Acute care pathways for patients calling the out-of-hours services.
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ABSTRACT:
SUBMITTER: Sovso MB
PROVIDER: S-EPMC7045402 | biostudies-literature | 2020 Feb
REPOSITORIES: biostudies-literature
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Acute care pathways for patients calling the out-of-hours services.
Søvsø Morten Breinholt MB Huibers Linda L Bech Bodil Hammer BH Christensen Helle Collatz HC Christensen Morten Bondo MB Christensen Erika Frischknecht EF
BMC health services research 20200227 1
<h4>Background</h4>In Western countries, patients with acute illness or injury out-of-hours (OOH) can call either emergency medical services (EMS) for emergencies or primary care services (OOH-PC) in less urgent situations. Callers initially choose which service to contact; whether this choice reflect the intended differences in urgency and severity is unknown. Hospital diagnoses and admission rates following an OOH service contact could elucidate this. We aimed to investigate and compare the pr ...[more]
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Project description:IntroductionCallers with acute shortness of breath (SOB) are a challenge for telephone triage at out-of-hours primary care (OHS-PC) as SOB could be the sign of a potentially life-threatening disease, yet mostly is a symptom of a broad range of self-limiting disorders. Current telephone triage practice is mainly expert based and clear evidence on accuracy, safety and efficiency of the use of the Netherlands Triage Standard (NTS) by triage nurses based on the eventual clinical outcome is lacking for this domain.Methods and data analysisMultiple methods study in five OHS-PC services in the Utrecht region, the Netherlands. Data will be collected from OHS-PC electronic health records (EHR) and backed up tapes of telephone triage conversations, which will be linked to routine primary care EHR data. In cross-sectional studies, we will (1) validate the NTS urgency classification for adults with SOB against final diagnoses and (2) develop diagnostic prediction models for urgent diagnoses (eg, composite endpoint of urgent diagnoses, pulmonary embolism, acute coronary syndrome, acute heart failure and pneumonia). We will develop improvement measures for the use of the NTS by triage nurses through practice observations and semistructured interviews with patients, triage nurses and general practitioners (GPs). In an action research approach, we will, in collaboration with these stakeholders, implement and evaluate our findings in both GP and triage nurse educational programmes as well as in OHS-PC services.Ethics and disseminationThe Medical Ethics Review Committee Utrecht, the Netherlands, approved the study protocol (protocol 21/361). We will take into account the 'code of conduct for responsible research' of the WHO, the EU General Data Protection Regulation and the 'Dutch Medical Treatment Contracts Act'. Results will be disseminated in peer-reviewed publications and at (inter)national meetings.Trial registration numberNL9682.
| S-EPMC9024277 | biostudies-literature
Project description:BackgroundIn out-of-hours primary care (OHS-PC), semi-automatic decision support tools are often used during telephone triage. In the Netherlands, the Netherlands Triage Standard (NTS) is used. The NTS is mainly expert-based and evidence on the diagnostic accuracy of the NTS' urgency allocation against clinically relevant outcomes for patients calling with shortness of breath (SOB) is lacking.MethodsWe included data from adults (≥18 years) who contacted two large Dutch OHS-PC centres for SOB between 1 September 2020 and 31 August 2021 and whose follow-up data about final diagnosis could be retrieved from their own general practitioner (GP). The diagnostic accuracy (sensitivity and specificity with corresponding 95% confidence intervals (CI)) of the NTS' urgency levels (high (U1/U2) versus low (U3/U4/U5) and 'final' urgency levels (including overruling of the urgency by triage nurses or supervising general practitioners (GPs)) was determined with life-threatening events (LTEs) as the reference. LTEs included, amongst others, acute coronary syndrome, pulmonary embolism, acute heart failure and severe pneumonia.ResultsOut of 2012 eligible triage calls, we could include 1833 adults with SOB who called the OHS-PC, mean age 53.3 (SD 21.5) years, 55.5% female, and 16.6% showed to have had a LTE. Most often severe COVID-19 infection (6.0%), acute heart failure (2.6%), severe COPD exacerbation (2.1%) or severe pneumonia (1.9%). The NTS urgency level had a sensitivity of 0.56 (95% CI 0.50-0.61) and specificity of 0.61 (95% CI 0.58-0.63). Overruling of the NTS' urgency allocation by triage nurses and/or supervising GPs did not impact sensitivity (0.56 vs. 0.54, p = 0.458) but slightly improved specificity (0.61 vs. 0.65, p < 0.001).ConclusionsThe semi-automatic decision support tool NTS performs poorly with respect to safety (sensitivity) and efficiency (specificity) of urgency allocation in adults calling Dutch OHS-PC with SOB. There is room for improvement of telephone triage in patients calling OHS-PC with SOB.Trial registrationThe Netherlands Trial Register, number: NL9682 .
