How far? Travel burdens for children admitted to hospitals in the Western Cape Province of South Africa.

BACKGROUND: The ability to access effective hospital care for children is a significant determinant of good health outcomes. The Western Cape is a large land area with a wide array of human settlements- both in urban and rural spaces. For many children in the Western Cape, after-hours access to healthcare becomes constrained when primary care clinics close and hospitals are either far away or difficult to get to. The cumulative travel burden of communities across this area is not known. The recently established data gathering capacity of the Provincial Health Data Centre of the Western Cape represents a new capacity to study this. OBJECTIVES: This study intends to describe the cumulative travel burdens of children in communities throughout the Western Cape, and how they compare relative to one another, with a particular focus on the after-hours period in a week. METHODS: Over a period of 5 years from 2017-2021, all the admission details to every hospital in the Western Cape of children under 18 years of age were collected, with basic demographic and disease data including place of residence. The distance each child travelled to their first admission facility was calculated and represented within defined communities across the metro of Cape Town and the rural Western Cape. RESULTS: There were 574 220 admissions over the 5-year period, of which 360 783 were able to be used for travel analysis. The majority of admissions were for children under 5 years of age, were in the City of Cape Town and occurred after hours. Median travel distance was less for children outside of Cape Town, but the range of travelled distances was greater. Communities across the Western Cape, particularly rural communities, reflected significant variation in their cumulative travel burdens. CONCLUSION: Using a large health dataset, this study demonstrates in a novel way for South Africa, the distances children travel to access admission facilities. A wide variation exists across all parts of the province, but particularly in rural areas. These findings could be further interrogated for people's choices of facility and method of travel. Detailed service area modelling and extending primary care working hours are potential considerations for improving access at scale and at the local community level.

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.

Task shifting from general practitioners to other health professionals in out-of-hours primary care - a systematic literature review on content and quality of task shifting.

BACKGROUND: Task shifting from general practitioners (GPs) to other health professionals could solve the increased workload, but an overview of the evidence is lacking for out-of-hours primary care (OOH-PC). OBJECTIVES: To evaluate the content and quality of task shifting from GPs to other health professionals in clinic consultations and home visits in OOH-PC. METHODS: Four database literature searches were performed on 13 December 2021, and updated in August 2023. We included articles that studied content (patient characteristics, reason for encounter) and/or quality (patient satisfaction, safety, efficiency) of task shifting in face-to-face contacts at OOH-PC. Two authors independently screened articles for inclusion and assessed the methodological quality of included articles using the JBI critical appraisal checklist. Data was extracted and results were synthesised in a narrative summary. RESULTS: The search identified 1,829 articles, resulting in the final inclusion of seven articles conducted in the UK or the Netherlands. Studies compared GPs with other health professionals (mainly nurses). These other health professionals saw patients with less urgent health problems, younger patients, and patients with less complex health problems than GPs. Most studies concluded that other health professionals provided safe and vastly efficient care corresponding to the level of GPs but findings about productivity were inconclusive. CONCLUSION: The level of safety and efficiency of care provided by other health professionals in OOH-PC seems like that of GPs, although they mainly see patients presenting with less urgent and less complex health problems.

Task shifting from general practitioners to other health professionals could increase treatment capacity in out-of-hours primary care.Task shifting occurs for care to patients with less urgent and less complex health issues.The long-term implications of task shifting in out-of-hours primary care should be investigated.

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.

Diabetes and risk of acute coronary syndrome in callers with chest discomfort: Cross-sectional study in out-of-hours primary care.

AIMS: We investigated the differences in prevalence of acute coronary syndrome (ACS) by presence versus absence of diabetes in males and females with chest discomfort who called out-of-hours primary care (OHS-PC). METHODS: A cross-sectional study performed in the Netherlands. Patients who called the OHS-PC in the Utrecht region, the Netherlands between 2014 and 2017 with acute chest discomfort were included. We compared those with diabetes with those without diabetes. Multivariable logistic regression was used to determine the relation between diabetes and (i) high urgency allocation and (ii) ACS. RESULTS: Of the 2,195 callers with acute chest discomfort, 180 (8.2%) reported having diabetes. ACS was present in 15.3% of males (22.0% in those with diabetes) and 8.4% of females (18.8% in those with diabetes). Callers with diabetes did not receive a high urgency more frequently (74.4% vs. 67.8% (OR: 1.38; 95% CI 0.98-1.96). However, such callers had a higher odds for ACS (OR: 2.17; 95% CI 1.47-3.19). These differences were similar for females and males. CONCLUSIONS: Diabetes holds promise as diagnostic factor in callers to OHS-PC with chest discomfort. It might help triage in this setting given the increased risk of ACS in those with diabetes.

