Accuracy of urgency allocation in patients with shortness of breath calling out-of-hours primary care: a cross-sectional study.

BACKGROUND: In out-of-hours primary care (OHS-PC), semi-automatic decision support tools are often used during telephone triage. In the Netherlands, the Netherlands Triage Standard (NTS) is used. The NTS is mainly expert-based and evidence on the diagnostic accuracy of the NTS' urgency allocation against clinically relevant outcomes for patients calling with shortness of breath (SOB) is lacking. METHODS: We included data from adults (≥18 years) who contacted two large Dutch OHS-PC centres for SOB between 1 September 2020 and 31 August 2021 and whose follow-up data about final diagnosis could be retrieved from their own general practitioner (GP). The diagnostic accuracy (sensitivity and specificity with corresponding 95% confidence intervals (CI)) of the NTS' urgency levels (high (U1/U2) versus low (U3/U4/U5) and 'final' urgency levels (including overruling of the urgency by triage nurses or supervising general practitioners (GPs)) was determined with life-threatening events (LTEs) as the reference. LTEs included, amongst others, acute coronary syndrome, pulmonary embolism, acute heart failure and severe pneumonia. RESULTS: Out of 2012 eligible triage calls, we could include 1833 adults with SOB who called the OHS-PC, mean age 53.3 (SD 21.5) years, 55.5% female, and 16.6% showed to have had a LTE. Most often severe COVID-19 infection (6.0%), acute heart failure (2.6%), severe COPD exacerbation (2.1%) or severe pneumonia (1.9%). The NTS urgency level had a sensitivity of 0.56 (95% CI 0.50-0.61) and specificity of 0.61 (95% CI 0.58-0.63). Overruling of the NTS' urgency allocation by triage nurses and/or supervising GPs did not impact sensitivity (0.56 vs. 0.54, p = 0.458) but slightly improved specificity (0.61 vs. 0.65, p < 0.001). CONCLUSIONS: The semi-automatic decision support tool NTS performs poorly with respect to safety (sensitivity) and efficiency (specificity) of urgency allocation in adults calling Dutch OHS-PC with SOB. There is room for improvement of telephone triage in patients calling OHS-PC with SOB. TRIAL REGISTRATION: The Netherlands Trial Register, number: NL9682 .

[Acute chest pain in out-of-hours primary care]. / Acute pijn op de borst op de huisartsenpost.

Out-of-hours primary care (OOH-PC) facilities act as a first point of contact in acute care in the Netherlands, including acute chest pain. The facilities perform initial triage to assess the patient's urgency using standardized triage protocols (Netherlands Triage Standard). The performance of the current protocol for chest pain assessment was recently evaluated and showed only moderate discriminatory properties. Although final triage decision-making is improved by the clinical experience of triage assistants and general practitioners, substantial over- and under-triage persists. Improving the care of patients with chest pain in OOH-PC should primarily be sought in improving the triage software, followed by the use of innovative diagnostic tools (such as troponine measurements).

Care by general practitioners for patients with asthma or COPD during the COVID-19 pandemic.

The impact of the COVID-19 pandemic on general practitioners' (GP) care for patients with asthma and/or COPD is largely unknown. To describe the impact of the pandemic on asthma or COPD-related GP care, we analysed routinely recorded electronic health records data from Dutch general practices and out-of-hours (OOH) services. During the COVID-19 pandemic (2020), the contact rates for asthma and/or COPD were significantly lower in GP practices and OOH services compared with the pre-pandemic period (2019) (respectively, 15% lower and 28% lower). The proportion of telephone contacts increased significantly with 13%-point in GP practices and 12%-point at OOH services, while the proportion of face-to-face contacts decreased. Furthermore, the proportion of high urgent contacts with OOH services decreased by 8.5%-point. To conclude, the overall contact rates in GP practices and OOH services decreased, while more contacts were remote. Lower contact rates have, after a short follow-up, not resulted in more patients with exacerbations in OOH care. However, this might still be expected after a longer follow-up.

Optimising telephone triage of patients calling for acute shortness of breath during out-of-hours primary care: protocol of a multiple methods study (Opticall).

