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Postoperative critical care provided by critical care specialists, or intensivists, improves outcomes after surgery. Although there are data supporting daytime intensivist coverage in the intensive care unit, it is not clear how nighttime specialist coverage impacts the quality of care or outcomes. Many surgical intensive care units have adopted continuous 24-hour critical care coverage. Here, we highlight an important study by Wallace and colleagues that reports the impact of nighttime intensivist staffing on outcomes in critically ill patients., (Copyright © 2012. Published by Elsevier Inc.)

Objective: For over a decade, out-of-hours primary care in the Netherlands has been provided by general practitioner (GP) cooperatives. In the past years, quality improvements have been made and patients have become acquainted with the service. This may have increased patient satisfaction. The objective of this study was to examine changes in patient satisfaction with GP cooperatives over time., Design: Longitudinal observational study. A validated patient satisfaction questionnaire was distributed in 2003-2004 (T1) and 2007-2008 (T2). Items were rated on a scale from 0 to 10 (1 = very bad; 10 = excellent)., Setting: Eight GP cooperatives in the Netherlands., Subjects: Stratified sample of 9600 patients. Response was 55% at T1 (n = 2634) and 51% at T2 (n = 2462)., Main Outcome Measures: Expectations met; satisfaction with triage nurses, GPs, and organization., Results: For most patients the care received at the GP cooperative met their expectations (T1: 86.1% and T2: 88.4%). Patients were satisfied with the triage nurses (overall grade T1: 7.73 and T2: 7.99), GPs (T1: 8.04 and T2: 8.25), and organization (overall grade T1: 7.60 and T2: 7.78). Satisfaction with triage nurses showed the largest increase over time. The quality and effectiveness of advice or treatment were given relatively low grades. Of all organizational aspects, the lowest grades were given for waiting times and information about the cooperative., Conclusion: In general, patients were initially satisfied with GP cooperatives and satisfaction had even increased four years later. However, there is room for improvement in the content of the advice, waiting times, and information supply. More research is needed into satisfaction of specific patient groups.

Objective: To assess the safety and efficiency of triaging low urgent self-referred patients at the emergency department (ED) to a general practitioner (GP) based on the Manchester triage system (MTS)., Methods: All self-referred patients in the evening, night and weekends were included in this prospective observational study. Patients were triaged by an ED nurse according to the MTS and allocated to a GP or the ED according to a predefined care scheme. For patients treated by the GP, assessments were made of safety as measured by hospitalisation and return to the ED within 2 weeks, and efficiency as measured by referral to the ED., Results: In 80% of cases allocation of the self-referrals to the ED or GP was according to a predefined scheme. Of the 3129 low urgent self-referred patients triaged to the GP, 2840 (90.8%) were sent home, 202 (6.5%) were directly referred to the ED, 36 (1.2%) were hospitalised. Within a random sample of low urgent patients sent home by the GP (222 of 2840), 8 (3.6%) returned to the ED within 2 weeks. Against the agreed MTS scheme, the ED also directly treated 664 low urgent patients, mainly for extremity problems (n=512). Despite the care agreements, 227 urgent patients were treated by the GP, with a referral rate to the ED of 18.1%, a hospitalisation rate of 4.0% and a 4.5% return rate to the ED within 2 weeks., Conclusions: Low urgent self-referrals, with the exception of extremity problems, were shown to be treated efficiently and safely by a GP. A selected group of more urgent patients also seem to be handled adequately by the GP. Triage of low urgent patients with extremity problems and reasons for nurses not following a predefined triage allocation scheme need further elaboration.

Background: Triage at out-of-hours GP cooperatives (GPCs) is aimed at determining medical urgency and guiding decisions. Both medical knowledge and communication skills are required for this complex task., Objective: To explore the impact of quality of consultation and estimated urgency on the appropriateness of decisions., Methods: We performed a secondary analysis of telephone triage consultations by nurses at 29 Dutch GPCs. Consultations were taped and assessed by trained observers, using a validated instrument. Measures concerned quality of consultation, nurse-estimated urgency (four levels) and appropriateness of decisions (urgency, follow-up advice and timing). Bivariate analyses and logistic multilevel regression analyses were used to explore the impact of quality of consultation (controlling for urgency) on appropriateness of decisions., Results: The sample included 6739 telephone contacts, most of which (90%) were non-urgent. The majority of decisions were appropriate (91% for urgency, 96% for follow-up advice and 95% for timing). In bivariate analyses, appropriateness of decisions was positively related to higher quality of consultation. Estimated urgency was negatively associated with quality of consultation. Logistic multilevel analysis showed that higher quality of consultation was related to a more appropriate estimation of urgency [odds ratio (OR) = 1.82; 95% confidence interval (CI): 1.69-1.95], follow-up advice (OR = 2.69; 95% CI: 2.41-3.01) and timing of decisions (OR = 2.41; 95% CI: 2.20-2.63)., Conclusions: High quality of consultation has a positive, but small, impact on the appropriateness of decisions. Quality of consultation needs to be targeted in training and support of triage nurses, especially when it concerns highly urgent contacts.

