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Background: Hospital care on weekends has been associated with delays in care, reduced quality, and poor clinical outcomes., Objective: The purpose of this study was to evaluate the impact of a weekend hospital intervention on processes of care and clinical outcomes. The multifaceted intervention included expanded weekend diagnostic services, improved weekend discharge processes, and increased physician and care management services on weekends., Design and Patients: This was an interrupted time series observational study of adult non-obstetric patients hospitalized at a single academic medical center between January 2011 and January 2014. The study included 18 months prior to and 19 months following the implementation of the intervention. Data were analyzed using segmented regression analysis with adjustment for confounders., Main Measures: The primary outcome was average length of stay. Secondary outcomes included percent of patients discharged on weekends, 30-day readmission rate, and in-hospital mortality rate., Key Results: The study included 57,163 hospitalizations. Following implementation of the intervention, average length of stay decreased by 13 % (95 % CI 10-15 %) and continued to decrease by 1 % (95 % CI 1-2 %) per month as compared to the underlying time trend. The proportion of weekend discharges increased by 12 % (95 % CI 2-22 %) at the time of the intervention and continued to increase by 2 % (95 % CI 1-3 %) per month thereafter. The intervention had no impact on readmissions or mortality. During the post-implementation period, the hospital was evacuated and closed for 2 months due to damage from Hurricane Sandy, and a new hospital-wide electronic health record was introduced. The contributions of these events to our findings are not known. We observed a lower inpatient census and found differences in patient characteristics, including higher rates of Medicaid insurance and comorbidities, in the post-Hurricane Sandy period as compared to the pre-Sandy period., Conclusions: The intervention was associated with a reduction in length of stay and an increase in weekend discharges. Our longitudinal study also illuminated the challenges of evaluating the effectiveness of a large-scale intervention in a real-world hospital setting.

Objectives: Dutch primary out-of-hours care is provided by general practice cooperatives (GPCs). Although most GPCs use the same standardised triage system, differences between GPCs exist in the urgency assigned to patients' health problems. This cross-sectional study aims to provide insight into factors associated with the variation in assigned urgency between GPCs., Design and Methods: Data were derived from routine electronic health records of 895 253 patients who attended 17 GPCs in 2012. Patients' gender, age, travel distance to the GPC, and the use of a computer-based decision support system for triage were investigated as possibly affecting assigned urgency. Multilevel linear regression analyses were executed for the 3 most frequently presented health problems (cystitis/other urinary infection, laceration/cut and fever)., Results: Variation in urgency levels between GPCs was significant for the selected health problems (p=0.00). Assigned urgency was mainly related to patient gender and age. It was not associated with the use of a computer-based decision support system, or with travel distance to the GPC. Most variation in urgency (93.4-96.7%) could be ascribed to variation in patient characteristics., Conclusions: There is significant variation in urgency levels between GPCs, even for the same health problem. This variation is mainly associated with differences in characteristics of individuals contacting the GPCs, rather than with variables such as patients' travel distance or the use of a computer-based decision support system. Since patient characteristics are likely to affect patients' clinical need, our results are an indication of the adequate functioning of the triage system., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Fever in children is common and mostly caused by benign self-limiting infections. Yet consultation rates in primary care are high, especially during GP out-of-hours care. Therefore, we aimed to explore experiences of parents when having visited GP out-of-hours services with their febrile child., Methods: We performed a qualitative study using 20 semi-structured interviews among parents from different backgrounds presenting to GP out-of-hours care with a febrile child <12 years. Questions were directed at parental motivations, expectations and experiences when visiting the GP out-of-hours centre with a febrile child. Interviews were audio-recorded, transcribed and analysed using constant comparison technique., Results: We identified four main categories emerging from the data; (1) cautiously seeking care, (2) discrepancy between rationality and emotion, (3) expecting reassurance from a professional and (4) a need for consistent, reliable information. Not one symptom, but a combination of fever with other symptoms, made parents anxious and drove care seeking. Although parents carefully considered when to seek care, they experienced increased anxiety with increases in their child's temperature. Because parents work during the day and fever typically rises during the early evening, the decision to seek care was often made during out-of-hours care. When parents consulted a GP they did not have any set expectations other than seeking reassurance, however a proper physical examination diminished their anxiety. Parents did not demand antibiotics, but trusted on the expertise of the GP to assess necessity. Parents requested consistent, reliable information on fever and self-management strategies., Conclusions: Parents were inexperienced in self-management strategies and had a subsequent desire for reassurance; this played a pivotal role in out-of-hours help seeking for childhood fever. These factors provide clues to optimise information exchange between GPs and parents, by providing written, tailored, consistent information on self-management strategies for current and future fever episodes. GPs' had incorrect assumptions that parents expected antibiotic treatment.

