The effectiveness of out-of-hours palliative care telephone advice lines: A rapid systematic review.

BACKGROUND: People with palliative care needs and their carers often rely on out-of-hours services to remain at home. Policymakers have recommended implementing telephone advice lines to ensure 24/7 access to support. However, the impact of these services on patient and carer outcomes, as well as the health care system, remains poorly understood. AIM: To evaluate the clinical- and cost-effectiveness of out-of-hours palliative care telephone advice lines, and to identify service characteristics associated with effectiveness. DESIGN: Rapid systematic review (PROSPERO ID: CRD42023400370) with narrative synthesis. DATA SOURCES: Three databases (Medline, EMBASE and CINAHL) were searched in February 2023 for studies of any design reporting on telephone advice lines with at least partial out-of-hours availability. Study quality was assessed using the Mixed Methods Appraisal Tool, and quantitative and qualitative data were synthesised narratively. RESULTS: Twenty-one studies, published 2000-2022, were included. Most studies were observational, none were experimental. While some evidence suggested that telephone advice lines offer guidance and reassurance, supporting care at home and potentially reducing avoidable emergency care use in the last months of life, variability in reporting and poor methodological quality across studies limit our understanding of patient/carer and health care system outcomes. CONCLUSION: Despite their increasing use, evidence for the clinical- and cost-effectiveness of palliative care telephone advice lines remains limited, primarily due to the lack of robust comparative studies. There is a need for more rigorous evaluations incorporating experimental or quasi-experimental methods and longer follow-up, and standardised reporting of telephone advice line models and outcomes, to guide policy and practice.

Identifying key items to be addressed by non-clinical operators to manage out-of-hours telephone triage services for older adults seeking non-urgent unplanned care in Belgium: an e-Delphi study.

BACKGROUND: This study aimed to achieve expert consensus regarding key items to be addressed by non-clinical operators using computer-software integrated medical dispatch protocols to manage out-of-hours telephone triage (OOH-TT) services for calls involving older adults seeking non-urgent unplanned care across Belgium. METHODS: A three-part classic e-Delphi study was conducted. A purposive sample of experts specialized in out-of-hours unplanned care and/or older persons across Belgium were recruited as panelists. Eligibility criteria included experts with at least 2 years of relevant experience. Level of consensus was defined to be reached when at least 70% of the panelists agreed or disagreed regarding the value of each item proposed within a survey for the top 10 most frequently used protocols for triaging older adults. Responses were analyzed over several rounds until expert consensus was found. Descriptive and thematic analyses were used to aggregate responses. RESULTS: N = 12 panelists agreed that several important missing protocol topics were not covered by the existing OOH-TT service. They also agreed about the nature of use (for the top 10 most frequently used protocols) but justified that some modifications should be made to keywords, interrogation questions, degree of urgency and/or flowcharts used for the algorithms to help operators gain better comprehensive understanding patient profiles, medical habits and history, level of support from informal caregivers, known comorbidities and frailty status. Furthermore, panelists also stressed the importance of considering feasibility in implementing protocols within the real-world setting and prioritizing the right type of training for operators which can facilitate the delivery of high-quality triage. Overall, consensus was found for nine of the top 10 most frequently used protocols for triaging older adults with no consensus found for the protocol on triaging patients unwell for no apparent reason. CONCLUSION: Our findings show that overall, a combination of patient related factors must be addressed to provide high quality triage for adults seeking non-urgent unplanned care over the telephone (in addition to age). However, further elements such as appropriate operator training and feasibility of implementing more population-specific protocols must also be considered. This study presents a useful step towards identifying key items which must be targeted within the larger scope of providing non-urgent out-of-hours telephone triage services for older adults seeking non-urgent unplanned care.

The impact on primary care of a large waterborne campylobacter outbreak in Norway: a controlled observational study.

