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Objective: To decrease the number of inappropriate pages after-hours by 50%., Methods: Over 9 weeks, after-hours pages to the on-call resident at University of Minnesota Department of Urology were documented. Pages were deemed "appropriate" or "inappropriate" by 3 independent reviewers. The source of each page was reviewed and after several plan-do-study-act (PDSA) cycles, 3 separate interventions were created, directed at floor nursing, patient phone calls, and the call triage center. After a 6-week implementation period, data were re-collected for 9 weeks. Descriptive statistics were generated, and a Mann-Whitney U test was used to compare inappropriate pages pre- and post- interventions., Results: In phase I, 48 shifts were recorded. The mean number of pages per shift was 8.9 (range 1-27), with 52.7% of pages considered "inappropriate." Most pages came from the wards (48.9%) followed by the emergency department (20.4%), patient phone calls (19.4%), and the call center (2.6%). From these domains, the call center had the highest proportion of inappropriate pages (90.9%). In phase II, 39 shifts were recorded. The mean number of pages per shift decreased to 6.0 (range 1-20), and inappropriate pages per shift decreased by 68.4%, (P <.0001)., Conclusion: By improving communication to nurses, patients, and call center personnel, inappropriate after-hours pages decreased by 68.4%-exceeding our aim. Future studies are needed to assess if the impact was sustainable over time., Competing Interests: Declaration of Competing Interest Rachel A. Mann: Boston Scientific—consultant/advisor; the remaining authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: We sought to determine the achievement of key performance indicators (KPIs) of initial trauma care at non-tertiary hospitals in Ghana during on-hours (8AM-5PM weekdays) compared to off-hours (nights, weekends, and holidays). We also sought to assess the effectiveness of a standardized trauma intake form (TIF) with built-in decision support prompts to improve care and to assess whether this effectiveness varied between on-hours and off-hours., Methods: A stepped-wedge cluster randomized trial was performed with research assistants directly observing trauma care before and after introducing the TIF at emergency units of eight hospitals for 17.5 months. Differences in KPIs and mortality were assessed using multivariable logistic regression and generalized linear mixed regression., Results: Management of 4,077 patients was observed; 1,126 (28 %) during on-hours and 2,951(72 %) during off-hours. At baseline, four of 20 KPIs were performed significantly more often during off-hours. TIF improved care during both on- and off-hours. Seventeen KPIs improved during on-hours and 18 KPIs improved during off-hours. After TIF, six KPIs were performed more often during on-hours, but differences, though significant, were small (1-5 %). Examples of KPIs which were performed more often during on-hours after TIF included: airway assessment (99 % for on-hours vs. 98 % for off-hours), evaluation for intra-abdominal bleeding (91 % vs. 87 %), and spine immobilization for blunt trauma (90 % vs. 85 %) (all p < 0.05). At baseline, mortality among seriously injured patients (Injury Severity Score >9) was higher during on-hours (27 %) compared to off-hours (17 %, p = 0.047). TIF lowered mortality for seriously injured patients during both on-hours (27 % before TIF, 8 % after, p = 0.027) and during off-hours (17 % before, 7 % after, p = 0.004). After TIF, mortality among seriously injured patients was equal between on- and off-hours (8 % vs. 7 %, NS)., Conclusions: At baseline, KPIs of trauma care were slightly better during off-hours compared with on-hours, and mortality was lower among seriously injured patient during off-hours. A quality improvement initiative (the TIF) using built-in decision support prompts improved care strongly in both on- and off-hours and eliminated the mortality difference between on- and off-hours. Use of similar decision support prompts during initial trauma care should be promoted widely in other low- and middle-income countries., Competing Interests: Declaration of competing interest The authors of the manuscript titled “Differences in trauma care between on-hours and off-hours and responsiveness to a trauma intake form with decision support prompts in Ghana: A stepped-wedge cluster randomized trial” declare no conflict of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objectives: To determine whether a new triage system safely diverts a proportion of emergency department (ED) patients to a general practitioner cooperative (GPC)., Methods: Unblinded randomised controlled trial with weekends serving as clusters (three intervention clusters for each control). The intervention was triage by a nurse using a new extension to the Manchester Triage System assigning low-risk patients to the GPC. During intervention weekends, patients were encouraged to follow this assignment; it was not communicated during control weekends (all patients remained at the ED). The primary outcome was the proportion of patients assigned to and handled by the GPC during intervention weekends. The trial was randomised for the secondary outcome: the proportion of patients assigned to the GPC. Additional outcomes were association of these outcomes with possible confounders (study tool parameters, nurse, and patient characteristics), proportion of patients referred back to the ED by the GPC, hospitalisations, and performance of the study tool to detect primary care patients (the opinion of the treating physician was the gold standard)., Results: In the intervention group, 838/6294 patients (13.3%, 95% CI 12.5 to 14.2) were assigned to the GPC, in the control group this was 431/1744 (24.7%, 95% CI 22.7 to 26.8). In total, 599/6294 patients (9.5%, 95% CI 8.8 to 10.3) experienced the primary outcome which was influenced by the reason for encounter, age, and the nurse. 