The English National Health Service is moving towards providing comprehensive 7-day hospital services in response to higher death rates for emergency weekend admissions. Using Hospital Episode Statistics between 1st April 2010 and 31st March 2011 linked to all-cause mortality within 30 days of admission, we estimate the number of excess deaths and the loss in quality-adjusted life years associated with emergency weekend admissions. The crude 30-day mortality rate was 3.70% for weekday admissions and 4.05% for weekend admissions. The excess weekend death rate equates to 4355 (risk adjusted 5353) additional deaths each year. The health gain of avoiding these deaths would be 29 727-36 539 quality-adjusted life years per year. The estimated cost of implementing 7-day services is £1.07-£1.43 bn, which exceeds by £339-£831 m the maximum spend based on the National Institute for Health and Care Excellence threshold of £595 m-£731 m. There is as yet no clear evidence that 7-day services will reduce weekend deaths or can be achieved without increasing weekday deaths. The planned cost of implementing 7-day services greatly exceeds the maximum amount that the National Health Service should spend on eradicating the weekend effect based on current evidence. Policy makers and service providers should focus on identifying specific service extensions for which cost-effectiveness can be demonstrated., (Copyright © 2015 John Wiley & Sons, Ltd.)

Background: There is growing concern that the quality of inpatient care may differ on weekends versus weekdays. We assessed the "weekend effect" in common urgent general operative procedures., Methods: The Healthcare Cost and Utilization Project Florida State Inpatient Database (2007-2010) was queried to identify inpatient stays with urgent or emergent admissions and surgery on the same day. Included were patients undergoing appendectomy, cholecystectomy for acute cholecystitis, and hernia repair for obstructed/gangrenous hernia. Outcomes included duration of stay, inpatient mortality, hospital-adjusted charges, and postoperative complications. Controlling for hospital and patient characteristics and type of surgery, we used multilevel mixed-effects regression modeling to examine associations between patient outcomes and admissions day (weekend vs weekday)., Results: A total of 80,861 same-day surgeries were identified, of which 19,078 (23.6%) occurred during the weekend. Patients operated on during the weekend had greater charges by $185 (P < .05), rates of wound complications (odds ratio [OR] 1.29, 95% confidence interval [95% CI] 1.05-1.58; P < .05), and urinary tract infection (OR 1.39, 95% CI 1.05-1.85; P < .05). Patients undergoing appendectomy had greater rates of transfusion (OR 1.43, 95% CI 1.09-1.87; P = .01), wound complications (OR 1.32, 95% CI 1.04-1.68; P < .05), urinary tract infection (OR 1.76, 95% CI 1.17-2.67; P < .01), and pneumonia (OR 1.41, 95% CI 1.05-1.88; P < .05). Patients undergoing cholecystectomy had a greater duration of stay (P = .001) and greater charges (P = .003)., Conclusion: Patients undergoing weekend surgery for common, urgent general operations are at risk for increased postoperative complications, duration of stay, and hospital charges. Because the cause of the "weekend effect" is still unknown, future studies should focus on elucidating the characteristics that may overcome this disparity., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The American Society of Anesthesiologists has embraced the concept of the Perioperative Surgical Home as a means through which anesthesiologists can add value to the health systems in which they practice. One key listed element of the Perioperative Surgical Home is to support "scheduling initiatives to reduce cancellations and increase efficiency." In this study, we explored the potential benefits of the Perioperative Surgical Home with respect to inpatient cancellations and add-on case scheduling. We evaluated 6 hypotheses related to the timing of inpatient cancellations and preoperative anesthesia evaluations., Methods: Inpatient cancellations were studied during 26 consecutive 4-week intervals between July 2012 and June 2014 at a tertiary care academic hospital. All timestamps related to scheduling, rescheduling, and cancellation activities were retrieved from the operating room (OR) case scheduling system. Timestamps when patients were seen by anesthesia residents were obtained from the preoperative evaluation system database. Batch mean methods were used to calculate means and SE. For cases cancelled, we determined whether, for "most" (>50%) cancellations, a subsequent procedure (of any type) was