Outcomes of antibiotic treatment for respiratory infections in children an observational study in primary care.

BACKGROUND: Antibiotic resistance is an increasing global threat, accelerated by both misuse and overuse of antibiotics. Most antibiotics to humans are prescribed in primary care, commonly for respiratory symptoms, and there is a need for research on the usage of and outcomes after antibiotic treatment to counteract antibiotic resistance. OBJECTIVE: To evaluate symptom duration, treatment length, and adverse events of antibiotic treatment in children. DESIGN AND SETTING: Observational study at four out-of-hours services and one paediatric emergency clinic in Norwegian emergency primary care. SUBJECTS: 266 children aged 0 to 6 years with fever or respiratory symptoms. MAIN OUTCOME MEASURES: Duration of symptoms and absenteeism from kindergarten/school, treatment length, and reported adverse events. RESULTS: There were no differences in duration of symptoms, fever or absenteeism when comparing the groups prescribed (30.8%) and not prescribed (69.2%) antibiotics. This lack of difference remained when analysing the subgroup with otitis media.In the group prescribed antibiotics, 84.5% of parents reported giving antibiotics for 5-7 days, and 50.7% reported no difficulties. Adverse events of antibiotics were reported in 42.3% of the cases, the vast majority being gastrointestinal disturbances. CONCLUSION: Children with fever or respiratory symptoms experience similar duration of symptoms and absenteeism regardless of antibiotic treatment. A substantial number of parents reported adverse events when the child received antibiotics. Several parents experienced additional difficulties with the treatment, some ending treatment within day 4. TRIAL REGISTRATION NUMBER: NCT02496559; Results.

Children with fever or respiratory symptoms treated at OOH services experience similar duration of symptoms or absenteeism, regardless of antibiotic treatment.Parents often choose to end antibiotic treatment prematurely due to adverse events, bad taste, or that they find treatment unnecessary.Children often experience adverse events when prescribed antibiotics, mainly gastrointestinal symptoms.

The associations between different types of infections and circadian preference and shift work.

Disturbed sleep and circadian disruption are reported to increase the risk of infections. People with an evening circadian preference and night workers typically report insufficient sleep, and the aims of the present study were to investigate possible associations between various types of infections and circadian preference and shift work status. Data were collected from an online cross-sectional survey of 1023 participants recruited from the Norwegian practice-based research network in general practice - PraksisNett. The participants completed questions about circadian preference (morning type, intermediate type, evening type), work schedule (day work, shift work without nights, shift work with night shifts), and whether they had experienced infections during the last three months (common cold, throat infection, ear infection, sinusitis, pneumonia/bronchitis, COVID-19, influenza-like illness, skin infection, gastrointestinal infection, urinary infection, venereal disease, eye infection). Data were analyzed with chi-square tests and logistic regression analyses with adjustment for relevant confounders (gender, age, marital status, country of birth, children living at home, and educational level). Results showed that evening types more often reported venereal disease compared to morning types (OR = 4.01, confidence interval (CI) = 1.08-14.84). None of the other infections were significantly associated with circadian preference. Shift work including nights was associated with higher odds of influenza-like illness (OR = 1.97, CI = 1.10-3.55), but none of the other infections. In conclusion, neither circadian preference nor shift work seemed to be strongly associated with risk of infections, except for venereal disease (more common in evening types) and influenza-like illness (more common in night workers). Longitudinal studies are needed for causal inferences.

Self-reported short and long sleep duration, sleep debt and insomnia are associated with several types of infections: Results from the Norwegian practice-based research network in general practice - PraksisNett.

Objective: The objective was to assess the association between self-reported infections and sleep duration, sleep debt, chronic insomnia, and insomnia severity. Methods: In total, 1023 participants were recruited from the Norwegian practice-based research network in general practice to a cross-sectional online survey with validated questions about sleep habits and insomnia symptoms (Bergen Insomnia Scale (BIS) and Insomnia Severity Index (ISI)), and whether they had experienced various infections during the last three months. Data were analyzed with chi-square tests and logistic regressions with adjustment for relevant confounders. Results: Self-reported short sleep duration (<6 h) was significantly associated with increased odds of throat infection (OR = 1.60), ear infection (OR = 2.92), influenzalike illness (OR = 1.81) and gastrointestinal infection (OR = 1.91) whereas long sleep duration (>9 h) was associated with increased odds of throat (OR = 3.33) and ear infections (OR = 5.82), compared to sleep duration of 6-9 h, respectively. Sleep debt of >2 h was associated with increased odds of the common cold (OR = 1.67), throat infection (OR = 2.58), ear infection (OR = 2.84), sinusitis (OR = 2.15), pneumonia/bronchitis (OR = 3.97), influenzalike illness (OR = 2.66), skin infection (OR = 2.15), and gastrointestinal infection (OR = 2.80), compared to no sleep debt. Insomnia (based on BIS and ISI) was associated with throat infection (OR = 2.06, 2.55), ear infection (OR = 2.43, 2.45), sinusitis (OR = 1.82, 1.80), pneumonia/bronchitis (OR = 2.23, 3.59), influenzalike illness (OR = 1.77, 1.90), skin infection (OR = 1.64, 2.06), gastrointestinal infection (OR = 1.94, 3.23), and eye infection (OR = 1.99, 2.95). Conclusions: These novel findings support the notion that people who have insufficient sleep or sleep problems are at increased risk of infections.

