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Morreel S, Philips H, De Graeve D, Monsieurs KG, Kampen JK, Meysman J, Lefevre E, Verhoeven V. Triaging and referring in adjacent general and emergency departments (the TRIAGE trial): A cluster randomised controlled trial. PLoS One 2021; 16:e0258561. [PMID: 34731198 PMCID: PMC8565772 DOI: 10.1371/journal.pone.0258561] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/13/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To determine whether a new triage system safely diverts a proportion of emergency department (ED) patients to a general practitioner cooperative (GPC). METHODS Unblinded randomised controlled trial with weekends serving as clusters (three intervention clusters for each control). The intervention was triage by a nurse using a new extension to the Manchester Triage System assigning low-risk patients to the GPC. During intervention weekends, patients were encouraged to follow this assignment; it was not communicated during control weekends (all patients remained at the ED). The primary outcome was the proportion of patients assigned to and handled by the GPC during intervention weekends. The trial was randomised for the secondary outcome: the proportion of patients assigned to the GPC. Additional outcomes were association of these outcomes with possible confounders (study tool parameters, nurse, and patient characteristics), proportion of patients referred back to the ED by the GPC, hospitalisations, and performance of the study tool to detect primary care patients (the opinion of the treating physician was the gold standard). RESULTS In the intervention group, 838/6294 patients (13.3%, 95% CI 12.5 to 14.2) were assigned to the GPC, in the control group this was 431/1744 (24.7%, 95% CI 22.7 to 26.8). In total, 599/6294 patients (9.5%, 95% CI 8.8 to 10.3) experienced the primary outcome which was influenced by the reason for encounter, age, and the nurse. 24/599 patients (4.0%, 95% CI 2.7 to 5.9) were referred back to the ED, three were hospitalised. Positive and negative predictive values of the studied tool during intervention weekends were 0.96 (95%CI 0.94 to 0.97) and 0.60 (95% CI 0.58 to 0.62). Out of the patients assigned to the GPC, 2.4% (95% CI 1.7 to 3.4) were hospitalised. CONCLUSIONS ED nurses using a new tool safely diverted 9.5% of the included patients to primary care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03793972.
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Affiliation(s)
- Stefan Morreel
- Department of Family and Population Health, University of Antwerp, Antwerp, Belgium
- * E-mail:
| | - Hilde Philips
- Department of Family and Population Health, University of Antwerp, Antwerp, Belgium
| | - Diana De Graeve
- Department of Economics, University of Antwerp, Antwerp, Belgium
| | - Koenraad G. Monsieurs
- Department ASTARC, University of Antwerp, Antwerp, Belgium
- Emergency Department, Antwerp University Hospital, Antwerp, Belgium
| | - Jarl K. Kampen
- Department of Epidemiology and Medical Statistics, Antwerp University Hospital, Antwerp, Belgium
| | - Jasmine Meysman
- Department of Economics, University of Antwerp, Antwerp, Belgium
| | - Eva Lefevre
- Department of Economics, University of Antwerp, Antwerp, Belgium
| | - Veronique Verhoeven
- Department of Family and Population Health, University of Antwerp, Antwerp, Belgium
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Smits M, Plat E, Alink E, Apotheker M, Giesen P. [The Netherlands Triage Standard applied to paediatric patients in emergency medicine: is it reliable and valid?]. Ned Tijdschr Geneeskd 2020; 164:D4464. [PMID: 32940982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To determine the inter-rater reliability and validity of the Netherlands Triage Standard (NTS) for paediatric triage. DESIGN A cross-sectional study using fictional cases for telephone and physical triage. METHOD An expert panel established in advance the urgency of 40 cases concerning emergency help requests from non-referred children (the reference standard). These requests were presented in an online survey to triagists from three general practitioner (GP) out-of-hours practices, three ambulance dispatching centres and three hospital emergency departments. Triagists assessed all cases, using the NTS. We determined the agreement on degrees of urgency between different triagists and compared them with the reference standard. The outcome measure for inter-rater reliability was the intraclass correlation coefficient (ICC). The outcome measures for validity were the degree of agreement with the reference standard, under-triage and over-triage, and sensitivity and specificity in identifying high-urgency (U0-U2) versus low-urgency cases (U30U5). RESULTS In total, 116 triagists participated in the study (response: 86%). The ICC was 0.73 among all triagists, and was highest in the out-of-hours GP cooperatives. There was 62.3% agreement with the reference standard, 17.4% under-triage and 20.2% over-triage. Of the divergent urgencies, 77% differed by only one urgency category. The sensitivity was 85.2% and the specificity 89.7%. The sensitivity and specificity of triage by the GP out-of-hours practices (82.7% and 92.7%, respectively) were almost the same as that by the hospital emergency departments (79.6% and 92.5%, respectively). Triage by the ambulance dispatching centres had relatively high sensitivity (93%), but relatively low specificity (82.4%). CONCLUSION The results of the study contribute to the evidence that the NTS is a reliable and valid triage standard for paediatric patients. The urgency assessments by triagists in the GP out-of-hours practices, ambulance dispatching centres and hospital emergency departments were broadly in agreement. Results were limited by cases being on paper and triage only on anamnestic characteristics.
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Affiliation(s)
- Marleen Smits
- Radboudumc, Scientific Center forQuality of Healthcare (IQ healthcare), Nijmegen
- Contact: Marleen Smits
| | - Erik Plat
- Radboudumc, Scientific Center forQuality of Healthcare (IQ healthcare), Nijmegen
| | - Elleke Alink
- Radboudumc, Scientific Center forQuality of Healthcare (IQ healthcare), Nijmegen
| | - Maartje Apotheker
- Radboudumc, Scientific Center forQuality of Healthcare (IQ healthcare), Nijmegen
| | - Paul Giesen
- Radboudumc, Scientific Center forQuality of Healthcare (IQ healthcare), Nijmegen
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Chetty S, Venter D, Speelman A. Determining the Need for After-Hours Diagnostic Radiological Reporting in Emergency Departments at Public Hospitals in South Africa: Perceptions of Emergency Physicians in KwaZulu-Natal. J Med Imaging Radiat Sci 2020; 51:470-479. [PMID: 32654979 DOI: 10.1016/j.jmir.2020.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 06/11/2020] [Accepted: 06/11/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Emergency departments in South African public hospitals have a high patient load after hours, with inadequate numbers of health care professionals available to satisfy patient influx. In addition, there is often no provision of after-hours diagnostic reporting services in public hospitals, to an extent that the emergency physician is responsible for interpreting all radiographic images requested themseves. Emergency physicians, in this study, can be described as any medical doctor registered with the Health Professions Council of South Africa and working in the emergency department as a registrar or consultant physician because there were no physicians specialized in emergency medicine working at the hospitals selected for this study. AIM The aim of this study was to determine the views of emergency physicians on whether there is a need for an after-hours diagnostic radiological reporting service in selected public hospitals in KwaZulu-Natal Province, South Africa. METHODS A descriptive cross-sectional quantitative research design was utilized, through means of a survey, to assess the emergency physicians' perceptions regarding the need for after-hours diagnostic radiological reporting. In addition, the study used a descriptive quantitative research design to record the number of conventional diagnostic radiographic examinations performed at the selected hospitals, after hours, and the proportional number of these radiographic examinations that were reported on by radiologists during office hours, the following day. The distribution of questionnaires and data collection, with regard to the number of examinations reported on, and those not reported on, were carried out simultaneously during the execution of this study. The study was conducted over a three-month period in 2017, at four public hospitals in KwaZulu-Natal-one of the nine provinces of South Africa. RESULTS This study found that, during the study period, between 0.1% and 0.6% of the conventional diagnostic radiographic examinations performed, after hours, were reported on by radiologists during office hours, the following day. The surveyed emergency physicians felt that the interpretation of diagnostic images took up valuable time that could be spent on patient management, and there was near-total agreement, whereby 92% (n = 36) of the physicians would have preferred after-hours reporting to be performed by a radiologist. Physicians agreed that having a radiologist or reporting radiographer to provide radiological reports would allow for more effective and efficient patient management. CONCLUSION The results of this study indicated that there is a need for after-hours radiographic reporting at the selected public hospitals and for the further training of emergency physicians in radiographic image interpretation. Based on the findings of this study, it is recommended that after-hours radiological reporting services be considered for public hospitals and that courses be offered to emergency physicians on the interpretation of diagnostic radiographic images. A hospital policy review may therefore be needed to adjust the focus of hospitals toward reducing the workload of emergency physicians, wherever possible, such as by incorporating support services like radiographic reporting and by providing further training on the interpretation of diagnostic radiographic images, which will both act to reduce the potential risk of misdiagnosis.
