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Objective: To examine patients' use of and satisfaction with the nurse-staffed Telephone Health Advisory Service (THAS) and physician after-hours care in a rostered Family Health Organization, as well as physicians' satisfaction with both types of services., Design: Cross-sectional telephone survey., Setting: A Family Health Organization in Hamilton, Ont., Participants: Nineteen family physicians and their patients who used an after-hours service during 9 selected weeks between March and December of 2007., Main Outcome Measures: Distribution of encounters directed to the on-call physician or to the THAS; types of health problems; and patient and physician satisfaction., Results: A total of 817 calls were recorded from 774 patients. Of these patients, 606 were contacted and 94.4% (572/606) completed encounter-specific surveys: 358 completed the on-call physician survey and 214 completed the THAS survey. Mean age of respondents was 40.8 years; most were women, and approximately one-third called on behalf of children. Most calls (66.8%, 546/817) were made directly to the on-call physicians. The most common problems were respiratory (34.3%, 271/789), gastrointestinal (10.1%, 80/789), and genitourinary (9.3%, 73/789). Most patients reported being very satisfied with the after-hours care provided by the THAS (62.5%, 125/200) or the on-call physicians (70.9%, 249/351). Almost all callers who bypassed the THAS knew about it (89.8%, 316/352), but either felt their problems were too serious or wished to talk to a physician. Most physicians agreed or strongly agreed that they were satisfied with their colleagues' on-call care (81.0%, 17/21); 47.6% (10/21) agreed that the THAS was helpful in managing on-call duty., Conclusion: When direct after-hours physician contact is available, a minority of patients uses a nurse-staffed triage. Physicians find the arrangements onerous and would prefer to see after-hours care managed and remunerated differently.

The study compared paper-based and electronic-based medical handover with respect to quality of information transfer during hospital out-of-hours shifts, and analysed the caseload burden of the hospital night team. The participants were 1645 hospital patients transferred from the day team to the out-of-hours team over four months in 2006. Quality of information transfer was determined by clinical data handed over within pre-set fields, and caseload burden by the frequency of tasks required at handover. Handover information fields comprised patient's demographics and location, primary diagnosis, current problem, plan of action and primary care team details. Electronic handover achieved a significantly higher number of completed fields than paper-based handover. Blood collection, checking blood and X-ray results, and adjusting fluid balance and intravenous cannulation account for most of the workload during the nightshift. Electronic handover provides better continuity of care than paper-based handover, and redistribution of tasks during working hours would benefit night staff.

Background: The UK National GP Patient Survey is one of the largest ever survey programmes of patients registered to receive primary health care, inviting five million respondents to report their experience of NHS primary healthcare. The third such annual survey (2008/9) involved the development of a new survey instrument. We describe the process of that development, and the findings of an extensive pilot survey in UK primary healthcare., Methods: The survey was developed following recognised guidelines and involved expert and stakeholder advice, cognitive testing of early versions of the survey instrument, and piloting of the questionnaire in a cross sectional pilot survey of 1,500 randomly selected individuals from the UK electoral register with two reminders to non-respondents., Results: The questionnaire comprises 66 items addressing a range of aspects of UK primary healthcare. A response rate of 590/1500 (39.3%) was obtained. Non response to individual items ranged from 0.8% to 15.3% (median 5.2%). Participants did not always follow internal branching instructions in the questionnaire although electronic controls allow for correction of this problem in analysis. There was marked skew in the distribution of responses to a number of items indicating an overall favourable impression of care. Principal components analysis of 23 items offering evaluation of various aspects of primary care identified three components (relating to doctor or nurse care, or addressing access to care) accounting for 68.3% of the variance in the sample., Conclusion: The GP Patient Survey has been carefully developed and pilot-tested. Survey findings, aggregated at practice level, will be used to inform the distribution of pound sterling 65 million ($107 million) of UK NHS resource in 2008/9 and this offers the opportunity for NHS service planners and providers to take account of users' experiences of health care in planning and delivering primary healthcare in the UK.

Objectives: To evaluate the quality of out-of-hours ENT on-call cover by junior doctors, in view of the European Working Time Directive and the recent changes in the National Health Service workforce due to the 'Modernising Medical Careers' initiative, in England., Methods: We performed a national survey of first-on-call doctors for ENT, using a telephone questionnaire. Hospital contact details were sourced from the National Health Service website. The inclusion criterion was hospitals providing acute ENT facilities overnight in England., Results: One hundred and nineteen hospitals were contacted; 91 were eligible, and 83 interviews were conducted. The grade of the first-on-call ENT doctor ranged from foundation year two (19 per cent) to registrar level or above (13 per cent). Forty-nine respondents (68 per cent) reported having no previous ENT experience. Fifty-three respondents (74 per cent) covered more than one speciality at night, with seven (10 per cent) covering four or more specialities. The second-on-call doctor was non-resident in 63 cases (88 per cent). Thirty respondents (42 per cent) stated that they did not feel comfortable managing common ENT emergencies as the first doctor on call. Otorhinolaryngology induction courses were offered in 37 of the respondents' hospitals (51 per cent), these courses were of varying duration., Conclusion: Night-time ENT care is often provided by junior doctors with little experience of the speciality, who are often also responsible for covering multiple specialities. Many reported not feeling comfortable managing common ENT emergencies. Structured induction programmes would help to provide basic knowledge and should be mandatory for all doctors covering ENT.