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.

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.

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.

A Single-resident Experience of Overnight Call Activity at a Multi-site Academic Health System.

OBJECTIVE: To characterize urology resident on-call activities overnight at a multi-site academic medical center and model the expected volume of clinical activity using inpatient beds, emergency room visits, and attendings covered. MATERIALS AND METHODS: On-call activities for 70 13-hour overnight shifts spanning 5 nonconsecutive months between May 2022 and February 2023 were recorded. Clinical coverage included 5 academic hospitals encompassing 1761 staffed inpatient beds and an expected nightly volume of 255 Emergency Department (ED) visits. The time, source, and clinical features of every call were documented. RESULTS: An average of 15 unique calls were received during each shift. Of these, 35% required an in-person evaluation and 12% required a bedside or operative procedure. Approximately a third of calls (36%) were received after midnight. An in-person evaluation occurred within the first hour of 53% of shifts and every shift required at least 1 evaluation. When normalized for inpatient bed volume, an average of 7 unique patient communications occurred per 1000 beds, leading to 2 in-person evaluations. When normalized for an expected number of overnight ED visits, an average of 1 new ED consultation occurred per 100 ED visits. CONCLUSION: After-hours clinical coverage models vary significantly by specialty and institution, and coverage decisions must balance quality clinical care with safe provider workload. Patient needs were appropriately addressed by a single overnight on-call resident, providing a robust clinical experience. The volume of patient care activities in this experience supports the practice of a "night-float" resident with the clear expectation on-site care is required.

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 .

Towards 24/7 MRI: the effect of routine weekend inpatient MRI scanning on patient waiting times.

BACKGROUND: Demand for inpatient MRI outstrips capacity which results in long waiting lists. The hospital commenced a routine weekend MRI service in January 2023. AIM: The aim of this study was to investigate the effect of a limited routine weekend MRI service on MRI turnaround times. METHODS: Waiting times for inpatient MRI scans performed before and after the introduction of weekend MRI from January 1 to August 31, 2022, and January 1 to August 31, 2023, were obtained. The turnaround time (TAT) and request category for each study were calculated. Category 1 requests were required immediately, category 2 requests were urgent and category 3 requests were routine. RESULTS: There was a 6% (n = 128) increase in MRI inpatient scanning activity in 2023 (n = 2449) compared to 2022 (n = 2322). There was a significant improvement in overall mean TAT for inpatient MRIs (p < .001) in 2023 (mean 65.2 h, range 0-555 h) compared to 2022 (mean 98.3 h, range 0-816 h). There was no significant difference in the mean waiting time for category 1 MRIs between 2022 and 2023. There was a significant improvement (p < .001) in mean waiting time in 2023 (mean 37.2 h, range 0-555) compared to 2022 (mean 55.4 h, range 0-816) for category 2 MRI. The mean waiting time for category 3 studies also significantly improved (p < .001) in 2023 (mean 93.4 h, range 1-2663) when compared to 2022 (mean 154.8, range 1-1706). CONCLUSION: Routine weekend inpatient MRI significantly shortens inpatient waiting times.

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.

Point-of-care testing and antibiotics prescribing in out-of-hours general practice: a register-based study in Denmark.

BACKGROUND: Point-of-care testing may reduce diagnostic uncertainty in case of suspicion of bacterial infection, thereby contributing to prudent antibiotic prescribing. We aimed to study variations in the use of point-of-care tests (C-reactive protein test, rapid streptococcal antigen detection test, and urine dipstick) among general practitioners (GPs) and the potential association between point-of-care testing and antibiotic prescribing in out-of-hours general practice. METHODS: We conducted a population-based observational register-based study, based on patient contacts with out-of-hours general practice in the Central Denmark Region in 2014-2017. The tendency of GPs to use point-of-care testing was calculated, and the association between the use of point-of-care testing and antibiotic prescribing was evaluated with the use of binomial regression. RESULTS: Out-of-hours general practice conducted 794,220 clinic consultations from 2014 to 2017, of which 16.1% resulted in an antibiotic prescription. The GP variation in the use of point-of-care testing was largest for C-reactive protein tests, with an observed variation (p90/p10 ratio) of 3.0; this means that the GPs in the 90th percentile used C-reactive protein tests three times as often as the GPs in the 10th percentile. The observed variation was 2.1 for rapid streptococcal antigen detection tests and 1.9 for urine dipsticks. The GPs who tended to use more point-of-care tests prescribed significantly more antibiotics than the GPs who tended to use fewer point-of-care tests. The GPs in the upper quintile of the tendency to use C-reactive protein test prescribed 22% more antibiotics than the GPs in the lowest quintile (21% for rapid streptococcal antigen detection tests and 8% for urine dipsticks). Up through the quintiles, this effect exhibited a positive linear dose-response correlation. CONCLUSION: The GPs varied in use of point-of-care testing. The GPs who tended to perform more point-of-care testing prescribed more antibiotics compared with the GPs who tended to perform fewer of these tests.