OBJECTIVE: Document the impact of an outbreak of gastroenteritis on local primary health care services, compared to a control period. DESIGN: Controlled observational study with data from the outbreak and a control period. Data obtained from electronic medical records (EMR) of general practitioners (GPs) and the out-of-hours (OOH) service. Telephone data from the OOH service's telephone records. SETTING: Campylobacteriosis outbreak in Askøy municipality, Norway in 2019. Over 2000 individuals were infected. SUBJECTS: Patients in contact with GPs and the OOH service during the outbreak and a control period. MAIN OUTCOME MEASURES: Patient contacts with GPs and the OOH service during the outbreak and a control period. RESULTS: There was a 36% increase in contacts during the outbreak compared to the control period (4798 vs. 3528), with the OOH service handling 78% of outbreak-related contacts. Telephone advice was the dominant method for managing the increase in contacts to primary care, both in OOH services and daytime general practice (OR 3.73 CI: [3.24-4.28]). Children aged 0-4 years had increased use of primary care during the outbreak (OR 1.51 CI: [1.28-1.78]). GPs referred 25% and OOH services referred 75% of 70 hospitalized cases. CONCLUSION: The OOH service handled most of the patients during the outbreak, with support from daytime general practice. The outbreak caused a shift towards telephone advice as a means of providing care. Young children significantly increased their use of primary care during the outbreak.

Preparing clinicians for practice: effectiveness and design of on-call simulation.

BACKGROUND: Final year medical students and postgraduate doctors regularly contend with feelings of under-preparedness when transitioning into new areas of clinical practice. This lack of confidence is most evident in the context of on-call work which frequently requires sound clinical prioritisation, rigorous decision making and the management of acutely unwell patients, often with reduced senior support and staffing. This has prompted the emergence of on-call simulation which seeks to enhance participant confidence in performing on-call tasks and facilitate the development of key clinical and non-technical skills. This narrative review examined the use of on-call simulation in medical student and newly qualified doctor cohorts, its effectiveness in achieving its stated outcomes and to identify novel areas for the development of existing models. METHOD: A search strategy was developed in conjunction with a specialist medical librarian. OVID Medline and Embase searches identified articles related to the use and design of on-call simulation in medical education with no restrictions placed upon date or language of publication. Key findings from articles were summarised to develop comprehensive themes for discussion. RESULTS: Twenty Three unique publications were reviewed which unanimously reported that on-call simulation had a positive effect on self-reported participant confidence in performing on-call roles. Furthermore the value on-call simulation when used as an induction activity was also evident. However, there was limited evidence around improved patient and performance outcomes following simulation. It also remains resource intensive as an educational tool and there is a distinct absence of interprofessional education in current models. CONCLUSIONS: We concluded that on-call simulation must adopt an interprofessional educational approach, incorporating other clinical roles. Further studies are needed to characterise the impact on patient outcomes. It remains highly useful as a confidence-boosting induction activity, particularly in specialities where clinical exposure is limited. Virtual and tabletop simulation formats, could potentially address the resource burden of manikin-based models, particularly with ever growing demands on medical educators and the expansion of training posts.

Traumatic dental injuries among children attending the public after-hours emergency dental clinic in Bergen, Norway.

OBJECTIVES: To investigate traumatic dental injuries (TDIs) among children who for 1 year attended a Norwegian public after-hours emergency public dental (EPD) clinic. MATERIALS AND METHODS: The study included 7-18-year-olds (n = 312) who presented at the EPD clinic, underwent a clinical dental examination, and consented to the disclosure of clinical information. Recording of TDIs was restricted to anterior permanent teeth. Potential TDI predictors were also analysed. RESULTS: Almost half (n = 148) of the children were assessed with TDIs in permanent teeth, showing a mean age of 11.0 (standard deviation [SD]: 3.5) years. Males constituted 54.7%. The children experienced TDIs often outside school hours (43.9%), and the majority (58.1%) were caused by falls/accidents. Sixty of them experienced only one TDI. The most common location was the maxillary central incisors. Assessment of TDIs according to severity, could only be done in 131 individuals, involving 253 TDIs. Of these, 81.8% were mild. The odds of visiting the emergency clinic for a TDI were higher (odds ratio [OR] = 2.64, confidence interval [CI]: 1.61-4.31) among children with previous TDIs and lower (OR = 0.28, CI: 0.12-0.68) among those with poor dental attendance. CONCLUSIONS: Traumatic dental injuries were a common reason for seeking emergency care. Milder injuries dominated and involved mostly one maxillary central incisor. Previous episodes of TDIs and attendance patterns seemed to be associated with seeking care for TDIs.

Weekend / holiday effect on stroke mortality in regional Australia: A ten-year retrospective study.