This survey looks at 'out of hours' maxillofacial operating in the United Kingdom during September 2006 and was sent out to all the maxillofacial consultants in the United Kingdom. Most respondents consider out of hours as '2200-0759'; however many hospitals now routinely work extended lists up to 2200 h. Since nearly 65% of respondents had no dedicated trauma list, the provision of theatre flexibility with prioritized trauma slots which would be used for other purposes depending upon the immediate departmental needs appears to be a viable compromise for the foreseeable future.

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

Neurosurgical registrars are frequently called upon by A&E staff and physicians to interpret emergency head CT (computed tomography) scans out of hours. This appears to reflect the reduced threshold for scanning patients and the nonavailability of a radiologist to report these scans. This study was undertaken to assess the safety of such practices. Five neurosurgical registrars, blinded to each other and to the radiology reports, interpreted 50 consecutive emergency head CT scans (both trauma and nontrauma) from the hospital's imaging system as a pilot study. These were initially graded as normal or abnormal. Abnormal scans were assessed for the presence of an intracranial bleed, pneumocephalus, skull fractures, cerebral contusions, mass effect, midline shift, ischaemia or hydrocephalus. The agreement of the observers' recordings with the report issued or approved by a consultant radiologist was evaluated using SPSS Version 13.0. Four of the five registrars assessed a further 150 scans in a similar manner to complete the study. There was a good general agreement between the formal reports and the neurosurgical registrars' identification of normal scans (average Kappa 0.79). The radiology reports and the registrars also agreed well on the presence or absence of intracranial blood, contusions and pneumocephalus (Kappa value > 0.70). The agreement was poorer for ischaemia, mass lesions (other than intracranial haematomas), grey white differentiation, evidence of raised intracranial pressure and midline shift (Kappa < 0.5). Neurosurgical registrars compared well with radiologists when it came to assessing emergency head CT scans as normal or detecting a surgical lesion. The agreement was poorer on subtle abnormalities. The practice of neurosurgical registrars informally 'reporting' on emergency head CT scans cannot be recommended.

Objective: To assess the quality of communication skills of triagists, working at out-of-hours (OOH) centres, and to determine the correlation between the communication score and the duration of the telephone consultation., Methods: Telephone incognito standardised patients (TISPs) called 17 OOH centres presenting different clinical cases. The assessment of communication skills was carried out using the RICE-communication rating list. The duration of each telephone consultation was determined., Results: The mean overall score for communication skills was 35% of the maximum feasible. Triagists usually asked questions about the clinical situation correctly and little about the patients' personal situation, perception of the problem or expectation. Advice about the outcome of triage and self-care advice was usually given without checking for patients' understanding and acceptance of the advice. Calls were often handled in an unstructured way, without summarizing or clarifying the different steps within the consultation. There was a positive correlation of 0.86 (p<0.01) between the overall communication score and the duration of the telephone consultation., Conclusion: Assessment of communication skills of triagists revealed specific shortcomings and learning points to improve the quality of communication skills during telephone triage., Practice Implications: Training in telephone consultation should focus more on patient-centred communication with active listening, active advising and structuring the call. Apart from adequate communication skills, triagists need sufficient time for telephone consultation to enable high quality performance.

Background: National standards for delivery of out-of-hours services have been refined. Health service users' preferences, reports, and evaluations of care are of importance in a service that aims to be responsive to their needs., Aim: To investigate NHS service users' reports and evaluations of out-of-hours care in the light of UK national service quality requirements., Design: Cross sectional survey., Setting: Three areas (Devon, Cornwall, Sheffield) of England, UK., Method: Participants were 1249 recent users of UK out-of-hours medical services. Main outcome measures were: users' reports and evaluations of out-of-hours services in respect of the time waiting for their telephone call to the service to be answered; the length of time from the end of the initial call to the start of definitive clinical assessment ('call back time'); the time waiting for a home visit; and the waiting time at a treatment centre., Results: UK national quality requirements were reported as being met by two-thirds of responders. Even when responders reported that they had received the most rapid response option for home visiting (waiting time of 'up to an hour'), only one-third of users reported this as 'excellent'. Adverse evaluations of care were consistently related to delays encountered in receiving care and (for two out of four measures) sex of patient. For 50% of users to evaluate their care as 'excellent', this would require calls to be answered within 30 seconds, call-back within 20 minutes, time spent waiting for home visits of significantly less than 1 hour, and treatment centre waiting times of less than 20 minutes., Conclusion: Users have high expectations of UK out-of-hours healthcare services. Service provision that meets nationally designated targets is currently judged as being of 'good' quality by service users. Attaining 'excellent' levels of service provision would prove challenging, and potentially costly. Delivering services that result in high levels of user satisfaction with care needs to take account of users' expectations as well as their experience of care.