performed on the patient within 7 days of the cancellation. Comparisons with most and other fractions were assessed using the 1 group, 1-sided Student t test. We evaluated whether a few procedures were highly represented among the cancelled cases via the Herfindahl (Simpson's) index, comparing it with <0.15. The rate of scheduling activity was assessed by computing the number of OR scheduling office decisions in each 1-hour bin between 6:00 AM and 3:59 PM. These values were compared with ≥1 decision per hour at the study hospital., Results: Data from 24,735 scheduled inpatient cases were assessed. Cases cancelled after 7 AM on the day before or at any time on the scheduled day of surgery accounted for 22.6% ± 0.5% (SE) of the scheduled minutes all scheduled cases, and 26.8% ± 0.4% of the case volume (i.e., number of cases). Most (83.1% ± 0.6%, P < 10) cases performed were evaluated on the day before surgery. Most (67.6% ± 1.6%, P < 10) minutes of cancelled cases were evaluated on the day before surgery. Most (62.3% ± 1.5%, P < 10) cases were seen earlier than 6:00 PM of the day before surgery. The Herfindahl index among cancelled procedures was 0.021 ± 0.001 (P < 10 compared not only to <0.15 but also to <0.05), showing large heterogeneity among the cancelled procedures. A subsequent procedure was not performed for most cancelled cases (50.6% ± 0.9% compared with >50%, P = 0.12), implying that the indication for the cancelled procedure no longer existed or the patient/family decided not to proceed with surgery. When only cancellations on the scheduled day of surgery were considered, the cancellation rate was 14.0% ± 0.3% of scheduled inpatient minutes and 11.8% ± 0.2% of scheduled inpatient cases. There were 0.59 ± 0.02 OR schedule decisions per hour per 10 ORs between 6:00 AM and 3:59 PM (P < 10, corresponding to ≥1 decision per hour at the 36 OR study hospital)., Conclusions: The study hospital had a high inpatient cancellation rate, despite the fact that most patients whose cases were cancelled were seen by an anesthesia resident by 6:00 PM of the day before surgery. This finding suggests that further efforts to reduce the cancellations by seeing patients sooner on the day before surgery, or seeing even more patients the day before surgery, would not be an economically useful focus of the Perioperative Surgical Home. The wide heterogeneity among cancelled cases indicates that focusing on a few procedures would not materially affect the overall cancellation rate. The relatively low rate of subsequent performance of a procedure on patients whose cases had been cancelled suggests that trying to decrease the cancellation rate might be medically counterproductive. The hourly rate of decisions in the scheduling office during regular work hours on the day of surgery highlights the importance of decisions made at the OR control desk and scheduling office throughout the day to reduce the hours of overused OR time. These data suggest that efforts of the Perioperative Surgical Home related to inpatient cancellations should focus on management decision-making to mitigate the disruptions to the planned OR schedule caused by inpatient case cancellations and add-on cases, more so than on efforts to reduce inpatient cancellation rates.

Background: The Night Float system (NFS) is often used in residency training programs to meet work hour regulations. The purpose of this study was to examine resident and attendings' perceptions of the NFS on issues of resident learning, well-being, work, non-educational activities and the health care system (patient safety and quality of care, inter-professional teams, workload on attendings and costs of on-call coverage)., Methods: A survey questionnaire with closed and open-ended questions (26 residents and eight attendings in an Internal Medicine program), informal discussions with the program and moonlighting and financial data were collected., Results and Discussion: The main findings included, (i) an overall congruency in opinions between resident and attendings across all mean comparisons, (ii) perceptions of improvement for most aspects of resident well-being (e.g. stress, fatigue) and work environment (e.g. supervision, support), (iii) a neutral effect on the resident learning environment, except resident opinions on an increase in opportunities for learning, (iv) perceptions of improved patient safety and quality of care despite worsened continuity of care, and (v) no increases in work-load on attendings or the health care system (cost-neutral call coverage). Patient safety, handovers and increased utilization of moonlighting opportunities need further exploration.