| S-EPMC10967202 | biostudies-literature
Project description:BackgroundPatient satisfaction questionnaires are increasingly used for assessing quality of care.AimTo review the evidence for the reliability and validity of patient satisfaction questionnaires for out-of-hours care.DesignSystematic review.SettingPrimary care out-of-hours services.MethodSearches of CINAHL, EMBASE, MEDLINE((R)) and PsycINFO using terms relevant to the measurement of patient satisfaction and out-of-hours services. Abstracts were reviewed and information relating to questionnaire content, data quality, reliability, and validity were extracted from articles by two independent researchers.ResultsFour questionnaires were found, two from the UK - the Patient Satisfaction with Out-of-Hours Care (PSOC) and Short Questionnaire for Out-of-Hours Care (SQOC) - and two from the Netherlands - the van Uden and Moll van Charante questionnaires. Questionnaire content was based on literature reviews and expert opinion; the PSOC and Moll van Charante questionnaires were also developed following interviews or focus groups with patients. Cronbach's alpha values were below 0.7 for some scales within the PSOC and van Uden questionnaires. Test-retest reliability was reported for the PSOC and Moll van Charante questionnaires. Tests of validity were few and did not give explicit consideration to the size of expected associations.ConclusionPotential users wishing to assess patient satisfaction should carefully consider the content of the questionnaires and its relevance to the application and patient group. The four questionnaires have limitations relating to their development and evaluation. The PSOC and van Uden questionnaires have low levels of reliability for some scales, which should be used with caution in future surveys.
| S-EPMC2151790 | biostudies-literature
Project description:ObjectivesTo examine the relation between patients' illness representations, presented in telephone consultation to out-of-hours (OOH) services, and self-reported degree-of-worry (DOW), as a measure of self-evaluated urgency. If a clear relation is found, incorporating DOW during telephone triage could aid the triage process, potentially increasing patient safety.DesignA convergent parallel mixed methods design with quantitative data; DOW and qualitative data from recorded telephone consultations. Thematic analysis of the qualitative data was used to explore the content of the quantitatively scaled DOW, using the Common-Sense Model of Self-Regulation (CSM).SettingA convenience sampling of calls to the OOH services in Copenhagen, Denmark, during 3 days was included in the study.ParticipantsCalls from adults (≥15 years of age) concerning somatic illness during the data collection period were eligible for inclusion. Calls made on behalf of another person, calls concerning perceived life-threatening illness or calls regarding logistical/practical problems were excluded, resulting in analysis of 180 calls.ResultsAll five components of the CSM framework, regardless of DOW, were present in the data. All callers referred to identity and timeline and were least likely to refer to consequence (37%). Through qualitative analysis, themes were defined. Callers with a strong identity, illness duration of less than 24 hours, clear cause and solution for cure/control seemed to present a lower DOW. Callers with a medium identity, illness duration of more than 24 hours and a high consequence seemed to present a higher DOW.ConclusionThis study suggests a relation between a patient's illness representation and self-evaluation of urgency. Incorporating a patient's DOW during telephone triage could aid the triage process in determining urgency and type of healthcare needed, potentially increasing patient safety. Research on patient outcome after DOW-assisted triage is needed before implementation of the DOW scale is recommended.