24/599 patients (4.0%, 95% CI 2.7 to 5.9) were referred back to the ED, three were hospitalised. Positive and negative predictive values of the studied tool during intervention weekends were 0.96 (95%CI 0.94 to 0.97) and 0.60 (95% CI 0.58 to 0.62). Out of the patients assigned to the GPC, 2.4% (95% CI 1.7 to 3.4) were hospitalised., Conclusions: ED nurses using a new tool safely diverted 9.5% of the included patients to primary care., Trial Registration: ClinicalTrials.gov Identifier: NCT03793972., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: The second author is a general practitioner working in the surroundings of the study site, and as such, he performed on call shifts at the study site and treated some of the studied patients. Due to the anonymity of the studied data, the exact number of study patients seen by him cannot be determined, but it was definitely below ten. He is also a board member of the studied general practice cooperative receiving meeting fees. Author HP is coordinator of the iCAREdata project (database used for this study). She had an appointment at the University of Antwerp for this project until September 2020. The authors declare no other relationships or activities that could appear to have influenced the submitted work.

Introduction: Out of hours (OOHs) primary care is a critical component of the acute care system overnight and at weekends. Referrals from OOH services to hospital will add to the burden on hospital assessment in the ED and on-call specialties., Methods: We studied the variation in referral rates (to the ED and direct specialty admission) of individual clinicians working in the Oxfordshire, UK OOH service covering a population of 600 000 people. We calculated the referral probability for each clinician over a 13-month period of practice (1 December 2014 to 31 December 2015), stratifying by clinician factors and location and timing of assessment. We used Simul8 software to determine the range of hospital referrals potentially due to variation in clinician referral propensity., Results: Among the 119 835 contacts with the service, 5261 (4.4%) were sent directly to the ED and 3474 (3.7%) were admitted directly to specialties. More referrals were made to ED by primary care physicians if they did not work in the local practices (5.5% vs 3.5%, p=0.011). For clinicians with >1000 consultations, percentage of patients referred varied from 1% to 21% of consultations. Simulations where propensity to refer was made less extreme showed a difference in maximum referrals of 50 patients each week., Conclusions: There is substantial variation in clinician referral rates from OOHs primary care to the acute hospital setting. The number of patients referred could be influenced by this variation in clinician behaviour. Referral propensity should be studied including casemix adjustment to determine if interventions targeting such behaviour are effective., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Physiotherapy in an adult intensive care unit (ICU) affects health outcome. To justify the investment in ICU physical therapy, the cost savings associated with its benefits need to be established. The main objective of this study is to evaluate the potential cost savings of implementing 24-hour, 7-days-per-week physiotherapist (24/7-PT) in a Chilean public high-complex specialized ICU., Methods: Using clinical data from a literature review and a micro-costing technique, we conducted a cost-benefit analysis in the National Institute of Thorax in Chile. Our example scenario involves 697 theoretical admissions of adult patients with cardiovascular or respiratory diseases, and the costs and benefits by reduction of length of stay in ICU, days of mechanical ventilation, and days with respiratory infections during the first year and 5 years of admissions. A sensitivity analysis was considered according to the variability in total costs, production income, and clinical benefits., Results: Net cost savings generated in our example scenario demonstrate that the implementation of 24/7-PT produces a minimum saving for the institution of $16 242 during the first year and $69 351 over a 5-year interval considering individual income production. Out of the 30 scenarios included in the sensitivity analyses, 26 (87%) demonstrated net savings., Conclusions: A financial model, based on literature review and actual cost data, projects that 24/7-PT intervention is a cost-benefit alternative in adult ICU patients with cardiovascular or respiratory diseases in Chile. It is necessary a scenario of at least 3 sessions per day with insurance payment for individual treatments to support the long-term implementation of a 24/7-PT program., (Copyright © 2020. Published by Elsevier Inc.)