Introduction: Differences in after-hours capability or performance of ST-elevation myocardial infarction (STEMI) centers has the potential to impact outcomes of patients presenting outside of regular hours., Methods: Using a prospective observational study, we analyzed all 1,247 non-transfer STEMI patients treated in 15 percutaneous coronary intervention (PCI) facilities in Dallas, Texas, during a 24-month period (2010-2012). Controlling for confounding factors through a variety of statistical techniques, we explored differences in door-to-balloon (D2B) and in-hospital mortality for those presenting on weekends vs. weekdays and business vs. after hours., Results: Patients who arrived at the hospital on weekends had larger D2B times compared to weekdays (75 vs. 65 minutes; KW=48.9; p<0.001). Patients who arrived after-hours had median D2B times >16 minutes longer than those who arrived during business hours and a higher likelihood of mortality (OR 2.23, CI [1.15-4.32], p<0.05)., Conclusion: Weekends and after-hour PCI coverage is still associated with adverse D2B outcomes and in-hospital mortality, even in major urban settings. Disparities remain in after-hour STEMI treatment.

Background: Most countries lack a well-coordinated approach to out-of-hours endoscopy. Economic constraints and lack of resources have been identified as important barriers., Objective: To assess the performance evaluation of an out-of-hours emergency endoscopy model of care., Design: During a 3 year period (January 2010 to December 2012), data from consecutive outpatients (n = 332) with non-variceal acute upper gastrointestinal bleeding admitted or transferred to a single referral hospital were prospectively collected., Results: 34% (n = 113) were direct admissions whereas 66% (n = 219) were transferred from other hospitals. Median time to upper endoscopy esophagogastroduodenoscopy (EGD) was 6 h and 7.7 h for direct admissions and transferred, respectively. EGD was performed within 24 h in 90% of the patients. Rebleeding, in-hospital mortality, 30 day mortality and need for surgery were respectively 9.8%, 5.8%, 7.4%, and 6.6% and were not significantly different between the two groups. Age, malignancy, and moderate to high clinical Rockall risk score were independent predictors of in-hospital mortality in both groups. Age remained as an important predictor of main outcomes in transferred patients, while comorbidities differed according to admission status and predictable outcomes., Conclusion: This gastroenterology emergency model improved access and equity to out-of-hours endoscopy in an effective, safe, and timely way, recognized by the rates and the homogeneity observed in the outcomes, between transferred patients and direct admissions.