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.

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.

Preparedness and management during the first phase of the COVID-19 outbreak - a survey among emergency primary care services in Norway.

BACKGROUND: The emergency primary care (EPC) services in Norway have been at the frontline of the COVID-19 pandemic. Knowledge about the EPC services' management of the COVID-19 outbreak can be used to prepare for future outbreaks and improve patient management. The objectives of this study were to identify pandemic preparedness and management strategies in EPC centres in Norway during the COVID-19 outbreak. METHODS: Questions regarding patient management of the COVID-19 outbreak were included in data collection for the National Out-Of-Hours Services Registry. The data collection was web-based, and an invitation was sent by email to the managers of all EPC services in Norway in June 2020. The EPC services were asked questions about pre-pandemic preparedness, access to personal protective equipment (PPE), organizational measures taken, and how staffing was organized during the onset of the pandemic. RESULTS: There were 169 municipal and inter-municipal EPC services in Norway in 2020, and all responded to the questionnaire. Among the EPC services, 66.7% (n = 112) had a pandemic plan, but only 4.2% had performed training for pandemic preparedness. Further, fewer than half of the EPC centres (47.5%) had access to supplies of PPE, and 92.8% answered that they needed extra supplies of PPE. 75.3% of the EPC services established one or more respiratory clinics. Staffing with other personnel than usual was done in 44.6% (n = 74) of the EPC services. All EPC services except one implemented new strategies for assessing patients, while about half of the wards implemented new strategies for responding to emergency calls. None of the largest EPC services experienced that their pandemic plan was adequate, while 13.3% of the medium-sized EPC services and 48.9% of the small EPC services reported having an adequate pandemic plan. CONCLUSIONS: Even though the EPC services lacked well-tested plans and had insufficient supplies of PPE at the outbreak of the COVID-19 pandemic, most services adapted to the pandemic by altering the ways they worked and by hiring health care professionals from other disciplines. These observations may help decision makers plan for future pandemics.

Health alliance for prudent prescribing and yield of antibiotics in a patient-centred perspective (HAPPY PATIENT): a before-and-after intervention and implementation study protocol.

BACKGROUND: Excessive and inappropriate use of antibiotics is the most important driver of antimicrobial resistance. The aim of the HAPPY PATIENT project is to evaluate the adaptation of European Union (EU) recommendations on the prudent use of antimicrobials in human health by evaluating the impact of a multifaceted intervention targeting different categories of healthcare professionals (HCPs) on common community-acquired infectious diseases, especially respiratory and urinary tract infections. METHODS/DESIGN: HAPPY PATIENT was initiated in January 2021 and is planned to end in December 2023. The partners of this project include 15 organizations from 9 countries. Diverse HCPs (doctors, nurses, pharmacists, and pharmacy technicians) will be audited by the Audit Project Odense (APO) method before and after an intervention in four different settings: general practice, out of hours services, nursing homes and community pharmacies in four high antibiotic prescribing countries (France, Poland, Greece, and Spain) and one low prescribing country (Lithuania). About 25 individuals from each professional group will be recruited in each country, who will register at least 25 patients with community-acquired infections during each audit period. Shortly before the second registration participants will undertake a multifaceted intervention and will receive the results from the first registration to allow the identification of possible quality problems. At these meetings participants will receive training courses on enhancement of communication skills, dissemination of clinical guidelines with recommendations for diagnosis and treatment, posters for the waiting rooms, and leaflets for patients. The results of the second registration will be compared with those obtained in the first audit. DISCUSSION: HAPPY PATIENT is an EU-funded project aimed at contributing to the battle against antibiotic resistance through improvement of the quality of management of common community-acquired infections based on interventions by different types of HCPs. It is hypothesized that the use of multifaceted strategies combining active intervention will be effective in reducing inappropriate prescribing and dispensing of antibiotics. STUDY REGISTRATION: EU Health programmes project database https://webgate.ec.europa.eu/chafea_pdb/health/projects/900024/summary ; date of registration: 1 January 2021.