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Affiliation(s)
- Seshree Chetty
- Master of Science Degree Programme, of Health and Wellness Sciences, Cape Peninsula University of Technology (CPUT), Bellville, Cape Town, South Africa.
| | - Dalene Venter
- Diagnostic Radiography, Faculty of Health and Wellness Sciences, Cape Peninsula University of Technology, Bellville, Cape Town, South Africa
| | - Aladdin Speelman
- Diagnostic Radiography, Faculty of Health and Wellness Sciences, Cape Peninsula University of Technology, Bellville, Cape Town, South Africa
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Bernet S, Gut L, Baechli C, Koch D, Wagner U, Mueller B, Schuetz P, Kutz A. Association of weekend admission and clinical outcomes in hospitalized patients with sepsis: An observational study. Medicine (Baltimore) 2020; 99:e20842. [PMID: 32590778 PMCID: PMC7329016 DOI: 10.1097/md.0000000000020842] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Sepsis is associated with impaired clinical outcomes. It requires timely diagnosis and urgent therapeutic management. Because staffing during after-hours is limited, we explored whether after-hour admissions are associated with worse clinical outcomes in patients with sepsis.In this retrospective cohort study, we analyzed nationwide acute care admissions for a main diagnosis of sepsis in Switzerland between 2006 and 2016 using prospective administrative data. The primary outcome was in-hospital mortality using multivariable logistic regression models. Secondary outcomes were intensive care unit (ICU) admission, intubation, and 30-day readmission.We included 86,597 hospitalizations for sepsis, 60.1% admitted during routine-hours, 16.8% on weekends and 23.1% during night shift. Compared to routine-hours, we found a higher odds ratio (OR) for in-hospital mortality in patients admitted on weekends (Adjusted OR 1.05, 95% confidence interval [95% CI] 1.01, 1.10, P = .041). Also, the OR for ICU admission (OR 1.14, 95% CI 1.10, 1.19, P < .001) and intubation (OR 1.18, 95% CI 1.12, 1.25 P < .001) was higher for weekends compared to routine-hours. Regarding 30-day readmission, evidence for an association could not be observed. Night shift admission, compared to routine-hours, was associated with a higher OR for ICU admission and intubation (ICU admission: OR 1.28 (1.23, 1.32), P < .001; intubation: OR 1.31, 95% CI 1.25, 1.37, P < .001) but with a lower OR for in-hospital mortality (OR 0.93, 19% CI 0.89, 0.97, P = .001).Among hospitalizations with a main diagnosis of sepsis, weekend admissions were associated with higher OR for in-hospital mortality, ICU admission, and intubation. Whether these findings can be explained by staffing-level differences needs to be addressed.
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Affiliation(s)
- Selina Bernet
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau
| | - Lara Gut
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau
| | - Ciril Baechli
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau
| | - Daniel Koch
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau
| | | | - Beat Mueller
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Alexander Kutz
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau
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Chew SY, Leow JYL, Chan AKW, Chan JJ, Tan KBK, Aman B, Tan D, Koh MS. Improving asthma care with Asthma-COPD Afterhours Respiratory Nurse at Emergency (A-CARE). BMJ Open Qual 2020; 9:e000894. [PMID: 32487527 PMCID: PMC7265035 DOI: 10.1136/bmjoq-2019-000894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 05/12/2020] [Accepted: 05/16/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Emergency departments (ED) are important providers of asthma care, particularly after-hours. We identified gaps for quality improvement such as suboptimal adherence rates to three key recommendations from the Global Initiative for Asthma (GINA) guidelines for discharge management asthma guidelines. These were: the prescription of oral and inhaled corticosteroids (OCS and ICS) and issuance of outpatient follow-up for patients discharged from the ED. AIM To achieve an adherence rate of 80% to GINA guidelines for ED discharge management by providing after-hours asthma counselling services. METHODS We implemented Asthma-COPD Afterhours Respiratory Nurse at Emergency (A-CARE) according to the Plan-Do-Study-Act (PDSA) framework to provide after-hours asthma counselling and clinical decision support to ED physicians three nights a week. Data on adherence rates to the GINA guidelines were collected and analysed on a run chart. RESULTS After 17 months' follow-up, a sustained improvement was observed in patients reviewed by A-CARE in the median adherence rates to OCS prescription (58% vs 86%), ICS initiation (27% vs 67%) and issuance of follow-up (69% vs 92%), respectively. The overall impact was, however, limited by a suboptimal referral rate to A-CARE (16%) in a clinical audit of all ED patients with asthma. Nonetheless, in this audit, attendance rates for patients referred to our respiratory department for follow-up were higher in those receiving asthma counselling compared with those who did not (41.7% vs 15.9%, p=0.0388). CONCLUSION Sustained improvements in the adherence rates to guidelines were achieved for patients reviewed by A-CARE but were limited in overall impact due to suboptimal referral rate. We plan to improve the quality of asthma care by implementing further PDSA cycles to increase the referral rates to A-CARE.
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Affiliation(s)
- Si Yuan Chew
- Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | | | - Adrian Kok Wai Chan
- Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Jing Jing Chan
- Emergency Medicine, Singapore General Hospital, Singapore
| | | | - Butta Aman
- Medical Affairs, Research, AstraZeneca Singapore, Singapore
| | - Donna Tan
- Medical Affairs, Research, AstraZeneca Singapore, Singapore
| | - Mariko Siyue Koh
- Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
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Foster H, Macdonald S, Patterson C, O'Donnell CA. No such thing as bad publicity? A quantitative content analysis of print media representations of primary care out-of-hours services. BMJ Open 2019; 9:e023192. [PMID: 30910877 PMCID: PMC6475237 DOI: 10.1136/bmjopen-2018-023192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To explore how out-of-hours primary healthcare services (OOHS) are represented in UK national newspapers, focusing on content and tone of reporting and the use of personal narratives to frame stories. DESIGN A retrospective cross-sectional quantitative content analysis of articles published in 2005, 2010 and 2015. DATA SOURCES Nexis database used to search 10 UK national newspapers covering quality, middle-market and tabloid publications. INCLUSION/EXCLUSION CRITERIA All articles containing the terms 'out-of-hours' (≥3 mentions per article) or ('NHS 24' OR 'NHS 111' OR 'NHS Direct') AND 'out-of-hours' (≥1 mention per article) were included. Letters, duplicate news items, opinion pieces and articles without a substantial portion of the story (>50% of an article's word count, as judged by researchers) concerning OOHS were excluded. RESULTS 332 newspaper articles were identified: 113 in 2005 (34.1%), 140 in 2010 (42.2%) and 79 in 2015 (23.8%). Of these, 195 (58.7%) were in quality newspapers, 99 (29.8%) in middle-market and 38 (11.3%) in tabloids. The most commonly reported themes were OOHS organisation, personal narratives and telephone triage. Stories about service-level crises and personal tragedy, including unsafe doctors and missed or delayed identification of rare conditions, predominated. The majority of articles (252, 75.9%) were negative in tone. This was observed for all included newspapers and by publication genre; middle-market newspapers had the highest percentage of negative articles (Pearson χ2=35.72, p<0.001). Articles presented little supporting contextual information, such as call rates per annum, or advice on how to access OOHS. CONCLUSION In this first reported analysis of UK national newspaper coverage of OOHS, media representation is generally negative in tone, with frequent reports of 'negative exemplars' of OOHS crises and fatal individual patient cases with little or no contextualisation. We present recommendations for the future reporting of OOHS, which could apply to the reporting of healthcare services more generally.