Objective: To assess the impact of personnel and unit factors on outcome from cardiac arrest in a dedicated pediatric cardiac intensive care unit., Design: Retrospective medical record review., Setting: Dedicated cardiac intensive care unit at a quaternary academic children's hospital., Patients: Children and young adults who had cardiac arrest while cared for in the pediatric cardiac intensive care unit from January 1, 2006, to December 31, 2008., Interventions: None., Measurements and Main Results: One hundred two index cardiac arrests over a 3-yr period in our pediatric cardiac intensive care unit were reviewed. We defined successful resuscitation as either return of spontaneous circulation or successful cannulation to extracorporeal membrane oxygenation. Differences in resuscitation rates were assessed across categorical systems variables using logistic regression. The rate of successful resuscitation was 84% (return of spontaneous circulation 74%, extracorporeal membrane oxygenation 10%). Survival to hospital discharge was 48% for patients who had a cardiac arrest. 11% of arrests during the week and 31% during weekends (odds ratio 3.8; 95% confidence interval 1.2-11.5) were not successfully resuscitated. Unsuccessful resuscitation was significantly more likely when the primary nurse had <1 yr of experience in the pediatric cardiac intensive care unit (50% <1 yr vs. 13% >1 yr; odds ratio 6.8; confidence interval 1.5-31.0). Cardiac arrest on a weekend day and <1-yr pediatric cardiac intensive care unit nursing experience were also associated with unsuccessful resuscitation in a multivariable model. Resuscitation outcomes were similar when senior intensive care unit attending physicians were on-call at the time of arrest compared with other intensive care unit staff (17% unsuccessful vs. 15%; odds ratio 1.2; confidence interval 0.4-3.7). Arrests where the attending physician was present at the onset resulted in unsuccessful resuscitation 18% of the time vs. 14% for events where the attending was not present (odds ratio 1.3; confidence interval 0.5-3.9)., Conclusions: Our data suggest that personnel and unit factors may impact outcome after cardiac arrest in a pediatric cardiac intensive care unit. Weekend arrests and less experience of the primary nurse were risk factors for unsuccessful resuscitation. Neither presence at arrest onset nor experience of the attending cardiac intensivist was associated with outcome.

Study Objectives: To determine 1) which proportion of academic departments have policies concerning older anesthesiologists, 2) whether departments with such policies, particularly those related to call, had characteristics such as departmental size and proportions of older anesthesiologists that differed from departments without these policies, 3) if departments routinely screened their older members for problem behaviors, and 4) if departments provided nonclinical roles for older anesthesiologists., Design: Survey instrument., Setting: Academic medical centers., Measurements: An anonymous, web-based questionnaire that included questions on demographics and specific policy-related issues was sent to chairpersons of all academic anesthesia departments in the ASA database., Main Results: No department directly addressed every issue listed in the survey. Department size and the number of anesthesiologists over 60 years of age were unrelated to whether that department had one or more policies for older anesthesiologists. Twenty percent of programs stopped night call at age 60 years. Most departments did not exempt older anesthesiologists of any age from call responsibilities. Almost all departments tracked critical incidents and errors in technique and/or judgment. Almost three quarters tracked substance abuse, and over half of the responding departments tracked physical and emotional impairment and fixation errors. A third of departments tracked all 6 types of problem behavior. Only 12% had specific assessment tools for tracking problem behaviors in the clinic, and no department used these tools specifically for older anesthesiologists. While only 17% of departments directed older anesthesiologists into nonclinical roles, older clinicians had teaching, mentoring, and administrative roles within most of the departments., Conclusions: Relatively few departments had specific policies for older anesthesiologists that addressed the issues raised in the survey. Further research is needed to determine whether departments should decrease ambiguity of their policies, formulate explicit policies for older anesthesiologists, especially in regard to call, and assess problem behaviors more directly., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Aim: This article is a report of a review that aimed to synthesize qualitative and quantitative evidence of 'off-shifts' (nights, weekends and/or holidays) on quality and employee outcomes in hospitals., Background: Healthcare workers provide 24-hour-a-day, 7-day-a-week service. Quality and employee outcomes may differ on off-shifts as compared to regular hours., Data Sources: Searches for studies occurred between the years 1985-2011 using computerized databases including Business Source Complete, EconLit, ProQuest, PubMed and MEDLINE. REVIEW DESIGN AND METHODS: Design was a mixed-method systematic review with quantitative and qualitative studies. To be included, studies met the following criteria: (1) the independent variable was an off-shift; (2) the article was a research study and peer-reviewed; (3) the article could be obtained in English; and (4) the article pertained to health care. Studies were not excluded on design., Results: Sixty studies were included. There were 37 quality outcome, 19 employee outcome and four qualitative studies. In the quality outcome studies, researchers often used quantitative, longitudinal study designs with large sample sizes. Researchers found important differences between patients admitted on weekends and mortality. Important differences were also found between nighttime birth and mortality and rotating night work and fatigue, stress and low mental well-being. Most studies (9 of 12) did not find an important association between patients admitted at night and mortality., Conclusion: Patient outcomes on weekends and employee outcomes at night are worse than during the day. It is important to further investigate why care on off-shifts differs from weekly day shifts.