Objective: Root cause analyses of serious adverse events (SAE) in out-of-hours primary care (OHS-PC) often point to errors in telephone triage. Such analyses are, however, hampered by hindsight bias. We assessed whether experts, blinded to the outcome, recognize (un)safety of triage of patients with chest discomfort, and we quantified inter-rater reliability., Study Design and Setting: This is a case-control study with triage recordings from 2013-2017 at OHS-PC. Cases were missed acute coronary syndromes (ACSs, considered as SAE). These cases were age- and gender-matched 1:8 with the controls, sampled from the remainder of people calling for chest discomfort. Fifteen experts listened to the recordings and rated the safety of triage. We calculated sensitivity and specificity of recognizing an ACS and the intraclass correlation., Results: In total, 135 calls (15 SAE, 120 matched controls) were relistened. The experts identified ACSs with a sensitivity of 0.86 (95% CI: 0.71-0.95) and a specificity of 0.51 (95% CI: 0.43-0.58). Cases were rated significantly more often as unsafe than the controls (73.3% vs. 22.5%, P < 0.001). The inter-rater reliability for safety was poor: ICC 0.16 (95% CI: 0.00-0.32)., Conclusions: Blinded experts rated calls of missed ACSs more often as unsafe than matched control calls, but with a low level of agreement among the experts., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Diagnostic error and diagnostic delays in health care are widespread. This article outlines an improvement effort targeting weekday evening inpatient radiology delays through staffing changes replacing trainees with faculty-trainee team coverage, pushing faculty coverage from 4 pm to 8 pm. Order-report turnaround times (TATs), critical findings TATs for pneumothorax and intracranial hemorrhage (ICH), and percentage meeting target were compared pre and post implementation for the 4 to 8 pm time frame using the Mann-Whitney U and χ 2 tests, respectively. Stakeholder surveys assessed patient safety, morale, education, and operational efficiency. Median TATs (minutes) improved: X-rays 906 to 112, computed tomography 994 to 84, magnetic resonance imaging 1172 to 233, and ultrasound 88 to 58. Median critical findings TATs (minutes) improved from 853 to 30 and 112 to 22 for pneumothorax and ICH, respectively, and the percentage meeting target improved from 45% to 65%. Survey results reported perceived improvement in patient safety, education, and operational efficiency and no impact on morale.

Background: Emergency departments in South African public hospitals have a high patient load after hours, with inadequate numbers of health care professionals available to satisfy patient influx. In addition, there is often no provision of after-hours diagnostic reporting services in public hospitals, to an extent that the emergency physician is responsible for interpreting all radiographic images requested themseves. Emergency physicians, in this study, can be described as any medical doctor registered with the Health Professions Council of South Africa and working in the emergency department as a registrar or consultant physician because there were no physicians specialized in emergency medicine working at the hospitals selected for this study., Aim: The aim of this study was to determine the views of emergency physicians on whether there is a need for an after-hours diagnostic radiological reporting service in selected public hospitals in KwaZulu-Natal Province, South Africa., Methods: A descriptive cross-sectional quantitative research design was utilized, through means of a survey, to assess the emergency physicians' perceptions regarding the need for after-hours diagnostic radiological reporting. In addition, the study used a descriptive quantitative research design to record the number of conventional diagnostic radiographic examinations performed at the selected hospitals, after hours, and the proportional number of these radiographic examinations that were reported on by radiologists during office hours, the following day. The distribution of questionnaires and data collection, with regard to the number of examinations reported on, and those not reported on, were carried out simultaneously during the execution of this study. The study was conducted over a three-month period in 2017, at four public hospitals in KwaZulu-Natal-one of the nine provinces of South Africa., Results: This study found that, during the study period, between 0.1% and 0.6% of the conventional diagnostic radiographic examinations performed, after hours, were reported on by radiologists during office hours, the following day. The surveyed emergency physicians felt that the interpretation of diagnostic images took up valuable time that could be spent on patient management, and there was near-total agreement, whereby 92% (n = 36) of the physicians would have preferred after-hours reporting to be performed by a radiologist. Physicians agreed that having a radiologist or reporting radiographer to provide radiological reports would allow for more effective and efficient patient management., Conclusion: The results of this study indicated that there is a need for after-hours radiographic reporting at the selected public hospitals and for the further training of emergency physicians in radiographic image interpretation. Based on the findings of this study, it is recommended that after-hours radiological reporting services be considered for public hospitals and that courses be offered to emergency physicians on the interpretation of diagnostic radiographic images. A hospital policy review may therefore be needed to adjust the focus of hospitals toward reducing the workload of emergency physicians, wherever possible, such as by incorporating support services like radiographic reporting and by providing further training on the interpretation of diagnostic radiographic images, which will both act to reduce the potential risk of misdiagnosis., (Copyright © 2020. Published by Elsevier Inc.)