Phone triage nurses' assessment of respiratory tract infections - the tightrope walk between gatekeeping and service providing. A qualitative study.

BACKGROUND: Phone nurses triage callers to Norwegian out-of-hours cooperatives to estimate the appropriate urgency and level of care for the caller. Many callers with mild symptoms of respiratory tract infections receive a doctor's consultation, which may lead to busy sessions and in turn impair clinical decisions. OBJECTIVE: This study explores how phone triage nurses assess callers with mild-to-moderate symptoms of respiratory tract infections and their views and experiences on triaging and counselling these callers. METHODS: We conducted four focus groups with 22 nurses (five men and 17 women aged 24-66 years) in three different locations in Norway. The interviews were transcribed verbatim and analysed by systematic text condensation. RESULTS: The informants were reluctant to call themselves gatekeepers. However, their description of their work indicates that they practice such a role. When nurses and callers disagreed about the right level of care, the informants sought consensus through strategies and negotiations. The informants described external factors such as organisational or financial issues as decisive for the population's use of out-of-hours services. They also described callers' characteristics, such as language deficiency and poor ability to describe symptoms, as determining their own clinical assessments. CONCLUSIONS: Nurses perceive assessments of callers with respiratory tract infections as challenging. They need skills and time to reach a consensus with the callers and guide them to the right level of health care. This should be considered when planning nurse training and staffing of out-of-hours cooperatives.KEY-POINTSPhone triage nurses assess callers to the out-of-hours service and estimate the level of urgencyThis study explores how phone triage nurses assess callers with respiratory tract infections and their views and experiences on this taskThe nurses describe their professional role as a tightrope walk between gatekeeping and service providingThe nurses seek consensus with callers through strategies and negotiations.

Out-of-hours workload among Norwegian general practitioners - an observational study.

BACKGROUND: Repeated studies of working hours among Norwegian regular general practitioners (RGPs) have shown that the average total number of weekly working hours has remained unchanged since 1994 and up until 2014. For both male and female RGPs, the mean total weekly working hours amounted to almost 50 h in 2014. In recent years, Norwegian RGPs have become increasingly dissatisfied. They experience significantly increased workload without compensation in the form of more doctors or better payment. A study from the Norwegian Directorate of Health in 2018 (the RGP study) showed that Norwegian RGPs worked 55.6 h weekly (median 52.5). 25% of the respondents worked more than 62.2 h weekly. Based on data from the RGP study we investigated Norwegian RGP's out-of-hours (OOH) work, how the working time was distributed, and to what extent the OOH work affected the regular working hours. METHODS: In early 2018, an electronic survey was sent to all 4640 RGPs in Norway. Each RGP reported how many minutes that were spent that particular day on various tasks during seven consecutive days. Working time also included additional tasks in the municipality, other professional medical work and OOH primary health care. Differences were analysed by independent t-tests, and regression analyses. RESULTS: One thousand eighty hundred seventy-six RGPs (40.4%) responded, 640 (34.1%) had registered OOH work. Male RGPs worked on average 1.5 h more doing regular work than did females (p = 0.001) and on average 2.3 h more OOH work than females (p = 0.079). RGPs with no OOH work registered a mean of 1.0 h more clinical work than RGPs working OOH (p = 0.043). There was a large variation in OOH working hours. A linear regression analysis showed that male RGPs and RGPs in rural areas had the heaviest OOH workload. CONCLUSIONS: One in three Norwegian RGPs undertook OOH work during the registration week in the RGP study. OOH work was done in addition to a sizeable regular workload as an RGP. We found small gender differences. OOH work was not compensated with reduced regular RGP work.

Workload in Norwegian general practice 2018 - an observational study.