Recently, the United Kingdom Haemophilia Centre Doctors Organisation published recommendations for the standard of care for assessment and treatment of patients with bleeding disorders in the emergency department (A&E). An audit was undertaken to compare the level of care to the acceptable standards in a tertiary hospital A&E, attached to a haemophilia comprehensive care centre. A&E attendances were found by cross referencing all patients with known bleeding disorders against the EDMS attendance system. Visits from the past 3 years were identified to produce sufficient data and electronic notes from these visits were then accessed, and marked against the proforma. Data were available from 45 of a total of 54 patients, who had a total of 75 emergency visits documented. In all aspects of care, the standards were not adequately met including the average length of time between booking and clinical assessment, early initiation of specific haemostatic treatment, seeking haematology advice and arrangement of follow-up. Also no specialist clotting investigations were done with only 9/11 patients admitted having their haematological diagnosis recorded. In addition, only very few patients had the severity of bleeding disorder noted and less than half their first line treatment documented. There were significant differences in the standard of care for haemophilia patients provided by the A&E department when compared with acceptable standards. Measures have been put in place and policies have been drafted to improve this situation and provide the best possible care to persons with haemophilia., (© 2011 Blackwell Publishing Ltd.)

Background: The purpose of this study was to validate and assess the accuracy and usefulness of sending short video clips in 3gp file format of an entire scan series of patients, using mobile telephones running on 3G-MMS technology, to enable consultation between junior doctors in a neurosurgical unit and the consultants on-call after office hours., Method: A total of 56 consecutive patients with acute neurosurgical problems requiring urgent after-hours consultation during a 6-month period, prospectively had their images recorded and transmitted using the above method. The response to the diagnosis and the management plan by two neurosurgeons (who were not on site) based on the images viewed on a mobile telephone were reviewed by an independent observer and scored. In addition to this, a radiologist reviewed the original images directly on the hospital's Patients Archiving and Communication System (PACS) and this was compared with the neurosurgeons' response., Results: Both neurosurgeons involved in this study were in complete agreement with their diagnosis. The radiologist disagreed with the diagnosis in only one patient, giving a kappa coefficient of 0.88, indicating an almost perfect agreement., Conclusion: The use of mobile telephones to transmit MPEG video clips of radiological images is very advantageous for carrying out emergency consultations in neurosurgery. The images accurately reflect the pathology in question, thereby reducing the incidence of medical errors from incorrect diagnosis, which otherwise may just depend on a verbal description.

Aims: To report on the safety and efficiency of a comprehensive stroke thrombolysis service and look for evidence of disparity between in-hours and out-of-hours treatment times., Method: Clinical audit of patients treated with tissue plasminogen activator, alteplase (rt-PA) for stroke at Wellington Hospital between 1 November 2009 and 31 October 2010., Results: Thirty-one patients were treated with rt-PA. All were treated within agreed clinical eligibility criteria. The median NIHSS score pre-treatment was 10; post treatment 5. Two patients died, both from intracranial haemorrhage. Overall the average time to treatment from symptom onset was 168 minutes. Those treated out-of-hours had an additional delay of 33 minutes compared to in-hours treatment (p=0.03)., Conclusions: Patients admitted out-of-hours had significantly longer delays to rt-PA treatment. Those planning Stroke Services should ensure this source of inequity is addressed within their localities.

Background: There is a heavy reliance on registrars for after-hours CT reporting with a resultant unavoidable error rate., Purpose: To determine the after-hours CT reporting error rate by radiology registrars and influencing factors on this error rate., Material and Methods: A 2-month prospective study was undertaken at two tertiary, level 1 trauma centers in Johannesburg, South Africa. Provisional CT reports issued by the registrar on call were reviewed by a qualified radiologist the following morning and information relating to the number, time and type of reporting errors made as well as the body region scanned, indication for the scan, year of training of the registrar, and workload during the call were recorded and analyzed., Results: A total of 1477 CT scans were performed with an overall error rate of 17.1% and a major error rate of 7.7%. The error rate for 2nd, 3rd, and 4th year registrars was 19.4%, 15.1%, and 14.5%, respectively. A significant difference was found between the error rate in reporting trauma scans (15.8%) compared to non-trauma scans (19.2%) although the difference between emergency scans (16.9%) and elective scans (22.6%) was found to be not significant, a finding likely due to the low number of elective scans performed. Abdominopelvic scans elicited the highest number of errors (33.9%) compared to the other body regions such as head (16.5%) and cervical, thoracic, or lumbar spine (11.7%). Increasing workload resulted in a significant increase in error rate when analyzed with a generalized linear model. There was also a significant difference noted in the time of scan groups which we attributed to a workload effect. Missed findings were the most frequent errors seen (57.3%)., Conclusion: We found an increasing error rate associated with increasing workload and marked increase in errors with the reporting of abdominopelvic scans. There was a decrease in the error rate when looking an increasing year of training although this there was only found to be significant difference between the 2nd and 3rd year registrars.