Objective: To determine the inter-rater reliability and validity of the Netherlands Triage Standard (NTS) for paediatric triage., Design: A cross-sectional study using fictional cases for telephone and physical triage., Method: An expert panel established in advance the urgency of 40 cases concerning emergency help requests from non-referred children (the reference standard). These requests were presented in an online survey to triagists from three general practitioner (GP) out-of-hours practices, three ambulance dispatching centres and three hospital emergency departments. Triagists assessed all cases, using the NTS. We determined the agreement on degrees of urgency between different triagists and compared them with the reference standard. The outcome measure for inter-rater reliability was the intraclass correlation coefficient (ICC). The outcome measures for validity were the degree of agreement with the reference standard, under-triage and over-triage, and sensitivity and specificity in identifying high-urgency (U0-U2) versus low-urgency cases (U30U5)., Results: In total, 116 triagists participated in the study (response: 86%). The ICC was 0.73 among all triagists, and was highest in the out-of-hours GP cooperatives. There was 62.3% agreement with the reference standard, 17.4% under-triage and 20.2% over-triage. Of the divergent urgencies, 77% differed by only one urgency category. The sensitivity was 85.2% and the specificity 89.7%. The sensitivity and specificity of triage by the GP out-of-hours practices (82.7% and 92.7%, respectively) were almost the same as that by the hospital emergency departments (79.6% and 92.5%, respectively). Triage by the ambulance dispatching centres had relatively high sensitivity (93%), but relatively low specificity (82.4%)., Conclusion: The results of the study contribute to the evidence that the NTS is a reliable and valid triage standard for paediatric patients. The urgency assessments by triagists in the GP out-of-hours practices, ambulance dispatching centres and hospital emergency departments were broadly in agreement. Results were limited by cases being on paper and triage only on anamnestic characteristics.

Ordering and protocolling CT scans after-hours from the emergency department (ED) at our institution previously required discussion between the ED physician and radiology resident, which led to workflow inefficiency. Our intervention consisted of creating an electronic list of CT requests that radiology residents would monitor. Radiology protocolled straightforward requests and contacted the ordering physician for more details when required. We aimed to improve workflow efficiency, increase provider satisfaction and reduce CT turnaround time without significantly affecting CT utilisation. Plan-do-study-act cycles were used to plan and evaluate the intervention. The intervention was initiated on weekday evenings and then expanded to weekend hours after an interim analysis. Qualitative outcomes were measured via electronic survey, and quantitative outcomes were collected from administrative data and analysed via control charts and other statistical methods. Survey response was high from ED physicians (76%, n=82/108) and radiology residents (79%, n=30/38). After the intervention, the majority of ED staff and radiology residents perceived improved workflow efficiency (96.3%, 73.3%), radiology residents noted a subjective decrease in disruptions (83.3%) and most ED staff felt that scans were performed more quickly (84.1%). Radiology residents received fewer pages per shift, adjusted for scan volume. There was a reduction in time from order entry to protocol on weekday shifts only, with no statistically significant effect on time from order entry to scan. Segmented regression analysis demonstrated a background increase in utilisation over time (0.7-2.0 CT/100 ED visits/year, p<0.0005), but the intervention itself did not contribute to an overall increase in CT utilisation. In conclusion, our intervention led to improved perceived workflow efficiency and reduced pages. Scans were protocoled more quickly on weekdays, but turnaround times were otherwise not significantly affected by the intervention. Background CT utilisation increased over time, but this increase was not attributable to our intervention., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Sepsis is associated with impaired clinical outcomes. It requires timely diagnosis and urgent therapeutic management. Because staffing during after-hours is limited, we explored whether after-hour admissions are associated with worse clinical outcomes in patients with sepsis.In this retrospective cohort study, we analyzed nationwide acute care admissions for a main diagnosis of sepsis in Switzerland between 2006 and 2016 using prospective administrative data. The primary outcome was in-hospital mortality using multivariable logistic regression models. Secondary outcomes were intensive care unit (ICU) admission, intubation, and 30-day readmission.We included 86,597 hospitalizations for sepsis, 60.1% admitted during routine-hours, 16.8% on weekends and 23.1% during night shift. Compared to routine-hours, we found a higher odds ratio (OR) for in-hospital mortality in patients admitted on weekends (Adjusted OR 1.05, 95% confidence interval [95% CI] 1.01, 1.10, P = .041). Also, the OR for ICU admission (OR 1.14, 95% CI 1.10, 1.19, P < .001) and intubation (OR 1.18, 95% CI 1.12, 1.25 P < .001) was higher for weekends compared to routine-hours. Regarding 30-day readmission, evidence for an association could not be observed. Night shift admission, compared to routine-hours, was associated with a higher OR for ICU admission and intubation (ICU admission: OR 1.28 (1.23, 1.32), P < .001; intubation: OR 1.31, 95% CI 1.25, 1.37, P < .001) but with a lower OR for in-hospital mortality (OR 0.93, 19% CI 0.89, 0.97, P = .001).Among hospitalizations with a main diagnosis of sepsis, weekend admissions were associated with higher OR for in-hospital mortality, ICU admission, and intubation. Whether these findings can be explained by staffing-level differences needs to be addressed.

