Reliability and validity of the Netherlands Triage Standard in emergency care settings: a case scenario study.

BACKGROUND: The Netherlands Triage Standard (NTS) is a triage system that can be used by different types of emergency care organisations. Our objective was to determine the interrater reliability and construct validity of the NTS when applied to self-presenting patients. METHODS: We performed a cross-sectional case scenario study consisting of two parts: (1) paediatric triage in January-February 2019 and (2) adult triage in October-November 2020. In each part, we invited nurse triagists from three general practitioner cooperatives, three ambulance dispatching centres and three hospital emergency departments in the Netherlands to participate. We used 40 case scenarios involving paediatric patients and 41 involving adult patients who could self-present to any emergency care organisation. In advance, an expert panel determined the urgency (six levels) of the case scenarios (reference standard). The main outcome for reliability was the intraclass correlation coefficient (ICC) for urgency level. The main outcomes for validity were degree of agreement with the reference standard, for urgency level, and sensitivity and specificity for high versus low urgency. We used descriptive statistics and logistic multilevel modelling with both case and triagist as random effects. RESULTS: 218 out of 240 invited triagists participated. The ICC among all triagists was 0.73 for paediatric cases and 0.88 for adult cases and was highest in general practitioner cooperatives. For paediatric cases, there was 62.3% agreement with the reference standard about urgency, 17.4% underestimation and 20.2% overestimation. The sensitivity of the NTS for identifying highly urgent paediatric cases was 85.2%; the specificity was 89.7%. For adult cases, there was 68.3% agreement, 13.7% underestimation and 18.0% overestimation. The sensitivity of triage for high urgency in adults was 94.5% and the specificity 83.3%. CONCLUSION: NTS appears to have good reliability and construct validity for estimating the urgency of health complaints of non-referred patients presenting themselves in emergency care.

[The Netherlands Triage Standard applied to paediatric patients in emergency medicine: is it reliable and valid?] / Toepassing van de Nederlandse Triage Standaard bij kinderen in de spoedzorg.

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.

Out-of-hours primary care in 26 European countries: an overview of organizational models.

BACKGROUND: Various models exist to organize out-of-hours primary care (OOH-PC). We aimed to provide an up-to-date overview of prevailing organizational models in the European Union (EU), implemented changes over the last decade and future plans. This baseline overview may provide information for countries considering remodelling their OOH-PC system. METHODS: A cross-sectional web-based questionnaire among 93 key informants from EU countries, Norway and Switzerland. Key informants with expertise in the field of primary health care were invited to participate. Themes in the questionnaire were the existing organizational models for OOH-PC, model characteristics, major organizational changes implemented in the past decade and future plans. RESULTS: All 26 included countries had different coexisting OOH-PC models, varying from 3 to 10 models per country. 'GP cooperative was the dominant model in most countries followed by primary care centre and rota group'. There was a large variation in characteristics between the models, but also within the models, caused by differences between countries and regions. Almost all countries had implemented changes over the past 10 years, mostly concerning the implementation of telephone triage and a change of organizational model by means of upscaling and centralization of OOH-PC. Planned changes varied from fine-tuning the prevailing OOH-PC system to radical nationwide organizational transitions in OOH-PC. CONCLUSIONS: Different organizational models for OOH-PC exist on international and national level. Compared with a decade ago, more primary care-oriented organizational models are now dominant. There is a trend towards upscaling and centralization; it should be evaluated whether this improves the quality of health care.

Substitution of general practitioners by nurse practitioners in out-of-hours primary care home visits: A quasi-experimental study.