Context Many countries now use call centres as an integral part of out-of-hours primary care. Although some research has been carried out on safety issues pertaining to telephone consultations, there has been no published research on how to train and use standardised patients calling for medical advice or on the accuracy of their role-play. Objectives This study aimed to assess the feasibility and validity of using telephone incognito standardised patients (TISPs), the accuracy of their role-play and the rate of detection. Further objectives included exploring the experiences of TISPs and the difficulties encountered in self-recording calls. Methods Twelve TISPs were trained in role-play by presenting their problem to a general practitioner and a nurse. They were also trained in self-recording calls. Calls were made to 17 different out-of-hours centres (OOHCs) from home. Of the four or five calls made per evening, one call was assessed for accuracy of role play. Retrospectively, the OOHCs were asked whether they had detected any calls made by a TISP. The TISPs filled in a questionnaire concerning their training, the self-recording technique and their personal experiences. Results The TISPs made 375 calls over 84 evenings. The accuracy of role-play was close to 100%. A TISP was called back the same evening for additional information in 11 cases. Self-recording caused extra tension for some TISPs. All fictitious calls remained undetected. Conclusions Using the method described, TISPs can be valuable both for training and assessment of performance in telephone consultation carried out by doctors, trainees and other personnel involved in medical services.

Aim: To investigate the clinical management of patients attending for emergency dental treatment., Design: A retrospective analysis of clinical record cards., Method: Information was collected from patient record cards concerning the patient's reason for attendance and their management at an emergency dental clinic in South Sefton, Liverpool., Results: Over a nine month period, 1,718 patients attended the clinic; 1,472 record cards were analysed. Over 80% of the patients attending the out of hours (OOH) clinic had pain associated with a localised dental infection or dental abscess. Where a diagnosis was recorded, only 67% of patients received appropriate treatment. Over 50% of patients received antibiotics alone with no other definitive treatment provided. The principal antibiotic prescribed for both adult and child patients was amoxicillin., Conclusion: The current study has highlighted that GDPs working within the OOH services are not adhering to current clinical and best practice guidelines with respect to patient examination, diagnosis, management, in particular the correct prescribing of antibiotics for dental infections, and clinical record keeping.

The establishment of the Grampians After-Hours Service has led to the development of a quality framework for nurse telephone triage. The service providers believe this framework is the basis for the service's success. While quality frameworks including critical evaluation and peer review are not new to the health industry, the development of organisational systems to improve quality in after-hours services is innovative. The framework developed is comprehensive, evidenced-based and emphasises training, protocols and documentation. It also involves a continuous and non-punitive quality review process that operates at the individual, small group, organisation and whole-system level. The framework will continue to improve and at this time provides a foundation for discussion and further application in the pursuit of quality improvement in rural after-hours health services.

Background: In the light of recent changes in the structure and provision of out-of-hours service in the UK, there is a need to re-assess the quality of care. One way to assess the quality of care is through patient experience., Objectives: This study aimed to explore patient expectations and help-seeking behaviour, in order to understand their relationship with satisfaction and experience of out-of-hours care., Methods: 30 semistructured telephone interviews were carried out with users of the general practitioner out-of-hours service in Gwent, South Wales. The interviews explored users' experiences of using the service. A thematic analysis of transcripts was carried out using NUD*IST software. Comparison of data within and across codes facilitated the identification of explanatory constructs. Double coding of a sample of transcripts and discussion of emerging themes by members of the research team ensured the reliability of findings., Results: Most (n = 25, 83%) respondents reported satisfaction with the overall service received but a few (n = 5, 17%) were dissatisfied. Patients generally had specific expectations of their consultation and there was a mismatch between patients' expectations of the service and what the service actually provides in some specific user groups. Unmet expectations resulted in subsequent, and in some cases, multiple consultations., Conclusions: Users' views and expectations may be used to inform service design and improve services, but the data also indicated a need to address user expectations of services, for example by enhanced information provision. Any such interventions to improve patient experience of out-of-hours care will need to be evaluated.