Background: Emergency departments (ED) are important providers of asthma care, particularly after-hours. We identified gaps for quality improvement such as suboptimal adherence rates to three key recommendations from the Global Initiative for Asthma (GINA) guidelines for discharge management asthma guidelines. These were: the prescription of oral and inhaled corticosteroids (OCS and ICS) and issuance of outpatient follow-up for patients discharged from the ED., Aim: To achieve an adherence rate of 80% to GINA guidelines for ED discharge management by providing after-hours asthma counselling services., Methods: We implemented Asthma-COPD Afterhours Respiratory Nurse at Emergency (A-CARE) according to the Plan-Do-Study-Act (PDSA) framework to provide after-hours asthma counselling and clinical decision support to ED physicians three nights a week. Data on adherence rates to the GINA guidelines were collected and analysed on a run chart., Results: After 17 months' follow-up, a sustained improvement was observed in patients reviewed by A-CARE in the median adherence rates to OCS prescription (58% vs 86%), ICS initiation (27% vs 67%) and issuance of follow-up (69% vs 92%), respectively. The overall impact was, however, limited by a suboptimal referral rate to A-CARE (16%) in a clinical audit of all ED patients with asthma. Nonetheless, in this audit, attendance rates for patients referred to our respiratory department for follow-up were higher in those receiving asthma counselling compared with those who did not (41.7% vs 15.9%, p=0.0388)., Conclusion: Sustained improvements in the adherence rates to guidelines were achieved for patients reviewed by A-CARE but were limited in overall impact due to suboptimal referral rate. We plan to improve the quality of asthma care by implementing further PDSA cycles to increase the referral rates to A-CARE., Competing Interests: Competing interests: AKWC has received speaking fees and honorarium from AstraZeneca and GlaxoSmithKline, all paid to his hospital, Singapore General Hospital. DT and BA are employees of AstraZeneca Singapore. MSK has received speaker fees and fees for serving on the advisory boards of GlaxoSmithKline, AstraZeneca and Sanofi, all paid to her hospital, Singapore General Hospital. The other authors do not have competing interests to declare., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: To explore and compare safety, efficiency, and health-related quality of telephone triage in out-of-hours primary care (OOH-PC) services performed by general practitioners (GPs), nurses using a computerised decision support system (CDSS), or physicians with different medical specialities., Methods: Natural quasi-experimental cross-sectional study conducted in November and December 2016. We randomly selected 1294 audio-recorded telephone triage calls from two Danish OOH-PC services triaged by GPs (n = 423), nurses using CDSS (n = 430), or physicians with different medical specialities (n = 441). An assessment panel of 24 physicians used a validated assessment tool (Assessment of Quality in Telephone Triage - AQTT) to assess all telephone triage calls and measured health-related quality, safety, and efficiency of triage., Results: The relative risk (RR) of poor quality was significantly lower for nurses compared to GPs in four out of ten items regarding identifying and uncovering of problems. For most items, the quality tended to be lowest for physicians with different medical specialities. Compared to calls triaged by GPs (reference), the risk of clinically relevant undertriage was significantly lower for nurses, while physicians with different medical specialties had a similar risk (GP: 7.3%, nurse: 3.7%, physician: 6.1%). The risk of clinically relevant overtriage was significantly higher for nurses (9.1%) and physicians with different medical specialities (8.2%) compared to GPs (4.3%). GPs had significantly shorter calls (mean: 2 min 57 s, SD: 105 s) than nurses (mean: 4 min 44 s, SD: 168 s)., Conclusions: Our explorative study indicated that nurses using CDSS performed better than GPs in telephone triage on a large number of health-related items, had a lower level of clinically relevant undertriage, but were perceived less efficient. Calls triaged by physicians with different medical specialities were perceived less safe and less efficient compared to GPs. Differences in the organisation of telephone triage may influence the distribution of workload in primary and secondary OOH services. Future research could compare the long-term outcomes following a telephone call to OOH-PC related to safety and efficiency.