We evaluated the quality of telephone triage and the appropriateness of the decisions resulting from it at a primary care out-of-hours service. Four simulated clinical cases were used in the Incognito Standardized Patient method: an adult with nosebleed, an adult with fever, a child with fever and a child with vomiting. There was a set of obligatory questions for each case, translated from those used in a previous study. Quality was assessed by the proportion of questions asked by the call-handlers during telephone triage versus those that should have been asked. A total of 22 out-of-hours doctors were involved in the study, working in two different locations in the Verona city area. Over a 4-month period each of the four simulated clinical cases was used five times in calls to the two centres involved. The proportion of obligatory questions asked compared to those expected to be asked was 27-36%. On three occasions out of the 40 simulations, all of which were considered to be manageable by telephone, the patient was advised to go to an outpatient clinic for a face-to-face evaluation. The average duration of the calls was 3 min 47 s. The quality of telephone triage in the regions studied was low and provided considerable room for improvement. This is relevant to patient safety and risk management of the service., (© The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Objectives: During the early ('containment') phase of the influenza A(H1N1) pandemic, when the severity of the pandemic was unclear, health care workers (HCWs) across the UK were deployed to swab and prescribe antiviral drugs to suspected cases. This study describes the knowledge, attitudes, experience and behaviour of frontline HCWs in Birmingham, West Midlands, during this period., Methods: During June 2009, a 25-item semi-structured questionnaire was used to survey HCWs who undertook defined clinical duties as part of the public health response during the early phase of the pandemic. Participants were clinical staff based in a primary care out-of-hours service provider., Results: The response rate was 50% (n = 20). All respondents provided direct clinical care that necessitated prolonged close contact with potentially infectious cases. Knowledge and use of personal protective equipment and infection control procedures was consistently high. However, the main source of infection control advice was local guidance. Uptake of, and attitude towards, vaccination as a preventive measure and antiviral prophylaxis was poor., Conclusions: HCWs were prepared to provide an essential health care response during the pandemic even when the severity of disease was unclear. However, more needs to be done to change health care workers' negative attitudes towards taking antivirals and receiving influenza vaccination., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background and Rationale: European countries face similar challenges in the provision of health care. Demographic factors like ageing, population growth, changing patient behaviour, and lack of work force lead to increasing demands, costs, and overcrowding of out-of-hours (OOH) care (i.e. primary care services, emergency departments (EDs), and ambulance services). These developments strain services and imply safety risks. In the last few decades, countries have been re-organizing their OOH primary health care services. AIM AND SCOPE OF THE NETWORK: We established a European research network for out-of-hours primary health care (EurOOHnet), which aims to transfer knowledge, share experiences, and conduct research. Combining research competencies and integrating results can generate a profound information flow to European researchers and decision makers in health policy, contributing towards feasible and high-quality OOH care. It also contributes to a more comparable performance level within European regions. CONDUCTED RESEARCH PROJECTS: The European research network aims to conduct mutual research projects. At present, three projects have been accomplished, among others concerning the diagnostic scope in OOH primary care services and guideline adherence for diagnosis and treatment of cystitis in OOH primary care., The Future: Future areas of research will be organizational models for OOH care; appropriate use of the OOH services; quality of telephone triage; quality of medical care; patient safety issues; use of auxiliary personnel; collaboration with EDs and ambulance care; and the role of GPs in OOH care.

Introduction: Foundation Training is designed for doctors in their first two years of post-graduation. The number of foundation doctors (FD) in the UK working nights has reduced because of a perception that clinical supervision at night is unsatisfactory and that minimal training opportunities exist. We aimed to assess the value of night shifts to FDs and hypothesised that removing FDs from nights may be detrimental to training., Methods: Using a survey, we assessed the number of FDs working nights in London, FDs views on working nights and their supervision at night. We evaluated whether working at night, compared to daytime working provided opportunities to achieve foundation competencies., Results: 83% (N = 2157/2593) of FDs completed the survey. Over 90% of FDs who worked nights felt that the experience they gained improved their ability to prioritise, make decisions and plan. FDs who worked nights reported higher scores for achieving competencies in history taking (2.67 vs. 2.51; p = 0.00), examination (2.72 vs. 2.59; p = 0.01) and resuscitation (2.27 vs. 1.96; p = 0.00). The majority (65%) felt adequately supervised., Conclusions: Our survey has demonstrated that FDs find working nights a valuable experience, providing important training opportunities, which are additional to those encountered during daytime working.

Introduction: The importance of supervision and of surgeons' level of experience in relation to patient outcome have been demonstrated in both hip fracture and arthroplasty surgery. The aim of this study was to describe the surgeons' experience level and the extent of supervision for: 1) fracture-related surgery in general; 2) the three most frequent primary operations and reoperations; and 3) primary operations during and outside regular working hours., Material and Methods: A total of 9,767 surgical procedures were identified from the Danish Fracture Database (DFDB). Procedures were grouped based on the surgeons' level of experience, extent of supervision, type (primary, planned secondary or reoperation), classification (AO Müller), and whether they were performed during or outside regular hours., Results: Interns and junior residents combined performed 46% of all procedures. A total of 90% of surgeries by interns were performed under supervision, whereas 32% of operations by junior residents were unsupervised. Supervision was absent in 14-16% and 22-33% of the three most frequent primary procedures and reoperations when performed by interns and junior residents, respectively. The proportion of unsupervised procedures by junior residents grew from 30% during to 40% (p < 0.001) outside regular hours., Conclusion: Interns and junior residents together performed almost half of all fracture-related surgery. The extent of supervision was generally high; however, a third of the primary procedures performed by junior residents were unsupervised. The extent of unsupervised surgery performed by junior residents was significantly higher outside regular hours., Funding: not relevant., Trial Registration: The Danish Fracture Database ("Dansk Frakturdatabase") was approved by the Danish Data Protection Agency ID: 01321.