BACKGROUND: There is a deficiency in the evidence from rural and regional centres in Australia on the weekend effect following presentation with acute stroke. OBJECTIVE: To estimate the association between admission over a weekend/holiday and all-cause mortality 3-day, 7-day, 14-day, 1-month, 3-month, 6-month, and 12-month following acute stroke. METHODS: The records of stroke patients admitted to a main regional hospital in Australia from 2010 to 2020 were linked with the National Death Index. Time to death following ischaemic, haemorrhagic, and total stroke at different time points was modelled using Weibull, Exponential, or Gompertz regression based on best model fit determined by Akaike's information criterion. RESULTS: Of 1669 patients, 1273 (76.3%) were admitted on a weekday, and 396 (23.7%) on a weekend/ or holiday. After adjusting for age, sex, and Charlson Comorbidity Index, stroke type and country of birth, admissions over a weekend/holiday following total stroke were significantly associated with an increased risk of dying within three days from admission [hazard ratio (HR): 1.59, 95% confidence interval: 1.01-2.50]. In haemorrhagic stroke, increased risk of death was significantly higher at three days (HR: 2.19, 95% confidence interval: 1.17-4.08), 14 days (HR: 1.73, 95% confidence interval: 1.02-2.93), and 1 month (HR: 1.82, 95% confidence interval: 1.09-3.03) following admission on the weekend/ or holiday compared to those admitted during the weekdays. CONCLUSIONS: This study reports a short-term adverse weekend/holiday effect following admission for haemorrhagic stroke or total stroke. No significant weekend/holiday effect was found in ischaemic stroke.

Trainee ANPs' experiences of having a clinical practice facilitator introduced into a Hospital at Night team.

BACKGROUND: The role of the advanced nurse practitioner (ANP) within Hospital at Night (H@N) teams has emerged in line with the demands of the service and the needs of patients in the out-of-hours period. The majority of ANPs with H@N teams are recruited as trainees. There is a high volume of trainees needing support against a low number of experienced ANPs. Introduction of the clinical practice facilitator (CPF) role is one way of addressing these issues. Within this evaluative study of one H@N service, the CPFs are experienced ANPs who have received additional training in the delivery of practice assessment and learner feedback. AIM: To explore the experiences and perceptions of those trainee ANPs who have had or are currently receiving support and supervision from the CPFs in an H@N service in one Scottish NHS health board. METHOD: The CPFs undertook a service evaluation following introduction of the role. Purposive sampling was undertaken whereby a descriptive questionnaire was sent to 22 eligible participants. RESULTS: 16 questionnaires were returned. Qualitative data from the questionnaire generated several themes from the participants' responses: validation of competencies, supporting wellbeing, accessibility of support, designated prescribing practitioner role and support post-qualification. CONCLUSIONS: CPFs are ideally placed to meet the required needs of trainees. Organisational commitment is key to ensuring ANPs are in optimal positions to provide support and supervision for the next generation of trainees.

Acute Gastroenteritis: A Qualitative Study of Parental Motivations, Expectations, and Experiences During Out-of-Hours Primary Care.

PURPOSE: Acute gastroenteritis is a common infectious disease in children younger than 6 years of age. Although it is a self-limiting disease, it nevertheless has a high consultation rate in primary care, especially during out-of-hours primary care (OOH-PC). Reasons for this high consultation rate remain unclear. METHODS: The aim of this qualitative study was to explore parental motivations, expectations, and experiences of OOH-PC contacts for children with acute gastroenteritis. We conducted 14 semistructured interviews with parents who contacted OOH-PC in the Netherlands. Interviews were audio-recorded, transcribed, and analyzed using elements of grounded theory and a constant-comparison approach. RESULTS: Unusual behavior of the sick child, absent micturition, and ongoing vomiting and/or diarrhea, with decreased or no fluid intake, motivated parents to contact OOH-PC. Parents initiated contact to prevent symptom deterioration and to be reassured by a general practitioner (GP), expecting them to perform a thorough physical examination, provide information, and make follow-up plans. Parents reported dissatisfaction if they felt unheard, misunderstood, or not taken seriously, and this increased their likelihood of seeking another consultation. General practitioners did not always meet parental expectations. CONCLUSION: Multiple factors affect the decision for parents to contact OOH-PC for their child with gastroenteritis. There is a mismatch between parental expectations and actions of the GP. Awareness regarding parental feelings and understanding their expectations can guide GPs in the interaction with parents, which could improve satisfaction with primary health care and OOH-PC specifically.