Aim: This paper explored the general phenomenon and psychological experience of the special background communication in night shift medical staff and provides better reference for night shift communication between doctors and nurses., Background: Physician-nurse communication has always been an important agenda for health care work and an important concept in nursing theory. During night shifts, effective doctor and nurse communication can enhance mutual trust, provide timely and appropriate medical services to patients, reduce adverse events and enhance patient safety., Design: A qualitative study was conducted., Methods: Husserl's descriptive phenomenology method and semi-structured in-depth interviews were used to collect data from 8 nurses and 5 doctors. Colaizzi's method was used to analyse data using MAXQDA 12. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was followed (see Appendix S1)., Results: Three themes were extracted after sorting out and refining: the need to achieve goals in night-time physician-nurse communication; obstacles in night-time physician-nurse communication; and relationship culture in night-time physician-nurse communication., Conclusion: Attention should be paid to the particularity of night shift and efficiency of achieving the goal of communication between doctors and nurses on night shift, and the hidden obstacles behind communication between doctors and nurses. Managers should pay attention to the cultural construction of night shift communication in the system, form a good night shift communication process and regularly train doctors' and nurses' related communication skills. And they should also study relationship culture rationally to improve the communication efficiency of night shift., Implications for Nursing Management: The experiences described in this study contribute to a better understanding of obstacles hidden behind night shift physician-nurse communication. This also provides valuable information to professional managers who develop good doctor-nurse relationship culture., (© 2020 John Wiley & Sons Ltd.)

Background: Pre-hospital emergency anaesthesia (PHEA) is frequently required for injured patients. National Institute for Health and Care Excellence (NICE) quality standards state that PHEA should be delivered within 45 min of an emergency call. We investigated whether there is geo-temporal variation in service provision to the UK population., Methods: We retrospectivly audited the time of day when PHEA is provided by UK Helicopter Emergency Medical Services (HEMS), by recording PHEA provision on a randomly selected week and weekend day in 2018. Pre-hospital emergency anaesthesia in the United Kingdom: an observational cohort study retrospectively assessed the time from emergency call to pre-hospital emergency anaesthesia delivery by HEMS during a 1 yr period from April 2017 to March 2018. The population coverage likely to receive pre-hospital emergency anaesthesia in accord with NICE guidelines was estimated by integrating population data with the median time to PHEA, hours of service provision, geographic location, and transport modality., Results: On a weekday 20 HEMS units (comprising from four to 31 enhanced care teams) were estimated to be able to meet NICE guidelines for delivery of PHEA to a poulation of 6.6-35.2 million individuals (at times of minimum and maximal staffing, respectively). At the weekend, 17 HEMS units (comprising from 5 to 28 enhanced care teams) were estimated to be able to meet NICE guidelines for PHEA deliveryto a population of 6.8-34.1 million individuals (minimum and maximal staffing, respectively)., Conclusions: There is marked geo-temporal variation in the ability of HEMS organisations to deliver pre-hospital emergency anaesthesia in the UK., (Copyright © 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Objectives: to evaluate the "access to first contact" attribute, from the perspective of Primary Care Health professionals., Methods: an evaluative and cross-sectional study, carried out from February to March 2017. The sample consisted of 163 health professionals, of both genders, who worked in the basic care of the Municipality of Juazeiro do Norte, Ceará. Access to first contact was evaluated by the Primary Care Assessment Tool (PCATool). The 6.60 mark was used as the cut-off point for the evaluated attribute., Results: access to first contact reached a score of 3.3, denoting a low degree of orientation for Primary Health Care. Nurses were the ones who evaluated the attribute more negatively (p=3.2)., Conclusions: access to first contact obtained a low score, pointing to the fragility of the Family Health Strategy as a gateway to the Brazilian Unified Health System (Sistema Único de Saúde).