Objective: To assess the quality of telephone triage by following the consecutive phases of its care process and the quality of the clinical questions asked about the patient's clinical condition, of the triage outcome, of the content of the home management advice, and of the safety net advice given at out of hours centres., Design: Cross sectional national study using telephone incognito standardised patients., Setting: The Netherlands., Participants: 17 out of hours centres., Main Outcome Measures: Percentages of clinical obligatory questions asked and items within home management and safety net advice, both in relation to pre-agreed standards, and of care advice given in relation to the required care advice., Results: The telephone incognito standardised patients presented seven clinical cases three times each over a period of 12 months, making a total of 357 calls. The mean percentage of obligatory questions asked compared with the standard was 21%. Answers to questions about the clinical condition were not always correctly evaluated from a clinical viewpoint, either by triagists or by general practitioners. The quality of information on home management and safety net advice varied, but it was consistently poor for all cases and for all out of hours centres. Triagists achieved the appropriate triage outcome in 58% of calls., Conclusion: In determining the outcome of the care process, triagists often reached a conclusion after asking a minimal number of questions. By analysing the quality of different phases within the process of telephone triage, evaluation of whether an appropriate triage outcome has been arrived at by means of good clinical reasoning or by an educated guess is possible. In terms of enhancing the overall clinical safety of telephone triage, apart from obtaining an appropriate clinical history, adequate home management and safety net advice must also be given.

Background: GP cooperatives are typically based in emergency primary care centres, and patients are frequently required to travel to be seen. Geography is a key determinant of access, but little is known about the extent of geographical variation in the use of out-of-hours services., Aim: To examine the effects of distance and rurality on rates of out-of-hours service use., Design of Study: Geographical analysis based on routinely collected data on telephone calls in June (n=14 482) and December (n=19 747), and area-level data., Setting: Out-of-hours provider in Devon, England serving nearly 1 million patients., Method: Straight-line distance measured patients' proximity to the primary care centre. At area level, rurality was measured by Office for National Statistics Rural and Urban Classification (2004) for output areas, and deprivation by The Index of Multiple Deprivation (2004)., Results: Call rates decreased with increasing distance: 172 (95% confidence interval [CI]=170 to 175) for the first (nearest) distance quintile, 162 (95% CI=159 to 165) for the second, and 159 (95% CI=156 to 162) per thousand patients/year for the third quintile. Distance and deprivation predicted call rate. Rates were highest for urban areas and lowest for sparse villages and hamlets. The greatest urban/rural variation was in patients aged 0-4 years. Rates were higher in deprived areas, but the effect of deprivation was more evident in urban than rural areas., Conclusion: There is geographical variation in out-of-hours service use. Patients from rural areas have lower call rates, but deprivation appears to be a greater determinant in urban areas. Geographical barriers must be taken into account when planning and delivering services.

Background: Prior studies have demonstrated an inconsistent association between patients' arrival time for acute myocardial infarction (AMI) and their subsequent medical care and outcomes., Methods and Results: Using a contemporary national clinical registry, we examined differences in medical care and in-hospital mortality among AMI patients admitted during regular hours (weekdays 7 am to 7 pm) versus off-hours (weekends, holidays, and 7 pm to 7 am weeknights). The study cohort included 62,814 AMI patients from the Get With the Guidelines-Coronary Artery Disease database admitted to 379 hospitals throughout the United States from July 2000 through September 2005. Overall, 33 982 (54.1%) patients arrived during off-hours. Compared with those arriving during regular hours, eligible off-hour patients were slightly less likely to receive primary percutaneous coronary intervention (adjusted odds ratio [OR], 0.93; 95% confidence interval [CI], 0.89 to 0.98), had longer door-to-balloon times (median, 110 versus 85 minutes; P<0.0001), and were less likely to achieve door-to-balloon < or = 90 minutes (adjusted OR, 0.34; 95% CI, 0.29 to 0.39). Arrival during off-hours was associated with slightly lower overall revascularization rates (adjusted OR, 0.94; 95% CI, 0.90 to 0.97). No measurable differences, however, were found in in-hospital mortality between regular hours and off-hours in the overall AMI, ST-elevated MI, and non-ST-elevated MI cohorts (adjusted OR, 0.99; 95% CI, 0.93 to 1.06; adjusted OR, 1.05; 95% CI, 0.94 to 1.18; and adjusted OR, 0.97; 95% CI, 0.90 to 1.04, respectively). Similar observations were made across most age and sex subgroups and with an alternative definition for arrival time (weekends/holidays versus weekdays)., Conclusions: Despite slightly fewer primary percutaneous coronary interventions and overall revascularizations and significantly longer door-to-balloon times, patients presenting with AMI during off-hours had in-hospital mortality similar to those presenting during regular hours.

Background: There is widespread concern that the quality of out-of-hours primary care for patients with complex needs may be at risk now that the new general medical services contract (GMS) has been implemented., Aim: To explore changes in the use of out-of-hours services around the time of implementation of the new contract for patients with complex needs, using patients with cancer as an example., Design of Study: Longitudinal observational study., Setting: Out-of-hours primary care provider covering Devon (adult population 900,000), UK., Method: Two, 1-year periods corresponding to pre- (April 2003 to March 2004) and post-contract implementation (October 2004 to September 2005) were sampled. Call rates per 1000 of the adult population (age>or=16 years) were calculated for all calls (any cause) and cancer-related calls. Anonymised outcome and process measures data were extracted., Results: Although overall call rates per 1000 population had increased by 26% (185 pre-contract to 233 post-contract), the proportion of cancer-related calls remained relatively constant (2.08% versus 1.96%). Around half (56%) of these callers had advanced cancer needs (including palliative care). By post-contract, the time taken to triage had significantly increased (P<0.001). Although the proportions admitted to hospital or receiving a home visit remained constant, calls where a special message was sent by the out-of-hours clinician to the in-hours team had decreased (P<0.001)., Conclusion: The demand for out-of-hours care for patients with cancer did not alter disproportionately after implementation of the contract. While potential quality indicators (for example, hospital admissions, home visiting rates) remained constant, potentially adverse changes to triage time and communication between out-of-hours and in-hours clinicians were observed. Quality standards and provider databases require further refinement to capture elements of care relevant to patients with complex needs.