BACKGROUND: General practitioners experience a high workload during out-of-hours care. A possible solution is the shifting of care to nurse practitioners. OBJECTIVES: To provide insight into patient- and care characteristics, safety, efficiency, and patient satisfaction of substituting general practitioners with nurse practitioners for home visits by out-of-hours primary care services. DESIGN: Quasi-experimental non-randomised study comparing home visits by nurse practitioners (intervention group; one out-of-hours care service) with home visits by general practitioners (control group; two out-of-hours care services) for 24 protocolised health problems. SETTING: Three out-of-hours primary care services in the East of the Netherlands. PARTICIPANTS: 1601 patients who received a home visit by a nurse practitioner (N = 386) or a general practitioner (N = 1215). Of these patients, 639 gave informed consent to be included in the protocol adherence assessment and follow-up record review (nurse practitioner: N = 358; general practitioner: N = 281). METHODS: Five nurse practitioners with experience in ambulance care were recruited and trained. From September 2016 to March 2017 the nurse practitioners took over home visits under supervision of a general practitioners. This was evaluated using: (1) data-extraction from the patient registration system, (2) follow-up record review in the patients' general practices, and (3) patient satisfaction survey. Two general practitioners independently assessed protocol adherence based on the extracted registration data. RESULTS: Nurse practitioners prescribed medication significantly less often than general practitioners (19.9% versus 30.6%), and referred patients significantly more often to the hospital (24.1% versus 15.9%). The mean length of the home visit was significantly longer for nurse practitioners (34.1 versus 21.1 min). Nurse practitioners adhered to the protocol significantly more often than general practitioners (84.9% versus 76.2%) and their medication prescribing was significantly more often appropriate (93.7% versus 79.5%). There were no differences in the number of missed diagnoses and complications. The number of follow-up contacts was also similar in both groups. Patient satisfaction was generally high and significantly higher for nurse practitioners on several items. CONCLUSIONS: Nurse practitioners with experience in ambulance care can safely, efficiently, and satisfactorily perform low complex out-of-hours primary care home visits. It is recommended to study the safety and efficiency of nurse practitioners' home visits in other regions and with nurse practitioners with different educational levels and different specialisations. In addition, we recommend to evaluate the cost-effectiveness and if it leads increased quality of care.

Quality of after-hours primary care in The Netherlands: adherence to national guidelines.

OBJECTIVE: To assess the quality of after-hours clinical care as delivered by general practitioner (GP) cooperatives in The Netherlands. METHODS: A cross-sectional analysis was undertaken of patient health records of five GP cooperatives during 1 year. We used quality indicators derived from national guidelines for the appropriate prescription of pain medication and antibiotics, clinical performance in emergency cases and referral to medical specialists. Data were collected from electronic health records. RESULTS: We analysed 7660 patient contacts. Average adherence to the guidelines was 77%. The guidelines on referrals to medical specialists and prescription of pain medication had the highest adherence scores (92% and 90%, respectively). Prescribing antibiotics and treatment in emergency cases had the lowest scores (69% and 71%, respectively). Antibiotics were overprescribed in 42% of the cases and underprescribed in 21%. CONCLUSIONS: In general, GPs adhered well to after-hours service national guidelines. There is room for improvement in care for people with acute illnesses and in the prescription of antibiotics.

Systematic review for the early prediction of motor and functional outcome after stroke by using motor-evoked potentials.

OBJECTIVE: To clarify the prognostic value of motor-evoked potentials (MEPs) in predicting motor and functional outcomes after acute stroke. DATA SOURCES: A computer-aided search to identify original prognostic studies published from 1988 through 2000; relevant references cited in the retrieved articles were also included. STUDY SELECTION: A preliminary screening selected studies in which transcranial magnetic stimulation was assessed as a prognostic determinant for outcome at the level of impairments (motor recovery) and disabilities (functional recovery). The studies were then subjected to a critical review according to a priori methodologic criteria. DATA EXTRACTION: Data from the studies were used to construct contingency tables with MEPs as a prognostic determinant. The distribution of cells was statistically assessed with the Fisher exact test. The prognostic test properties were expressed as sensitivity and specificity. The clinical significance was determined by odds ratios. DATA SYNTHESIS: Of 85 potentially relevant studies, 20 met the criteria for the preliminary screening; after the critical review, 5 studies were included for analysis and discussion. CONCLUSIONS: Analysis of the data from the 5 studies indicated obvious evidence for the prognostic value of MEPs for both motor and functional recovery. The prognostic test properties for subgroups of patients could be established. In predicting motor recovery of the upper extremity, the specificity was consistently very high for subgroups of patients with paralysis or severe paresis; this test property might be used in clinical practice. We discuss the prognostic value of MEPs and offer suggestions for further research.

Spared error-related potentials in mild to moderate Parkinson's disease.

Several lines of evidence indicate that people with Parkinson's disease are impaired at detecting their own motor errors. In the present study, we use a component of the event-related brain potential called the error-related negativity (ERN) to ask whether a high-level, generic error-processing system is compromised in Parkinson's disease. We recorded the electroencephalogram (EEG) from nine patients with mild to moderate Parkinson's disease and from nine normal control subjects while they performed a choice reaction time task. We found that the amplitude of the ERN was the same for both populations, indicating that the error-processing system associated with the ERN is not severely compromised in this Parkinson's disease population. These results are discussed in terms of disease progression.