Undertaking an accurate and comprehensive consultation history is considered one of the most important factors in ensuring a safe prescribing decision (Young et al, 2009). This can be particularly challenging when using telephone and video consultation methods where visual clues and the subtleties of language can be difficult to interpret (Car et al, 2004). Remote consultations have been a fixture in healthcare for some time but their use has been expedited in response to COVID-19 restrictions (Churchouse et al, 2021). In the out-of-hours (OOH) urgent primary care setting, the initial consultation with the patient is via a phone call and a follow-up in-person consultation only occurs when deemed clinically necessary.
This article discusses the evolution of consultation models and the adaptation of these for use in the telephone triage system used in an OOH setting. This will focus on a clinical review involving a 60-year-old gentleman, Dan (a false name for anonymity), who contacted the OOH service with concerns about potentially contracting Lyme disease following a tick bite.
Consultation models
Consultation models were originally developed as a means to explore and understand the psychological aspects of doctor–patient consultations, in addition to providing a structure to the process (Denness, 2013). Predominantly, these were based on a traditional medical approach of a face-to-face consultation with a hierarchical balance veering towards the clinician who led both the consultation and decision making. Over time, the consultation process evolved from physician-centric to become more patient-centred with the emphasis placed on establishing a therapeutic relationship to explore individual health and wellbeing while also focusing on public health promotion (Willcox and Munson, 2007).
Consultation models which have gained popularity, such as Neighbour's (1987) inner consultation model and the Calgary-Cambridge model (Silverman, 2013), encourage patient-centredness with a holistic, shared partnership approach. Neighbour (1987) focuses on five checkpoints that summarise the patient's story to ensure an accurate interpretation, while using both open and closed questioning to clarify factual information and encouraging negotiation between the clinician and the patient. However, it has been suggested Neighbour's method of structured questioning leads to vital pieces of information being missed and that it does not provide a means to complete the consultation (Munson and Willcox, 2007). Conversely, Young et al (2009) argue Neighbour's model does complete the consultation by considering the ‘what ifs’ and safety netting so that the patient understands what to do if the agreed treatment is not effective. The Calgary-Cambridge model, although similar in its step-wise holistic, patient-centred approach, aims to develop a rapport throughout and provides direction in completing the consultation, summarising and clarifying any agreed plan. Although this model identifies five core tasks, there are 70 substeps to consider, which can be time-consuming and add complexity to a consultation process.
Opinion on the variety of models available has progressed to Denness (2013) suggesting there was no ideal consultation model, whereas Pawlikowska et al (2012) recommended a flexible approach to each patient interaction. Willcox and Munson (2007), while also advocating flexibility, question if practitioners should use a hybrid mix of different consultation models to meet individual patient needs and expectations. More recently, Nuttall and Rutt-Howard (2019) introduced the consultation umbrella, which incorporates aspects from the Neighbour, Pendleton and Calgary-Cambridge models. This aims to promote an organised approach to therapeutic communication and clinical decision-making, elements that are essential to the success of the patient encounter in contemporary healthcare.
The out-of-hours consultation process
In the urgent OHH setting, members of the public initially contact NHS 24. Based on the severity of the patient's clinical condition they are triaged to either a telephone consultation or immediate referral for an in-person appointment. Dan's call regarding his tick bite was triaged for a telephone consultation with either the duty doctor or the advanced nurse practitioner. The Royal College of Nursing (2018) identified advanced nurse practitioners as autonomous decision-makers, who can assess, diagnose and implement treatment appropriate to the healthcare needs of their patients. They are accountable for the decisions they make for patients which includes prescribing medicines. Prior to contacting Dan, preparation for the consultation involved reviewing the triage information and accessing any relevant evidence-based guidelines. During the initial process of information gathering, it is essential to remain open-minded to differential diagnosis as there is a risk of pre-conceived outcomes and assumptions being made before the encounter.
