Urgent and unscheduled care

As a GP, your role is to:

• make the patient’s safety a priority. Recognise patients with urgent needs and act promptly and effectively to ensure correct and timely treatment and reduce the risk of death or morbidity
• meet the additional challenge of gathering information and communicating effectively, professionally and sensitively with patients, carers and family members in urgent and unscheduled care contexts. This includes accurately assessing a patient who may be acutely ill through telephone, video, online and face-to-face consultations
• coordinate care with other services and professionals (such as ambulance service, community nurses and secondary care) and follow agreed protocols where appropriate, ensuring appropriate referral or follow-up where necessary
• apply legal frameworks in urgent situations where you may need to make decisions for the patient’s overall benefit (sometimes known as ‘best interests’). Consider the appropriateness of interventions according to the patient’s wishes, the severity of the illness, any comorbid diseases and best evidence, while managing any differences of opinion with and between relatives and carers
• offer patients and carers tailored advice on self-management, including when and who to call for help if their problem worsens or does not follow the expected course of recovery (‘safety-netting’).

The provision of urgent and unscheduled care is becoming increasingly diverse across the four UK nations and services in one area may differ substantially from another. It is therefore important that the experience attained and capabilities developed during training are sufficient to work in a variety of urgent and unscheduled care contexts.

The models for delivering urgent and unscheduled care (UUC) in different communities and regions are changing, and it is important to stay up to date with your local arrangements. Within UUC, there is an increasing focus on the delivery of integrated multiprofessional care in the most appropriate setting, with more care being provided ‘closer to home’ or in the home itself. This requires a more flexible and team-based approach.

Reviews of the urgent and emergency care (UEC) system¹ and subsequent reports have outlined five key elements to be developed in relation to UUC:

1. Provide better support for self-care 
2. Help people to get the right advice or treatment in the right place, first time 
3. Provide a highly responsive urgent care service outside of hospital 
4. Ensure that those people with more serious or life-threatening emergency needs receive treatment in centres with the right facilities and expertise 
5. Connect the whole UEC system together through networks.

Specifically, national priorities for UEC include focus on simplifying access for the public, improved mental health care, development of NHS 111 and triage services and increasing patient access to primary care through online tools and apps. Skills and capabilities required through training will increasingly need to be applied to these new contexts and may include calculation and interpretation of clinical prediction tools for severe illness (such as early warning scores).

For each problem or disease, consider the following areas within the general context of primary care:

• the natural history of the untreated condition, including whether acute or chronic
• the prevalence and incidence across all ages and any changes over time
• typical and atypical presentations
• appropriate application of infection control principles, including the use of personal protective equipment (PPE)
• recognition of normal variations throughout life
• risk factors, including lifestyle, socio-economic and cultural factors
• diagnostic features and differential diagnosis
• recognition of deterioration, ‘alarm’ or ‘red flag’ features
• appropriate and relevant investigations
• interpretation of test results
• management, including self-care, initial, emergency and continuing care, chronic disease monitoring
• patient information and education, including self-care and ‘safety-netting’.

Symptoms and signs

• Symptoms and signs of acute illness in adults, including patients with learning disabilities, dementia or other communication problems
• Symptoms and signs of the acutely ill child (see also the RCGP Children and young people topic guide)
• Symptoms that may indicate an acute exacerbation of a chronic disease
• Chronic or comorbid diseases, risk factors and treatments that can influence the incidence and presentation of acute illnesses
• Important symptoms and signs that may indicate severe illness, but which may be produced by other, less severe illnesses, and strategies to avoid missing those severe illnesses when not obvious at initial presentation (for example, viral symptoms in a child should not exclude the recognition of sepsis)
• Factors that may alter the presentation of symptoms and signs of severe illness, particularly when there are limitations to immune competency (including pregnant women, infants, very elderly people or those who are immunosuppressed)
• Factors suggestive of a high risk of harm to self or others
• Features of severe or life-threatening injuries
• Features of serious illnesses that require an immediate response. Examples include:
  • cardiovascular: chest pain, abnormal pulses (arrhythmias, bradycardia, tachycardia), hypertension, dyspnoea, oedema, hypotension, dizziness, syncope, vascular compromise, haemorrhage
  • central nervous system: reduced conscious level, seizures, dizziness, confusion, loss of sensation or function, cerebellar and vestibular dysfunction, weakness, spasticity, paraesthesia, speech and language deficits, headache, visual problems including reduced acuity, diplopia, pupillary abnormalities, visual field defects, ophthalmoplegia
  • digestive: abdominal pain, dysphagia, melaena, bloody diarrhoea, haematemesis
  • endocrine: lethargy, polyuria, polydipsia, pain
  • renal: dehydration, anuria or oliguria
  • mental health: abuse, self-harm, psychosis, delusional states, substance misuse
  • respiratory: wheeze, dyspnoea, stridor, drooling, choking, respiratory distress and respiratory failure, cyanosis, hypoxia, tachypnoea, low oxygen saturations, low peak flow, chest pain, haemoptysis, swelling of face or tongue
  • sepsis: tachypnoea, hypotension, and altered mentation, fever, rashes and meningism.
• When providing UUC, it is especially important to consider how acute illness and distress can affect communication, as well as the emotional effect this has on patients, carers and healthcare professionals.