Emergency out-of-hours catheter ablation for ventricular arrhythmia storm: a UK and Australian experience.

AIMS: There are limited data on emergency catheter ablation (CA) for ventricular arrhythmia (VA) storm. We describe the feasibility and safety of performing emergency CA in an out-of-hours setting for VA storm refractory to medical therapy at 2 tertiary hospitals. METHODS AND RESULTS: Twenty-five consecutive patients underwent out-of-hours (5pm-8am [weekday] or Friday 5pm-Monday 8am [weekend]) CA for VA storm refractory to anti-arrhythmic drugs and sedation. Baseline and procedural characteristics along with outcomes were compared to 91 consecutive patients undergoing weekday daytime-hours (8am-5pm) CA for VA storm. More patients undergoing out-of-hours CA had a left ventricular ejection fraction ≤35% (68% vs. 42%, P = 0.022), chronic kidney disease (60% vs. 20%, P < 0.001), and presented following a resuscitated out-of-hospital cardiac arrest (56% vs. 5%, P < 0.001), compared to the daytime-hours group. During median follow-up (377 [interquartile range 138-826] days), both groups experienced similar survival free from recurrent VA and VA storm. Survival free from cardiac transplant and/or mortality was lower in the out-of-hours group (44% vs. 81%, P = 0.007), but out-of-hours CA was not independently associated with increased cardiac transplant and/or mortality (hazard ratio 1.34, 95% confidence interval 0.61-2.96, P = 0.47). Of the 11 patients in the out-of-hours group who survived follow-up, VA-free survival was 91% and VA storm-free survival was 100% at 1-year after CA. CONCLUSION: Out-of-hours CA may occasionally be required to control VA storm and can be safe and efficacious in this scenario. During follow-up, cardiac transplant and/or mortality is common but undergoing out-of-hours CA was not predictive of this composite endpoint.

Co-designing Community Out-of-hours Palliative Care Services: A systematic literature search and review.

BACKGROUND: In order to provide responsive, individualised and personalised care, there is now greater engagement with patients, families and carers in designing health services. Out-of-hours care is an essential component of community palliative care. However, little is known about how patients, families and carers have been involved in the planning and design of these services. AIM: To systematically search and review the research literature that reports on how out-of-hours palliative care services are provided in the community and to identify the extent to which the principles of co-design have been used to inform the planning and design of these services. DESIGN: Systematic literature search and review. DATA SOURCES: A systematic search for published research papers from seven databases was conducted in MEDLINE, PsycINFO, Embase, Emcare, PubMed, CINAHL and Web of Science, from January 2010 and December 2021. Reference list searches of included papers were undertaken to source additional relevant literature. A manifest content analysis was used to analyse the data. RESULTS: A total of 77 papers were included. The majority of out-of-hours services in the community were provided by primary care services. The review found little evidence that patients, families or carers were involved in the planning or development of out-of-hours services. CONCLUSION: Incorporating patients, families and carers priorities and preferences in the planning and designing of out-of-hours palliative care service is needed for service providers to deliver care that is more patient-centred. Adopting the principles of co-design may improve how out-of-hours care scan be delivered.

How is community based 'out-of-hours' care provided to patients with advanced illness near the end of life: A systematic review of care provision.

BACKGROUND: Deaths in the community are increasing. However, community palliative care out-of-hours is variable. We lack detailed understanding of how care is provided out-of-hours and the associated outcomes. AIM: To review systematically the components, outcomes and economic evaluation of community-based 'out-of-hours' care for patients near the end of life and their families. DESIGN: Mixed method systematic narrative review. Narrative synthesis, development and application of a typology to categorise out-of-hours provision. Qualitative data were synthesised thematically and integrated at the level of interpretation and reporting. DATA SOURCES: Systematic review searching; MEDLINE, EMBASE, PsycINFO, CINAHL from January 1990 to 1st August 2022. RESULTS: About 64 publications from 54 studies were synthesised (from 9259 retrieved). Two main themes were identified: (1) importance of being known to a service and (2) high-quality coordination of care. A typology of out-of-hours service provision was constructed using three overarching dimensions (service times, focus of team delivering the care and type of care delivered) resulting in 15 categories of care. Only nine papers were randomised control trials or controlled cohorts reporting outcomes. Evidence on effectiveness was apparent for providing 24/7 specialist palliative care with both hands-on clinical care and advisory care. Only nine publications reported economic evaluation. CONCLUSIONS: The typological framework allows models of out-of-hours care to be systematically defined and compared. We highlight the models of out-of-hours care which are linked with improvement of patient outcomes. There is a need for effectiveness and cost effectiveness studies which define and categorise out-of-hours care to allow thorough evaluation of services.