| S-EPMC6144483 | biostudies-literature
Project description:ObjectivesTelephone triage of patients suspected of transient ischaemic attack (TIA) or stroke is challenging. Both TIA and stroke more likely occur during daytime, with a peak in the morning hours. Thus, the time of calling might be a helpful determinant during telephone triage. We assessed the time of calling in patients with stroke-like symptoms who called the out-of-hours services in primary care (OHS-PC), and evaluated whether the time of calling differed between patients with TIA or stroke compared with those with mimics.DesignCross-sectional study.SettingSix OHS-PC locations in the Netherlands.Participants1269 telephone triage recordings of patients calling the OHS-PC because of stroke-like symptoms. We collected information on patient characteristics, symptoms, time of calling and urgency allocation. The final diagnosis related to each triage call was based on letters from the neurologist (retrieved from the patient's general practitioner).Primary and secondary outcome measuresThe primary outcome measures were the time of calling hourly and 4 hourly, and the risk of TIA or stroke/hour. The secondary outcome measure was the risk ratio of TIA or stroke in the morning (08:00-12:00h) versus other hours.ResultsMean age was 68.6 (SD±18.5) years, 56.9% were women and 50.0% had a TIA or stroke. The risk ratio of TIA or stroke among people calling with stroke-like symptoms between 08:00-12:00h versus other hours was 1.13 (95% CI 1.00 to 1.28, p=0.070). After correction for age and sex, the adjusted risk ratio was 0.94 (95% CI 0.80 to 1.10, p=0.434).ConclusionIn patients who called the OHS-PC because of stroke-like symptoms, the time of calling did not differ between patients with TIA or stroke and patients with mimics.Trial registration numberThe Netherlands National Trial Registry (NTR7331).
| S-EPMC7747588 | biostudies-literature
Project description:BackgroundIn order to provide responsive, individualised and personalised care, there is now greater engagement with patients, families and carers in designing health services. Out-of-hours care is an essential component of community palliative care. However, little is known about how patients, families and carers have been involved in the planning and design of these services.AimTo systematically search and review the research literature that reports on how out-of-hours palliative care services are provided in the community and to identify the extent to which the principles of co-design have been used to inform the planning and design of these services.DesignSystematic literature search and review.Data sourcesA systematic search for published research papers from seven databases was conducted in MEDLINE, PsycINFO, Embase, Emcare, PubMed, CINAHL and Web of Science, from January 2010 and December 2021. Reference list searches of included papers were undertaken to source additional relevant literature. A manifest content analysis was used to analyse the data.ResultsA total of 77 papers were included. The majority of out-of-hours services in the community were provided by primary care services. The review found little evidence that patients, families or carers were involved in the planning or development of out-of-hours services.ConclusionIncorporating patients, families and carers priorities and preferences in the planning and designing of out-of-hours palliative care service is needed for service providers to deliver care that is more patient-centred. Adopting the principles of co-design may improve how out-of-hours care scan be delivered.
| S-EPMC9843546 | biostudies-literature
Project description:BACKGROUND: In previous years, out- of-hours primary care has been organised in large-scale organisations in many countries. This may have lowered the threshold for many patients to present health problems at nights and during the weekend. Comparisons of out-of-hours care between countries require internationally comparable figures on symptoms and diagnoses, which were not available. This study aimed to describe the symptoms and diagnoses in out-of-hours primary care services in regions in eight European countries. METHODS: We conducted a retrospective observational study based on medical records from out-of-hours primary care services in Belgium, Denmark, Germany, the Netherlands, Norway, Slovenia, Spain, and Switzerland. We aimed to include data on 1000 initial contacts from up to three organisations per country. Excluded were contacts with an administrative reason. The International Classification for Primary Care (ICPC) was used to categorise symptoms and diagnoses. In two countries (Slovenia and Spain) ICD10 codes were translated into ICPC codes. RESULTS: The age distribution of patients showed a high consistency across countries, while the percentage of males varied from 33.7% to 48.3%. The ICPC categories that were used most frequently concerned: chapter A 'general and unspecified symptoms' (mean 13.2%), chapter R 'respiratory' (mean 20.4%), chapter L 'musculoskeletal' (mean 15.0%), chapter S 'skin' (mean 12.5%), and chapter D 'digestive' (mean 11.6%). So, relatively high numbers of patients presenting with infectious diseases or acute pain related syndromes. This was largely consistent across age groups, but in some age groups chapter H ('ear problems'), chapter L ('musculoskeletal') and chapter K ('cardiovascular') were frequently used. Acute life-threatening problems had a low incidence. CONCLUSIONS: This international study suggested a highly similar diagnostic scope in out-of-hours primary care services. The incidence rates of acute life-threatening health problems were low in all countries.