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Affiliation(s)
- Hamish Foster
- General Practice and Primary Care, Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Sara Macdonald
- General Practice and Primary Care, Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Chris Patterson
- MRC/CSO Social & Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Catherine A O'Donnell
- General Practice and Primary Care, Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
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Williams H, Donaldson SL, Noble S, Hibbert P, Watson R, Kenkre J, Edwards A, Carson-Stevens A. Quality improvement priorities for safer out-of-hours palliative care: Lessons from a mixed-methods analysis of a national incident-reporting database. Palliat Med 2019; 33:346-356. [PMID: 30537893 PMCID: PMC6376594 DOI: 10.1177/0269216318817692] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Patients receiving palliative care are often at increased risk of unsafe care with the out-of-hours setting presenting particular challenges. The identification of improved ways of delivering palliative care outside working hours is a priority area for policymakers. Aim: To explore the nature and causes of unsafe care delivered to patients receiving palliative care from primary-care services outside normal working hours. Design: A mixed-methods cross-sectional analysis of patient safety incident reports from the National Reporting and Learning System. We characterised reports, identified by keyword searches, using codes to describe what happened, underlying causes, harm outcome, and severity. Exploratory descriptive and thematic analyses identified factors underpinning unsafe care. Setting/participants: A total of 1072 patient safety incident reports involving patients receiving sub-optimal palliative care via the out-of-hours primary-care services. Results: Incidents included issues with: medications (n = 613); access to timely care (n = 123); information transfer (n = 102), and/or non-medication-related treatment such as pressure ulcer relief or catheter care (n = 102). Almost two-thirds of reports (n = 695) described harm with outcomes such as increased pain, emotional, and psychological distress featuring highly. Commonly identified contributory factors to these incidents were a failure to follow protocol (n = 282), lack of skills/confidence of staff (n = 156), and patients requiring medication delivered via a syringe driver (n = 80). Conclusion: Healthcare systems with primary-care-led models of delivery must examine their practices to determine the prevalence of such safety issues (communication between providers; knowledge of commonly used, and access to, medications and equipment) and utilise improvement methods to achieve improvements in care.
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Affiliation(s)
- Huw Williams
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Simon Noble
- Marie Curie Research Centre, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Peter Hibbert
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW, Australia
| | - Rhiannon Watson
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW, Australia
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
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Graversen DS, Pedersen AF, Carlsen AH, Bro F, Huibers L, Christensen MB. Quality of out-of-hours telephone triage by general practitioners and nurses: development and testing of the AQTT - an assessment tool measuring communication, patient safety and efficiency. Scand J Prim Health Care 2019; 37:18-29. [PMID: 30689490 PMCID: PMC6454404 DOI: 10.1080/02813432.2019.1568712] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To develop a valid and reliable assessment tool able to measure quality of communication, patient safety and efficiency in out-of-hours (OOH) telephone triage conducted by both general practitioners (GP) and nurses. DESIGN The Dutch KERNset tool was translated into Danish and supplemented with items from other existing tools. Face validity, content validity and applicability in OOH telephone triage (OOH-TT) were secured through a two-round Delphi process involving relevant stakeholders. Forty-eight OOH patient contacts were assessed by 24 assessors in test-retest and inter-rater designs. SETTING OOH-TT services in Denmark conducted by GPs, nurses or doctors with varying medical specialisation. PATIENTS Audio-recorded OOH patient contacts. MAIN OUTCOME MEASURES Test-retest and inter-rater reliability were analysed using ICCagreement, Fleiss' kappa and percent agreement. RESULTS Major adaptations during the Delphi process were made. The 24-item assessment tool (Assessment of Quality in Telephone Triage - AQTT) measured communicative quality, health-related quality and four overall quality aspects. The test-retest ICCagreement reliability was good for the overall quality of communication (0.85), health-related quality (0.83), patient safety (0.81) and efficiency (0.77) and satisfactory when assessing specific aspects. Inter-rater reliability revealed reduced reliability in ICCagreement and in Fleiss' kappa. Percent agreement revealed satisfactory agreements when differentiating between 'poor' and 'sufficient' quality). CONCLUSION The AQTT demonstrated high face, content and construct validity, satisfactory test-retest reliability, reduced inter-rater reliability, but satisfactory percent agreement when differentiating between 'poor' and 'sufficient' quality. The AQTT was found feasible and clinically relevant for assessing the quality of GP- and nurse-led OOH-TT. KEYPOINTS Comparative knowledge is sparse regarding quality of out-of-hours telephone triage conducted by general practitioners and nurses. The assessment tool (AQTT) enables assessment of quality in OOH telephone triage conducted by nurses and general practitioners AQTT is feasible and clinically relevant for assessment of communication, patient safety and efficiency. AQTT can be used to identify areas for improvement in telephone triage.
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Affiliation(s)
- D. S. Graversen
- Research Unit for General Practice, Aarhus, Denmark & Department of Public Health, Aarhus University, Aarhus C, Denmark
- CONTACT Dennis Schou Graversen Research Unit for General Practice, Aarhus, Denmark & Department of Public Health, Aarhus University, Bartholins Allé 2, 8000Aarhus C, Denmark
| | - A. F. Pedersen
- Research Unit for General Practice, Aarhus, Denmark & Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - A. H. Carlsen
- Research Unit for General Practice, Aarhus, Denmark & Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - F. Bro
- Research Unit for General Practice, Aarhus, Denmark & Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - L. Huibers
- Research Unit for General Practice, Aarhus, Denmark & Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - M. B. Christensen
- Research Unit for General Practice, Aarhus, Denmark & Department of Public Health, Aarhus University, Aarhus C, Denmark
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Sutton E, Bion J, Aldridge C, Boyal A, Willars J, Tarrant C. Quality and safety of in-hospital care for acute medical patients at weekends: a qualitative study. BMC Health Serv Res 2018; 18:1015. [PMID: 30594209 PMCID: PMC6310936 DOI: 10.1186/s12913-018-3833-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The increased mortality risk associated with weekend admission to hospital (the 'weekend effect') has been reported across many health systems. More recently research has focused on causal mechanisms. Variations in the organisation and delivery of in-hospital care between weekends and weekdays have been identified, but this is not always to the detriment of weekend admissions, and the impact on mortality is uncertain. The insights of frontline staff and patients have been neglected. This article reports a qualitative study of patients and clinicians, to explore their views on quality and safety of care at weekends. METHODS We conducted focus groups and interviews with clinicians and patients with experience of acute medical care, recruited from three UK hospital Trusts. We analysed the data using a thematic analysis approach, aided by the use of NVivo, to explore quality and safety of care at weekends. RESULTS We held four focus groups and completed six in-depth interviews, with 19 clinicians and 12 patients. Four threats to quality and safety were identified as being more prominent at weekends, relating to i) the rescue and stabilisation of sick patients; ii) monitoring and responding to deterioration; iii) timely accurate management of the therapeutic pathway; iv) errors of omission and commission. CONCLUSIONS At weekends patients and staff are well aware of suboptimal staffing numbers, skill mix and access to resources at weekends, and identify that emergency admissions are prioritised over those already hospitalised. The consequences in terms of quality and safety and patient experience of care are undesirable. Our findings suggest the value of focusing on care processes and systems resilience over the weekends, and how these can be better supported, even in the limited resource environment that exists in many hospitals at weekends.
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Affiliation(s)
- Elizabeth Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Julian Bion
- University Hospitals Birmingham, Birmingham, UK
| | | | | | - Janet Willars
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
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Posocco A, Scapinello MP, De Ronch I, Castrogiovanni F, Lollo G, Sergi G, Tomaselli I, Tonon L, Solmi M, Pescador D, Battistuz E, Traversa S, Zambianco V, Veronese N. Role of out of hours primary care service in limiting inappropriate access to emergency department. Intern Emerg Med 2018; 13:549-555. [PMID: 28547207 DOI: 10.1007/s11739-017-1679-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 05/09/2017] [Indexed: 11/28/2022]
Abstract
Out of hours (OOH) doctors can have an important gate-keeping role over the access to the emergency department (ED), but the outcome and the quality of their ED referrals have been poorly studied. We aimed to investigate the outcome of patients referred to ED from OOH service and the determinants of admission or short-stay dispositions. We collected retrospectively data about referrals to ED from a local OOH service in the north-east of Italy using the OOH paper register and the ED electronic database, over the period of 01/10/2012 to 31/03/2013. Out of 5217 patients accessing the OOH service, 408 referrals were included in our analysis. 45.3% (185) of the referrals were admitted to hospital or the short-stay unit, 26 patients (=6.4%) were discharged as non-urgent outgoing codes after no specialist consultation or test, suggesting inappropriate referrals, and, of the remaining 197 (=48%), only 10 did not undergo any investigation or consultation. Significant determinants of admission were: age ≥65 years (OR = 2.619; 95% CI 1.528-4.491, p < 0.0001), domiciliary examination (OR = 2.168; 95% CI 1.353-3.476, p = 0.001), nursing home/palliative care setting (OR = 2.563; 95% CI 1.228-5.351, p = 0.012) and OOH triage code, ranging from an OR of 7.47 (95% CI 3.028-18.433) for minor urgencies to an OR of 26.835 (95% CI 6.761-106.508, p < 0.0001) for emergencies, in comparison to no urgent codes. OOH service seems to play an effective gate-keeping role limiting ED access. Determinants of admission to hospital suggest some simple interventions that could improve the adequacy of ED referral from OOH service.
