Rural GPs' attitudes toward participating in emergency medicine: a qualitative study

Primary care doctors in acute call-outs to severe trauma incidents in Norway - variations by rural-urban settings and time factors

BACKGROUND

A severely injured patient needs fast transportation to a hospital that can provide definitive care. In Norway, approximately 20% of the population live in rural areas. Primary care doctors (PCDs) play an important role in prehospital trauma care. The aim of this study was to investigate how variations in PCD call-outs to severe trauma incidents in Norway were associated with rural-urban settings and time factors.

METHODS

In this study on severe trauma patients admitted to Norwegian hospitals from 2012 to 2018, we linked data from four official Norwegian registries. Through this, we investigated the call-out responses of PCDs to severe trauma incidents. In multivariable log-binomial regression models, we investigated whether factors related to rural-urban settings and time factors were associated with PCD call-outs.

RESULTS

There was a significantly higher probability of PCD call-outs to severe trauma incidents in the municipalities in the four most rural centrality categories compared to the most urban category. The largest difference in adjusted relative risk (95% confidence interval (CI)) was 2.08 (1.27-3.41) for centrality category four. PCDs had a significantly higher proportion of call-outs in the Western (RR = 1.46 (1.23-1.73)) and Central Norway (RR = 1.30 (1.08-1.58)) Regional Health Authority areas compared to in the South-Eastern area. We observed a large variation (0.47 to 4.71) in call-out rates to severe trauma incidents per 100,000 inhabitants per year across the 16 Emergency Medical Communication Centre areas in Norway.

CONCLUSIONS

Centrality affects the proportion of PCD call-outs to severe trauma incidents, and call-out rates were higher in rural than in urban areas. We found no significant difference in call-out rates according to time factors. Possible consequences of these findings should be further investigated.

Primary care doctors in acute call-outs to severe trauma incidents in Norway - associations with factors related to patients and doctors

OBJECTIVE

Severe trauma patients need immediate prehospital intervention and transfer to a specialised trauma hospital. In Norway, primary care doctors (PCDs) are an integrated part of the prehospital trauma care. The aim of this study was to investigate the degree to which PCDs were involved in prehospital care of severe trauma patients and how factors related to patients and doctors were associated with call-outs to these incidents.

DESIGN

This was a registry-based study in Norway on severe trauma patients with acute hospital admission during the period 2012-2018.

SETTING

Data was obtained from three Norwegian official registries.

SUBJECTS

By linking the registries, we studied the actions taken by the PCDs, whether they called out to severe trauma incidents.

MAIN OUTCOME MEASURES

In multivariable regression models, we investigated whether factors related to the PCDs (age, sex, specialisation in general practice (GP)) and patients (age, sex, duration of hospital stay, type of injury) were associated with call-outs.

RESULTS

Out of 4342 severe trauma incidents, PCDs had documented involvement in 1683 (39%) and called out to 644 (15%). Increased proportions of PCD call-outs to severe trauma incidents were significantly associated with lower age of PCD, being a GP specialist, lower patient age, being a male patient, increased length of hospital stay and injuries to the head and the neck.

CONCLUSIONS

PCDs called out to a relatively low proportion of severe trauma patients. Several factors related to patients and doctors were associated with call-outs to severe trauma incidents in Norway.

General practitioners not available - out-of-hospital emergency patients handled by anaesthesiologist in a large Norwegian municipality

BACKGROUND

Until autumn 2018 the GPs in Bergen Municipality did not attend emergency patients outside the emergency primary care centre. The ambulance staff handled emergencies on their own or were assisted by an anaesthesiologist from the helicopter emergency medical service (HEMS). The aim of this study was to investigate procedures performed by the HEMS anaesthesiologist and to assess the level of skills needed to perform these procedures.

METHODS

This study was a retrospective assessment of data from the period 2011 to 2013 on all emergency missions in which patients were dealt with by HEMS, using a rapid-response car in Bergen Municipality. All emergency missions were sorted into three categories: No intervention, Basic or Advanced intervention. This list was made by a research group with anaesthesiologists working for Bergen HEMS and GPs with OOH experience. The list is based on curriculum found in acute medicine courses.

RESULTS

HEMS responded to 716 (2.3%) out of a total of 31,696 emergencies in Bergen Municipality during the three years. In more than two-thirds (71%) of these missions, no intervention or only a basic intervention was performed. Most advanced procedures were performed in patients with cardiac arrest.