INTRODUCTION: Callers with acute shortness of breath (SOB) are a challenge for telephone triage at out-of-hours primary care (OHS-PC) as SOB could be the sign of a potentially life-threatening disease, yet mostly is a symptom of a broad range of self-limiting disorders. Current telephone triage practice is mainly expert based and clear evidence on accuracy, safety and efficiency of the use of the Netherlands Triage Standard (NTS) by triage nurses based on the eventual clinical outcome is lacking for this domain. METHODS AND DATA ANALYSIS: Multiple methods study in five OHS-PC services in the Utrecht region, the Netherlands. Data will be collected from OHS-PC electronic health records (EHR) and backed up tapes of telephone triage conversations, which will be linked to routine primary care EHR data. In cross-sectional studies, we will (1) validate the NTS urgency classification for adults with SOB against final diagnoses and (2) develop diagnostic prediction models for urgent diagnoses (eg, composite endpoint of urgent diagnoses, pulmonary embolism, acute coronary syndrome, acute heart failure and pneumonia). We will develop improvement measures for the use of the NTS by triage nurses through practice observations and semistructured interviews with patients, triage nurses and general practitioners (GPs). In an action research approach, we will, in collaboration with these stakeholders, implement and evaluate our findings in both GP and triage nurse educational programmes as well as in OHS-PC services. ETHICS AND DISSEMINATION: The Medical Ethics Review Committee Utrecht, the Netherlands, approved the study protocol (protocol 21/361). We will take into account the 'code of conduct for responsible research' of the WHO, the EU General Data Protection Regulation and the 'Dutch Medical Treatment Contracts Act'. Results will be disseminated in peer-reviewed publications and at (inter)national meetings. TRIAL REGISTRATION NUMBER: NL9682.

Impact of an internal medicine nocturnist service on care of patients with cancer at a large Canadian teaching hospital: a quality-improvement study.

BACKGROUND: Nocturnists (overnight hospitalists) are commonly implemented in US teaching hospitals to adhere to per-resident patient caps and improve care but are rare in Canada, where patient caps and duty hours are comparatively flexible. Our objective was to assess the impact of a newly implemented nocturnist program on perceived quality of care, code status documentation and patient outcomes. METHODS: Nocturnists were phased in between June 2018 and December 2019 at Toronto General Hospital, a large academic teaching hospital in Toronto, Ontario. We performed a quality-improvement study comparing rates of code status entry into the electronic health record at admission, in-hospital mortality, the 30-day readmission rate and hospital length of stay for patients with cancer admitted by nocturnists and by residents. Surveys were administered in June 2019 to general internal medicine faculty and residents to assess their perceptions of the impact of the nocturnist program. RESULTS: From July 2018 to June 2019, 30 nocturnists were on duty for 241/364 nights (66.5%), reducing the mean maximum overnight per-resident patient census from 40 (standard deviation [SD] 4) to 25 (SD 5) (p < 0.001). The rate of admission code status entry was 35.3% among patients admitted by residents (n = 133) and 54.9% among those admitted by nocturnists (n = 339) (p < 0.001). The mortality rate was 10.5% among patients admitted by residents and 5.6% among those admitted by nocturnists (p = 0.06), the 30-day readmission rate was 8.3% and 5.9%, respectively (p = 0.4), and the mean acute length of stay was 7.2 (SD 7.0) days and 6.4 (SD 7.8) days, respectively (p = 0.3). Surveys were completed by 15/24 faculty (response rate 62%), who perceived improvements in patient safety, efficiency and trainee education; however, only 30/102 residents (response rate 29.4%) completed the survey. INTERPRETATION: Although implementation of a nocturnist program did not affect patient outcomes, it reduced residents' overnight patient census, and improved faculty perceptions of quality of care and education, as well as documentation of code status. Our results support nocturnist implementation in Canadian teaching hospitals.

The Cheshire & Merseyside Collaborative trainee-led on-call service: a review of safety and efficiency.

AIM: To assess safety and efficiency of the Cheshire & Merseyside Collaborative, the largest trainee led on-call service in the UK, based on discrepancy rates and time taken to issue reports. MATERIALS & METHODS: All studies reported by the collaborative in a 4-week period were evaluated for discrepancy and the time taken to issue a report. These figures were compared against the Royal College of Radiologists (RCR) guidelines and a recent national audit of discrepancy rates. The time taken to report was measured against the National Institute of Health and Clinical Excellence (NICE) and Trauma Audit Research Network (TARN) guidelines. RESULTS: The overall discrepancy rates for the collaborative were 2.5% for minor discrepancies and 2% for major discrepancies, which is within the RCR standard. The median time taken to issue a report was 30 min, which is within the NICE and TARN 1-h targets. CONCLUSIONS: The Cheshire & Merseyside Collaborative can be deemed a safe and efficient way of delivering an out-of-hours radiology service.

