Urgent and Out-of-Hours Primary Care

A practical guide for clinicians

Hardeep Bhupal

• Publisher: Scion Publishing
• Year: 2022
• eBook ISBN: 9781914961113
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

Covers the most common conditions seen in an out-of-hours primary care or urgent medical care setting. Urgent and Out-of-Hours Primary Care provides practical guidance on the diagnosis and management of the acute medical conditions seen most commonly in an out-of-hours setting.

• Covers over 200 acute medical conditions commonly encountered when working in an urgent and primary care setting
• Colour photographs provide the reader with further important information on assessing patients presenting with acute medical conditions
• Key 'red flag' features are highlighted in boxes
• The latest guidance and prescribing information is provided
• Uses a consistent approach: each condition features discussions of presentation, assessment and management
• Offers practical guidance on how to use telephone triage, video consultations and home visits effectively
• Assumes access to basic diagnostic aids only
• Provides differential diagnoses by symptom
• Indicates when to refer to hospital and when to order an emergency ambulance

This book is aimed at GPs, GP trainees, doctors, medical students, nurses, paramedics, pharmacists and other healthcare professionals involved in providing urgent and out-of-hours primary care to patients.

1 Chapter 1: Medico-legal aspects of providing out-of-hours medical care

“Live your life as if your every act was to become a universal law.”

Immanuel Kant

The evidence

• From 2014 to 2017 the Medical Defence Union (MDU) paid out over £30 million in compensation and legal costs for out-of-hours (evening and weekend) consultations and encounters.
• This is more than would be expected when compared to in-hours consultations; for this reason most indemnity providers will charge higher premiums for clinicians providing urgent or out-of-hours (OOH) medical care.
• In 2019/20 NHS Resolution, which manages claims for compensation on behalf of the NHS, paid out £2.3 billion in compensation^[1].
• In 2019 the NHS agreed to provide limited indemnity cover to all primary care doctors working within the UK. As a result there was a significant drop in subscription charges and premiums.
• However, there is little doubt the cost of claims continues to rise.
• Several risk factors in an OOH or urgent care setting increase the risk of litigation; these include^[2]:
  • ○ diagnostic uncertainty
  • ○ patients being more acutely unwell and the increased severity of illness
  • ○ lack of patient medical records and unfamiliarity with the patient
  • ○ lack of continuity of care, hence only a snapshot is obtained
  • ○ greater use of non-face-to-face consultations, e.g. telephone
  • ○ use of non-medically qualified staff such as call handlers and case advisors.

In 2017 the MDU provided a list of the most common causes of litigation resulting in settled claims^[3]:

1. Delayed or failed diagnosis	= 71%
2. Failure to refer	= 18%
3. Medication issues	= 9%
4. Inadequate or inappropriate treatment	= 1%
5. Other	= 1%

The most common conditions which were missed or diagnosed with a delay were^[3]:

1. Cauda equina syndrome

2. Limb ischaemia

3. Gastrointestinal and urological complaints: perforation, obstruction, abscess, appendicitis, testicular torsion

4. Myocardial infarction

5. Meningitis and septicaemia (in a review of 15 cases, 40% were in an OOH setting).

How to minimise the risk of complaints and litigation

• Firstly being aware of the common pitfalls helps, as well as bearing in mind that patients who present in an urgent care or OOH setting are more likely to be acutely unwell.
• When assessing a patient, key factors to consider are:
  • ○ what is the worst-case scenario this could be? For example, if a patient presents with a headache, have I ruled out features of meningitis and documented my negative findings?
  • ○ could the patient’s condition deteriorate? If so, have I expressed my concerns to the patient and documented this in the notes?
  • ○ note-keeping is extremely important. Always remember, if it has not been recorded in the notes it has not been done.
• Additional tips which may help to minimise the risk of litigation are:
  • ○ review of any: past notes, previous consultations, special notes recorded on the system, summary care records or patient medical records available for sharing between healthcare organisations.
  • ○ contemporaneous note-keeping: use quotation marks to record any key phrases the patient may use, and record negative findings, such as the absence of a rash.
  • ○ structure to note-keeping: the mnemonic SOAPS can be used as a framework:
    Subjective findings: e.g. patient looked well, alert, smiling, and comfortable
    Objective ...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Index of conditions
• Index of conditions by symptom
• Preface
• Acknowledgements
• About the Author
• The Declaration of Geneva
• Abbreviations
• Chapter 1: Medico-legal aspects of providing out-of-hours medical care
• Chapter 2: Telephone consultations and telephone triage
• Chapter 3: Video consultations
• Chapter 4: Home visits
• Chapter 5: Head injuries
• Chapter 6: Acute injuries, bites and wounds
• Chapter 7: Cardiovascular
• Chapter 8: Respiratory
• Chapter 9: Neurology
• Chapter 10: Endocrinology
• Chapter 11: Gastroenterology
• Chapter 12: Rheumatology
• Chapter 13: Urology
• Chapter 14: Ophthalmology
• Chapter 15: Mental health
• Chapter 16: Poisoning, overdose and foreign body ingestion
• Chapter 17: Dermatology
• Chapter 18: ENT
• Chapter 19: Musculoskeletal
• Chapter 20: Women’s health
• Chapter 21: Men’s health
• Chapter 22: Paediatrics
• Chapter 23: Cancer / palliative care
• Chapter 24: Safeguarding and non-accidental injury
• Chapter 25: Basic life support
• Chapter 26: Confirmation of life extinct
• Back Cover