The impact of variation in out-of-hours doctors' referral practices: a Norwegian registry-based observational study.

BACKGROUND: In a gatekeeping system, the individual doctor's referral practice is an important factor for hospital activity and patient safety. OBJECTIVE: The aim of the study was to investigate the variation in out-of-hours (OOH) doctors' referral practice, and to explore these variations' impact on admissions for selected diagnoses reflecting severity, and 30-day mortality. METHODS: National data from the doctors' claims database were linked with hospital data in the Norwegian Patient Registry. Based on the doctor's individual referral rate adjusted for local organizational factors, the doctors were sorted into quartiles of low-, medium-low-, medium-high-, and high-referral practice. The relative risk (RR) for all referrals and for selected discharge diagnoses was calculated using generalized linear models. RESULTS: The OOH doctors' mean referral rate was 110 referrals per 1,000 consultations. Patients seeing a doctor in the highest referring practice quartile had higher likelihood of being referred to hospital and diagnosed with the symptom of pain in throat and chest, abdominal pain, and dizziness compared with the medium-low quartile (RR 1.63, 1.49, and 1.95). For the critical conditions of acute myocardial infarction, acute appendicitis, pulmonary embolism, and stroke, we found a similar, but weaker, association (RR 1.38, 1.32, 1.24, and 1.19). The 30-day mortality among patients not referred did not differ between the quartiles. CONCLUSIONS: Doctors with high-referral practice referred more patients who were later discharged with all types of diagnoses, including serious and critical conditions. With low-referral practice, severe conditions might have been overlooked, although the 30-day mortality was not affected.

A major task for primary care doctors working out-of-hours (OOH) is to refer patients in need of acute specialized care to hospital. Acute referrals capture the major dilemma of not missing critically ill patients without overloading the hospital capacity. There is a known variation in referral practice between OOH doctors, and here we asked what impact this variation has for OOH patients. We divided OOH doctors in Norway into 4 groups according to their referral practice low, medium-low, medium-high, and high. Low had few referrals as a proportion of the total consultations, while the high group had many. If the patient saw a doctor in the high-referral group, there was an increased likelihood to be referred to hospital and given a symptom diagnosis, indicating that no severe disease was revealed. High-referral practice therefore may lead to more avoidable admissions. However, we also found the same but weaker effect for some critical conditions (heart infarction, acute appendicitis, pulmonary embolism, and stroke). Therefore, a low-referral practice may increase the risk of critical conditions being overlooked. These aspects of referral practice variation should be taken into consideration and call for strengthening the OOH framework for decision making regarding acute referrals.

Evaluation of telephone triage among chest pain patients in out-of-hours primary care in the Netherlands (TRACE).

BACKGROUND: Telephone triage is fully integrated in Dutch out-of-hours primary care (OOH-PC). Patients presenting with chest pain are initially assessed according to a standardized protocol ("Netherlands Triage Standard" [NTS]). Nevertheless, little is known about its (diagnostic) performance, nor on the impact of subsequent clinical judgements made by triage assistants and general practitioners (GPs). OBJECTIVE: To evaluate the performance of the current NTS chest pain protocol. METHODS: Observational, retrospective cohort study of adult patients with chest pain who contacted a regional OOH-PC facility in the Netherlands, in 2017. The clinical outcome measure involved the occurrence of a "major event," which is a composite of all-cause mortality and urgent cardiovascular and noncardiovascular conditions, occurring ≤6 weeks of initial contact. We assessed the performance using diagnostic and discriminatory properties. RESULTS: In total, 1,803 patients were included, median age was 54.0 and 57.5% were female. Major events occurred in 16.2% of patients with complete follow-up, including 99 (6.7%) cases of acute coronary syndrome and 22 (1.5%) fatal events. NTS urgency assessment showed moderate discriminatory abilities for predicting major events (c-statistic 0.66). Overall, NTS performance showed a sensitivity and specificity of 83.0% and 42.4% with a 17.0% underestimated major event rate. Triage assistants' revisions hardly improved urgency allocation. Further consideration of the clinical course following OOH-PC contact did generate a more pronounced improvement with a sensitivity of 89.4% and specificity of 61.9%. CONCLUSION: Performance of telephone triage of chest pain appears moderate at best, with acceptable safety yet limited efficiency, even after including further work-up by GPs.