[Out-of-hours General Practice: a case-report about Neisseria meningitidis in the health district of Grado (Gorizia), Italy.] / Continuità assistenziale: un case-report su Neisseria meningitidis nel distretto sanitario di Grado (Gorizia).

Neisseria meningitidis causes life-threatening invasive diseases, such as sepsis, pneumonia, and meningitis. In Italy, as in many other countries, despite vaccination programs, the misdiagnosis of meningococcal infections and the persistence of vaccination hesitancy and of unvaccinated people can lead to possible epidemics. Following the CARE Guidelines, this case-report describes a young woman presented with fever and a strange rash to the General Practice out-of-hours in the island of Grado (Gorizia - Italy), lately recognized as Neisseria meningitidis infection. After a prompt evaluation, she was referred to a central hospital for correct diagnosis and treatment. Study and management of the case and its close-contacts was also carried out by the Prevention Department to provide prophylaxis. The Italian Ooh service is active every night, weekend and on holidays, representing an aid to limit improper access to the Emergency Department, but especially in rural areas, patients with urgent conditions also mainly go to the Ooh, first or alternatively to reach a hospital equipped with ER. The presented case underlines the fundamental role played by Ooh in the timely identification of a meningococcal infection in a patient presenting with non-neurological symptoms, making the correct referral to the specialist department of the nearest central hospital. It is essential to conduct a detailed medical history, even by telephone, and carry out a visit to evaluate the opportunity for hospital admission, especially to achieve early identification of life-threatening communicable diseases. It is also important that medical training, even after graduation, emphasizes the importance of maintaining awareness and making rapid recognition of the key symptoms of these conditions, although rare.

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.

Shortness of breath as a diagnostic factor for acute coronary syndrome in male and female callers to out-of-hours primary care.

OBJECTIVE: Chest discomfort and shortness of breath (SOB) are key symptoms in patients with acute coronary syndrome (ACS). It is, however, unknown whether SOB is valuable for recognising ACS during telephone triage in the out-of-hours primary care (OHS-PC) setting. METHODS: A cross-sectional study performed in the Netherlands. Telephone triage conversations were analysed of callers with chest discomfort who contacted the OHS-PC between 2014 and 2017, comparing patients with SOB with those who did not report SOB. We determine the relation between SOB and (1) High urgency allocation, (2) ACS and (3) ACS or other life-threatening diseases. RESULTS: Of the 2195 callers with chest discomfort, 1096 (49.9%) reported SOB (43.7% men, 56.3% women). In total, 15.3% men (13.2% in those with SOB) and 8.4% women (9.2% in those with SOB) appeared to have ACS. SOB compared with no SOB was associated with high urgency allocation (75.9% vs 60.8%, OR: 2.03; 95% CI 1.69 to 2.44, multivariable OR (mOR): 2.03; 95% CI 1.69 to 2.44), but not with ACS (10.9% vs 12.0%; OR: 0.90; 95% CI 0.69 to 1.17, mOR: 0.91; 95% CI 0.70 to 1.19) or 'ACS or other life-threatening diseases' (15.0% vs 14.1%; OR: 1.07; 95% CI 0.85 to 1.36, mOR: 1.09; 95% CI 0.86 to 1.38). For women the relation with ACS was 9.2% vs 7.5%, OR: 1.25; 95% CI 0.83 to 1.88, and for men 13.2% vs 17.4%, OR: 0.72; 95% CI 0.51 to 1.02. For 'ACS or other life-threatening diseases', this was 13.0% vs 8.5%, OR: 1.60; 95% CI 1.10 to 2.32 for women, and 7.5% vs 20.8%, OR: 0.81; 95% CI 0.59 to 1.12 for men. CONCLUSIONS: Men and women with chest discomfort and SOB who contact the OHS-PC more often receive high urgency than those without SOB. This seems to be adequate in women, but not in men when considering the risk of ACS or other life-threatening diseases.