Objective: Telephone triage in patients requesting help may compromise patient safety, particularly if urgency is underestimated and the patient is not seen by a physician. The aim was to assess the research evidence on safety of telephone triage in out-of-hours primary care., Methods: A systematic review was performed of published research on telephone triage in out-of-hours care, searching in PubMed and EMBASE up to March 2010. Studies were included if they concerned out-of-hours medical care and focused on telephone triage in patients with a first request for help. Study inclusion and data extraction were performed by two researchers independently. Post-hoc two types of studies were distinguished: observational studies in contacts with real patients (unselected and highly urgent contacts), and prospective observational studies using high-risk simulated patients (with a highly urgent health problem)., Results: Thirteen observational studies showed that on average triage was safe in 97% (95% CI 96.5-97.4%) of all patients contacting out-of-hours care and in 89% (95% CI 86.7-90.2%) of patients with high urgency. Ten studies that used high-risk simulated patients showed that on average 46% (95% CI 42.7-49.8%) were safe. Adverse events described in the studies included mortality (n = 6 studies), hospitalisations (n = 5), attendance at emergency department (n=1), and medical errors (n = 6)., Conclusions: There is room for improvement in safety of telephone triage in patients who present symptoms that are high risk. As these have a low incidence, recognition of these calls poses a challenge to health care providers in daily practice.

There are many challenges associated with providing out-of-hours care in hospital. Recognising the need to improve patient safety and clinical governance, Nottingham University Hospitals Trust has introduced IT to improve its Hospital at Night (HaN) service. Before this, the service suffered delays in care delivery and information inaccuracy, leading to safety concerns. These concerns were highlighted in two internal reviews of out-of-hours care undertaken at the trust. This article outlines how the technology has made the HaN service more efficient, safer, and improved staff satisfaction.

Background: In the Netherlands, out-of-hours primary care has been re-organized from small on-call rota groups to large-scale GP co-operatives. However, out-of-hours palliative care is an area of concern. According to studies in the UK, the transfer of information about terminally ill patients to GP co-operatives seems to be poor, resulting in care that is often inadequate. Our aim was to investigate the experiences of GPs in the Netherlands about the quality of out-of-hours palliative care provided by GP co-operatives, and to identify elements of care that might need to be improved., Setting: General practice., Design: Qualitative study, using three focus group discussions, analysed in a qualitative descriptive approach., Results: GPs participating in the focus groups, considered the quality of out-of-hours palliative care that is provided by GP co-operatives to be meagre. The service provided by the co-operatives was designed for acute medical problems, rather than for palliative care needs. The GPs reported three major problems: ( 1 ) lack of adequate information at the GP out-of-hours service; ( 2 ) lack of anticipatory care during office hours; and ( 3 ) absence of a palliative care policy in the GP co-operatives., Conclusions: Although GP co-operatives are capable of providing continuity in palliative care, improvements could be achieved if GPs and GP co-operatives address the problems mentioned above.

Many Western countries are seeking an organizational model for after-hours primary care that is safe, efficient, and satisfactory for patients and health care professionals. Around the year 2000, Dutch primary care physicians (PCPs) reorganized their after-hours primary care and shifted from small rotation groups to large-scale PCP cooperatives. This article provides a narrative review of studies on a range of issues about after-hours primary care in the Netherlands, including experiences of health care professionals and patients, patient-safety incidents, adherence to practice guidelines, waiting times, and quality of telephone triage. Physicians expressed high satisfaction with PCP cooperatives; their workload decreased, and job satisfaction increased compared with the situation before the reorganization. In general, patients were also satisfied, but areas for improvement included telephone consultations, patient education, and distance to a pharmacy. A study identified patient-safety incidents in 2.4% of all contacts, of which most did not result in harm to patients. The average adherence to clinical guidelines by physicians was 77%, with lowest adherence scores for prescribing antibiotics and treatment in emergency cases. The average waiting time for home visits was 30 minutes. Seventy percent of patients with life-threatening problems were visited within the time target of 15 minutes. Telephone triage by nurses had positive effects on care efficiency by increasing the proportion of telephone consultations and decreasing the proportion of clinic consultations and home visits. The after-hours primary care system in the Netherlands might set an example for other countries struggling to find a good solution for the problems they encounter with after-hours primary care. Future developments in the Netherlands include integration and extensive collaboration with the accident and emergency departments of hospitals, in which PCPs take care of self-referring patients.