Effect of an educational intervention for telephone triage nurses on out-of-hours attendance: a pragmatic randomized controlled study.

BACKGROUND: Telephone triage has been established in many countries as a response to the challenge of non-urgent use of out-of-hours primary care services. However, limited evidence is available regarding the effect of training interventions on clinicians' telephone consultation skills and patient outcomes. METHODS: This was a pragmatic randomized controlled educational intervention for telephone triage nurses in 59 Norwegian out-of-hours general practitioners' (GPs) cooperatives, serving 59% of the Norwegian population. Computer-generated randomization was performed at the level of out-of-hours GP cooperatives, stratified by the population size. Thirty-two out-of-hours GP cooperatives were randomized to intervention. One cooperative did not accept the invitation to participate in the educational programme, leaving 31 cooperatives in the intervention group. The intervention comprised a 90-minute e-learning course and 90-minute group discussion about respiratory tract infections (RTIs), telephone communication skills and local practices. We aimed to assess the effect of the intervention on out-of-hours attendance and describe the distribution of RTIs between out-of-hours GP cooperatives and list-holding GPs. The outcome was the difference in the number of doctor's consultations per 1000 inhabitants between the intervention and control groups during the winter months before and after the intervention. A negative binomial regression model was used for the statistical analyses. The model was adjusted for the number of nurses who had participated in the e-learning course, the population size and patients' age groups, with the out-of-hours GP cooperatives defined as clusters. RESULTS: The regression showed that the intervention did not change the number of consultations for RTIs between the two groups of out-of-hours GP cooperatives (incidence rate ratio 0.99, 95% confidence interval 0.91-1.07). The winter season's out-of-hours patient population was younger and had a higher proportion of RTIs than the patient population in the list-holding GP offices. Laryngitis, sore throat, and pneumonia were the most common diagnoses during the out-of-hours primary care service. CONCLUSIONS: The intervention did not influence the out-of-hours attendance. This finding may be due to the intervention's limited scope and the intention-to-treat design. Changing a population's out-of-hours attendance is complicated and needs to be targeted at several organizational levels.

Pandemic preparedness and management in European out-of-hours primary care services - a descriptive study.

BACKGROUND: Primary care is the first point of contact for all acute health problems. As such, primary care was at the frontline in the COVID-19 pandemic, playing a significant role in clinical responses and information to the public. This study aimed to describe the variations in patient management strategies used in the out-of-hours services in different European countries during the first phase of the pandemic. METHOD: We conducted a cross-sectional web-based survey in August 2020, selecting key informants from European countries using European networks. The questionnaire was developed in collaboration with researchers in the field of out-of-hours primary care. We performed descriptive analyses per region, structuring results into themes. RESULTS: Key informants from 38 regions in 20 European countries responded. Seven regions reported that their out-of-hours services had a pandemic preparedness plan, three had trained on the plan, and two had stockpiles of personal protection equipment before the outbreak. Extension of telephone triage lines and establishment of local infection-control teams and clinics were the main patient management strategies. Other strategies for patient contacts were also used in the regions, such as video-consultations (13 regions), electronic consultations (21 regions), patient's car as alternative waiting room (19 regions), outside tents for testing (24 regions), "drive-through" testing (26 regions), and separate departments for infected patients (14 regions). CONCLUSION: Few out-of-hours services were well prepared for a pandemic, but all expanded and reorganized rapidly, adopting new strategies for patient management and treatment. The results could be useful for planning of organization preparedness of out-of-hours primary care service for future pandemics.

The association between municipal pandemic response and COVID-19 contacts to emergency primary health care services: an observational study.