Predicting sepsis-related mortality and ICU admissions from telephone triage information of patients presenting to out-of-hours GP cooperatives with acute infections: A cohort study of linked routine care databases.

BACKGROUND: General practitioners (GPs) often assess patients with acute infections. It is challenging for GPs to recognize patients needing immediate hospital referral for sepsis while avoiding unnecessary referrals. This study aimed to predict adverse sepsis-related outcomes from telephone triage information of patients presenting to out-of-hours GP cooperatives. METHODS: A retrospective cohort study using linked routine care databases from out-of-hours GP cooperatives, general practices, hospitals and mortality registration. We included adult patients with complaints possibly related to an acute infection, who were assessed (clinic consultation or home visit) by a GP from a GP cooperative between 2017-2019. We used telephone triage information to derive a risk prediction model for sepsis-related adverse outcome (infection-related ICU admission within seven days or infection-related death within 30 days) using logistic regression, random forest, and neural network machine learning techniques. Data from 2017 and 2018 were used for derivation and from 2019 for validation. RESULTS: We included 155,486 patients (median age of 51 years; 59% females) in the analyses. The strongest predictors for sepsis-related adverse outcome were age, type of contact (home visit or clinic consultation), patients considered ABCD unstable during triage, and the entry complaints"general malaise", "shortness of breath" and "fever". The multivariable logistic regression model resulted in a C-statistic of 0.89 (95% CI 0.88-0.90) with good calibration. Machine learning models performed similarly to the logistic regression model. A "sepsis alert" based on a predicted probability >1% resulted in a sensitivity of 82% and a positive predictive value of 4.5%. However, most events occurred in patients receiving home visits, and model performance was substantially worse in this subgroup (C-statistic 0.70). CONCLUSION: Several patient characteristics identified during telephone triage of patients presenting to out-of-hours GP cooperatives were associated with sepsis-related adverse outcomes. Still, on a patient level, predictions were not sufficiently accurate for clinical purposes.

Nurses' experience with presenteeism and the potential consequences on patient safety: a qualitative study among nurses at out-of-hours emergency primary care facilities.

OBJECTIVES: This study aimed to gain new insight and knowledge on out-of-hours emergency primary care nurses' experience of presenteeism in their workplace and their outlook on the impact they recognised the phenomenon to have on patient safety when caring for acute patients. DESIGN: An explorative qualitative study. SETTING: The study was conducted at three out-of-hours primary care facilities in southwest Norway. PARTICIPANTS: A total of 10 female nurses were recruited as interviewees. Nurses providing direct patient care were included in the study. RESULTS: The analysis resulted in four major themes: strong work ethics influence the decision to attend work unwell; work environment factors have a negative impact on nurses' health; nurses' awareness of consequences on the quality of care and patient safety and nurses make use of coping strategies when engaging in presenteeism. CONCLUSION: Presenteeism is a common experience among nurses at out-of-hours emergency primary care clinics, with work-related stress being a significant contributing factor. Despite recognising a decrease in performance while engaging in presenteeism, nurses displayed adaptive behaviour. They were confident that their suboptimal health issues did not significantly impact patient safety while caring for acute patients. However, the true impact of presenteeism on patient safety in an out-of-hours emergency care setting remains uncertain due to the reliance on subjective reporting systems as quality indicators. More research is needed to understand the phenomenon and its implications on patient safety fully.

Out-of-hours decision-making in deteriorating patients by foundation year doctors: Relationship to moral distress.

BACKGROUND: Moral distress (MD) refers to psychological unease when healthcare professionals identify morally correct actions to take but are constrained in their ability to take those actions. METHODS: This study evaluated the relationship between out-of-hours decisions and MD among 40 Foundation Year 2 (FY2) doctors. They were asked to choose the 'expected' and the 'right' management options for five out-of-hours scenarios and complete an adapted Measure of Moral Distress for Health Professionals (MMD-HP) questionnaire. RESULTS: 28/40 (70%) reported discordance between 'expected' and 'right' options more frequently than concordance. The mean total MMD-HP score was low: 64.9 (SD = 26.9), range 13-143, maximum 288. The association between decision-making discordance and MMD-HP score was weak. CONCLUSION: Out-of-hours decisions by FY2 doctors were characterised by doing what is 'expected' rather than what is perceived to be 'right'. Providing guidance regarding decision-making in deteriorating patients is needed for patient safety and staff well-being.