Background: European disease-specific antibiotic prescribing quality indicators (APQI) were proposed for seven acute indications (bronchitis, upper respiratory infection, cystitis, tonsillitis, sinusitis, otitis media and pneumonia): (a) the percentage of patients prescribed an antibiotic; (b) the percentage of patients receiving the guideline recommended antibiotic; (c) the percentage of patients receiving quinolones., Objectives: To assess the feasibility of calculating values for these 21 APQI using primary care databases; and to assess the quality of antibiotic prescribing in office hours and out-of-hours general practice., Methods: Data was extracted from a morbidity registration network ( http://www.intego.be ) and the out-of-hours service centre in Flanders. Within both databases diagnoses are labelled using the revised second edition of International Classification of Primary Care (ICPC-2-R) and antibiotic prescriptions using Anatomical Therapeutic Chemical (ATC) classification., Results: Both databases allow calculation of APQI values and results are similar. Only for cystitis was the percentage of patients prescribed an antibiotic within the proposed acceptable range. For all indications, the percentage of recommended antibiotics was below the proposed acceptable range (80-100%). The percentage of quinolones was within the proposed acceptable range (0-5%) for otitis media, upper respiratory infection and tonsillitis., Conclusion: Primary care databases can produce APQI values. These values revealed huge opportunities to improve the quality of antibiotic prescribing in office hours and out-of-hours Flemish general practice, especially the prescription of recommended antibiotics.

Background: After-hours out-of-hospital phone consultations require physicians to make decisions based on information provided by a nurse over the phone., Methods: We conducted a simulation study to evaluate physicians' actions following communication of key information. 22 nurses were asked to call physicians with six cases based on the six most common reasons for after-hours phone calls. We evaluated physicians' actions following the communication of key clinical information: A situation cue described a patient's problem (eg, confusion). A background cue described a specific clinical finding regarding the cause of the problem (eg, patient's sodium is low). For each cue we defined a list of indicators, based on the medical literature, to ascertain whether physicians acted upon the provided information (which was defined as addressing at least one of the indicators)., Results: A total of 108 phone consultations (containing 88 situation and 93 background cues) were analysed. Situation cues were communicated in 90% (79/88) of the calls and background cues in 33% (31/93). Physician acted upon the provided information in 57% (45/79) and 48% (15/31) of the communicated situation and background cues, respectively. When the background cues were not communicated, physicians asked questions expected to elicit the cue in 12% of the cases. Responding to the situation cue was associated with longer conversations and active inquiry by the physician., Conclusions: After-hours phone calls are error prone. Both nurse communication and physician decision-making are problematic. Efforts to improve patient safety in this setting must address both communication and decision-making.

This study reviews the clinical and workforce impact of a suggested protocol designed for the management of suspected acute deep venous thrombosis (DVT) in patients seen after standard vascular laboratory business hours. The protocol included the use of Wells score, D-dimer and a single dose of therapeutic anticoagulant to defer venous duplex ultrasound (VDU) testing until routine business hours unless contraindicated. Information was collected on medical history, physical exam and the timing of any diagnostic studies and treatment provided. Over 15% of studies done after-hours were deemed unnecessary by our protocol and in every individual the results were negative for an acute DVT. There were no adverse events from a one-time dose of anticoagulant. Limiting emergency VDU coverage to evaluate for acute DVT based on a management protocol can eliminate unnecessary after-hours VDU testing without having a negative impact on patient care.

Background: The Hospital at Night system has been widely adopted to manage Out-of-Hours workload. However, it has the potential to introduce delays and corruption of information. The introduction of newer technologies to replace landlines, pagers and paper may ameliorate these issues., Aim: To establish if the introduction of a Hospital at Night system supported by a wireless taskflow system affected the escalation of high Early Warning Scores (EWSs) to medical attention, and the time taken to medical review., Design: Prospective 'pre and post' observational study in a teaching hospital in the UK., Methods: Review of observation charts and medical records, and data extraction from the electronic taskflow system., Results: The implementation of a technology-supported Hospital at Night system was associated with a significant decrease in time to documentation of initial review in those who were reviewed. However, there was no change in the proportion of those with a high EWS that were reviewed, and throughout the study a majority of patients with high EWSs were not reviewed in accordance with guidelines., Conclusion: Introduction of a Hospital at Night system supported by mobile technology appeared to improve the transfer of information, but did not affect the nursing decision whether to escalate abnormal findings.

