Dial for triage
By Dr Valerie Finigan on 23 November 2018 Midwives Magazine
Midwives are a valuable asset to telephone triage services, says Dr Valerie Finigan. And working in out-of-hours care can also benefit their work-life balance.
Telephone triage (TT) is important for the provision of accurate, timely healthcare management. Midwives’ skill in TT is not a new phenomenon (Bailey et al, 2017). Despite this, very little attention has been paid to investigating TT as an area of midwifery practice, or even to the advantages midwives can bring to TT in out-of-hours (OOH) and urgent primary care services (Bailey et al, 2017).
I recently took up a nursing position in TT, providing assessment and safe dispositions for patients in OOH services. This prompted me to raise awareness of the role and its flexible working opportunities, and to enable midwives to consider TT as a career option.
In OOH, the wider multidisciplinary team – medical, nursing, paediatric, mental health, dental and midwifery – focus on holistic individualised pathways of care. Their critical-thinking skills, experience and expert knowledge are the most crucial element of successful triage. This gives them an intuitive grasp of each person’s individual situation and needs (Benner, 1984). Midwifery skill and knowledge can enhance care for those patients who call for advice with pregnancy and postpartum issues (see panel, right).
New ways of working
Briggs (2011) writes: ‘The appropriate use of healthcare resources is one of the biggest challenges in today’s healthcare environment.’ Visits to A&E and family doctors have spiralled, pushing up NHS costs. TT services have been set up and funded by some local CCG consortiums to minimise these costs and limit unwarranted or unnecessary access to doctors and A&E. The TT services are supplementary to NHS 111, a national triage service that, according to Anderson and Roland (2015), employs mostly non-medically trained staff. NHS 111 may be more ‘risk averse’ in directing patients to attend A&E or to call an ambulance unnecessarily in comparison with services that use skilled nurses (Anderson and Roland, 2015).
More technological ways of working will be required for the future if the NHS is to achieve the budget cuts enforced by the government. Treatments are moving from clinical environments, with patients now connecting to some services via apps, smartphones and ‘virtual clinic’ spaces. Over 20,000 calls were made to OOH every day last year (NHS England, 2018).
There is no concrete agreement that constitutes whether best practice is to use clinically or non-clinically trained TT staff. Indeed, NICE (2017) graded available evidence as low or poor quality because evidence only exists regarding A&E attendances, and none provides insight into patient experiences and outcomes.
TT provides 24-hour patient access outside of normal surgery hours – evenings, weekends, bank holidays and training days for GPs. The flexibility of either bank or contracted hours can provide family-friendly working opportunities. In my workplace, staff shifts are flexible, often between three and eight hours depending on service and staff needs. At weekends, variable hours are worked between 7am and midnight; on weekday evenings between 6pm and midnight. There are some afternoon shifts during the week to cover GP training (Wednesdays and Thursdays 12.30pm to 5pm). A 24-hour service is offered on bank holidays, as well as a ‘red-eye’ shift at night (red-eye and weekend shifts can be between five and eight hours long).
Responsibilities in TT
TT practitioners play a key role in the decision-making maze in accordance with the NMC code. They ensure that patients receive care based on the best available evidence, and is delivered in the right place, at the right time. Clear accurate records are made for all consultations, so decisions and advice can be defended if necessary at a later date. The care may include self-care advice, OOH review by GP, and attending own GP, walk-in centre, A&E, early pregnancy unit, psychiatric care or dental service.
The TT nurse has the responsibility of communicating with the patient, assessing presenting concerns, developing a working diagnosis and plan of management, determining the seriousness of the situation, and prioritising care, while providing appropriate safety-net advice and contact numbers so that any deterioration in the patient’s condition or symptoms can be re-assessed.
Midwives may want to work in TT for various reasons:
- To broaden their knowledge
- To maintain competences for revalidation where they hold dual qualification
- To build confidence in general nursing
- As a new challenge
- To change career.
Midwives entering TT will need to undertake a robust induction and education programme to enable them to develop the skills required, for example, the use of algorithms and computer systems to enable identification of red-flag symptoms. Robust clinical governance and audit are fundamental components of the service. A strong supportive relationship within the TT team is critical to nurture and develop midwives entering this career pathway.
Promoting women’s health
Midwives are ideal providers of health promotion services for women (see panel below). Their entire philosophy of care centres on promotion of women’s health throughout their life-cycle. The skills and knowledge they bring to TT can influence care provided to patients in the antenatal and postpartum period who use the OOH service. The expert knowledge of the midwife, her experience and her critical-thinking skills are the most crucial element of successful TT.
Dr Valerie Finigan MBE is senior clinical midwife/nurse at Gtd Healthcare