Background: Most febrile children contacting a GP cooperative are seen by a GP, although the incidence of serious illness is low. The guidelines for triage might not be suitable in primary care., Aim: To investigate the determinants related to the outcome of triage in febrile children., Design of Study: Cross-sectional study., Setting: Dutch GP cooperative., Method: Receptionists filled out a triage questionnaire when parents called regarding their febrile child (aged between 3 months and 6 years) and estimated the level of concern of the parents. The outcome was either telephone advice, a consultation, or a home visit. Children were divided in subgroups based on age <18 months or > or = 18 months, and prognostic models for a consultation were constructed., Results: Of 422 children, 73% were seen by a GP. Children aged <18 months were more likely to be seen when their parents reported less drinking or shortness of breath. In children aged > or = 18 months, a duration of fever of > or = 3 days, drowsiness, or a pale, ashen, or mottled skin were predictors of consultation. Children with alarm symptoms were seen according to the guideline. In both subgroups, children without alarm symptoms were more likely to be seen when their parents were concerned., Conclusion: The available guideline was followed to a large extent at a GP cooperative. Because, surprisingly, most children were reported to have alarm symptoms, the validity of the triage questions asking parents about alarm symptoms is questionable.

Background and Objective: Provision of out-of-hours care in the UK National Health Service (NHS) has changed in recent years with new models of provision and the introduction of national quality requirements. Existing survey instruments tend to focus on users' satisfaction with service provision; most were developed without undertaking supporting qualitative fieldwork. In this study, a survey instrument was developed taking account of these changes in service provision and undertaking supporting qualitative fieldwork. This paper reports on the development and psychometric properties of the new survey instrument, the Out-of-hours Patient Questionnaire (OPQ), which aims to capture information on the entirety of users' experiences of out-of-hours care, from the decision to make contact through to completion of their care management., Methods: An iterative approach was undertaken to develop the new instrument which was then tested in users of out-of-hours services in three geographically distributed UK settings. For the purposes of this study, "service users" were defined as "individuals about whom contact was made with an out-of-hours primary care medical service", whether that contact was made by the user themselves, or via a third party. Analysis was undertaken of the acceptability, reliability and validity of the survey instrument., Results: The OPQ tested is a 56-item questionnaire, which was distributed to 1250 service users. Respondents were similar in respect of gender, but were older and more affluent (using a proxy measure) than non-respondents. Item completion rates were acceptable. Respondents sometimes completed sections of the questionnaire which did not equate to their principal mode of management as recorded in the record of the contact. Preliminary evidence suggests the OPQ is a valid and reliable instrument which contains within it two discrete scales--a consultation satisfaction scale (nine items) and an "entry-access" scale (four items). Further work is required to determine the generalisability of findings obtained following use of the OPQ, especially to non-white user populations., Conclusion: The OPQ is an acceptable instrument for capturing information on users' experiences of out-of-hours care. Preliminary evidence suggests it is both valid and reliable in use. Further work will report on its utility in informing out-of-hours service planning and configuration and standard-setting in relation to UK national quality requirements.

Although the advisory opinion issued by the Department of Health and Human Services' Office of Inspector General (OIG) specifically states it only applies to the pay-for-call arrangement at one hospital, experts say the ED manager can use the opinion to establish bench-marks for their own on-call arrangements. * At the very least, the OIG has made it clear that paying for on-call coverage is not in and of itself a violation of any statutes. * Any per diem rates paid to ensure that specialists agree to take call must be "reasonable" and meet "fair market value." * The fact that the specialists also may be paid for the services they provide may not necessarily mean your arrangement is improper.

Aim: To compare the satisfaction levels of patients and carers with a community night nursing service., Method: Thirty seven patients and 23 carers completed satisfaction postal questionnaires. Respondents were further subdivided into acute, chronic and terminally ill patients and their carers., Results: Satisfaction levels with the service were generally high, although respondents from the terminally ill group showed the lowest levels of satisfaction overall. The Kruskal-Wallis test showed that results between the groups were not significantly different (Chi-square (chi2) test = 3.52; df = 2; P = 0.172)., Conclusion: Although the results demonstrated positive levels of satisfaction with the community night nursing service, there were some respondents who indicated a low level of satisfaction. This could be explained by patients' and carers' lack of autonomy and inadequate provision of psychological care.