CONCLUSION

By retrospective evaluation of HEMS missions by car in Bergen municipality, we found that nearly one-third of the patients received advanced procedures. Cardiac arrest was the medical condition in which the most advanced procedures were performed. More research is needed to evaluate procedures and the importance of clinical evaluation and physicians' experience in treating these patient groups.KEY POINTSBoth HEMS and on-call GPs are needed in emergency care, and more knowledge will be useful to highlight the level of practical skills needed in these missions.There is a need for better prioritization of when to use HEMS resources and when to use on-call GPs in emergency missions.More than two-thirds of the patients involved in emergency missions received no intervention or just a basic intervention when dealt with by HEMS.This raises the issue of whether an on-call GP could have adequately treated many of the patients in this study in terms of practical skills.

GP decisions to participate in emergencies: a randomised vignette study

Background

GPs use their judgement on whether to participate in emergencies; however, little is known about how GPs make their decisions on emergency participation.

Aim

To test whether GPs' participation in emergencies is associated with cause of symptoms, distance to the patient, other patients waiting, and out-of-hours (OOH) clinic characteristics.

Design & setting

An online survey was sent to all GPs in Norway (n = 4701).

Method

GPs were randomised to vignettes describing a patient with acute shortness of breath and asked whether they would participate in a callout. The vignettes varied with respect to cause of symptoms (trauma versus illness), distance to the patient (15 minutes versus 45 minutes), and other patients waiting at the OOH clinic (crowding versus no crowding). The survey included questions about OOH clinic characteristics.

Results

Of the 1013 GPs (22%) who responded, 76% reported that they would participate. The proportion was higher in trauma (83% versus 69%, χ² 24.8, P<0.001), short distances (80% versus 71%, χ² 9.5, P=0.002), and no crowding (81% versus 70% χ² 14.6, P<0.001). Participation was associated with availability of a manned-response vehicle (adjusted odds ratio [OR] 2.06, 95% confidence interval [CI] = 1.25 to 3.41), and team training at the OOH clinic once a year (OR = 1.78, 95% CI = 1.12 to 2.82) or more than once a year (OR = 3.78, 95% CI = 1.64 to 8.68).

Conclusion

GPs were less likely to participate in emergencies when the incident was not owing to trauma, was far away, and when other patients were waiting. A manned-response vehicle and regular team training were associated with increased participation.

GPs who volunteer to be first responders for out-of-hospital cardiac arrest: A qualitative study

Background: Out-of-hospital cardiac arrest (OHCA) is a major cause of premature mortality. Survival is possible when timely cardiopulmonary resuscitation and defibrillation are available in the community. GPs are well placed to provide early OHCA care and significantly increased rates of survival are achieved when GPs participate in resuscitation. A novel project alerts volunteer GP first responders to nearby OHCAs in Ireland.

Objectives: To explore the reasons why GPs volunteer to be OHCA first responders and their experience of participation.

Methods: A qualitative study involving in-depth, semi-structured interviews followed by thematic analysis was undertaken in 2017/18. Fourteen GPs from differing geographical areas in Ireland, who volunteered as OHCA first-responders were recruited to participate by purposive methods.

Results: GP participation in OHCA voluntary first response was understood as a function of GPs relationship to the community, their ability to manage competing demands in their personal and professional lives and also specific participatory gains. GPs expressed both altruistic motivations and a sense of obligation. GPs described a complex, multifaceted role in providing OHCA first response; they derived an inherent sense of satisfaction in delivering potentially life-saving interventions but also in the provision of holistic, compassionate end-of-life care for patients and their families. Participation was not without psychosocial risk for GPs.

Conclusion: GPs volunteer to provide early OHCA emergency care because of their relationship to the community. Care provided is complex and includes both resuscitation and end-of-life care.

Treatment, transport, and primary care involvement when helicopter emergency medical services are inaccessible: a retrospective study

OBJECTIVE

To examine handling of cancelled helicopter emergency medical services (HEMS) missions with a persisting medical indication.

DESIGN

Retrospective observational study.

SETTING AND SUBJECTS

Cancelled HEMS missions with persisting medical indication within Sogn og Fjordane county in Norway during the period of 2010-2013. Both primary and secondary missions were included.

MAIN OUTCOME MEASURES

Primary care involvement, treatment and cooperation within the prehospital system.