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Affiliation(s)
- Andrea Posocco
- Unità Locale Socio Sanitaria 2 "Marca Trevigiana", Treviso, Continuità Assistenziale di Vittorio Veneto (TV), Vittorio Veneto (TV), Italy
- Scuola di Formazione Specifica in Medicina Generale, Regione Veneto, Venice, Italy
| | - Maria Paola Scapinello
- Unità Locale Socio Sanitaria 2 "Marca Trevigiana", Treviso, Continuità Assistenziale di Vittorio Veneto (TV), Vittorio Veneto (TV), Italy
| | - Irene De Ronch
- Unità Locale Socio Sanitaria 2 "Marca Trevigiana", Treviso, Continuità Assistenziale di Vittorio Veneto (TV), Vittorio Veneto (TV), Italy
| | - Francesco Castrogiovanni
- Unità Locale Socio Sanitaria 2 "Marca Trevigiana", Treviso, Continuità Assistenziale di Vittorio Veneto (TV), Vittorio Veneto (TV), Italy
| | - Gianluca Lollo
- Unità Locale Socio Sanitaria 2 "Marca Trevigiana", Treviso, Continuità Assistenziale di Vittorio Veneto (TV), Vittorio Veneto (TV), Italy
| | - Guglielmo Sergi
- Unità Locale Socio Sanitaria 2 "Marca Trevigiana", Treviso, Continuità Assistenziale di Vittorio Veneto (TV), Vittorio Veneto (TV), Italy
| | - Iginio Tomaselli
- Unità Locale Socio Sanitaria 2 "Marca Trevigiana", Treviso, Continuità Assistenziale di Vittorio Veneto (TV), Vittorio Veneto (TV), Italy
| | - Loris Tonon
- Unità Locale Socio Sanitaria 2 "Marca Trevigiana", Treviso, Continuità Assistenziale di Vittorio Veneto (TV), Vittorio Veneto (TV), Italy
| | - Marco Solmi
- Department of Neurosciences, University of Padova, Padua, Italy
| | - Daniele Pescador
- Unità Locale Socio Sanitaria 2 "Marca Trevigiana", Treviso, Continuità Assistenziale di Vittorio Veneto (TV), Vittorio Veneto (TV), Italy
| | - Elena Battistuz
- Unità Locale Socio Sanitaria 2 "Marca Trevigiana", Treviso, Continuità Assistenziale di Vittorio Veneto (TV), Vittorio Veneto (TV), Italy
| | - Stefano Traversa
- Unità Locale Socio Sanitaria 2 "Marca Trevigiana", Treviso, Continuità Assistenziale di Vittorio Veneto (TV), Vittorio Veneto (TV), Italy
| | - Vincenzo Zambianco
- Unità Locale Socio Sanitaria 2 "Marca Trevigiana", Treviso, Continuità Assistenziale di Vittorio Veneto (TV), Vittorio Veneto (TV), Italy
| | - Nicola Veronese
- Unità Locale Socio Sanitaria 2 "Marca Trevigiana", Treviso, Continuità Assistenziale di Vittorio Veneto (TV), Vittorio Veneto (TV), Italy.
- Neuroscience Institute, Aging Branch, National Research Council, Via Giustiniani 2, 35128, Padua, Italy.
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Colliers A, Coenen S, Philips H, Remmen R, Anthierens S. Optimising the quality of antibiotic prescribing in out-of-hours primary care in Belgium: a study protocol for an action research project. BMJ Open 2017; 7:e017522. [PMID: 29038184 PMCID: PMC5652575 DOI: 10.1136/bmjopen-2017-017522] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Antimicrobial resistance is a major public health threat driven by inappropriate antibiotic use, mainly in general practice and for respiratory tract infections. In Belgium, the quality of general practitioners' (GPs) antibiotic prescribing is low. To improve antibiotic use, we need a better understanding of this quality problem and corresponding interventions. A general practitioners cooperative (GPC) for out-of-hours (OOH) care presents a unique opportunity to reach a large group of GPs and work on quality improvement. Participatory action research (PAR) is a bottom-up approach that focuses on implementing change into daily practice and has the potential to empower practitioners to produce their own solutions to optimise their antibiotic prescribing. METHODS This PAR study to improve antibiotic prescribing quality in OOH care uses a mixed methods approach. In a first exploratory phase, we will develop a partnership with a GPC and map the existing barriers and opportunities. In a second phase, we will focus on facilitating change and implementing interventions through PDSA (Plan-Do-Study-Act) cycles. In a third phase, antibiotic prescribing quality outside and antibiotic use during office hours will be evaluated. Equally important are the process evaluation and theory building on improving antibiotic prescribing. ETHICS The study protocol was approved by the Ethics Committee of the Antwerp University Hospital/University of Antwerp. PAR unfolds in response to the needs and issues of the stakeholders, therefore new ethics approval will be obtained at each new stage of the research. DISSEMINATION Interventions to improve antibiotic prescribing are needed now more than ever and outcomes will be highly relevant for GPCs, GPs in daily practice, national policymakers and the international scientific community. TRIAL REGISTRATION NUMBER NCT03082521; Pre-results.
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Affiliation(s)
- Annelies Colliers
- Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
| | - Samuel Coenen
- Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
- Vaccine & Infectious Disease Institute (VAXINFECTIO), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
- Department of Epidemiology and Social Medicine (ESOC), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
| | - Hilde Philips
- Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
| | - Roy Remmen
- Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
| | - Sibyl Anthierens
- Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
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Roberts CM, Lowe D, Skipper E, Steiner MC, Jones R, Gelder C, Hurst JR, Lowrey GE, Thompson C, Stone RA. Effect of time and day of admission on hospital care quality for patients with chronic obstructive pulmonary disease exacerbation in England and Wales: single cohort study. BMJ Open 2017; 7:e015532. [PMID: 28882909 PMCID: PMC5588982 DOI: 10.1136/bmjopen-2016-015532] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To evaluate if observed increased weekend mortality was associated with poorer quality of care for patients admitted to hospital with chronic obstructive pulmonary disease (COPD) exacerbation. DESIGN Prospective case ascertainment cohort study. SETTING 199 acute hospitals in England and Wales, UK. PARTICIPANTS Consecutive COPD admissions, excluding subsequent readmissions, from 1 February to 30 April 2014 of whom 13 414 cases were entered into the study. MAIN OUTCOMES Process of care mapped to the National Institute for Health and Care Excellence clinical quality standards, access to specialist respiratory teams and facilities, mortality and length of stay, related to time and day of the week of admission. RESULTS Mortality was higher for weekend admissions (unadjusted OR 1.20, 95% CI 1.00 to 1.43), and for case-mix adjusted weekend mortality when calculated for admissions Friday morning through to Monday night (adjusted OR 1.19, 95% CI 1.00 to 1.43). Median time to death was 6 days. Some clinical processes were poorer on Mondays and during normal working hours but not weekends or out of hours. Specialist respiratory care was less available and less prompt for Friday and Saturday admissions. Admission to a specialist ward or high dependency unit was less likely on a Saturday or Sunday. CONCLUSIONS Increased mortality observed in weekend admissions is not easily explained by deficiencies in early clinical guideline care. Further study of out-of-hospital factors, specialty care and deaths later in the admission are required if effective interventions are to be made to reduce variation by day of the week of admission.