Variation in referral rates to emergency departments and inpatient services from a GP out of hours service and the potential impact of alternative staffing models.

INTRODUCTION: Out of hours (OOHs) primary care is a critical component of the acute care system overnight and at weekends. Referrals from OOH services to hospital will add to the burden on hospital assessment in the ED and on-call specialties. METHODS: We studied the variation in referral rates (to the ED and direct specialty admission) of individual clinicians working in the Oxfordshire, UK OOH service covering a population of 600 000 people. We calculated the referral probability for each clinician over a 13-month period of practice (1 December 2014 to 31 December 2015), stratifying by clinician factors and location and timing of assessment. We used Simul8 software to determine the range of hospital referrals potentially due to variation in clinician referral propensity. RESULTS: Among the 119 835 contacts with the service, 5261 (4.4%) were sent directly to the ED and 3474 (3.7%) were admitted directly to specialties. More referrals were made to ED by primary care physicians if they did not work in the local practices (5.5% vs 3.5%, p=0.011). For clinicians with >1000 consultations, percentage of patients referred varied from 1% to 21% of consultations. Simulations where propensity to refer was made less extreme showed a difference in maximum referrals of 50 patients each week. CONCLUSIONS: There is substantial variation in clinician referral rates from OOHs primary care to the acute hospital setting. The number of patients referred could be influenced by this variation in clinician behaviour. Referral propensity should be studied including casemix adjustment to determine if interventions targeting such behaviour are effective.

Surgery out of office hours for type A aortic dissection: does night-time and weekend surgery worsen outcome?

OBJECTIVES: Immediate surgical repair for type A aortic dissection is gold standard and at most centres is performed by the surgeon on call during night-time and weekends. The objective was to evaluate whether emergency surgery during night-time or weekends has an influence on 30-day mortality. METHODS: In 319 patients undergoing surgery for type A aortic dissection, skin incision was documented. Patients were divided into 2 groups according to the time point of skin incision (05:00 a.m. to 07:00 p.m. = daytime group; 07:01 p.m. to 04:59 a.m. = night-time group). We also noted whether their surgeries were started on weekdays (Monday 00:00 to Friday 23:59) or weekends (Saturday 00:00 to Sunday 23:59). RESULTS: The median age was 61 years (interquartile range 49-70) and 69.6% (n = 222) were male. Almost 50% (n = 149) of patients presented in a critical preoperative state. Forty-one percent of patients (n = 131) underwent night-time surgery. There were no differences in baseline data, time from onset of symptoms to surgery or surgical treatment between groups, except from preferred femoral access for arterial cannulation during night-time. Advanced age [odds ratio 1.042, 95% confidence interval (CI) 1.014-1.070], preoperative malperfusion syndrome (odds ratio 2.542, 95% CI 1.279-5.051) and preoperative tamponade (odds ratio 2.562, 95% CI 1.215-5.404) emerged as risk factors for 30-day mortality. Night-time or weekend surgery did not have any impact on 30-day mortality when covariates were considered. CONCLUSIONS: Based on the natural course of the disease and our results, surgery for type A aortic dissection should be performed as an emergency surgery regardless of time and day.

Effect of Access to After-Hours Primary Care on the Association Between Home Nursing Visits and Same-Day Emergency Department Use.

PURPOSE: Previous work has demonstrated that home care patients have an increased risk of visiting the emergency department after a home nursing visit on the same day. We investigated whether this association is modified by greater access to after-hours primary care. METHODS: We conducted a population-based case-crossover study of home care patients in Ontario, Canada in 2014-2016. Emergency department visits after 5:00 pm were selected as case periods and matched, within the same patient, to control periods within the previous week. The association between home nursing visits and same-day emergency department visits was estimated with conditional logistic regression. Access to after-hours primary care, measured on the patient and practice level, was tested for effect modification using an interaction term approach. Analysis was performed separately for all emergency department visits and a less urgent subset not admitted to hospital. RESULTS: A total of 11,840 patients contributed cases to the analysis. Patients with a history of after-hours primary care use had a smaller increased risk of a same-day after-hours emergency department visit (OR = 1.18; 95% CI, 1.06-1.30) compared with patients with no after-hours care (OR = 1.31; 95% CI, 1.25-1.39). The modifying effect was stronger among emergency department visits not admitted to hospital (OR = 1.11; 95% CI, 0.97-1.28 vs OR = 1.41; 95% CI, 1.31-1.51). CONCLUSION: Greater access to after-hours primary care reduced the risk of less-urgent emergency department use associated with home nursing visits. These findings suggest increasing access to after-hours primary care could prevent some less-urgent emergency department visits.