RESULTS

Our analysis included 172 missions with 180 patients. Two-thirds of the patients (118/180) were from primary missions. In 95% (112/118) of primary missions, GPs were alerted, and they examined 62% (70/112) of these patients. Among the patients examined by a GP, 30% (21/70) were accompanied by a GP during transport to hospital. GP involvement did not differ according to time of day (p = 0.601), diagnostic group (p = 0.309), or patient's age (p = 0.409). In 41% of primary missions, the patients received no treatment or oxygen only during transport. Among the secondary missions, 10% (6/62) of patients were intubated or received non-invasive ventilation and were accompanied by a physician or nurse anaesthetist during transport.

CONCLUSIONS

Ambulance workers and GPs have an important role when HEMS is unavailable. Our findings indicated good collaboration among the prehospital personnel. Many of the patients were provided minimal or no treatment, and treatment did not differ according to GP involvement. Key Points Knowledge about handling and involvement of prehospital services in cancelled helicopter emergency medical services (HEMS) missions are scarce. Ambulance workers and general practitioners have an important role when HEMS is unavailable Minimal or no treatment was given to a large amount of the patients, regardless of which health personnel who encountered the patient.

Effect of requiring a general practitioner at scenes of serious injury: A systematic review

BACKGROUND

In Norway, each municipality is responsible for providing first line emergency healthcare, and it is mandatory to have a primary care physician/general practitioner on call continuously. This mandate ensures that a physician can assist patients and ambulance personnel at the site of severe injuries or illnesses. The compulsory presence of the general practitioner at the scene could affect different parts of patient treatment, and it might save resources by obviating resources from secondary healthcare, like pre-hospital anaesthesiologists and other specialized resources. This systematic review aimed to examine how survival, time spent at the scene, the choice of transport destination, assessment of urgency, the number of admissions, and the number of cancellations of specialized pre-hospital resources were affected by the presence of a general practitioner at the scene of a suspected severe injury.

METHODS

We searched for published and planned systematic reviews and primary studies in the Cochrane Library, Medline, Embase, OpenGrey, GreyLit and trial registries. The search was completed in December 2017. Two individuals independently screened the references and assessed the eligibility of all potentially relevant studies.

RESULTS

The search for systematic reviews and primary studies identified 5981 articles. However, no studies met the pre-defined inclusion criteria.

CONCLUSION

No studies met our inclusion criteria; consequently, it remains uncertain how the presence of a general practitioner at the injury scene might affect the selected outcomes.

Inter-disciplinary cooperation in a physician-staffed emergency medical system

BACKGROUND

On-scene management of pre-hospital emergencies is often inter-disciplinary, involving ground-emergency medical services (EMS), police- and fire services, and in Norway general practitioners on-call. This can also be supplemented by physician-staffed EMS (P-EMS), utilizing helicopters or rapid response vehicles. We hypothesized that P-EMS cooperates extensively with other emergency services, and therefore the primary aim of this study was to investigate the fraction of inter-disciplinary cooperation between P-EMS and other emergency services.

METHODS

Retrospective, observational study of primary pre-hospital missions with patient contact performed at a Norwegian P-EMS base from 01.01.06 to 31.12.15. Descriptive statistics, comparisons using Student`s t-test, and chi-squared test for trend were applied.

RESULTS

Inter-disciplinary cooperation occurred in 94.3% of the 8580 missions, of which physician-staffed EMS cooperated with ground EMS in 92.4%, general practitioner 32.9%, police service 11.6% and fire service 11.8%. Trauma constituted 34.4 and cardiac arrest 14.1% of missions. The mean National Advisory Committee for Aeronautics score was 4.21 (95% Confidence Interval 4.18-4.24). There was an overall decrease in cooperation with general practitioners and the police service (P < 0.001). During helicopter missions, we reported a decrease in general practitioner cooperation compared to an increase during rapid response car missions (P < 0.001). In cardiac arrest cases, cooperation with both general practitioners and the fire service increased (P < 0.001).

CONCLUSION

Physician-staffed EMS cooperates extensively with other professional emergency services, especially ground-EMS. On-scene cooperation with general practitioners decreased, whereas there was an increased cooperation with the fire service in a "first-responder" role during cardiac arrest missions.

Self reported involvement in emergency medicine among GPs in Norway

OBJECTIVE

To examine general practitioners' (GPs') perception of their role in emergency medicine and participation in emergency services including ambulance call outs, and the characteristics of the GPs and casualty clinics associated with the GPs' involvement in emergency medicine.

DESIGN

Cross-sectional online survey.

SETTING

General practice.