Objective: To evaluate the impact of emergency care practitioners (ECPs) on the patient care pathway for children presenting with minor conditions in unscheduled care settings., Design: A pragmatic quasi-experimental multi-site community intervention trial comparing ECPs with usual care providers., Setting: Three pairs of emergency and urgent care services in the UK: minor injury unit (MIU), urgent care centre (UCC) and general practitioner out of hours., Patients: Paediatric acute episodes (n=415 intervention and n=748 control) in participating services presenting with minor conditions., Main Outcome Measures: Percentage of patients discharged following care episode and percentage of patients referred to hospital and primary care services. Interventions ECPs operational in emergency and unscheduled care settings., Results: ECPs discharged significantly fewer patients than usual care providers (percentage difference 7.3%, 95% CI 13.6% to 0.9%). ECPs discharged fewer patients within all three pairs of services (out of hours percentage difference 6.33%, 95% CI 15.17% to 2.51%; UCC percentage difference 8.73%, 95% CI 19.22% to 1.76%; MIU percentage difference 6.80%, 95% CI 24.36% to 10.75%). ECPs also referred more patients to hospital (percentage difference 4.6%, 95% CI -2.9% to 12.0%) and primary care providers (percentage difference 3.0%, 95% CI 3.7% to 9.7%)., Conclusions: ECPs are not as effective as usual health providers in discharging children after assessment of urgent healthcare problems. This has implications for the workload of other paediatric providers such as the emergency department. ECPs may be better targeted to settings and patients groups in which there is more evidence of their effectiveness in patient care pathways.

Background and Objective: Out-of-hours services for primary care provision are increasing in policy relevance. The aim of this qualitative study was to explore service users' recent experiences of out-of-hours services and to identify suggestions for improvement for services and practitioners involved., Methods: We used data from a cross-sectional survey of service users' self-reported experiences of 13 out-of-hours centres in Wales. Three hundred and forty-one respondents provided free-text comments focusing on suggestions for improvement within the survey instrument (the Out-of-hours Patient Questionnaire). A coding framework was based on previous literature focusing on patients' experiences of out-of-hours services, built upon and refined as it was systematically applied to the data. Emergent themes and subthemes were charted and interpreted to comprise the findings., Results: Central themes emerged from users' perspectives of the structure of out-of-hours services, process of care and outcomes for users. Themes included long waiting times, perceived quality of service user-practitioner communication, consideration for parents and children and accessibility of the service and medication. Suggestions for improving care were made across these themes, including triaging patients more effectively and efficiently, addressing specific aspects of practitioners' communication with patients, reconsidering the size of areas covered by services and number of professionals required for the population covered, extending GP and pharmacy opening times and medication delivery services., Conclusions: It is important to consider ways to address service users' principal concerns surrounding out-of-hours services. Debate is required about prioritizing and implementing potential improvements to out-of-hours services in the light of resource constraints.

Objectives: Changes in the contractual responsibilities of primary care practitioners and health boards have resulted in a plethora of arrangements relating to out-of-hours healthcare services. Rather than being guaranteed access to a GP (usually either their own or another through a local GP co-operative), patients have a number of alternative routes to services. Our objective was to identify and assess the availability and adequacy of relevant standards, responsibilities and information systems in Scotland to monitor the impact of contractual changes to out-of-hours healthcare services on equity of access., Design: Cross-sectional study., Setting: All providers of primary care out-of-hours services in Scotland., Participants: Not applicable., Main Outcome Measures: First, identification and policy review of current standards and performance monitoring systems, data and information, primarily through directly contacting national and local organizations responsible for monitoring out-of-hours care, supplemented by literature searches to highlight specific issues arising from the review; and second, mapping of data items by out-of-hours provider type to identify overlap and significant gaps., Results: In Scotland, data monitoring systems have not kept pace with changes in the organization of out-of-hours care, so the impact on access to services for different population groups is unknown. There are significant gaps in information collected with respect to workforce, distribution of services, service utilisation and clinical outcomes., Conclusions: Since 2004 there have been major changes to the way patients access out-of-hours healthcare in the UK. In Scotland, none of the current systems provide information on whether the new services satisfy the key NHS principle of equity of access. There is an urgent need for a comprehensive review of data standards and systems relating to out-of-hours care in order to monitor and evaluate inputs, processes and outcomes of care not least in respect of access and fairness of distribution of resources.

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

In 2008, a patient died in the UK after being given an excessive dose of diamorphine by an overseas-trained doctor working in out-of-hours (OOH) primary care. This incident led to a debate on the recourse to international medical graduates and on the shortcomings of the OOH system. It is argued here that a historical reflection on the ways in which the NHS uses migrant labour can serve to reframe these discussions. The British Medical Association, the General Medical Council, and the House of Commons Health Committee have emphasised the need for more regulation of overseas graduates. Such arguments fit into a well-established pattern of dependency on and denigration of overseas graduates. They give insufficient weight to the multiple systemic failings identified in reports on OOH provision by the Department of Health and the Care Quality Commission. Medical migrants are often found in under-resourced and unpopular parts of healthcare systems, in the UK and elsewhere. Their presence provides an additional dimension to Julian Tudor Hart's inverse care law: the resources are fewer where the need is greatest, and the practitioner dealing with the consequences is more likely to be a migrant. The failings of the UK OOH system need to be understood in this context. Efforts to improve OOH care should be focused on controlling quality rather than the movement of doctors. A wider reflection on the nature of the roles that international medical graduates are asked to play in healthcare systems is also required.