BACKGROUND: Rising workload in general practice has been a recent cause for concern in several countries; this is also the case in Norway. Long working hours and heavy workload seem to affect recruitment and retention of regular general practitioners (RGPs). We investigated Norwegian RGPs' workload in terms of time used on patient-related office work, administrative work, municipality tasks and other professional activities in relation to RGPs, and gender, age, employment status and size of municipality. METHODS: In early 2018, an electronic survey was sent to all 4716 RGPs in Norway. In addition to demographic background, the RGP reported minutes per day used on various tasks in the RGP practice prospectively during 1 week. Working time also included additional tasks in the municipality, other professional work and on out-of-hours primary health care. Differences were analysed by chi square test, independent t-tests, and one-way ANOVA. RESULTS: Among 1876 RGPs (39.8%), the mean total working hours per week was 55.6, while the mean for regular number of working hours was 49.0 h weekly. Men worked 1.5 h more than women (49.7 vs. 48.2 h, p = 0.010). Self-employed RGPs work more than salaried RGPs (49.3 vs. 42.5 h, p < 0.001), and RGPs age 55-64 years worked more than RGPs at age 30-39 (51.1 vs. 47.3 h, p < 0.001). 54.1% of the regular working hours was used on face-to-face patient work. CONCLUSIONS: Norwegian RGPs have long working hours compared to recommended regular working hours in Norway, with small gender differences. Only half of the working time is used on face-to-face consultations. There seems to be a trend of increasing workload among Norwegian GPs, at the cost of direct patient contact. Further research should address identifying factors that can reduce long working hours.

Factors predicting antibiotic prescription and referral to hospital for children with respiratory symptoms: secondary analysis of a randomised controlled study at out-of-hours services in primary care.

OBJECTIVES: Acute respiratory infections and fever among children are highly prevalent in primary care. It is challenging to distinguish between viral and bacterial infections. Norway has a relatively low prescription rate of antibiotics, but it is still regarded as too high as the antimicrobial resistance is increasing. The aim of the study was to identify predictors for prescribing antibiotics or referral to hospital among children. DESIGN: Secondary analysis of a randomised controlled study. SETTING: 4 out-of-hours services and 1 paediatric emergency clinic in Norwegian primary care. PARTICIPANTS: 401 children aged 0-6 years with respiratory symptoms and/or fever visiting the out-of-hours services. OUTCOMES: 2 main outcome variables were registered: antibiotic prescription and referral to hospital. RESULTS: The total prescription rate of antibiotics was 23%, phenoxymethylpenicillin was used in 67% of the cases. Findings on ear examination (OR 4.62; 95% CI 2.35 to 9.10), parents' assessment that the child has a bacterial infection (OR 2.45; 95% CI 1.17 to 5.13) and a C reactive protein (CRP) value >20 mg/L (OR 3.57; 95% CI 1.43 to 8.83) were significantly associated with prescription of antibiotics. Vomiting in the past 24 hours was negatively associated with prescription (OR 0.26; 95% CI 0.13 to 0.53). The main predictors significantly associated with referral to hospital were respiratory rate (OR 1.07; 95% CI 1.03 to 1.12), oxygen saturation <95% (OR 3.39; 95% CI 1.02 to 11.23), signs on auscultation (OR 5.57; 95% CI 1.96 to 15.84) and the parents' assessment before the consultation that the child needs hospitalisation (OR 414; 95% CI 26 to 6624). CONCLUSIONS: CRP values >20 mg/L, findings on ear examination, use of paracetamol and no vomiting in the past 24 hours were significantly associated with antibiotic prescription. Affected respiration was a predictor for referral to hospital. The parents' assessment was also significantly associated with the outcomes. TRIAL REGISTRATION NUMBER: NCT02496559; Results.

Out-of-hours antibiotic prescription after screening with C reactive protein: a randomised controlled study.

OBJECTIVE: To evaluate the effect of preconsultation C reactive protein (CRP) screening on antibiotic prescribing and referral to hospital in Norwegian primary care settings with low prevalence of serious infections. DESIGN: Randomised controlled observational study at out-of-hours services in Norway. SETTING: Primary care. PARTICIPANTS: 401 children (0-6 years) with fever and/or respiratory symptoms were recruited from 5 different out-of-hours services (including 1 paediatric emergency clinic) in 2013-2015. INTERVENTION: Data were collected from questionnaires and clinical examination results. Every third child was randomised to a CRP test before the consultation; for the rest, the doctor ordered a CRP test if considered necessary. OUTCOME MEASURES: Main outcome variables were prescription of antibiotics and referral to hospital. RESULTS: In the group pretested with CRP, the antibiotic prescription rate was 26%, compared with 22% in the control group. In the group pretested with CRP, 5% were admitted to hospital, compared with 9% in the control group. These differences were not statistically significant. The main predictors for ordering a CRP test were parents' assessment of seriousness of the illness and the child's temperature. Paediatricians ordered CRP tests less frequently than did other doctors (9% vs 56%, p<0.001). CONCLUSIONS: Preconsultation screening with CRP of children presenting to out-of-hours services with fever and/or respiratory symptoms does not significantly affect the prescription of antibiotics or referral to hospital. TRIAL REGISTRATION NUMBER: NCT02496559; Results.

