Special arrangements for payment then exist. Several schemes operate side by side:
- PCO OOH centres. PCO run centres employing GPs, usually on a sessional basis, to cover OOH care
- Hospital based OOH cover. GPs and primary care nurses in Accident and Emergency departments.
- Commercial OOH services. OOH provided by a commercial profit-making organization employing GPs and specialist nurses.
- NHS Direct. Twenty-four hour, nurse-led telephone advice service available throughout the UK. It is designed as a first-line service and aims to have links to local primary care and OOH services. There is also an NHS Direct website and advice booths in public places.
- NHS Walk-in centres. Walk-in clinics tend to offer nurse consultation and use NHS Direct algorithms. Most are sited in urban areas. They aim to provide easier access to medical care and are increasingly used to cover the OOH period.
- Enhanced paramedic services. Providing initial assessment of patients who are not able to get to OOH centres and/or patient transport to OOH centres.
- Enhanced community nursing teams. Providing care to patients terminally ill and initial assessment of patients who do not feel able to get to an OOH centre for other reasons.
- In-practice rotas. This is the traditional model of care, but is becoming increasingly rare in the UK. It is usually organized as a rota undertaken by practice GPs and is largely based on home visiting.
- Extended rotas. GPs are on call in rotation for a small group of practices.
- GP cooperatives. GPs grouped together (often with over a hundred in a cooperative group) within a district to cover OOH care between themselves. Often several GPs are on call at any time—1 doing visits; 1 taking calls and 1 seeing patients in a central clinic.
The Committee of Postgraduate General Practice Education Directors has stated that GP Registrars should continue to obtain experience in OOH care irrespective of whether their trainer has opted out of providing OOH care. Local deaneries should have arrangements in place for their registrars to allow them to gain OOH experience.
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Reflection |
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TOPAbstractThe GP curriculum and...SymptomsCommon and/or important...InvestigationTreatmentEmergency careResourcesPreventionEquipment and drugsEmergency callsEmergency home visitsThe emergency consultationOut-of-hours careReflectionReferences |
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Emergencies in primary care can be very stressful and/or distressing for GPs. It is often helpful to take time to reflect on difficult situations that you have encountered either alone, with your trainer, or as a team, both to debrief, and also to learn from the situation. Points to consider are as follows:
- Could the scenario have been prevented?
- Do measures need to be put in place to prevent it reoccurring?
- Was the patient managed appropriately? What went well? What did not go so well?
- Have the family and carers had their needs and expectations met?
- Were there any psychosocial factors to consider?
- How things could be improved in a similar situation next time round?
- What changes/actions need to be taken to ensure these improvements are made?
- Who will make them?
- How can you check that these have been done and are effective in future encounters?
Significant event audit is a recognized methodology for reflecting on important events in a practice. It is a form of peer review. Practices undertaking significant event audit are eligible for quality points in the Quality and Outcomes Framework. Practices undertaking 12 significant event audits in the past 3 years are eligible for 4 points (Education 7), and practices undertaking three or more significant events in the past year are eligible for six quality points (Education 10).
Discussion of specific events can identify learning objectives and provoke emotions that can be harnessed to achieve change. For it to be effective, it must be practiced in a culture that avoids blame and involves all disciplines. There are three steps:
- Step 1: Decide on a topic and plan a meeting. The Quality and Outcomes Framework guidance specifies suitable events as any death occurring in the practice premises; new cancer diagnoses; deaths where terminal care has taken place at home; any suicides; admissions under the Mental Health Act; child protection cases; medication errors and near miss events (defined as any event occurring when a patient may have been subjected to harm, had the circumstances or outcome been different).
- Step 2: At the end of the discussion, come to a decision about the case. For example, was it well managed? Is there a need for a change in procedure?
- Step 3: Prepare a report. The two acceptable formats for laying out these reports for QOF purposes are described in Table 3.
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Key points
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References |
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TOPAbstractThe GP curriculum and...SymptomsCommon and/or important...InvestigationTreatmentEmergency careResourcesPreventionEquipment and drugsEmergency callsEmergency home visitsThe emergency consultationOut-of-hours careReflectionReferences |
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Drugs & Therapeutics Bulletin. Website: www.dtb.bmj.com.
Drugs for the doctor's bag 1—Adults (September 2005).
Drugs for the doctor's bag 2—Children (November 2005).
NHS Direct. 0845 4647. Website: www.nhsdirect.nhs.uk.
Separate services for Scotland and Wales. Website: www.show.scot.nhs.uk/ and www.wales.nhs.uk/.
Pringle M, Bradley CP, Carmichael CM, Wallis H, Moore A. Occasional paper 70: Significant event audit—a study of the feasibility and potential of case-based auditing in primary medical care (1995, RCGP). www.rcgp.org.uk/default.aspx?page=3492 [date last accessed 01.04.08].
RCGP. GP curriculum statement 7: care of acutely ill people. www.rcgp-curriculum.org.uk/PDF/curr_7_Acutely_ill_people.pdf [date last accessed 01.04.08].
Simon C, Everitt H, Kendrick T. Oxford Handbook of General practice (2005) 2ndedition. Oxford: Oxford University Press.
Simon C, O’Reilly K, Proctor R, Buckmaster J. Emergencies in primary care (2007) Oxford: Oxford University Press.
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