Use these practical tips to help inform and review practice protocols and policies on home visits for GPs and staff, particularly reception staff taking calls from patients. A revamped home visits policy could also be an aid for your GP appraisal and revalidation as well as helping you to avoid medico-legal problems. An added bonus is that you may even begin to enjoy home visits.
Tip 1 Expecting the unexpected
All GPs can recall cases of requests for unnecessary visits. But you can never be sure until you get inside the patient’s home. It is so easy to make assumptions, like never suspecting from surgery consultations that a family is living in squalid conditions.I can remember someone who rang saying that her husband would not wake up and asking if I visit as she was worried he would be late for his breakfast. It transpired that he had been dead for hours and rigor mortis had set it.
Tip 2 Getting good directions
A major challenge of homes visits is the time wasted if taken if you cannot find the house. If the patient says ‘You can’t miss it’, you will. Streets seldom follow a logical order; housing estates can have the same name for a road with branches off it in different directions without out any pattern in relation to odd and even numbers.
Always ask for a landmark: your GPS will take you to a postcode, not to a house. In rural locations, houses may have names but no numbers. If it s late at night ask for the hazard lights on a car to be left on.
Tip 3 Feverish children
Whenever possible insist that an ill feverish child is brought to the surgery. Although rare, a meningococcal rash can present on any part of the body but you need good light to see it. So often on home visits you are brought into a darkened room to see a lethargic child lying covered by a quilt. If seen at the surgery, you can see if the child is alert. The child may be irritable, but you can remove clothing and check whether or not a rash is present in good light.
Tip 4 Abdominal pain
As a GP your time is at a premium. Whatever the patient’s age, if you receive a phone request to see person with abdominal pain, suggest that the patient is put on/in a bed while you drive to their house so that you can examine their abdomen.There is nothing worse than having to wait 10 minutes to move an unwell patient from armchair to bed. Examining the abdomen of a patient on small settee or chair is far from ideal:you may have to kneel close to where the patient has vomited or next to a source of heat (radiator, fireplace).
Tip 5 Pets
It is not just dogs that you should be concerned about. I have been bitten and scratched by a cat. Insist that dogs and cats are removed from the room where a patient is, no matter what reassurance an owner may give Beware of the dog that lets you in the house, but becomes threatening when you try to leave. If a dog is loose in the garden, phone the house and say you will not enter until it is put on a lead and taken to a room away from the patient.
Tip 6 Snow
When it snows heavily there is often an expectation that you will make a superhuman effort to visit. When snow is forecast always take waterproof boots, de-icer and gloves. Put some old mats in your boot in case your rear wheels get stuck so can put them underneath the wheels to obtain traction.
Don’t attempt to go down a steep drive. Leave your car on the road where hopefully the gritting vehicle or snow plough has been. The last thing you want to do is to get stuck.
Tip 7 Dangerous situations
It is better to be safe than sorry. Always tell someone when you are going to do a visit and give them the patient’s address. Check you have got your mobile phone. If you have any suspicions when accepting a call out, take someone with you. There may be circumstances where it is appropriate to seek help from the police.
Be careful about visiting a house alone and do not perform an intimate examination without a chaperone, no matter how well you think you know the patient. Ideally, such an examination should be conducted at the surgery with the necessary equipment and support staff.
Tip 8 Doctor’s bag
Make sure your doctor’s bag has appropriate equipment to make a medical assessment together with emergency drugs. Take a printout of the patient summary record if you cannot access it when away from the computer system, stationery to write a letter and local contact numbers to admit a patient into hospital if required.
Tip 9 Learning more about the patient
Some GPs who have written about visiting say it is a privilege to enter a person’s home and that you may learn something new about them. How true. Some can recall asking an elderly person where their tablets are kept only to find a decade’s worth of unused medication. The patient when asked why said they did not to take their tablets but did not want to upset the doctor so kept ordering repeats.
You cannot discover or learn from things like this by staying behind your consulting room desk.
Tip 10 End of life
One of the most difficult and yet rewarding experiences is visiting a dying patient or the bereaved. It is important not to go reluctantly as this home visit will remembered by the patients’ relative(s)/carers more than any other and is one of the many arts of good general practice in danger being lost.
- Professor Rodger Charlton is professor of medical education at Swansea University and a GP