Point-of-care testing with CRP in primary care: a registry-based observational study from Norway.

BACKGROUND: Norwegian primary health care is maintained on the regular general practitioners (RGPs), GP's contracted to the municipalities in a list patient system, working at daytime and at out-of-hours services (OOH services). Respiratory disease is most prevalent during OOH services, and in more than 50 % of the consultations, a CRP test is performed. Children in particular have a high consultation rate, and the CRP test is frequently conducted, but the contributing factors behind its frequent use are not known. This study compares the RGPs rate of CRP use at daytime and OOH in consultations with children and how this rate is influenced by characteristics of the RGPs. METHODS: A cross-sectional register study was conducted based on all (N = 2,552,600) electronic compensation claims from consultations with children ≤ 5 year during the period 2009-2011 from primary health care. Consultation rates and CRP use were estimated and analysed using descriptive methods. Being among the 20% of RGPs with the highest rate of CRP use at daytime or OOH was an outcome measure in regression analyses using RGP-, and RGP list characteristics as explanatory variables. RESULTS: One third of all RGPs work regularly in OOH services, and they use CRP 1.42 times more frequently in consultations with children in OOH services than in daytime services even when the distribution of diagnosis according to ICPC-2 chapters is similar. Not being approved specialist, have a large number at their patient-lists but relatively few children on their list and a large number of consultations with children were significantly associated with frequent use of CRP in daytime services. The predictors for frequent CRP use in OOH services were being a young doctor, having many consultations with children during OOH and a frequent use of CRP in daytime services. CONCLUSIONS: The increase in the frequency of CRP test use from daytime to OOH occurs in general for RGPs and for all most used diagnoses. The RGPs who use the CRP test most frequently in their daytime practice have the highest rate of CRP in OOH services.

Use of laboratory tests in out-of-hours services in Norway.

OBJECTIVE: To investigate the use of laboratory tests and which factors influence the use in Norwegian out-of-hours (OOH) services. DESIGN: Cross-sectional observational study. SETTING: Out-of-hours services in Norway. SUBJECTS: All electronic reimbursement claims from doctors at OOH services in Norway in 2007. MAIN OUTCOME MEASURES: Number of contacts and laboratory tests in relation to patients' and doctors' characteristics. RESULTS: 1 323 281 consultations and home visits were reported. Laboratory tests were used in 31% of the contacts. C-reactive protein (CRP) was the most common test (27% of all contacts), especially in respiratory illness (55%) and infants (44%). Electrocardiogram and rapid strep A test were used in 4% of the contacts. Young doctors, female doctors, and doctors in central areas used laboratory tests more often. CONCLUSION: CRP is extensively used in OOH services, especially by young and inexperienced doctors, and in central areas. Further investigations are required to see if this extensive use of CRP is of importance for correct diagnosis and treatment.

[Equipment for diagnostics, laboratory analyses and treatment in out-of-hours services]. / Utstyr, laboratorieanalyser og medikamenter ved kommunale legevakter.

BACKGROUND: Availability of equipment for diagnostics and treatment in out-of-hours services in Norway is not documented and no guidelines exist on requirements for the various types of equipment (including drugs) needed. A knowledge basis on status and needs should be established so minimum requirements can be developed. MATERIAL AND METHODS: The National Centre for Emergency Primary Health Care sent a questionnaire on availability of diagnostic equipment, laboratory tests, medication and quality assurance systems to all 261 municipal out-of-hours services in Norway in February 2006. RESULTS: 223/261 (86 %) of the services responded. 150 used the same office as a day-time practice, 59 had their own office and 14 were localised in a hospital/ emergency care unit. Services located in GP surgeries with a daytime-practice had a wider range of equipment, laboratory tests and medicines. Physicians on duty in the out-of-hours services with shared facilities did much of the laboratory work, but the quality control was done by the personnel at daytime. 27 % of the independent services did not have external control of their laboratory work (they were not members of the Norwegian Quality Improvement of Primary Care Laboratories). GPs were trained on acute medical situations more than once a year in 52 % of all the out-of-hours-services, but for only 40 % in the independent services. Other personnel were trained more than once a year in 74 % of the independent services. INTERPRETATION: Availability of equipment and laboratory test repertoire for GPs on duty at out-of-hours services seems to depend on whether the services are shared with GP surgeries and also used at daytime, and the distance to ambulance, hospital and pharmacy. Lack of routines for laboratory work and low training frequency in acute medical procedures may lead to poor quality of the analyses and lower competence than needed.