BACKGROUND: Norwegian municipalities had diverse strategies for handling tasks related to the COVID-19 pandemic. The emergency primary health care services were involved to different extents. The aim of this study was to describe how contacts with the emergency primary health care service were affected by the pandemic, in terms of patient contacts related to COVID-19, prioritisation and first actions taken, and to analyse differences between the services. METHODS: In this observational study, patient contacts to seven emergency primary health care services, from January 2020 to June 2021, were analysed. Descriptive analyses were applied. Data on the seven services' involvement in the municipal pandemic response, in relation to testing the inhabitants for COVID-19, were collected. RESULTS: There were 145 685 registered patient contacts within the study period. In total, 24% (n = 35,563) of the contacts were related to COVID-19, varying from 16 to 40% between the seven services. Of the COVID-19 related contacts, 96% (n = 34,069) were triaged to the lowest urgency level (range 76-99%) and 66% (n = 23,519) were patients contacting the services in order to be tested for COVID-19 (range 5-88%). The number of COVID-19 related contacts were unrelated to the number of confirmed COVID-19 cases among the inhabitants of the respective municipalities. The burden of COVID-19-related contacts mainly reflected the services' involvement in COVID-19 testing as part of the municipal pandemic response. CONCLUSIONS: During the COVID-19 pandemic, several of the emergency primary health care services were assigned new tasks, such as being part of the municipalities' system for carrying out testing for COVID-19. This had a major impact on their activity level. In the preparation for future pandemics, it should be discussed to which extent such use of the emergency primary health care system is appropriate, as additional tasks might affect the services' preparedness to provide urgent medical care among the inhabitants.

Development over time in point-of-care test use in Danish daytime and out-of-hours general practice: a register-based study.

OBJECTIVE: To describe the development over time of the use of C-reactive protein (CRP) and rapid streptococcal detection test (RADT) point-of-care tests (POCT) in Danish general practice and to explore associations between patient characteristics and POCT use (i.e. CRP and RADT). DESIGN AND SETTINGS: A register-based study including all general practice clinic consultations in daytime and out-of-hours (OOH) settings in Denmark between 2003 and 2018. SUBJECTS: All citizens who had at least one clinic consultation in daytime or OOH general practice within the study period. MAIN OUTCOME MEASURES: We estimated the total and relative use of CRP and RADT POCTs and described the development over time. Crude and adjusted proportion ratios (PRs) were calculated to explore associations between patient characteristics and POCT use. RESULTS: Overall, the relative use of CRP POCTs increased. At OOH, a steep increase was noticed around 2012. The relative use of RADT decreased. Patient age 40-59 years and existing comorbidity were significantly associated with a higher use of CRP testing in both settings. A significantly lower use of CRP testing was found for patients with higher educational level. We found a significantly higher use of RADT testing for patients aged 0-19 years and with higher household educational level, whereas comorbidity was associated with a lower use of RADT testing. CONCLUSION: The use of CRP POCT increased over time, whereas the use of RADT POCT decreased. Perhaps the success of implementing CRP as a tool for reducing antibiotic use has reached it limit. Future studies should focus on how and when POCT are used most optimal.Key pointsCRP POC tests and RADT POCTs are frequently used diagnostic tools in general practice, both in daytime and in the out-of-hours setting.There was an increased use of CRP POCTs, particularly in out-of-hours general practice, whereas the use of RADT POCTs declined between 2003 and 2018.CRP POCTs were associated with age of 40-59 years and co-morbidity, while the use of RADT was mostly associated with younger age.

Out-of-hours versus in-hours delivery of antenatally diagnosed transposition of the great arteries: outcomes from a United Kingdom Tertiary Centre.

OBJECTIVE: To study the impact of out-of-hours delivery on outcome for neonates with antenatally diagnosed transposition of the great arteries. SETTING: Tertiary paediatric cardiology centre (Yorkshire, United Kingdom), with co-located tertiary neonatal unit. PATIENTS: Neonates with antenatally diagnosed simple transposition of the great arteries delivered out-of-hours (Monday to Friday 17:00-08:00 and weekends) versus in-hours between 2015 and 2020. OUTCOME: The primary outcome was survival to hospital discharge. Secondary outcomes included neurological morbidity, length of stay, and time to balloon atrial septostomy. RESULTS: Of 51 neonates, 38 (75%) were delivered out-of-hours. All neonates born in the tertiary centre survived to discharge. Time to balloon atrial septostomy was slightly longer for out-of-hours deliveries compared to in-hours (median 130 versus 93 mins, p = 0.33). Neurological morbidity occurred for nine (24%) patients in the out-of-hours group and one (8%) in-hours (OR 3.72, 95% CI: 0.42-32.71, p = 0.24). Length of stay was also similar (18.5 versus 17.3 days, p = 0.59). Antenatal diagnosis of a restrictive atrial septum was associated with a lower initial pH (7.03 versus 7.13; CI: 0.03-0.17, p = 0.01), longer length of stay (22.6 versus 17.3 days; CI: 0.37-10.17, p = 0.04), and increased neurological morbidity (44% versus 14%; OR 4.80, CI 1.00-23.15, p = 0.05). A further three neonates were delivered in surrounding hospitals, with a mortality of 67% (versus 0 in tertiary centre; OR 172, CI 5-5371, p = 0.003). CONCLUSION: Neonates with antenatally diagnosed transposition of the great arteries have similar outcomes when delivered out-of-hours versus in-hours. Antenatal diagnosis of restrictive atrial septum is a significant predictor of worse outcomes. In our region, delivery outside the tertiary cardiac centre had a significantly higher risk of mortality.