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Affiliation(s)
- Christopher Michael Roberts
- Barts Health, Queen Mary University of London, London, UK
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
| | - Derek Lowe
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
| | - Emma Skipper
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
| | - Michael C Steiner
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
- Respiratory Biomedical Sciences Research Unit, Institute for Lung Health, Glenfield Hospital NHS Trust, Leicester, Leicestershire, United Kingdom
| | - Rupert Jones
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
- Clinical Trials & Health Research - Institute of Translational & Stratified Medicine, Plymouth University, Plymouth, Devon, United Kingdom
| | - Colin Gelder
- Department of respiratory medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, Warwickshire, United Kingdom
| | - John R Hurst
- UCL Respiratory, University College London, London, London, United Kingdom
| | - Gillian E Lowrey
- Department of respiratory medicine, Derby Teaching Hospitals NHS Foundation Trust, Derby, Derbyshire, United Kingdom
| | | | - Robert A Stone
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
- Somerset Lung Centre, Musgrove Park Hospital, Taunton, Somerset, UK
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Abstract
BACKGROUND We previously reported weekend emergency admissions to have a higher mortality; we have now examined the time profile of deaths, by weekday or weekend admission, in all emergency medical patients admitted between 2002 and 2014. METHODS We divided admissions by a weekday or weekend (After 17.00 Friday-Sunday) hospital arrival. We examined survival following an admission using Cox proportional hazard models and Kaplan-Meier time to event analysis. RESULTS In total 82 368 admissions were recorded in 44, 628 patients. Weekend admissions had an increased mortality of 5.0% (95% CI 4.7, 5.4) compared with weekday admissions of 4.5% (95% CI 4.3, 4.7) ( P = 0.007). The univariate adjusted Odds Ratio (OR) of death for a weekend admission was significantly increased OR = 1.15 (95% CI 1.05, 1.24) ( P = 0.001). Mortality following an admission declined exponentially over time with a long tail, ∼25% of deaths occurred after day 28. Only 11.4% of deaths occurred on the weekend of the admission. Survival curves showed no mortality difference at 28 days ( P = 0.21) but a difference at 90 days ( P = 0.05). The higher mortality for a weekend admission was attributable to late deaths in the cohort with an extended stay; compared with weekday, these weekend admissions were more likely to be older and have greater co-morbidity. CONCLUSION Survival rates following a weekend or weekday admission were similar out to 28 days. The higher overall mortality for weekend admissions is due to divergence in survival between 28 and 90 days. Most deaths in weekend admissions occurred when the hospital was fully staffed.
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Affiliation(s)
- R Conway
- From the Department of Internal Medicine, St James's Hospital, James's Street, Dublin 8, Ireland
| | - S Cournane
- Department of Medical Physics and Bioengineering, St. James Hospital, James's Street, Dublin 8, Ireland
| | - D Byrne
- From the Department of Internal Medicine, St James's Hospital, James's Street, Dublin 8, Ireland
| | - D O'Riordan
- From the Department of Internal Medicine, St James's Hospital, James's Street, Dublin 8, Ireland
| | - Bernard Silke
- From the Department of Internal Medicine, St James's Hospital, James's Street, Dublin 8, Ireland
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Rimmer A. Lack of workforce planning raises safety concerns, says former health minister. BMJ 2017; 356:j46. [PMID: 28053175 DOI: 10.1136/bmj.j46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Heutmekers M, Naaldenberg J, Frankena TK, Smits M, Leusink GL, Assendelft WJJ, van Schrojenstein Lantman-de Valk HMJ. After-hours primary care for people with intellectual disabilities in The Netherlands-Current arrangements and challenges. Res Dev Disabil 2016; 59:1-7. [PMID: 27484922 DOI: 10.1016/j.ridd.2016.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 06/29/2016] [Accepted: 07/12/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Little is known about the organisation of after-hours primary care for people with intellectual disabilities (ID), and mainstream care is not self-evidently accessible or fit for this group. A first step towards improvement is a greater understanding of current after-hours primary ID care. AIMS This study explores the organisation of and experiences with after-hours primary care provided for people with ID in The Netherlands. METHODS AND PROCEDURES A telephone survey amongst 68 care provider services including questions on organisational characteristics, problem areas, facilitators, and inhibitors. OUTCOMES AND RESULTS A multitude of different after-hours primary care arrangements were found. Primary care physicians (PCPs) were involved in almost all care provider services, often in alliance with PCP cooperatives. Specialised ID physicians had differing roles as gatekeeper, primary caregiver, or consultant. Most problems during the after-hours arose regarding daily care professionals' competences. Facilitators and inhibitors of after-hours primary care were themed around complexity of, and need for, specialised care, multidisciplinary team of professionals, communication and information, and prerequisites at organisational level. CONCLUSIONS AND IMPLICATIONS Evidence on specific after-hours health needs of people with ID is needed to strengthen collaboration between specialist ID care services and mainstream healthcare services to adequately provide care.
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Affiliation(s)
- Marloes Heutmekers
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Jenneken Naaldenberg
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Tessa K Frankena
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Marleen Smits
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department IQ healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Geraline L Leusink
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Willem J J Assendelft
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
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Ha HJ, Han KT, Kim SJ, Sohn TY, Jeon B, Park EC. Changes in Saturday outpatient volume and billings after introducing the Saturday incentive programme to clinics in South Korea: a longitudinal cohort study using claims data from 2012 to 2014. BMJ Open 2016; 6:e011248. [PMID: 27288380 PMCID: PMC4908875 DOI: 10.1136/bmjopen-2016-011248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE In October 2013, the South Korean government introduced an incentive programme to increase the availability of Saturday treatment at clinics, hoping to increase the role of primary care providers as gatekeepers to medical care. To the best of our knowledge, no one has yet investigated this programme's effect on overall outpatient care. Our study aims to analyse the change in Saturday outpatient volume and billings in clinics that adopted the Saturday incentive programme. SETTING Our study used 3 types of data from the period October 2012 to March 2014: National Health Insurance Service (NHIS) claims data, hospital evaluation data and medical institution data. PARTICIPANTS These data consisted of 66 825 881 outpatient cases from 2837 clinics. INTERVENTIONS Introducing the Saturday incentive programme. OUTCOME MEASURE We performed a multilevel analysis that adjusted for clinic-level and outpatient-level variables to examine the difference in the percentage of Saturday outpatient volume and billings after introducing the Saturday incentive programme. RESULTS The percentages of Saturday outpatient volume and billings were higher after introducing the programme (outpatient volume: β=2.065, p<0.001; outpatient billings: β=3.518, p<0.001). In addition, outpatient volume and billings on Friday and Saturday increased after introducing the programme, while those on weekdays, excluding Friday, decreased. CONCLUSIONS Our findings suggest that the Saturday incentive programme has affected clinic outpatient care and is a worthwhile health policy in terms of promoting primary care. Thus, it may improve healthcare accessibility and quality of care, and prevent inappropriate usage such as emergency room visits by providing patients with weekend clinic hours.
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Affiliation(s)
- Hyun Ji Ha
- Department of Health Policy and Management, Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea
- Health Insurance Review and Assessment Service, Seoul, Republic of Korea
| | - Kyu-Tae Han
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sun Jung Kim
- Department of Health Administration and Management, Soonchunhyang University, Asan, Republic of Korea
| | - Tae Yong Sohn
- Department of Health Services Administration, Yuhan University, Bucheon, Republic of Korea
| | - Byungyool Jeon
- Department of Preventive Medicine, CHA University College of Medicine, Pocheon, Republic of Korea
| | - Eun-Cheol Park
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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Affiliation(s)
| | - Ben Bray
- Royal College of Physicians, London NW1 4LE, UK
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Abstract
Whilst the nature of human illness is not determined by time of day or day of week, we currently structure health service delivery around a five-day delivery model. At least one country is endeavouring to develop a systems-based approach to planning a transition from five- to seven-day healthcare delivery models, and some services are independently instituting program reorganization to achieve these ends as research, amongst other things, highlights increased mortality and morbidity for weekend and after-hours admissions to hospitals. In this article, we argue that this issue does not merely raise instrumental concerns but also opens up a normative ethical dimension, recognizing that clinical ethical dilemmas are impacted on and created by systems of care. Using health policy ethics, we critically examine whether our health services, as currently structured, are at odds with ethical obligations for patient care and broader collective goals associated with the provision of publicly funded health services. We conclude by arguing that a critical health policy ethics perspective applying relevant ethical values and principles needs to be included when considering whether and how to transition from five-day to seven-day models for health delivery.