Practical Family Medicine: After-Hours Video Telehealth, Office Procedures, Polyp Follow-up in Older Patients, Terminology for Domestic Violence Intervention.

This issue primarily contains practice-based research reports. For a commentary on these articles, see Tapp.1 JABFM also has a call for submissions and accepted pre-print articles specifically on COVID at our Web site, www.jabfm.org These online COVID-related articles will be collated into a future print issue. This issue also has additional articles, encompassing a range of issues, as is common for JABFM.

Patient Interest in Video Integration for After-Hours Telemedicine.

PURPOSE: To understand patient attitudes, access toward video calling to enhance efficiency of after-hours triage calls. METHODS: We surveyed patients aged 18 to 89 years. Questions included demographics, preferences, access to video calling devices, and perceived advantages and disadvantages of this technology. Answers were entered into Qualtrics database and analyzed using JMP 11 (SAS, Cary, NC). RESULTS: Two hundred ninety-eight patients agreed to participate. Mean age was 47.9 years; 71.6% were female; and 75.1% had access to video calling device. Device proficiency was inversely related to age and greatest in 18-to-32-years group (χ2 = 71.18, P < .0001). Seventy-one percent of patients enjoyed video communication, directly proportional to education (trend test Z = 2.78, P < .005). Adjusted for both age and education, respondents with college education or above were 3 times more likely to self identify as "good' with video (OR, 3.11; 95% CI, 1.48-6.64); those under age 48 had even higher proficiency (Odds ratio (OR), 13.9; 95% CI, 4.79-59.34). Patients with prior video experience were 3 times more likely to prefer video calling (Relative risk (RR) = 3.46; 95% CI, 1.95-6.11). Patients calling their doctor 5 or more times annually preferred video calling significantly more than calling by telephone (RR, 1.61; 95% CI, 1.31-1.97). Faster contact with the primary care provider (19.8%) was the most perceived advantage. Loss of in-person interaction with doctor (37.1%) was the greatest perceived disadvantage. CONCLUSIONS: Patients seem to have access and interest in video communication for after-hours calls. Further studies are needed to evaluate whether addition of video component to after-hours triage calls will help reduce unnecessary emergency department visits.

Limited reliability of experts' assessment of telephone triage in primary care patients with chest discomfort.

OBJECTIVE: Root cause analyses of serious adverse events (SAE) in out-of-hours primary care (OHS-PC) often point to errors in telephone triage. Such analyses are, however, hampered by hindsight bias. We assessed whether experts, blinded to the outcome, recognize (un)safety of triage of patients with chest discomfort, and we quantified inter-rater reliability. STUDY DESIGN AND SETTING: This is a case-control study with triage recordings from 2013-2017 at OHS-PC. Cases were missed acute coronary syndromes (ACSs, considered as SAE). These cases were age- and gender-matched 1:8 with the controls, sampled from the remainder of people calling for chest discomfort. Fifteen experts listened to the recordings and rated the safety of triage. We calculated sensitivity and specificity of recognizing an ACS and the intraclass correlation. RESULTS: In total, 135 calls (15 SAE, 120 matched controls) were relistened. The experts identified ACSs with a sensitivity of 0.86 (95% CI: 0.71-0.95) and a specificity of 0.51 (95% CI: 0.43-0.58). Cases were rated significantly more often as unsafe than the controls (73.3% vs. 22.5%, P < 0.001). The inter-rater reliability for safety was poor: ICC 0.16 (95% CI: 0.00-0.32). CONCLUSIONS: Blinded experts rated calls of missed ACSs more often as unsafe than matched control calls, but with a low level of agreement among the experts.

Paediatric contacts with the UK out-of-hours primary care service and contact outcomes: a regional service evaluation.