Background: Although technical advances help achieve haemodialysis adequacy, we hypothesise remediable non-therapy factors exacerbate patient dissatisfaction, non-adherence to treatment time and failure to meet dialysis goals. Scheduling inefficiencies lead to the total time in the unit far greater than actual treatment time, impacting facility efficiency and patient frustration., Objectives: We used queuing theorem principles to optimise schedules by incorporating timing and workflow for every dialysis process step to design a new schedule, rather than the whole-shift blocks at baseline., Design: The goals were to: (1) craft schedules that maximised efficiency and economics from a facility perspective, and (2) minimise total time in the dialysis unit from a patient viewpoint. As dialysis units are held to a national standard of urea clearance, reduction ratios (URRs) were measured for the 3 months before and after the new scheduling was implemented., Results: Dialysis staff and process parameters were measured to craft queued schedules of staggered small groups of patients instead of baseline blocks of 2 large shifts, 24 each. A total of 65 patients changed to groups of 8, with entry-to-exit at 290 minutes for four hours treatments. The URRs improved from 72.8 ± 6.9 to 75.2 ± 5.4% (p < 0.001). Before implementation, only 89% of subjects reached the URR facility compliance target of 65%, and afterwards 97% (p < 0.001)., Conclusion: Queuing theorem principles can be successfully adopted to optimise haemodialysis scheduling. The resultant staggered timing increases facility efficiency, minimises the long wait time dissatisfier, and is associated with improved URRs with more patients reaching target clearance thresholds., (© 2019 European Dialysis and Transplant Nurses Association/European Renal Care Association.)

Objective: to analyze night admission characteristics at a Psychosocial Care Center III (CAPS III - Centro de Atenção Psicossocial)., Method: a qualitative research, whose data were collected with 15 nursing professionals from November to April 2016, through a semi-structured interview., Results: it was verified that night admission is provided by the nursing team in different dynamics from the day care. This team has strategies of care during crisis, avoiding search for other network services and maintaining the CAPS in its function within the psychosocial model., Final Considerations: service operation depends on the nursing team for its permanence condition in all shifts, which leads to the need to think about the legislation reformulation that structures the CAPS III team, in order to guarantee the interdisciplinary care provided by the Brazilian Psychiatric Reform in this device, which should replace hospitalization in a specialized institution.

Background: As of December 31, 2016, in the United States, 22 866 patients received left ventricular assist devices (LVADs) (J Heart Lung Transplant. 2017;36(10):1080-1086). First responders are generally unfamiliar with LVAD equipment functionality (J Heart Lung Transplant. 2018;37(4):S275). When a patient has an emergency either clinically or with a controller alarm or failure, speaking with ventricle assist device (VAD)-trained personnel is imperative to the prevention of adverse events. Starting February 2017, an LVAD program totaling 181 patients at a large teaching hospital changed their afterhours process to reduce wait time between patient call and talking to VAD-trained personnel to increase patient safety and patient satisfaction., Methods: The Plan-Do-Check-Act quality improvement method was used to evaluate this project from February 2017 to July 2018 by the program's clinical information analyst. An afterhours summary of telephone interactions between VAD program clinicians (VAD coordinators, physician assistants, and nurse practitioner) was used to analyze the use of the "VAD Emergency Line." An annual patient satisfaction survey was completed to analyze patient satisfaction of the VAD Emergency Line., Interventions: Review of the afterhours summary was conducted to determine the use of the VAD Emergency Line. The process of afterhours patient calls was changed so that calls are answered immediately by a 24-hour LVAD-trained medical ambulance service, called VAD Emergency Line. Patient use of the VAD Emergency Line was continuously assessed. In November 2017, it was recognized that only 57% of patient calls used the VAD Emergency Line, and further intervention was needed. In November 2017, patients were provided visual reminders to ensure compliance., Results: Seventeen months after the implementation of the VAD Emergency Line, 92% of patient's afterhours calls were through the VAD Emergency Line. Although there was no statistical significance found, there was clinical significance. Since the implementation of the VAD Emergency Line, patient use of the VAD Emergency Line increased 56% from March 2017 to July 2018. There have been zero adverse safety events. Sixty-one percent of patients strongly agreed to the question "You are able to communicate emergent needs after hours (VAD Emergency Line)?, Conclusion: Implementation of the LVAD Emergency Line has improved communication between patients in the outpatient setting. This increased patient safety by allowing patients to speak to LVAD-trained first responders and VAD coordinator personnel immediately without ever being put on hold. This communication process can be applied to other clinical programs.