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Affiliation(s)
- Anthony Bell
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, MetroNorth Hospital and Health Service, Butterfield St, Herston, 4029, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- School of Public Health, Queensland University of Technology, Brisbane, Australia
| | - Fiona McDonald
- Australian Centre for Health Law Research, Queensland University of Technology, GPO Box 2434, Brisbane, QLD, 4001, Australia.
- Department of Bioethics, Dalhousie University, Halifax, NS, Canada.
| | - Tania Hobson
- QEII Jubilee Hospital and Community Based Services, Metro South Health Level 5, QEII Jubilee Hospital, 360 Troughton Road Coopers Plains, Brisbane, Queensland, Australia, 4108
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Breuckmann F, Remberg F, Böse D, Waltenberger J, Fischer D, Rassaf T. On- versus off-hour care for patients with non-ST-segment elevation myocardial infarction in Germany : Exemplary results within the chest pain unit concept. Herz 2016; 41:725-731. [PMID: 27193907 DOI: 10.1007/s00059-016-4425-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 03/01/2016] [Indexed: 12/11/2022]
Abstract
AIM The aim of this study was to analyze differences in the timing of invasive management of patients with high-risk acute coronary syndrome without persistent ST-segment elevation (hr-NSTE-ACS) or myocardial infarction without persistent ST-segment elevation (NSTEMI) between on- and off-hours in a German chest pain unit (CPU). PATIENTS AND METHODS We retrospectively enrolled 160 NSTEMI patients in the study, who were admitted to two German CPUs in 2013. Patients presenting on weekdays between 8 a.m. and 6 p.m. were compared with patients presenting during off-hours. Data analysis included time intervals from admission to invasive management (goals: for hr-NSTE-ACS, <2 h; for NSTEMI, <24 h) and the resulting guideline adherence. RESULTS Guideline-adherent timing of an invasive strategy did not differ significantly between the on-hour (6.5 h [3.0-22.0 h], 79.9 %) and off-hour groups (10.5 h [2.0-20.0 h], 75.3 %; p = 0.94), without additional significant differences between admissions during off-hours Monday to Thursday and weekends (10.0 h [2.0-19.0 h], 75.6 % vs. 7.5 h [2.0-20.0 h], 76.2 %; p = 0.96). CONCLUSION Our exemplary experience in two different German CPUs demonstrates adequate timing of coronary catheterization in over 75 % of cases, irrespective of admission during on- or off-hours. Nationwide validation of our findings by the German CPU registry is mandatory.
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Affiliation(s)
- F Breuckmann
- Klinik für Kardiologie, Klinikum Arnsberg, Stolte Ley 5, 59759, Arnsberg, Germany.
| | - F Remberg
- Klinik für Kardiologie, Klinikum Arnsberg, Stolte Ley 5, 59759, Arnsberg, Germany
| | - D Böse
- Klinik für Kardiologie, Klinikum Arnsberg, Stolte Ley 5, 59759, Arnsberg, Germany
| | - J Waltenberger
- Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany
| | - D Fischer
- Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany
| | - T Rassaf
- West German Heart and Vascular Center Essen, Department of Cardiology, University Duisburg-Essen, Essen, Germany
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Wong DJN. Seven day services: how relevant is the junior doctors' contract? BMJ 2016; 352:i1576. [PMID: 27001485 DOI: 10.1136/bmj.i1576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Danny J N Wong
- National Institute of Academic Anaesthesia Health Services Research Centre and Department of Applied Health Research, UCL, London, UK
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Gulland A. Seven day services: how are trusts doing against Keogh's clinical standards? BMJ 2016; 352:i1258. [PMID: 26931479 DOI: 10.1136/bmj.i1258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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McCartney M. Margaret McCartney: is Jeremy Hunt our colleague? BMJ 2015; 351:h5995. [PMID: 26546585 DOI: 10.1136/bmj.h5995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
OBJECTIVES Dutch primary out-of-hours care is provided by general practice cooperatives (GPCs). Although most GPCs use the same standardised triage system, differences between GPCs exist in the urgency assigned to patients' health problems. This cross-sectional study aims to provide insight into factors associated with the variation in assigned urgency between GPCs. DESIGN AND METHODS Data were derived from routine electronic health records of 895 253 patients who attended 17 GPCs in 2012. Patients' gender, age, travel distance to the GPC, and the use of a computer-based decision support system for triage were investigated as possibly affecting assigned urgency. Multilevel linear regression analyses were executed for the 3 most frequently presented health problems (cystitis/other urinary infection, laceration/cut and fever). RESULTS Variation in urgency levels between GPCs was significant for the selected health problems (p=0.00). Assigned urgency was mainly related to patient gender and age. It was not associated with the use of a computer-based decision support system, or with travel distance to the GPC. Most variation in urgency (93.4-96.7%) could be ascribed to variation in patient characteristics. CONCLUSIONS There is significant variation in urgency levels between GPCs, even for the same health problem. This variation is mainly associated with differences in characteristics of individuals contacting the GPCs, rather than with variables such as patients' travel distance or the use of a computer-based decision support system. Since patient characteristics are likely to affect patients' clinical need, our results are an indication of the adequate functioning of the triage system.
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Affiliation(s)
- Marieke Zwaanswijk
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Markus M J Nielen
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Karin Hek
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Robert A Verheij
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
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Brunschot DMDÖV, Hoitsma AJ, van der Jagt MFP, d'Ancona FC, Donders RART, van Laarhoven CJHM, Hilbrands LB, Warlé MC. Nighttime kidney transplantation is associated with less pure technical graft failure. World J Urol 2015; 34:955-61. [PMID: 26369548 PMCID: PMC4921110 DOI: 10.1007/s00345-015-1679-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 08/28/2015] [Indexed: 01/06/2023] Open
Abstract
Purpose To minimize cold ischemia time, transplantations with kidneys from deceased donors are frequently performed during the night.
However, sleep deprivation of those who perform the transplantation may have adverse effects on cognitive and psychomotor performance and may cause reduced cognitive flexibility. We hypothesize that renal transplantations performed during the night are associated with an increased incidence of pure technical graft failure. Methods A retrospective analysis of data of the Dutch Organ Transplant Registry concerning all transplants from deceased donors between 2000 and 2013 was performed. Nighttime surgery was defined as the start of the procedure between 8 p.m. and 8 a.m. The primary outcome measure was technical graft failure, defined as graft loss within 10 days after surgery without signs of (hyper)acute rejection. Results Of 4.519 renal transplantations in adult recipients, 1.480 were performed during the night. The incidence of pure technical graft failure was 1.0 % for procedures started during the night versus 2.6 % for daytime surgery (p = .001). In a multivariable model, correcting for relevant donor, recipient and graft factors, daytime surgery was an independent predictor of pure technical graft failure (p < .001). Conclusions Limitation of this study is mainly to its retrospective design, and the influence of some relevant variables, such as the experience level of the surgeon, could not be assessed. We conclude that nighttime surgery is associated with less pure technical graft failures. Further research is required to explore factors that may positively influence the performance of the surgical team during the night.
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Affiliation(s)
- Denise M D Özdemir-van Brunschot
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center Nijmegen, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - Andries J Hoitsma
- Department of Nephrology, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Michel F P van der Jagt
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center Nijmegen, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Frank C d'Ancona
- Department of Urology, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Rogier A R T Donders
- Department of Health Evidence, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Cees J H M van Laarhoven
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center Nijmegen, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Luuk B Hilbrands
- Department of Nephrology, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Michiel C Warlé
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center Nijmegen, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
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Meacock R, Doran T, Sutton M. What are the Costs and Benefits of Providing Comprehensive Seven-day Services for Emergency Hospital Admissions? Health Econ 2015; 24:907-912. [PMID: 26010243 DOI: 10.1002/hec.3207] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 04/30/2015] [Indexed: 06/04/2023]
Abstract
The English National Health Service is moving towards providing comprehensive 7-day hospital services in response to higher death rates for emergency weekend admissions. Using Hospital Episode Statistics between 1st April 2010 and 31st March 2011 linked to all-cause mortality within 30 days of admission, we estimate the number of excess deaths and the loss in quality-adjusted life years associated with emergency weekend admissions. The crude 30-day mortality rate was 3.70% for weekday admissions and 4.05% for weekend admissions. The excess weekend death rate equates to 4355 (risk adjusted 5353) additional deaths each year. The health gain of avoiding these deaths would be 29 727-36 539 quality-adjusted life years per year. The estimated cost of implementing 7-day services is £1.07-£1.43 bn, which exceeds by £339-£831 m the maximum spend based on the National Institute for Health and Care Excellence threshold of £595 m-£731 m. There is as yet no clear evidence that 7-day services will reduce weekend deaths or can be achieved without increasing weekday deaths. The planned cost of implementing 7-day services greatly exceeds the maximum amount that the National Health Service should spend on eradicating the weekend effect based on current evidence. Policy makers and service providers should focus on identifying specific service extensions for which cost-effectiveness can be demonstrated.