BACKGROUND: Demand on hospital emergency departments for paediatric problems is increasing. However, the volume and nature of paediatric health demands placed on other parts of the urgent care system have not been explored. This understanding is an important first step in developing and improving out-of-hospital care. We aimed to describe the volume, nature, and outcomes of paediatric contacts with out-of-hours general practice (OOH GP). We performed a retrospective service evaluation using data from 12 months of paediatric patient contacts with the Oxfordshire OOH GP service. METHODS: A database of contacts with the Oxfordshire OOH GP service was created for a 12 month period from December 2014 to November 2015. Descriptive statistics were calculated using SPSS Version 25. RESULTS: 27,455 contacts were made by 18,987 individuals during a 12 month period. The majority of these were for children aged under 5. Over 70% of contacts were at the weekend. The peak contact period was between 18:30 and 21:30. Over 40% of contacts resulted in advice only (no onward referral, requirement for GP follow up, or prescription). 19.7% of contacts resulted in an antibiotic prescription, most commonly those linked with ear, chest, and throat infections. DISCUSSION: Paediatric contacts with the Oxfordshire OOH GP service were predominantly in younger age groups and in the evening, with 19.7% resulting in an antibiotic prescription. Almost half of the contacts had no follow up or prescription, suggesting non-prescribing health care professionals could be involved in providing care in OOH GP. Further research should consider how children and their parents can be best supported to optimise OOH consulting.

Optimising after-hours workflow of computed tomography orders in the emergency department.

Ordering and protocolling CT scans after-hours from the emergency department (ED) at our institution previously required discussion between the ED physician and radiology resident, which led to workflow inefficiency. Our intervention consisted of creating an electronic list of CT requests that radiology residents would monitor. Radiology protocolled straightforward requests and contacted the ordering physician for more details when required. We aimed to improve workflow efficiency, increase provider satisfaction and reduce CT turnaround time without significantly affecting CT utilisation. Plan-do-study-act cycles were used to plan and evaluate the intervention. The intervention was initiated on weekday evenings and then expanded to weekend hours after an interim analysis. Qualitative outcomes were measured via electronic survey, and quantitative outcomes were collected from administrative data and analysed via control charts and other statistical methods. Survey response was high from ED physicians (76%, n=82/108) and radiology residents (79%, n=30/38). After the intervention, the majority of ED staff and radiology residents perceived improved workflow efficiency (96.3%, 73.3%), radiology residents noted a subjective decrease in disruptions (83.3%) and most ED staff felt that scans were performed more quickly (84.1%). Radiology residents received fewer pages per shift, adjusted for scan volume. There was a reduction in time from order entry to protocol on weekday shifts only, with no statistically significant effect on time from order entry to scan. Segmented regression analysis demonstrated a background increase in utilisation over time (0.7-2.0 CT/100 ED visits/year, p<0.0005), but the intervention itself did not contribute to an overall increase in CT utilisation. In conclusion, our intervention led to improved perceived workflow efficiency and reduced pages. Scans were protocoled more quickly on weekdays, but turnaround times were otherwise not significantly affected by the intervention. Background CT utilisation increased over time, but this increase was not attributable to our intervention.

Improving asthma care with Asthma-COPD Afterhours Respiratory Nurse at Emergency (A-CARE).

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.

General phenomenon and communication experience of physician and nurse in night shift communication: A qualitative study.

AIM: This paper explored the general phenomenon and psychological experience of the special background communication in night shift medical staff and provides better reference for night shift communication between doctors and nurses. BACKGROUND: Physician-nurse communication has always been an important agenda for health care work and an important concept in nursing theory. During night shifts, effective doctor and nurse communication can enhance mutual trust, provide timely and appropriate medical services to patients, reduce adverse events and enhance patient safety. DESIGN: A qualitative study was conducted. METHODS: Husserl's descriptive phenomenology method and semi-structured in-depth interviews were used to collect data from 8 nurses and 5 doctors. Colaizzi's method was used to analyse data using MAXQDA 12. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was followed (see Appendix S1). RESULTS: Three themes were extracted after sorting out and refining: the need to achieve goals in night-time physician-nurse communication; obstacles in night-time physician-nurse communication; and relationship culture in night-time physician-nurse communication. CONCLUSION: Attention should be paid to the particularity of night shift and efficiency of achieving the goal of communication between doctors and nurses on night shift, and the hidden obstacles behind communication between doctors and nurses. Managers should pay attention to the cultural construction of night shift communication in the system, form a good night shift communication process and regularly train doctors' and nurses' related communication skills. And they should also study relationship culture rationally to improve the communication efficiency of night shift. IMPLICATIONS FOR NURSING MANAGEMENT: The experiences described in this study contribute to a better understanding of obstacles hidden behind night shift physician-nurse communication. This also provides valuable information to professional managers who develop good doctor-nurse relationship culture.

Night Admission at a Psychosocial Care Center III.