Common and important conditions

• ‘Dangerous diagnoses’ – these are conditions that always require urgent action if they are suspected. Some important examples include: 
  • acute psychosis or mania
  • aneurysms 
  • Appendicitis
  • cancer (for example, hypercalcaemia, neutropenic sepsis, spinal cord compression, superior vena cava obstruction)
  • intestinal obstruction or perforation
  • limb ischaemia
  • meningitis
  • serious suicide risk
  • mental health, including crisis
  • myocardial infarction
  • pregnancy-related issues, including ectopic
  • pulmonary embolus
  • sepsis
  • stroke or cerebrovascular accident (CVA)
  • subarachnoid haemorrhage 
• Emergency conditions where the underlying diagnosis may not be known (such as anaphylaxis, choking, loss of consciousness, cardiorespiratory arrest) 
• Emergencies that may occur in relation to certain healthcare activities (for example, anaphylaxis or allergic reaction after immunisation, local anaesthetic toxicity, vasovagal episodes) 
• Emergencies arising in patients receiving palliative or end-of-life care (see the RCGP topic guide People at the end of life)
• Multifactorial problems associated with patients who live alone and/or with multiple comorbidities, particularly older adults with an acute presentation who may be frail and have both social and medical care needs
• Conditions associated with social, cultural and lifestyle factors that influence the incidence, severity and presentation of acute illnesses (such as delayed presentation and increased mental distress in some cultures in relation to certain illnesses that may be considered stigmatising,; or acute illness relating to omitting medication during periods of religious fasting)
• Death (both expected and unexpected) including the assessment and confirmation, and the legal requirements

Examinations and procedures

• Basic life support (BLS) skills, including performing cardiopulmonary resuscitation (CPR), using automated external defibrillators (AEDs) and giving emergency drugs
• Examination of the relevant system or body part as appropriate
• Mental state examinations and risk assessments to ensure the safety of others
• Giving emergency or urgent medications in primary care, including oxygen, adrenaline, glyceryl trinitrate (GTN), intramuscular or subcutaneous injections, inhalers and nebulisers

Investigations

• Electrocardiogram (ECG) interpretation
• Recognise and differentiate between patients who require urgent investigation, patients who can wait longer for a routine investigation and those where time should be used as a diagnostic tool
• Near-patient blood testing (such as glucose, haemoglobin, C-reactive protein (CRP), D-dimer)
• Peak flow measurement and interpretation
• Urinalysis tests, including pregnancy test
• Vital signs measurement, including respiratory rate, blood pressure and oxygen saturation

Service issues

• Knowledge of how to access the key services, organisations and professionals, both in the community and in secondary care, who provide unscheduled care for patients in and out of hours, to organise effective care in the most appropriate location for the patient
• Familiarity with available prescribing options, medicines and equipment in the workplace, and car or bag and maintenance of appropriate equipment and drugs
• Local and national protocols and decision support systems for urgent care (such as National Institute for Health and Care Excellence (NICE), Clinical Knowledge Summaries (CKS) and Scottish Intercollegiate Guidelines Network (SIGN) guidance)
• Options available to enable timely review of acutely ill patients to monitor their condition and determine changes to initial management plans
• Options available to maintain continuity of care for a patient undergoing an episode of acute illness, including appropriate communication between team members. This includes access to the patient’s medical records and other relevant information about them
• The importance of providing appropriate documentation and records for each patient contact, which must be communicated to the next professional involved with that patient
• Appropriate use of emergency services, including the logistics of communicating with an ambulance or paramedic crew and the response time required
• Strategies for ensuring effective and appropriate communication and escalation of concern regarding deteriorating patients to ambulance services, the emergency department (ED) or accident and emergency (A&E) and acute service colleagues
• Clinical, administrative and pastoral support that a GP needs to provide at times of crisis or bereavement (including certification of illness or death)
• Approaches for managing patients who may make inappropriate or frequent demands on the health service (for example, because of a disorganised lifestyle or mental health disorder)
• The role of integrated care systems in commissioning UUC in your community
• The administrative and operating processes for the urgent care organisations you may be working in. These include: 
  • information technology (IT) systems, including electronic patient records
  • the process for recording and transmitting information about patients and the outcomes of any contact with them
  • the communication systems used by the organisation, particularly regarding an urgent or deteriorating patient