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Affiliation(s)
- Rachel Meacock
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
| | - Matt Sutton
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
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Saxena A, Desanghere L, Skomro RP, Wilson TW. Residents' and attendings' perceptions of a night float system in an internal medicine program in Canada. Educ Health (Abingdon) 2015; 28:118-123. [PMID: 26609011 DOI: 10.4103/1357-6283.170125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND The Night Float system (NFS) is often used in residency training programs to meet work hour regulations. The purpose of this study was to examine resident and attendings' perceptions of the NFS on issues of resident learning, well-being, work, non-educational activities and the health care system (patient safety and quality of care, inter-professional teams, workload on attendings and costs of on-call coverage). METHODS A survey questionnaire with closed and open-ended questions (26 residents and eight attendings in an Internal Medicine program), informal discussions with the program and moonlighting and financial data were collected. RESULTS AND DISCUSSION The main findings included, (i) an overall congruency in opinions between resident and attendings across all mean comparisons, (ii) perceptions of improvement for most aspects of resident well-being (e.g. stress, fatigue) and work environment (e.g. supervision, support), (iii) a neutral effect on the resident learning environment, except resident opinions on an increase in opportunities for learning, (iv) perceptions of improved patient safety and quality of care despite worsened continuity of care, and (v) no increases in work-load on attendings or the health care system (cost-neutral call coverage). Patient safety, handovers and increased utilization of moonlighting opportunities need further exploration.
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Affiliation(s)
- Anurag Saxena
- Department of Pathology; Dean's Office, Postgraduate Medical Education, Saskatoon, SK, Canada
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Wagner K. 5 ways to optimize performance for the night shift. Healthc Financ Manage 2015; 69:38. [PMID: 26665521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Wise J. Out-of-hours services are mostly good but quality still varies, says regulator. BMJ 2014; 349:g6028. [PMID: 25287970 DOI: 10.1136/bmj.g6028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Iacobucci G. NHS England is criticised for failing to robustly oversee out of hours care. BMJ 2014; 349:g4591. [PMID: 25022476 DOI: 10.1136/bmj.g4591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Coomber R, Smith D, McGuinness D, Shao E, Soobrah R, Frankel AH. Foundation doctors working at night: what training opportunities exist? Med Teach 2014; 36:632-638. [PMID: 24787535 DOI: 10.3109/0142159x.2014.899688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Foundation Training is designed for doctors in their first two years of post-graduation. The number of foundation doctors (FD) in the UK working nights has reduced because of a perception that clinical supervision at night is unsatisfactory and that minimal training opportunities exist. We aimed to assess the value of night shifts to FDs and hypothesised that removing FDs from nights may be detrimental to training. METHODS Using a survey, we assessed the number of FDs working nights in London, FDs views on working nights and their supervision at night. We evaluated whether working at night, compared to daytime working provided opportunities to achieve foundation competencies. RESULTS 83% (N = 2157/2593) of FDs completed the survey. Over 90% of FDs who worked nights felt that the experience they gained improved their ability to prioritise, make decisions and plan. FDs who worked nights reported higher scores for achieving competencies in history taking (2.67 vs. 2.51; p = 0.00), examination (2.72 vs. 2.59; p = 0.01) and resuscitation (2.27 vs. 1.96; p = 0.00). The majority (65%) felt adequately supervised. CONCLUSIONS Our survey has demonstrated that FDs find working nights a valuable experience, providing important training opportunities, which are additional to those encountered during daytime working.
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Andersen MJ, Gromov K, Brix M, Troelsen A. The Danish Fracture Database can monitor quality of fracture-related surgery, surgeons' experience level and extent of supervision. Dan Med J 2014; 61:A4839. [PMID: 24947619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION The importance of supervision and of surgeons' level of experience in relation to patient outcome have been demonstrated in both hip fracture and arthroplasty surgery. The aim of this study was to describe the surgeons' experience level and the extent of supervision for: 1) fracture-related surgery in general; 2) the three most frequent primary operations and reoperations; and 3) primary operations during and outside regular working hours. MATERIAL AND METHODS A total of 9,767 surgical procedures were identified from the Danish Fracture Database (DFDB). Procedures were grouped based on the surgeons' level of experience, extent of supervision, type (primary, planned secondary or reoperation), classification (AO Müller), and whether they were performed during or outside regular hours. RESULTS Interns and junior residents combined performed 46% of all procedures. A total of 90% of surgeries by interns were performed under supervision, whereas 32% of operations by junior residents were unsupervised. Supervision was absent in 14-16% and 22-33% of the three most frequent primary procedures and reoperations when performed by interns and junior residents, respectively. The proportion of unsupervised procedures by junior residents grew from 30% during to 40% (p < 0.001) outside regular hours. CONCLUSION Interns and junior residents together performed almost half of all fracture-related surgery. The extent of supervision was generally high; however, a third of the primary procedures performed by junior residents were unsupervised. The extent of unsupervised surgery performed by junior residents was significantly higher outside regular hours. FUNDING not relevant. TRIAL REGISTRATION The Danish Fracture Database ("Dansk Frakturdatabase") was approved by the Danish Data Protection Agency ID: 01321.
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Affiliation(s)
- Morten Jon Andersen
- Ortopædkirurgisk Afdeling, Hvidovre Hospital, Kettegård Allé 30, 2650 Hvidovre, Denmark.
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Abstract
BACKGROUND The Hospital at Night system has been widely adopted to manage Out-of-Hours workload. However, it has the potential to introduce delays and corruption of information. The introduction of newer technologies to replace landlines, pagers and paper may ameliorate these issues. AIM To establish if the introduction of a Hospital at Night system supported by a wireless taskflow system affected the escalation of high Early Warning Scores (EWSs) to medical attention, and the time taken to medical review. DESIGN Prospective 'pre and post' observational study in a teaching hospital in the UK. METHODS Review of observation charts and medical records, and data extraction from the electronic taskflow system. RESULTS The implementation of a technology-supported Hospital at Night system was associated with a significant decrease in time to documentation of initial review in those who were reviewed. However, there was no change in the proportion of those with a high EWS that were reviewed, and throughout the study a majority of patients with high EWSs were not reviewed in accordance with guidelines. CONCLUSION Introduction of a Hospital at Night system supported by mobile technology appeared to improve the transfer of information, but did not affect the nursing decision whether to escalate abnormal findings.
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Affiliation(s)
- P J J Herrod
- Department of Orthopaedic Surgery, King's Mill Hospital, Sutton in Ashfield, Nottinghamshire NG17 4JL, UK.
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Moore A. 24/7 care. The seven day forecast. Health Serv J 2014; 124:24-25. [PMID: 24660432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Philips H, Huibers L, Holm Hansen E, Bondo Christensen M, Leutgeb R, Klemenc-Ketis Z, Chmiel C, Muñoz MA, Kosiek K, Remmen R. Guidelines adherence to lower urinary tract infection treatment in out-of-hours primary care in European countries. Qual Prim Care 2014; 22:221-231. [PMID: 25695532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The substantial prevalence of bacterial lower urinary tract infections (LUTIs) in out-of-hours (OOH) primary care is a reason for frequent prescription of antibiotics. Insight in guideline adherence in OOH primary care concerning treatment of LUTIs is lacking. AIMS To check feasibility of the use of OOH routine data to assess guideline adherence for the treatment of LUTI in OOH primary care, in different regions of Europe. METHODS We compared guidelines for diagnosis and treatment of uncomplicated LUTIs in nine European countries, followed by an observational study on available data of guideline adherence. In each region a convenience sample of registration data of at least 100 contacts per OOH primary care setting was collected. Data on adherence (% of contacts) was identified for type of antibiotic and for full treatment adherence (i.e. recommended type and dose and duration). RESULTS Six countries were able to provide data on treatment of LUTIs. Four of them succeeded to collect data on type, dosage and duration of treatment. Mostly, trimethoprim was the treatment of first choice, sometimes combined with sulfamethoxazol or sulfamethizol. Adherence with the type of antibiotics varied from 25% to 100%. Denmark achieved a full treatment adherence of 40.0%, the Netherlands 72.7%, Norway 38.3%, and Slovenia 22.2%. CONCLUSION Guidelines content is similar to a large extent in the participating countries. The use of OOH routine data for analysis of guideline adherence in OOH primary care seems feasible, although some challenges remain. Adherence regarding treatment varies and suggests room for improvement in most countries.