| S-EPMC3114765 | biostudies-literature
Project description:BackgroundThe aim of this article is to describe the courses of vomiting, diarrhea, fever, and clinical deterioration, in children with uncomplicated gastroenteritis at presentation. This study was performed as a 7-day prospective follow-up study in an out-of-hours primary care service. The course of vomiting, diarrhea, and fever was analyzed by generalized linear mixed modeling. Because young children (≤ 12 months) and children with severe vomiting are at increased risk of dehydration, the potentially more complicated courses of these groups are described separately. The day(s) most frequently associated with deterioration and the symptoms present in children who deteriorated during follow-up were also described.ResultsIn total, 359 children presented with uncomplicated acute gastroenteritis to the out-of-hours primary care service. Of these, 31 (8.6%) developed a complicated illness and needed referral or hospitalization. All symptoms decreased within 5 days in most children (> 90%). Vomiting and fever decreased rapidly, but diarrhea decreased at a somewhat slower pace, especially among children aged 6-12 months. Children who deteriorated during follow-up had a higher frequency of vomiting at presentation and higher frequencies of vomiting and fever during follow-up.ConclusionsThe frequency of vomiting, not its duration, appears to be the more important predictor of deterioration. When advising parents, it is important to explain the typical symptom duration and to focus on alarm symptoms. Clinicians should be vigilant for children with higher vomiting frequencies at presentation and during follow-up because these children are more likely to deteriorate.
| S-EPMC9128130 | biostudies-literature
Project description:IntroductionIt is believed that some patients are more likely to use out-of-hours primary care services because of difficulties in accessing in-hours care, but substantial evidence about any such association is missing.MethodsWe analysed data from 567,049 respondents to the 2011/2012 English General Practice Patient Survey who reported at least one in-hours primary care consultation in the preceding 6?months. Of those respondents, 7% also reported using out-of-hours primary care. We used logistic regression to explore associations between use of out-of-hours primary care and five measures of in-hours access (ease of getting through on the telephone, ability to see a preferred general practitioner, ability to get an urgent or routine appointment and convenience of opening hours). We illustrated the potential for reduction in use of out-of-hours primary care in a model where access to in-hours care was made optimal.ResultsWorse in-hours access was associated with greater use of out-of-hours primary care for each access factor. In multivariable analysis adjusting for access and patient characteristic variables, worse access was independently associated with increased out-of-hours use for all measures except ease of telephone access. Assuming these associations were causal, we estimated that an 11% relative reduction in use of out-of-hours primary care services in England could be achievable if access to in-hours care were optimal.ConclusionsThis secondary quantitative analysis provides evidence for an association between difficulty in accessing in-hours care and use of out-of-hours primary care services. The findings can motivate the development of interventions to improve in-hour access.
| S-EPMC4413677 | biostudies-literature
Project description:BackgroundEnglish National Quality Requirements mandate out-of-hours primary care services to routinely audit patient experience, but do not state how it should be done.ObjectivesWe explored how providers collect patient feedback data and use it to inform service provision. We also explored staff views on the utility of out-of-hours questions from the English General Practice Patient Survey (GPPS).MethodsA qualitative study was conducted with 31 staff (comprising service managers, general practitioners and administrators) from 11 out-of-hours primary care providers in England, UK. Staff responsible for patient experience audits within their service were sampled and data collected via face-to-face semistructured interviews.ResultsAlthough most providers regularly audited their patients' experiences by using patient surveys, many participants expressed a strong preference for additional qualitative feedback. Staff provided examples of small changes to service delivery resulting from patient feedback, but service-wide changes were not instigated. Perceptions that patients lacked sufficient understanding of the urgent care system in which out-of-hours primary care services operate were common and a barrier to using feedback to enable change. Participants recognised the value of using patient experience feedback to benchmark services, but perceived weaknesses in the out-of-hours items from the GPPS led them to question the validity of using these data for benchmarking in its current form.ConclusionsThe lack of clarity around how out-of-hours providers should audit patient experience hinders the utility of the National Quality Requirements. Although surveys were common, patient feedback data had only a limited role in service change. Data derived from the GPPS may be used to benchmark service providers, but refinement of the out-of-hours items is needed.
| S-EPMC5136714 | biostudies-literature