Background: The substantial prevalence of bacterial lower urinary tract infections (LUTIs) in out-of-hours (OOH) primary care is a reason for frequent prescription of antibiotics. Insight in guideline adherence in OOH primary care concerning treatment of LUTIs is lacking., Aims: To check feasibility of the use of OOH routine data to assess guideline adherence for the treatment of LUTI in OOH primary care, in different regions of Europe., Methods: We compared guidelines for diagnosis and treatment of uncomplicated LUTIs in nine European countries, followed by an observational study on available data of guideline adherence. In each region a convenience sample of registration data of at least 100 contacts per OOH primary care setting was collected. Data on adherence (% of contacts) was identified for type of antibiotic and for full treatment adherence (i.e. recommended type and dose and duration)., Results: Six countries were able to provide data on treatment of LUTIs. Four of them succeeded to collect data on type, dosage and duration of treatment. Mostly, trimethoprim was the treatment of first choice, sometimes combined with sulfamethoxazol or sulfamethizol. Adherence with the type of antibiotics varied from 25% to 100%. Denmark achieved a full treatment adherence of 40.0%, the Netherlands 72.7%, Norway 38.3%, and Slovenia 22.2%., Conclusion: Guidelines content is similar to a large extent in the participating countries. The use of OOH routine data for analysis of guideline adherence in OOH primary care seems feasible, although some challenges remain. Adherence regarding treatment varies and suggests room for improvement in most countries.

Background: This study aimed to perform a structural analysis of determinants of risk of critical incidents in care for women with a low risk profile at the start of pregnancy with a view on improving patient safety., Methods: We included 71 critical incidents in primary midwifery care and subsequent hospital care in case of referral after 36 weeks of pregnancy that were related to substandard care and for that reason were reported to the Health Care Inspectorate in The Netherlands in 36 months (n = 357). We performed a case-by-case analysis, using a previously validated instrument which covered five broad domains: healthcare organization, communication between healthcare providers, patient risk factors, clinical management, and clinical outcomes., Results: Determinants that were associated with risk concerned healthcare organization (n = 20 incidents), communication about treatment procedures (n = 39), referral processes (n = 19), risk assessment by telephone triage (n = 10), and clinical management in an out of hours setting (n = 19). The 71 critical incidents included three cases of maternal death, eight cases of severe maternal morbidity, 42 perinatal deaths and 12 critical incidents with severe morbidity for the child. Suboptimal prenatal risk assessment, a delay in availability of health care providers in urgent situations, miscommunication about treatment between care providers, and miscommunication with patients in situations with a language barrier were associated with safety risks., Conclusions: Systematic analysis of critical incidents improves insight in determinants of safety risk. The wide variety of determinants of risk of critical incidents implies that there is no single intervention to improve patient safety in the care for pregnant women with initially a low risk profile.

Background: Mortality among emergency medical admissions has been reported to be higher when patients are admitted to hospital at nights and weekends., Aim: We studied the outcome of ST elevation myocardial infarction (STEMI) patients presenting at different times to our centre with 24/7 primary percutaneous coronary intervention (PPCI) service., Methods: We divided all patients who underwent PPCI between September 2009 and November 2011 into three groups according to the time of admission as group 1: in-hours (0800-1800 h weekdays), group 2: out-of-hours (1800- 0800 h weekdays) and group 3: weekends (Sat to Mon 0800-0800 h)., Results: A total of 605 (41.1%), 397 (27%) and 469 (31.9%) were included in group 1, 2 and 3, respectively. Apart from cardiogenic shock (8.9%, 5.5% and 7.7%, P = 0.05) and door to balloon time (median 29, 33 and 36 min, P < 0.0001), there was no significant difference noted in the baseline and procedural characteristics between the groups. In-hospital mortality (4.6%, 4.3% and 5.3%, P = 0.5), 30-day mortality (6.4%, 6.3% and 7%, P = 0.7), 30-day stent thrombosis (0.8%, 0.8% and 0.2%, P = 0.1) and 1-year mortality (10.7%, 10.8% and 9.8%, P = 0.7) were no difference between the groups. On logistic regression analysis, out-of-hours and weekend admissions were not found to be a predictor of both 30-day and 1-year mortality., Conclusion: In this consecutive series of patients admitted to a high volume PPCI centre, there was no difference in mortality when patients were admitted at different times. The involvement of senior medical staff early in the patients' admission may have contributed to these consistent outcomes.