SUBJECTS

General practitioners in Norway (n = 1002).

MAIN OUTCOME MEASURES

Proportion of GPs perceiving that they have a large role in emergency medicine, regularly being on call, and the proportion of ambulance callouts with GP participation.

RESULTS

Forty six percent of the GPs indicated that they play a large role in emergency medicine, 63 percent of the GPs were regularly on call, and 28 percent responded that they usually took part in ambulance call outs. Multivariable logistic regression analyses indicated that these outcomes were strongly associated with participation in multidisciplinary training. Furthermore, the main outcomes were associated with traits commonly seen at smaller casualty clinics such as those with an absence of nursing personnel and extra physicians, and based on the distance to the hospital.

CONCLUSION

Our findings suggest that GPs play an important role in emergency medicine. Multidisciplinary team training may be important for their continued involvement in prehospital emergencies. Key Points   Health authorities and other stakeholders have raised concerns about general practitioner's (GPs) participation in emergency medicine, but few have studied opinions and perceptions among the GPs themselves.   • Norwegian GPs report playing a large role in emergency medicine, regularly being on call, and taking part in selected ambulance call outs.   • A higher proportion of GPs who took part in team training perceived themselves as playing a large role in emergency medicine, regularly being on call, and taking part in ambulance call outs.   • These outcomes were also associated with attributes commonly seen at smaller casualty clinics.

Application of four-dimension criteria to assess rigour of qualitative research in emergency medicine

Background

The main objective of this methodological manuscript was to illustrate the role of using qualitative research in emergency settings. We outline rigorous criteria applied to a qualitative study assessing perceptions and experiences of staff working in Australian emergency departments.

Methods

We used an integrated mixed-methodology framework to identify different perspectives and experiences of emergency department staff during the implementation of a time target government policy. The qualitative study comprised interviews from 119 participants across 16 hospitals. The interviews were conducted in 2015–2016 and the data were managed using NVivo version 11. We conducted the analysis in three stages, namely: conceptual framework, comparison and contrast and hypothesis development. We concluded with the implementation of the four-dimension criteria (credibility, dependability, confirmability and transferability) to assess the robustness of the study,

Results

We adapted four-dimension criteria to assess the rigour of a large-scale qualitative research in the emergency department context. The criteria comprised strategies such as building the research team; preparing data collection guidelines; defining and obtaining adequate participation; reaching data saturation and ensuring high levels of consistency and inter-coder agreement.

Conclusion

Based on the findings, the proposed framework satisfied the four-dimension criteria and generated potential qualitative research applications to emergency medicine research. We have added a methodological contribution to the ongoing debate about rigour in qualitative research which we hope will guide future studies in this topic in emergency care research. It also provided recommendations for conducting future mixed-methods studies. Future papers on this series will use the results from qualitative data and the empirical findings from longitudinal data linkage to further identify factors associated with ED performance; they will be reported separately.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2915-2) contains supplementary material, which is available to authorized users.

Local emergency medical response after a terrorist attack in Norway: a qualitative study

INTRODUCTION

On 22 July 2011, Norway suffered a devastating terrorist attack targeting a political youth camp on a remote island. Within a few hours, 35 injured terrorist victims were admitted to the local Ringerike community hospital. All victims survived. The local emergency medical service (EMS), despite limited resources, was evaluated by three external bodies as successful in handling this crisis. This study investigates the determinants for the success of that EMS as a model for quality improvement in healthcare.

METHODS

We performed focus group interviews using the critical incident technique with 30 healthcare professionals involved in the care of the attack victims to establish determinants of the EMS' success. Two independent teams of professional experts classified and validated the identified determinants.

RESULTS

Our findings suggest a combination of four elements essential for the success of the EMS: (1) major emergency preparedness and competence based on continuous planning, training and learning; (2) crisis management based on knowledge, trust and data collection; (3) empowerment through multiprofessional networks; and (4) the ability to improvise based on acquired structure and competence. The informants reported the successful response was specifically based on multiprofessional trauma education, team training, and prehospital and in-hospital networking including mental healthcare. The powerful combination of preparedness, competence and crisis management built on empowerment enabled the healthcare workers to trust themselves and each other to make professional decisions and creative improvisations in an unpredictable situation.

CONCLUSION

The determinants for success derived from this qualitative study (preparedness, management, networking, ability to improvise) may be universally applicable to understanding the conditions for resilient and safe healthcare services, and of general interest for quality improvement in healthcare.