The telephone consultation with Dan began with initial introductions as an ice-breaker, using Neighbour's (1987) inner consultation model, Dan was encouraged to relay in his own words what had happened and express his concerns. Silverston (2013) reported that most patients will tell you what the problem is within the first few minutes if left uninterrupted, however, it is important to also use verbal encouragement to show interest. Using a structured approach based on a consultation model ensures that important information is not missed, an understanding of what is important to the patient is gained while also allowing a natural flow to the conversation. Chaudhry et al (2020) identified potential adverse effects of telephone triage on patient safety because of difficulties in rapport building resulting in limited or irrelevant data gathering.
Dan had found a tick on his lower abdomen while showering that morning. He thought this may have occurred at least 5 days previously when last out hill walking. His wife removed the tick, exposing a red circular rash on his abdomen. Over the past 2 days, Dan had experienced mild flu-like symptoms and headache and he had self-medicated with paracetamol but remained symptomatic. Past medical history, current medications and allergies were verified to complete a full history consultation.
The presence of an erythema migrans rash at the site of a tick bite is considered indicative of exposure to Lyme borreliosis but the differential of tick bite hypersensitivity or other concerning symptoms must be excluded (National Institute for Health and Care Excellence (NICE), 2018). Given the potential diagnosis of Lyme disease, an in-person consultation and physical examination were warranted.
The in-person consultation began with a recap of the information provided during the telephone assessment. Neighbour (1987) advocates ‘summarising’ as a way of showing understanding of the patient history and concerns, and it allowed Dan to amend or add further details. Using ‘closed’ questioning more in keeping with a traditional medical model allows a focus on potential ‘red flags’ in the history, particularly for more serious symptoms which may indicate referral to secondary care (Churchouse et al, 2021). On clinical examination, a red rash over the site of the tick bite with a ‘bullseye’ centre was evident. This was not itchy, hot or painful, confirming the lesion as erythema migrans while excluding the differential of a local reaction to the tick bite.
Lyme disease
Lyme disease is a tick-borne disease caused by members of the spirochaetal complex Borrelia burgdorferi (Nuttall, 2018). It has become the most common tick-borne infection in many parts of Europe, with predicted estimates of upward of 8000 annual cases in the UK with greatest prevalence in Scotland, South West of England and least cases in Northern
Ireland (Cairns et al, 2019). The presence of erythema migrans, a ‘bullseye’ rash around the bite area from an infected tick, and flu-like symptoms represent an early manifestation of Lyme borreliosis, although it can clinically present as a range of conditions, including neurological, joint or cardiac abnormalities, as well as chronic fatigue and myalgia (Tulloch et al, 2019). If left untreated, Lyme borrelia may progress to more serious and chronic manifestations.
Much of the evidence-based research for treating Lyme disease is sparse and of low quality. Internationally, clinical opinion differs regarding the use of antibiotic prophylaxis for known tick bites, the need for diagnostic confirmation of Lyme borrelia exposure and the antimicrobial choice, dose and length of treatment (Torbahn et al, 2016). The International Lyme and Associated Diseases Society (ILADS) acknowledge the variability of treatment options for prophylaxis treatment, the effectiveness of erythema migrans treatment and which antibiotic to prescribe as retreatment in persistent Lyme disease manifestations (Cameron et al, 2014). Given the sparsity of evidence, the ILADS guideline strongly advocates a patient-centred approach to effectively engage patients in shared decision-making. Individuals make differing assessments of perceived risk to benefit based on risk tolerance and personal preference, which highlights the need to ensure the person is well informed and has a sufficient level of understanding of the full implications of their treatment choices.
NICE (2018) guidance highlights the lack of epidemiological data on Lyme disease in the UK but notes that most tick bites do not transmit the disease. As the majority of UK, native ticks are not infected with the bacteria, having been bitten by a tick does not presume the transmission of Lyme disease when there are no accompanying symptoms. Conversely, confirmation of a tick bite is not required in those who are symptomatic with an erythema migrans rash as this is considered sufficient evidence to initiate treatment and prescribe antimicrobial therapy. Guidance recommends diagnosing and offering antimicrobial treatment for Lyme disease without the need for laboratory testing in people who present with erythema migrans (NICE, 2018).