Commercial teleradiology is well established in the US. There are many factors to consider when engaging a teleradiology provider. One of the basic questions is what do you expect to gain from it? Do you want a final reading from an attending radiologist (known as a consultant radiologist in many countries) or would you be satisfied with a preliminary reading from a teleradiology provider and a final reading from your own in-house radiologist the following day? Do you simply require after-hours coverage or do you need to supplement the coverage provided by your own internal radiologists during normal working hours? Teleradiology is not without its drawbacks. It can add additional costs, particularly for after-hours coverage. Teleradiology rarely provides in-house coverage for procedures, and the interpreting radiologist may sometimes be difficult to contact for consultation. Choosing a teleradiology vendor requires due diligence. When the contracting entity defines its expectations well and chooses its teleradiology vendor with care, the end result will be satisfactory for all concerned, including the patients.

Background: The global demand for diagnostic imaging exceeds the supply of radiologists and is of particular significance in poorly resourced healthcare environments where many radiographs are unreported. Delayed or absent reporting may negatively impact patient management. In well-resourced countries there is recognition that extending the role of radiographers to radiological reporting tasks helps meet service demands. Aim. To determine the accuracy of acute fracture detection by South African radiographers working in an after-hour setting., Method: We performed a retrospective study of radiographers at a Western Cape Regional Hospital over 2 months in 2011. The sensitivity and specificity of radiographers' fracture detection were compared with that of a consultant radiologist. Differences were evaluated using the McNemar chi-squared test, with p<0.05 regarded as significant., Results: A total of 369 radiographs were analysed. The overall accuracy of reporting by radiographers was 93.7%, with 74.4% sensitivity for fracture detection. Experienced radiographers performed better than inexperienced radiographers; adult fractures were more consistently identified than paediatric fractures, and appendicular fractures were better visualised than axial fractures. In all instances there was a significant difference between fracture detection by radiographers and the radiologist. Experienced radiographers evaluating appendicular fractures in adults achieved the highest sensitivity (89.9%), which was not significantly different from that of a consultant radiologist (p=0.88)., Conclusion: The performance of experienced radiographers in our study is comparable with that of experienced radiographers internationally, who have no specific training in trauma radiograph reporting. However, additional training is required if role extension is to be considered.

Background: Overnight radiology services (ORSs) provide computed tomography (CT) scan readings that are automatically reviewed by staff radiologists (SRs) and the trauma service. Discordant readings and their clinical significance were investigated., Methods: ORS-read CT scans over 3 years were reviewed. A discordant reading was clinically significant if it resulted in a substantive change in patient care. All clinically significant findings were reviewed by a blinded radiologist., Results: Five hundred thirty-four CT scans were identified: 191 (35.8%) head, 187 (35%) cervical, 66 (12.4%) chest, and 90 (16.9%) abdomen/pelvis scans. One hundred twenty-three scans (23%) were abnormal with a DR of 16%: 5 head, 2 cervical, 7 chest, and 6 abdomen/pelvis scans. Seven (6%) scans had clinically significant findings missed: 3 head and 4 abdomen/pelvis scans. ORSs missed 7, and SRs missed 3 clinically significant findings. A blinded radiologist confirmed the clinically significant findings., Conclusions: The discordant rate of readings for abnormal CT scans was 16% with 37% considered to be clinically significant. ORSs missed 100%, and 29% of the clinically significant findings were identified after SR/trauma service rounds. SR/trauma service review of ORS readings is supported., (Copyright © 2013 Elsevier Inc. All rights reserved.)