Background: Within the UK, patients place a fairly high value on the out-of-hours GP home visiting service. Although satisfaction with the range of out-of-hours services has been found to be high, little is known about patients' specific experiences of the home visiting services., Objective: To investigate the satisfaction with, and experiences of, patients receiving a GP out-of-hours (OOH) home visit from a GP cooperative., Methods: A postal questionnaire study sent to all patients receiving a home visit from a single cooperative. The questionnaire asked patients a range of questions about their experiences of the home visiting service that they received and also contained a validated satisfaction measure., Results: The OOH home visiting services largely provide care for an older population, most of whom consider that they are either too ill to travel or have limited mobility. The majority (43%) of home visits are made during the daytime at weekends, with just 25% of visits made during the night-time. If the home visit was not available, 67% of patients stated that they would have phoned for an ambulance or gone directly to hospital. The majority of patients (87%) were satisfied with the overall home visiting service that they received; however, 32% of patients were dissatisfied with the time it took for them to see a doctor or a nurse., Conclusions: Although the OOH services have received considerable criticism over the past 5 years, this study reveals that patients remain largely satisfied with the service and would have called 999 or gone directly to hospital if there had been no service.

Background: Most patients receive healthcare in primary care settings, but relatively little is known about patient safety. Out-of-hours contacts are of particular importance to patient safety. Our aim was to examine the incidence, types, causes, and consequences of patient safety incidents at general practice cooperatives for out-of-hours primary care and to examine which factors were associated with the occurrence of patient safety incidents., Methods: A retrospective study of 1,145 medical records concerning patient contacts with four general practice cooperatives. Reviewers identified records with evidence of a potential patient safety incident; a physician panel determined whether a patient safety incident had indeed occurred. In addition, the panel determined the type, causes, and consequences of the incidents. Factors associated with incidents were examined in a random coefficient logistic regression analysis., Results: In 1,145 patient records, 27 patient safety incidents were identified, an incident rate of 2.4% (95% CI: 1.5% to 3.2%). The most frequent incident type was treatment (56%). All incidents had at least partly been caused by failures in clinical reasoning. The majority of incidents did not result in patient harm (70%). Eight incidents had consequences for the patient, such as additional interventions or hospitalisation. The panel assessed that most incidents were unlikely to result in patient harm in the long term (89%). Logistic regression analysis showed that age was significantly related to incident occurrence: the likelihood of an incident increased with 1.03 for each year increase in age (95% CI: 1.01 to 1.04)., Conclusion: Patient safety incidents occur in out-of-hours primary care, but most do not result in harm to patients. As clinical reasoning played an important part in these incidents, a better understanding of clinical reasoning and guideline adherence at GP cooperatives could contribute to patient safety.

Introduction: In many countries, a reassessment of after-hours primary care has become necessary. In particular, centralised general practitioner deputizing services (GPDS) have emerged. In this study, consumers' preferences for after-hours medical care were obtained and the use of the new GPDS was predicted., Method: On the basis of the Theory of Reasoned Action, a survey was developed that was used at the Free Newborn and Child health care services in Antwerp. Consumers were asked about their knowledge, experience and perceptions concerning the performance of different medical services., Results: 350 questionnaires were used for analysis. 98.6% of the respondents knew about the existence of the emergency department, whereas the GPDS was known by 81.7% of the respondents. The main reasons for preferring emergency department over the other services were an easy access, good explanation by the doctor and a late due time of the payment. Respondents preferred the GPDS mainly because of an expected shorter waiting time. Experience had a strong positive influence on choosing a particular after-hours medical service., Conclusion: In our study, the consumers' preferences concerning after-hours medical care were assessed. The following items are crucial for choosing after-hours care: experience with the services, easy access to the service, explanation by the doctor about the illness and the treatment and waiting time.

Background: considerable changes have occurred over the last 5 years in the organization of out-of-hours care in the UK. Users' experiences of their care are an important part of 'quality of care' and are valuable for identifying areas for improvement., Aim: to identify strengths and weaknesses of out-of hours service provision in Wales. The design of the study is a cross-sectional survey. The setting of the study is nine GP services, three Accident and Emergency units and NHS Direct in Wales., Method: survey using the validated Out-of-Hours questionnaire. We identified the four most and least favourably rated items regarding users' experience of care. These were analysed by type of care provided, telephone advice, treatment centre and home visit groups., Results: eight hundred and fifty-five of 3250 users responded (26% response rate). Across providers and types of care, consistent strengths were the 'manner of treatment by call operator' and the 'explanation of the next step by call operator'. Consistent weaknesses were the 'speed of call back by the clinician', the 'information provided by the GP', 'getting medication after the consultation' and 'when to contact the (in-hours) GP'., Conclusions: users of out-of-hours care identify clear and consistent strengths and weaknesses of service provision across Wales. Specific areas for improvement concern the interface between in-hours care and out-of-hours care and between out-of-hours care and self-care. GP surgeries need to give better information on how to access the out-of-hours services. Out-of-hours providers should improve their advice on how and when to access in-hours surgeries and also improve the availability of medicines after out-of-hours consultations.