OBJECTIVE: to analyze night admission characteristics at a Psychosocial Care Center III (CAPS III - Centro de Atenção Psicossocial). METHOD: a qualitative research, whose data were collected with 15 nursing professionals from November to April 2016, through a semi-structured interview. RESULTS: it was verified that night admission is provided by the nursing team in different dynamics from the day care. This team has strategies of care during crisis, avoiding search for other network services and maintaining the CAPS in its function within the psychosocial model. FINAL CONSIDERATIONS: service operation depends on the nursing team for its permanence condition in all shifts, which leads to the need to think about the legislation reformulation that structures the CAPS III team, in order to guarantee the interdisciplinary care provided by the Brazilian Psychiatric Reform in this device, which should replace hospitalization in a specialized institution.

Point-of-care blood tests during home visits by out-of-hours primary care clinicians; a mixed methods evaluation of a service improvement.

OBJECTIVES: We aimed to evaluate test usage and patient and clinician experience following the introduction of point-of-care (POC) blood tests into a primary care out-of-hours service. DESIGN: A mixed methods service evaluation comprising quantitative records of the clinical contexts of tests taken and qualitative interviews with clinicians. Research permissions and governance were obtained for patient interviews. SETTING: Out-of-hours primary care. PARTICIPANTS: All patients requiring home visits from the service during the implementation period. INTERVENTIONS: The i-STAT POC blood test platform was introduced to two bases providing home visits for a period of 8 months. Venous blood samples were used and two cartridges were available. The CHEM8 cartridge measures sodium, potassium, chloride, total carbon dioxide (TCO2), anion gap, ionised calcium, glucose, urea, creatinine, haematocrit and haemoglobin. The CG4 cartridge measures lactate, pH, PaO2 and PCO2, TCO2, bicarbonate, base excess and oxygen saturation. PRIMARY AND SECONDARY OUTCOME MEASURES: The proportion of home visits where tests were taken, the clinical contexts of those tests, the extent to which clinicians felt the tests had influenced their decisions, time taken to perform the test and problems encountered. Clinician and patient experiences of using POC tests. RESULTS: i-STAT POC tests were infrequently used, with successful tests taken at just 47 contacts over 8 months of implementation. The patients interviewed felt that testing had been beneficial for their care. Clinician interviews suggested barriers to POC tests, including practical challenges, concerns about time, doubt over whether they would improve clinical decision making and concern about increased medicolegal risk. Suggestions for improving adoption included sharing learning, adopting a whole team approach and developing protocols for usage. CONCLUSIONS: POC tests were not successfully adopted by an out-of-hours home visiting service in Oxfordshire. While some clinicians felt they could not add value, in other cases they resulted in improved patient experience. Adoption could be promoted by improving technical, team and education factors.

Tinkering and overruling the computer decision support system: Working strategies of telephone triage nurses who assess the urgency of callers suspected of having an acute cardiac event.

AIMS AND OBJECTIVES: To understand clinical reasoning and decision-making of triage nurses during telephone conversations with callers suspected of having acute cardiac events, and support from a computer decision support system (CDSS) herewith. BACKGROUND: In telephone triage, nurses assess the urgency of callers' conditions with clinical reasoning, often supported by CDSS. The use of CDSS may trigger interactional workability dilemmas. DESIGN: Qualitative study using principles of a grounded theory approach following COREQ criteria for qualitative research. METHODS: Audio-stimulated recall interviews were conducted amongst twenty-four telephone triage nurses at nine out-of-hours primary care centres (OHS-PC). RESULTS: Telephone triage nurses use clinical reasoning elements for urgency assessment. Typically in telephone triage, they interpret the vocal-but not worded-elements in communication (paralanguage) such as tone of voice and shortness of breath and create a mental image to compensate for lack of visual information. We confirmed that interactional workability dilemmas occur. Congruence, established when the CDSS supports the triage nurses' decision-making, is essential for the CDSS' value. If congruence is absent, triage nurses may apply four working strategies: (a) tinker to make CDSS final recommendation align with their own assessment, (b) overrule the CDSS recommendation, (c) comply with the CDSS recommendation or (d) transfer responsibility to the GP. CONCLUSION: Triage nurses who assess urgency may experience absence of congruence between the CDSS and their decision-making. Awareness of how triage nurses reason and make decisions about urgency and what aspects influence their working strategies can help in achieving optimal triage of callers suspected of acute cardiac events at OHS-PC. RELEVANCE TO CLINICAL PRACTICE: Triage nurses' reasoning and their working strategies are vital for outcome of triage decisions. Understanding these processes is essential for CDSS developers and OHS-PC managers, who should value how triage nurses interact with the CDSS, while they have the benefit of callers in mind.