Medicines management
The first-choice antibiotic treatment for Lyme disease in adults is determined by the symptom presentation (NICE, 2018). The antimicrobials recommended are Doxycycline, Amoxycillin or Cefuroxime. Alternative choices include azithromycin in patients with no Lyme disease-associated cardiac abnormalities. Dan was already aware of the potential for Lyme disease, highlighting this among his concerns and reason for contacting health services, and was keen to start treatment. Given the clinical presentation, a shared decision was reached to commence antimicrobial treatment with the prescription of Doxycycline (Table 1).
Table 1. Medicine management
| Treatment plan |
|
| Administration |
|
| Safety netting |
|
The consultation was completed with safety netting advice and ensuring Dan understood how to take his medication. Doxycycline is a second-generation Tetracycline antimicrobial used as a broad-spectrum treatment in a variety of conditions, and although unlicensed for this use, it includes Lyme borreliosis (BNF, 2022). It was important to discuss with Dan the use of an unlicensed medication in addition to the implications of the treatment choices to facilitate concordance (Barratt, 2018). Dan was made aware of common side effects and it was highlighted that doxycycline can cause increased photosensitivity to sunlight and to protect his skin, particularly if he was to resume hill walking during the 21-day course. As with all antimicrobial treatments, consideration was given to minimising the spread of antimicrobial resistance through patient awareness (Dexter and Mortimore, 2020). The importance of completing the full course of doxycycline was stressed, and although the lesion should improve in approximately 2 weeks, Dan should not stop taking the medication. The caveat to this was that the lesion may take longer than 2 weeks to heal and follow-up would be required with his GP. Health education was discussed in relation to potential signs of worsening Lyme disease which would warrant further investigation or treatment. Dan was also supplied with health promotional information on Lyme disease and how to safely remove a tick in future (NHS inform, 2022) (Table 2).
Table 2. Be tick aware health promotion
| Be tick aware |
|
| What to do if you are bitten by a tick |
|
Conclusion
Consultation models provide an essential structure to the assessment of health and wellbeing to support the development of safe and effective prescribing practice. It enables sharing of information but also an understanding between the practitioner and patient to reach a mutually agreed management plan. Like healthcare provisions, these have evolved to meet the requirements of contemporary practice. This case study demonstrates the adaptability of OOH practice with a hybrid consultation process to ensure appropriate diagnosis and management of Lyme disease, given the constraint of virtual assessment. It also underscores the necessity of safety netting when practising within the confines of an isolated patient encounter when dealing with a disease which can progress to a chronic condition, with resulting impact on patient and societal outcomes.
Key Points
- Consultation processes and models must evolve and adapt to meet contemporary healthcare provision of virtual and telephone health assessment
- The incidence of Lyme disease in the UK is predicted to be greater than 8000 annual cases, leading to an increasing burden on patient morbidity, resources and society
- The research evidence on antibiotic prophylaxis and treatment of Lyme disease has been described as sparse, conflicting and of low quality
- NICE guidelines state the presence of an erythema migrans rash can be considered diagnostic of Lyme disease and antimicrobial treatment is indicated without conflrmation from laboratory testing.
CPD reflective questions
- A consultation model provides structure, but one size does not fit all. Consider whether a hybrid approach could be adapted to individual patients' needs in your specialist area of practice.
- Using evidence-based guidelines are an essential factor in prescribing decisions but it is also imperative that the practitioner reviews the evidence behind these guidelines. How does this promote shared-decision making with the patient?
- Ticks infected with Lyme borrelia are more prevalent in certain geographic areas and conditions. What health promotion advice would you give to someone who is concerned about exposure to tick bites and how to minimise their risk?