Background: several different models of out-of-hours primary care now exist in the UK. Important outcomes of care include users' satisfaction and enablement to manage their illness or condition, but the determinants of these outcomes in the unscheduled care domain are poorly understood. Aim. To identify predictors of user satisfaction and enablement across unscheduled care or GP out-of-hours service providers in Wales. The design of the study is a cross-sectional survey. The setting of the study is nine GP out-of-hours services, three Accident and Emergency units and an all Wales telephone advice service in Wales., Methods: postal survey using the Out-of-hours Patient Questionnaire. Logistic regression was used to fit both satisfaction and enablement models, based on demographic variables, service provider and treatment received and perceptions or ratings of the care process., Results: eight hundred and fifty-five of 3250 users responded (26% response rate, range across providers 14-41%, no evidence of non-response bias for age or gender). Treatment centre consultations were significantly associated with decreased patient satisfaction and decreased enablement compared with telephone advice. Delays in call answering or callback for triage and shorter consultations were significantly associated with lower satisfaction. Waiting more than a minute for initial call answering was associated with lower enablement., Conclusions: giving users more time to discuss their illness in consultations may enhance satisfaction and enablement but this may be resource intensive. More simple interventions to improve access by quicker response and triage, and keeping users informed of waiting times, could also serve to increase satisfaction and ultimately impact on their enablement.

Purpose: To check the occurrence of post-visit, the patient's understanding and the assessments of the doctor on duty about the efficacy of the process, at the ophthalmology emergency sector., Methods: It was conducted a transversal, analytical research among doctors on duty and patients being seen consecutively in the ophthalmology emergency sector of Hospital das Clínicas da Universidade de São Paulo., Results: The sample was made of 28 doctors on duty and 561 patients, 51.3% male and 48.7% female, with a mean age of 39.8 years old. From 34.1% of the patients who were previously seen by other sectors, 8.4% looked for two services and 5.7% three or more services. In the previous visits, 56.9% of the patients mentioned that they did not receive any explanation about their diagnostic. From the patients seen at Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, 95.1% mentioned that the ophthalmologists explained the diagnostic and from those 84.0% understood what was explained. Among 40.4% of the patients who received medicine prescriptions in the previous services, 85.5% mentioned that they received explanation about its use and 82.9% followed the orientation. At Hospital das Clínicas - FMUSP 95.0% of the patients understood how and why to use the medicine. At the ophthalmologists point of view, more than 90.0% of the patients understood the diagnostic and the prescribed treatment., Conclusion: According to this research, for most of the patients, it was provided post-visit orientation and patients' understanding about the disease and the treatments proposed.

Objective: To determine the effect of time and day of birth on the risk of neonatal death at term., Design: Population based retrospective cohort study., Setting: Data from the linked Scottish morbidity records, Stillbirth and Infant Death Survey, and birth certificate database of live births in Scotland, 1985-2004., Subjects: Liveborn term singletons with cephalic presentation. Perinatal deaths from congenital anomalies excluded. Final sample comprised 1,039,560 live births., Main Outcome Measure: All neonatal deaths (in the first four weeks of life) unrelated to congenital abnormality, plus a subgroup of deaths ascribed to intrapartum anoxia., Results: The risk of neonatal death was 4.2 per 10,000 during the normal working week (Monday to Friday, 0900-1700) and 5.6 per 10 000 at all other times (out of hours) (unadjusted odds ratio 1.3, 95% confidence interval 1.1 to 1.6). Adjustment for maternal characteristics had no material effect. The higher rate of death out of hours was because of an increased risk of death ascribed to intrapartum anoxia (adjusted odds ratio 1.7, 1.2 to 2.3). Though exclusion of elective caesarean deliveries attenuated the association between death ascribed to anoxia and delivery out of hours, a significant association persisted (adjusted odds ratio 1.5, 1.1 to 2.0). The attributable fraction of neonatal deaths ascribed to intrapartum anoxia associated with delivery out of hours was 26% (95% confidence interval 5% to 42%)., Conclusions: Delivering an infant outside the normal working week was associated with an increased risk of neonatal death at term ascribed to intrapartum anoxia.

Recent changes to out-of-hours primary care in the UK have generated concerns about care for palliative care patients. The aim of this study was to identify key challenges and improvements to out-of-hours palliative care in a mixed urban and rural deprived area. We integrated data from three sources: interviews with patients and professionals, direct observations of services, and routine statistics. Key issues in the provision of care were the importance of good communication and having information available, the unwieldy process of accessing medical care out of hours, professionals bypassing routine out-of-hours care for palliative care patients, and out-of-hours care being provided by practitioners unaware of local services. We recommend provision to out-of-hours services of an enhanced 'special note' for palliative care patients, to be completed early in the course of the illness and updated regularly. The provision for certain complex patients to bypass NHS24 should be considered if routine care is not satisfactory.