Background: Dutch general practitioners have reorganized their out-of-hours primary health care to general practice cooperatives. Good insight into the quality of delivered medical care is important to make the accountability of health practitioners and managers transparent to society and to identify and minimize medical errors., Objective: Development of a set of quality indicators for internal quality improvement in out-of-hours primary clinical care., Method: A systematic approach combining the opinion of three different general practitioner expert panels, and an empirical test in daily practice. The indicators were based on clinical, evidence-based, national guidelines. We tested the validity, feasibility, reliability and opportunity for quality improvement., Results: Of the 80 available national clinical guidelines, 29 were approved and selected by the first general practitioner expert panel. Out of these 29 guidelines, 73 indicators concerning prescribing and referring were selected by the second panel. In an empirical test on 36 254 patient contacts, 7344 patient contacts (22.7%) were relevant for the assessment of these 73 indicators. Six indicators were excluded because they scored more than 15% missing values. In total, 38 indicators were excluded because the opportunity for quality improvement was limited (performance score > or =90%). In the final meeting, the third general practitioner expert panel excluded five indicators, leading to a final set of 24 indicators., Conclusion: This study shows the importance of subjecting indicators to an empirical test in practice. The national clinical guidelines are only partially applicable in the assessment of out-of-hours primary care. They need to be expanded with topics that are related to general practitioner care in an out-of-hours setting and acute medical problems.

This article examines a recent Coronial inquest in which the Coroner made recommendations to general practitioners regarding the process of notification by pathology practices of abnormal and life threatening results and how GPs respond to such notifications. An addendum to the Standards for general practices provides guidance for GPs and their staff on the systems to manage the follow up of test results outside normal general practice opening hours.

Background: Patient satisfaction questionnaires are increasingly used for assessing quality of care., Aim: To review the evidence for the reliability and validity of patient satisfaction questionnaires for out-of-hours care., Design: Systematic review., Setting: Primary care out-of-hours services., Method: Searches of CINAHL, EMBASE, MEDLINE((R)) and PsycINFO using terms relevant to the measurement of patient satisfaction and out-of-hours services. Abstracts were reviewed and information relating to questionnaire content, data quality, reliability, and validity were extracted from articles by two independent researchers., Results: Four questionnaires were found, two from the UK - the Patient Satisfaction with Out-of-Hours Care (PSOC) and Short Questionnaire for Out-of-Hours Care (SQOC) - and two from the Netherlands - the van Uden and Moll van Charante questionnaires. Questionnaire content was based on literature reviews and expert opinion; the PSOC and Moll van Charante questionnaires were also developed following interviews or focus groups with patients. Cronbach's alpha values were below 0.7 for some scales within the PSOC and van Uden questionnaires. Test-retest reliability was reported for the PSOC and Moll van Charante questionnaires. Tests of validity were few and did not give explicit consideration to the size of expected associations., Conclusion: Potential users wishing to assess patient satisfaction should carefully consider the content of the questionnaires and its relevance to the application and patient group. The four questionnaires have limitations relating to their development and evaluation. The PSOC and van Uden questionnaires have low levels of reliability for some scales, which should be used with caution in future surveys.

Background: In recent years, there has been a growth in the use of triage nurses to decrease general practitioner (GP) workloads and increase the efficiency of telephone triage. The actual safety of decisions made by triage nurses has not yet been assessed., Objectives: To investigate whether triage nurses accurately estimate the urgency level of health complaints when using the national telephone guidelines, and to examine the relationship between the performance of triage nurses and their education and training., Method: A cross-sectional, multicentre, observational study employing five mystery (simulated) patients who telephoned triage nurses in four GP cooperatives. The mystery patients played standardised roles. Each role had one of four urgency levels as determined by experts. The triage nurses called were asked to estimate the level of urgency after the contact. This level of urgency was compared with a gold standard., Results: Triage nurses estimated the level of urgency of 69% of the 352 contacts correctly and underestimated the level of urgency of 19% of the contacts. The sensitivity and specificity of the urgency estimates provided by the triage nurses were found to be 0.76 and 0.95, respectively. The positive and negative predictive values of the urgency estimates were 0.83 and 0.93, respectively. A significant correlation was found between correct estimation of urgency and specific training on the use of the guidelines. The educational background (primary or secondary care) of the nurses had no significant relationship with the rate of underestimation., Conclusion: Telephone triage by triage nurses is efficient but possibly not safe, with potentially severe consequences for the patient. An educational programme for triage nurses is recommended. Also, a direct second safety check of all cases by a specially trained GP telephone doctor is advisable.