[Advance Directives and Palliative Medical Care in Nursing Homes: A Study on Everyday Life and Relevance in Out-of-Hours Medical Care]. / Patientenverfügungen und palliative ärztliche Versorgung in Pflegeheimen ­ Studie zu Alltag und Relevanz außerhalb regulärer Praxiszeiten.

BACKGROUND: The percentage of nursing home residents that have documented advance directives (AD) is increasing. However, there are no studies concerning the consideration of these directives within the out-of-hours primary care or the emergency service. There is also a lack of information on the differences in the attitudes of doctors on duty in various disciplines towards therapeutic options in palliative situations. METHODS: In the context of research about the medical care of nursing home residents outside regular practice hours, the existence of AD and their consideration by the doctors on duty or emergency doctors was investigated (n=101). Furthermore, the attitudes of the doctors on duty (n=60) and of a reference group of palliative doctors (n=19) towards experience in palliative medicine, asking for AD of the patients and the approach in a fictive palliative case were recorded. RESULTS: 71% of the 82 residents had documented a living will. In 54% of the 101 cases, the doctors on duty and emergency doctorsmade enquiries about AD. In 92% of cases, the doctors followed the given directives. Significant differences between doctors on duty and emergency doctors could not be confirmed. Given a fictive palliative case, 92% of the doctors on duty and 95% of the reference group stated they would enquire about an AD. In acute palliative situations, general practitioners, internists and palliative physicians were more likely to use rapid-acting opioids and anxiolytics, were less likely to call the emergency doctor and were less likely to admit patients to hospital. This distinguishes them from other disciplines. CONCLUSIONS: In only 54% of all contacts between patient and doctors on duty or emergency doctors, enquiries were about an AD. That is why doctors need to be further sensitized on the issue of making enquiries about AD from unknown. Additionally, the patient's will should be visible in short form in the respective patient file. Arrangements made with foresight, early involvement of doctors with palliative experience (AAPV, SAPV) as well as increased palliative medical training could improve the care of nursing home residents.

The prevalence and associations of Australian early-career general practitioners' provision of after-hours care.

INTRODUCTION: Access to after-hours care (AHC) is an important aspect of general practice service provision. OBJECTIVE: To establish the prevalence and associations of early-career GPs' provision of AHC. DESIGN: An analysis of data from the New alumni Experiences of Training and independent Unsupervised Practice (NEXT-UP) cross-sectional questionnaire-based study. Participants were early-career GPs (6-month to 2-year post-Fellowship) following the completion of GP vocational training in NSW, the ACT, Victoria or Tasmania. The outcome factor was 'current provision of after-hours care'. Associations of the outcome were established using multivariable logistic regression. FINDINGS: Three hundred and fifty-four early-career GPs participated (response rate 28%). Of these, 322 had responses available for analysis of currently performing AHC. Of these observations, 128 (40%) reported current provision of AHC (55% of rural participants and 32% of urban participants). On multivariable analysis, participants who provided any AHC during training were more likely to be providing AHC (odds ratio (OR) 5.51, [95% confidence interval (CI) 2.80-10.80], p < 0.001). Current rural location and in-training rural experience were strongly associated with currently providing AHC in univariable but not multivariable analysis. DISCUSSION: Early-career GPs who provided AHC during training, compared with those who did not, were more than five times more likely to provide after-hours care in their first 2 years after gaining Fellowship, suggesting participation in AHC during training may have a role in preparing registrars to provide AHC as independent practitioners. CONCLUSION: These findings may inform future GP vocational training policy and practice concerning registrars' provision of AHC during training.