To date, the experiences of out-of-hours general practitioners with regard to palliative care patients and their management are yet to be evaluated, since the new General Medical Services contract came into force. In 2007 the National Institute for Health Research highlighted the need to identify factors that improve and hinder the delivery of optimum palliative out-of-hours care. By interviewing general practitioners who work out-of-hours shifts, this project explored factors influencing confidence in dealing with symptom control and palliative care provision outside regular working hours. Face-to-face semi-structured interviews were conducted with nine out-of-hours general practitioners employed by Serco. Interviews were conducted by a specialist doctor in palliative care who had in the past worked as an out-of-hours general practitioner. Interviews were analysed using Interpretative Phenomenological Analysis. General practitioners expressed concerns relating to constraints within the system provided by the private company-owned out-of-hours provider. Data from interviews was thematically very rich and brought out many different subject areas, some similar to previous interviews, some different. Sub-themes related to the process-driven aspects of working in out-of-hours: * Motivation, * Time-pressure constraints and continuity, * The out-of-hours doctor within the domain of palliative care, * Isolation within system. General practitioners stated that their motivation was mainly financial. There was clear concern about the lack of continuity, and inadequacy of notes and follow-up, and there was a demonstrated need for more learning on the topic of palliative care. Pressure from the out-of-hours provider to see more patients was felt to be oppositional with the need to spend adequate time with this vulnerable patient group. General practitioners felt as unwanted strangers who were viewed with suspicion by patients and carers in palliative care situations. It was clear that most of the doctors interviewed felt a strong sense of isolation when working out-of-hours shifts, and some felt less inclined to contact specialist palliative care services.

Objective: The effect of nightshift on ED staff performance is of clinical and risk-management significance. Previous studies have demonstrated deterioration in psychomotor skills but the present study specifically assessed the impact of nightshift on clinical performance., Methods: The ED registrars in a tertiary hospital were enrolled in a prospective observational study and served as their own controls. During nightshift, subjects were presented simulated scenarios and tested with eight clinical questions developed to Fellowship examination standard. Matched scenarios and questions for the same subjects during dayshift served as controls. Two investigators, blinded to subject identity and the setting in which questions were attempted, independently collated answers., Results: Of 22 eligible subjects, all were recruited; four were excluded owing to incomplete data. A correlation of 0.99 was observed between the independent scoring investigators. Of a possible score of 17, the median result for nightshift was 9.5 (interquartile range: 8-11); corresponding value for dayshift was 12 (interquartile range: 10-13); P = 0.047., Conclusion: Nightshift effect on clinical performance is anecdotally well known. The present study quantifies such effects, specifically for the ED setting, and paves the way for focused research. The implications for clinical governance strategies are significant, as the fraternity embraces the mandate to maintain quality emergency care 24 h per day.

Objective: To develop and evaluate the Patient Experiences Questionnaire for Out-of-Hours Care (PEQ-OHC) in Norway., Design: Questionnaire development was based on a systematic literature review of existing questionnaires, interviews with users, and expert group consultation. Questionnaire testing followed a postal survey of users who had attended out-of-hours centres in the North, West, and South of Norway., Setting: Primary care out-of-hours services., Subjects: The questionnaire was pre-tested with 13 users and was then mailed to 542 users who had had telephone contact and/or had a consultation with one of three out-of-hours centres., Main Outcome Measures: Data quality, internal consistency, reliability, and construct validity., Results: The questionnaire was considered to have good content validity by the expert group. There were 225 (41.51%) respondents to the postal questionnaire. Levels of missing data at the item and scale level were acceptable. Principal component analysis supported the four scales of user experiences relating to telephone contact, doctor services, nursing services, and organization. Item-total correlations were all above 0.5 and Cronbach's alpha was above 0.80 for all scales. Statistically significant associations based on explicit hypotheses were evidence for the construct validity of the PEQ-OHC., Conclusion: The development of the PEQ-OHC followed a rigorous process based on a systematic review, interviews with users, and an expert group which lend the questionnaire content validity. The PEQ-OHC has evidence for data quality, internal consistency, reliability, and construct validity.

Background: Several models of GP out-of-hours provision exist in the UK but there is little detail about their effectiveness to meet users' needs and expectations., Aim: To explore users' needs, expectations, and experiences of out-of-hours care, and to identify proposals for service redesign., Setting: Service providers in urban (GP cooperative), mixed (hospital based), rural (private) locations in Wales., Participants: Sixty recent service users or carers (20 in each location)., Method: Semi-structured telephone interviews; thematic analysis., Results: Users' concerns were generally consistent across the three different services. Efficiency was a major concern, with repetitive triage procedures and long time delays at various stages in the process being problematic. Access to a doctor when required was also important to users, who perceived an obstructive gatekeeping function of preliminary contacts. Expectations moderated the relationship between user concerns and satisfaction. Where expectations of outcome were unfulfilled, participants reported greater likelihood of reconsulting with the same or alternative services for the same illness episode. Accurate expectations concerning contacts with the next administrative, nursing, or medical staff professional were managed by appropriate information provision., Conclusion: Users require more streamlined and flexible triage systems. Their expectations need to be understood and incorporated into how services advise and provide services for users, and actively managed to meet the aims of both enhancing satisfaction and enabling users to cope with their condition. Better information and education about services are needed if users are to derive the greatest benefit and satisfaction. This may influence choices about using the most appropriate forms of care.