Objectives: This study analyzed our family medicine department's after-hours telephone medicine systems at an academic health center from a patient safety perspective. The research questions were (1) What are the threats to patient safety associated with after-hours telephone medicine and (2) What kinds of errors are made during after-hours telephone medicine?, Methods: Subjects were patients at the University of Kentucky family medicine practice who called in to the after-hours answering service. Telephone interviews were conducted with 64 patients over 10 weeks. During the interviews, patients described their telephone medicine experience, identified any problems, and reported potential or actual harm (patient-identified threats to patient safety). Two registered nurses and one physician analyzed the patient narratives to identify threats to patient safety (medical personnel-identified threats to patient safety)., Results: Sixty-three analyzable patient interviews identified four instances (6%) of temporary physical harm. Two separate after-hours calls (3%) involved four medical errors with potentially serious consequences to patient safety (wrong dose, serious illness not ruled out). Fourteen calls (22%) involved events that could have threatened patient safety., Conclusions: Situations that threaten patient safety occur frequently in telephone medicine. Although this study is too small to draw strong conclusions, it suggests that there are risks to patient safety associated with after-hours telephone medicine.

Background: The aim of the study was to determine whether the official numbers of regular general practitioners (GPs) participating in out-of-hours duty have been correct., Method: Data were collected from the Norwegian labour and welfare organisation's (NAV's) regular GP database. This is a database with information collected from Statistics Norway and the Norwegian Social Science Data Services., Results: The study has revealed an error in one of the sources used by the national health authorities to evaluate the regular GP Scheme "Fastlegeordningen". Official figures indicate that the number of regular GPs who participate in out-of-hours duty increased with 5% the first three years after implementation of the regular GP Scheme (2001-2004). New analyses show that the number of regular GPs instead decreased with 12%., Interpretation: Our study uncovers weaknesses with the quality assurance of data used by the health authorities to calculate the work force needed for out-of-hours duty. This misinformation may have prevented action needed to recruit regular GPs to work in the out-of-hours emergency services, as the problem has not been recognised.

Background: Out-of-hours centres provide telephone support to patients with medical problems. In most of these centres specially-trained nurses handle incoming telephone calls. They assess patients' needs, the degree of urgency, and determine the level of care required. Assessment of the medical problem and the quality of 'care-by-phone' depend on the medical and communication skills of the call handlers., Aim: To develop a valid, reliable, and practical rating scale to evaluate the communication skills of call handlers working at an out-of-hours centre and to improve quality of communication., Design of Study: Qualitative study with focus groups followed by validation of the rating scale and measurement of reliability (internal consistency)., Setting: Out-of-hours centres in the Netherlands., Method: A focus group developed the rating scale. Experts with experience in training and evaluating communication skills of medical students and GPs commented on the scale to ensure content validity. The reliability of the rating scale was tested in a pilot in which ten specially-trained assessors scored six telephone calls each., Results: The scale, known as the RICE rating scale, has 17 items divided over four different phases of the telephone consultation: Reason for calling; Information gathering; Conclusion; and Evaluation (RICE). Content validity of the scale was assessed by two experts. Reliability of the scale tested in the pilot was 0.73 (Cronbach's alpha)., Conclusion: Establishing a rating scale to assess the communication skills of call handlers which meets common scientific demands, such as content validity and reliability, proved successful. This instrument can be used to give feedback to call handlers.

The issues regarding on-call radiology are complex and contentious. Both academic and private practice radiology centers have encountered increasing workloads in recent years. Some academic centers are utilizing night float systems or other models of call to address the increasing complexity and volume of after-hours cases. Many private practice groups are outsourcing after-hours work to commercial nighthawk radiology services. Emergency medicine department and ACR guidelines place additional expectations on the on-call radiologist.

Objective: The shift towards large-scale organization of out-of-hours primary healthcare in different western countries has created an important role for the nurse telephone consultation. We explored the association between negative patient evaluation of nurse telephone consultations and characteristics of patients and GP cooperatives., Methods: A cross-sectional study using postal patient questionnaires sent to patients receiving a nurse telephone consultation from one of 26 GP cooperatives in the Netherlands., Results: The total response was 49.3% (2583/5239). Negative evaluations were most frequently encountered for the general information received on the GP cooperative (35%). When patients expected a centre consultation or home visit, but only received a nurse telephone consultation, they were more negative about the accessibility (OR 1.7, CI 1.4-2.1) and nurse telephone consultation (OR 4.2, CI 3.2-5.6). In the presence of a special supervising telephone doctor at the cooperative's call centre, nurse telephone consultation was evaluated significantly less negative (OR 0.4, CI 0.2-0.8)., Conclusion: Expectation of care mode was most strongly associated with a negative evaluation of nurse telephone consultation. The presence of a supervising telephone doctor may lead to a better evaluation of nurse telephone consultations., Practice Implications: More attention should be paid to the provision of patient information on the GP cooperative and discrepancies between the care expected and the care offered.

There are indications that after-hours care in some countries is of poor quality. European after-hours care is shifting away from individual and group practices with local after-hours call schedules toward large-scale after-hours care services. Experiences with primary care cooperatives in three countries show that this model can lighten physicians' workloads, reduce the number of face-to-face contacts, reduce use of emergency services and hospital admissions, and lower costs. Most patients accept these new models but are dissatisfied if they expect to see a physician. Local or regional integration of all emergency services seems to be the most promising model for after-hours care.