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Affiliation(s)
- Hilde Philips
- Department of Primary and Multidisciplinary Care, General Practice, University of Antwerp, Universiteitsplein 1, gebouw R, 3de Verd., B-2610 Wilrijk, Belgium.
| | - Linda Huibers
- Radboud University Medical Centre, Nijmegen, Scientific Institute for Quality of Healthcare, Netherlands
| | - Elisabeth Holm Hansen
- National Centre for Emergency Primary Health Care, Uni Research, Uni Health, Norway; Haraldsplass Deaconess University College, Norway
| | | | - Rüdiger Leutgeb
- Department of General Practice and Health Services Research, University of Heidelberg, Germany
| | - Zalika Klemenc-Ketis
- Department of Family Medicine, Medical School, University of Maribor, and Department of Family Medicine, Medical School, University of Ljubljana, Slovenia
| | - Corinne Chmiel
- Institute of General Practice and Health Services Research University of Zurich, Switzerland
| | - Miguel-Angel Muñoz
- Primary Healthcare University Research Institute IDIAP-Jordi Gol and Catalan Institute of Health, Barcelona, Spain
| | - Katarzyna Kosiek
- Department of Family and Community Medicine, Medical University of Lodz, Poland
| | - Roy Remmen
- Department of Primary and Multidisciplinary Care, General Practice, University of Antwerp, Belgium
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Arce HE. [Concerning an article on the relation between mortality and the day of surgery, commented on Caveat lector]. Medicina (B Aires) 2014; 74:86-87. [PMID: 24561856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Affiliation(s)
- Hugo E Arce
- Fundación Barceló, Buenos Aires, Argentina. E-mail:
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Martijn L, Jacobs A, Amelink-Verburg M, Wentzel R, Buitendijk S, Wensing M. Adverse outcomes in maternity care for women with a low risk profile in The Netherlands: a case series analysis. BMC Pregnancy Childbirth 2013; 13:219. [PMID: 24286376 PMCID: PMC4219453 DOI: 10.1186/1471-2393-13-219] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 11/23/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aimed to perform a structural analysis of determinants of risk of critical incidents in care for women with a low risk profile at the start of pregnancy with a view on improving patient safety. METHODS We included 71 critical incidents in primary midwifery care and subsequent hospital care in case of referral after 36 weeks of pregnancy that were related to substandard care and for that reason were reported to the Health Care Inspectorate in The Netherlands in 36 months (n = 357). We performed a case-by-case analysis, using a previously validated instrument which covered five broad domains: healthcare organization, communication between healthcare providers, patient risk factors, clinical management, and clinical outcomes. RESULTS Determinants that were associated with risk concerned healthcare organization (n = 20 incidents), communication about treatment procedures (n = 39), referral processes (n = 19), risk assessment by telephone triage (n = 10), and clinical management in an out of hours setting (n = 19). The 71 critical incidents included three cases of maternal death, eight cases of severe maternal morbidity, 42 perinatal deaths and 12 critical incidents with severe morbidity for the child. Suboptimal prenatal risk assessment, a delay in availability of health care providers in urgent situations, miscommunication about treatment between care providers, and miscommunication with patients in situations with a language barrier were associated with safety risks. CONCLUSIONS Systematic analysis of critical incidents improves insight in determinants of safety risk. The wide variety of determinants of risk of critical incidents implies that there is no single intervention to improve patient safety in the care for pregnant women with initially a low risk profile.
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Affiliation(s)
- Lucie Martijn
- IQ healthcare, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, 114 IQ healthcare, P.O. Box 9101, 6500, HB Nijmegen, The Netherlands
| | - Annelies Jacobs
- IQ healthcare, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, 114 IQ healthcare, P.O. Box 9101, 6500, HB Nijmegen, The Netherlands
| | | | - Renske Wentzel
- Dutch Health Care Inspectorate, The Hague, The Netherlands
| | | | - Michel Wensing
- IQ healthcare, Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, 114 IQ healthcare, P.O. Box 9101, 6500, HB Nijmegen, The Netherlands
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O'Dowd A. MPs challenge Serco over its trustworthiness to run public services. BMJ 2013; 347:f7019. [PMID: 24270376 DOI: 10.1136/bmj.f7019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Showkathali R, Davies JR, Sayer JW, Kelly PA, Aggarwal RK, Clesham GJ. The advantages of a consultant led primary percutaneous coronary intervention service on patient outcome. QJM 2013; 106:989-94. [PMID: 23737507 DOI: 10.1093/qjmed/hct132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Mortality among emergency medical admissions has been reported to be higher when patients are admitted to hospital at nights and weekends. AIM We studied the outcome of ST elevation myocardial infarction (STEMI) patients presenting at different times to our centre with 24/7 primary percutaneous coronary intervention (PPCI) service. METHODS We divided all patients who underwent PPCI between September 2009 and November 2011 into three groups according to the time of admission as group 1: in-hours (0800-1800 h weekdays), group 2: out-of-hours (1800- 0800 h weekdays) and group 3: weekends (Sat to Mon 0800-0800 h). RESULTS A total of 605 (41.1%), 397 (27%) and 469 (31.9%) were included in group 1, 2 and 3, respectively. Apart from cardiogenic shock (8.9%, 5.5% and 7.7%, P = 0.05) and door to balloon time (median 29, 33 and 36 min, P < 0.0001), there was no significant difference noted in the baseline and procedural characteristics between the groups. In-hospital mortality (4.6%, 4.3% and 5.3%, P = 0.5), 30-day mortality (6.4%, 6.3% and 7%, P = 0.7), 30-day stent thrombosis (0.8%, 0.8% and 0.2%, P = 0.1) and 1-year mortality (10.7%, 10.8% and 9.8%, P = 0.7) were no difference between the groups. On logistic regression analysis, out-of-hours and weekend admissions were not found to be a predictor of both 30-day and 1-year mortality. CONCLUSION In this consecutive series of patients admitted to a high volume PPCI centre, there was no difference in mortality when patients were admitted at different times. The involvement of senior medical staff early in the patients' admission may have contributed to these consistent outcomes.
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Affiliation(s)
- Refai Showkathali
- Department of Cardiology, The Essex Cardiothoracic Centre, Basildon, Essex SS16 5NL, UK.
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Vaernet J. [Open letter to the Medical Association: Take responsibility for ensuring physician coverage throughout Denmark]. Ugeskr Laeger 2013; 175:2663. [PMID: 26504922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Pedersen P. [Dear patients in the capital region]. Ugeskr Laeger 2013; 175:2509-2510. [PMID: 26504937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Johnston J, Loughrey C, Bonnar G. Evaluating out-of-hours GP training: the Northern Ireland experience. Educ Prim Care 2013; 24:466-468. [PMID: 24196604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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O'Dowd A. GPs should have more oversight of out of hours care, say leaders. BMJ 2013; 347:f5013. [PMID: 23935061 DOI: 10.1136/bmj.f5013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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O'Dowd A. MPs condemn Serco for substandard out of hours service in Cornwall. BMJ 2013; 347:f4479. [PMID: 23847211 DOI: 10.1136/bmj.f4479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Wilkie P. Take the hours out of out of hours care. Health Serv J 2013; 123:22-23. [PMID: 23946997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Law: case studies. Never again. Health Serv J 2013; 123:suppl 8-9. [PMID: 24066494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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O'Dowd A. GPs' out of hours arrangements are not to blame for pressure on emergency departments, MPs hear. BMJ 2013; 346:f3363. [PMID: 23697832 DOI: 10.1136/bmj.f3363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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