Additional important content

• Knowledge of how to access and use the processes and procedures in place to ensure patient safety in the urgent care setting (such as clinical governance, quality control and health and safety)
• The medico-legal issues and indemnity requirements for the UUC you provide
• The importance of positive, caring and respectful attitudes to the patients, carers and colleagues with whom you work in urgent care contexts, many of whom you may not have met before
• Processes for reporting and analysing significant and untoward events relating to acutely ill patients

Case discussion

You are working in an urgent care clinic. You take a phone call from a father who is worried about his four-year-old daughter, Jana Petrov, who has ‘tummy pain’. He tells you they have recently moved to the UK from Russia and that he has already consulted another GP earlier the same day who diagnosed an upper respiratory tract infection with mesenteric adenitis.

The father has a thermometer at home and reports that Jana’s temperature is now 39.6°C. He is worried because she has not recovered since her appointment earlier and he asks you to prescribe some antibiotics for him to collect from a nearby pharmacy, as he has no car and feels Jana is too unwell to bring to the clinic in a taxi or on the bus.

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.

Workplace-based learning

As a GP registrar, you must gain experience of managing patients presenting with urgent and unscheduled healthcare needs, which is an important feature of both ‘in-hours’ and ‘out-of-hours’ GP care. There are particular features of unscheduled care that require a specific educational focus, such as the increased risk of working in isolation, the ‘high-stakes’ nature of clinical decisions, the relative lack of supporting services and the frequent need to promote self-care.

There are a number of organisations involved in the delivery of urgent and unscheduled primary care, including pharmacies, dentists, NHS 111, GP practices, urgent care centres, out-of-hours providers, seven-day access services and EDs or A&Es. The model of service provided varies, but there will be a need for partnership and collaboration between all agencies at the local level. As part of your training programme, you need exposure to a variety of community-based emergency and out-of-hours models.

The hospital environment can be an ideal setting for you to see concentrated groups of acutely ill children and adults. All doctors entering general practice training programmes are expected to have acquired the competences in acute care described in the foundation programme curriculum. Many doctors will have acquired additional competences during their hospital training before entering GP specialty training. Some GP training programmes will contain placements of varying length in acute medicine and EDs that are ideal environments for learning about acutely ill people and their management. While you will have learned CPR skills in the foundation programme (or equivalent), it is important to maintain these skills once in practice through regular updates and practical training sessions. Hospital resuscitation departments usually have excellent learning resources for you to keep up to date with these skills.

All GP registrars and GPs should have access to BLS and CPR courses and learning resources during their primary care placements to help them address their learning needs.

Learning with other healthcare professionals

Teamwork is essential for the effective management of acutely ill patients in primary and secondary care. It is vital that all members of the primary healthcare team (both clinical and non-clinical members) understand their roles in managing acutely ill patients and contribute to the development of practice guidelines.

Formal structured learning opportunities can include organisation induction programmes (such as when starting to train or work in an out-of-hours GP centre), telephone consulting skills courses and eLearning opportunities. You can find an eLearning module(s) relevant to this topic guide at elearning for healthcare.

Applied Knowledge Test (AKT)

• Differential diagnosis of acute confusional state
• Signs and symptoms of sepsis
• Management of an epileptic seizure

Simulated Consultation Assessment (SCA)

• Phone call: a paramedic asks for a routine visit to a middle-aged man who has a four-hour history of paraesthesia in his arm. The paramedic’s provisional diagnosis is nerve entrapment
• House call: a young man with acute headache and vomiting. An examination is expected
• A young woman feels unwell and is sweating and light-headed and has a rapid pulse. An examination is expected

Workplace-based Assessment (WPBA)

• Take a history with a parent about their febrile child
• Case-based Discussion (CbD) about an elderly patient with pneumonia who has capacity and is refusing admission to hospital
• Clinical examination of an acute abdomen for possible appendicitis

References

1. https://www.england.nhs.uk/publication/delivery-plan-for-recovering-urgent-and-emergency-care-services/