Objective: To examine whether the perinatal mortality of infants born during holidays differs from that of infants born on workdays, and to elucidate its cause., Design: Cross-sectional study. Setting Vital statistics linked to the National Infant Mortality Survey data for 1999 births in Korea., Population: In all, 628 485 births in 1999 in Korea., Methods: Number of births and perinatal mortality were classified according to the day of the week using the occurrence index. After adjusting for confounding factors, the odds ratios (ORs) for increased holiday mortality were estimated using logistic regression., Main Outcome Measure: Birthweight-adjusted perinatal mortality., Results: Births on holidays were 33% fewer and perinatal deaths 24% higher than expected (PMR, Perinatal Mortality Rate, 16.4 versus 12.8; OR, 1.3; 95% CI, 1.2-1.4). After the adjustment of birthweight, gender, plurality and congenital anomalies, the odds ratio for death of infants born during holidays was 1.2 (95% CI, 1.1-1.3)., Conclusions: The higher perinatal mortality during holidays in Korea appears to be due to different qualities of perinatal care, rather than difference in case-mix.

Objective: To identify opportunities for quality improvement in long-term care telephone medicine using a model of interdisciplinary focus groups., Design: Descriptive pilot project., Setting: Extended Care and Rehabilitation Center (ECRC), Durham VA Medical Center, Durham, North Carolina., Participants: Eight of 20 registered or licensed practical nurses and 4 of 6 geriatric medicine fellows voluntarily participated in this quality improvement project., Measurements: In two 45-minute focus groups, participants were asked to discuss 3 open-ended questions related to telephone medicine. Comments were recorded during the discussions; topical themes were identified by the authors., Results: Participant comments could be categorized into 4 domains describing the characteristics of nurses and physicians who practice the best telephone medicine: (1) provides the appropriate medical component of patient care; (2) appreciates contextual issues; (3) respects the other party's time and resources; and (4) possesses a collaborative attitude. The focus groups identified 5 quality improvement goals: (1) better nursing assessment and provision of patient information; (2) minimization of non-urgent calls after hours; (3) more decisive physician action (or explanation of inaction); (4) better physician familiarity with facility policies/logistics; and (5) better communication/paging system. The discussion format allowed nurses and physicians to identify and respond to potential barriers to improving quality in each area., Conclusion: Nurses and physicians appreciate unique aspects of long-term care telephone medicine and identify distinct barriers to improving practice. Interdisciplinary focus groups were a productive step toward understanding the telephone medicine experience in our facility and developing quality improvement interventions for both nurses and physicians.

Background: Malaria is currently diagnosed almost exclusively by microscopy in clinical laboratories. The introduction of rapid diagnostic tests (RDTs) may be useful in achieving rapid detection of malaria parasites, especially in situations where malaria is not often seen or where staff are inexperienced., Aim: To explore the use of RDT in UK laboratories., Methods: The current use of RDTs was surveyed in UK laboratories subscribing to the United Kingdom National External Quality Assessment Scheme blood parasitology and haematology schemes., Results: An overall survey response rate of 60.3% was seen. RDTs were found to be the preferred choice, either alone or in conjunction with microscopy in 31.2% of the samples examined during normal working hours and in 44.3% of the specimens examined on call., Conclusions: During on-call hours, the use of RDTs was observed to increase and RDTs changed the diagnosis in 12% of laboratories. No established protocol for RDT use was, however, observed in the UK. A protocol that needs to be validated in the laboratory setting is suggested.

Background: Since the turn of the millennium, out-of-hours primary health care in The Netherlands has faced a substantial change from small locum groups towards large GP cooperatives. Improving the quality of care requires evaluation of patient satisfaction., Objective: To develop a reliable postal questionnaire for wide-scale use by patients contacting their out-of-hours GP cooperative and to present the results of a national survey., Methods: Literature review and interviews with both patients and health carers were carried out to identify issues of potential relevance, followed by two postal pilot studies and additional interviews to remove or rephrase items. Finally, postal questionnaires were sent to 14,400 people who contacted one of 24 GP cooperatives in The Netherlands., Results: Overall response was 52.2% for all types of contact. Three scales were identified prior to the field phase and confirmed by principal components analysis: telephone nurse, doctor and organization. Reliability was high, with Cronbach's alphas and intraclass correlation coefficients exceeding 0.70 for all scales. Only items in the organization scale showed clear differences among the participating cooperatives. Respondents receiving telephone advice showed lower levels of satisfaction than respondents with other types of contact (P < 0.001); centre consultation scored lower than home visit (P < 0.030 or less for all differences)., Conclusion: A reliable measure of patient satisfaction has been developed that can also be used for the comparison of GP cooperatives on an organizational level. Overall satisfaction was high, showing highest levels for home visit and lowest levels for telephone advice.