Competing Interests: Competing interests: None declared.

Background: Diagnostic errors made by radiology resident physicians may lead to significant morbidity/mortality and patient dissatisfaction., Objective: To determine the etiology and disposition associated with radiology discrepancies on emergency department (ED) patients., Methods: We conducted a retrospective electronic chart review of patients presenting to our ED during "off hours" at the Penn State Hershey Medical Center during October 2013-November 2014 and had a radiology discrepancy, defined as a patient discharged from the ED with a diagnostic interpretation disagreement between the initial radiology resident physician read and final radiology attending physician read., Results: 81,201 images were performed during "off hours", with 174 radiology discrepancies (0.214%) identified. Most discrepancies were associated with CT scans (62%). The most common final diagnostic interpretations associated with discrepancies were missed fracture (10.9%), incidental findings of mass or cyst (10.3%), gastrointestinal inflammation (6.3%), and pneumonia (5.7%). 10% of radiology discrepancies were instructed to emergently return to the ED. The most common modality associated with ED follow-up was CT scan of the abdomen/pelvis (50%). Of the 17 patients that returned to the ED, 10 had additional diagnostic imaging, 9 received a subspecialist consult, 5 required surgical treatment, 5 required additional medications, and 1 required a medical hospitalization., Conclusions: Based on our sample, discrepancies were a small percentage of images performed during "off hours", and were associated with CT scans, missed fractures, and non-emergent outpatient follow-up. We suggest that ED and radiology departments work collaboratively to monitor their own rates of discrepancies, and subsequent morbidities and mortalities, to improve patient care., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Reversal of anticoagulation with four-factor prothrombin complex concentrate (4F-PCC) is critical, yet the optimal timing to 4F-PCC administration and whether quicker administration improves hemostasis remains unknown., Objective: The objective of this study was to determine if pharmacist presence is predictive of faster time to 4F-PCC., Methods: This retrospective cohort study included patients receiving 4F-PCC for life-threatening bleeding or urgent procedure in the emergency department (ED) from 2014 to 2018. Patients with pharmacists at bedside (PharmD group) were compared with physician teams alone (control group). The primary outcome was time from ED presentation to 4F-PCC administration., Results: Of 252 patients evaluated, 116 patients (46%) were included (n = 50 PharmD group; n = 66 control group). Most patients presented on warfarin (68.1%), and of the life-threatening bleeds (94%), intracranial hemorrhage was most common (67.2%). The median time to 4F-PCC administration was significantly shorter in the PharmD group (66.5 vs. 206.5 min, p < 0.001). Pharmacist at bedside was the only factor independently associated with reduction in time to 4F-PCC (β coefficient -163.5 min, 95% confidence interval -249.4 to -77.7). Although there was no difference in hemostasis or mortality, patients in the PharmD group had a shorter intensive care unit length of stay (LOS) (2 vs. 5 days, p < 0.01) and hospital LOS (5.5 vs. 8 days, p = 0.02)., Conclusion: A pharmacist at the bedside of patients who present to the ED with life-threatening bleeding or need for emergent procedure decreased time to 4F-PCC administration by 140 min, even after accounting for confounders. Faster time to 4F-PCC was associated with significantly shorter intensive care unit and hospital LOS., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Giving birth in a health care facility does not guarantee high-quality care or favorable outcomes. The working-hour phenomenon describes adverse outcomes of institutional births outside regular working hours., Objectives: The objectives of the study were to evaluate whether the time of birth is associated with adverse neonatal outcomes and to identify the riskiest time periods for obstetrical care., Study Design: This nationwide retrospective cohort study analyzed data from 2008 to 2016 from all 82 obstetric departments in Austria. Births at ≥ 23+0 gestational weeks with ≥500 g birthweight were included. Independent variables were categorized by the time of day vs night as core time (morning, day) and off hours (evening, nighttime periods 1-4). The composite primary outcome was adverse neonatal outcome, defined as arterial umbilical cord blood pH <7.2, 5 minute Apgar score <7, and/or admission to the neonatal intensive care unit. Multivariate logistic regression was used to develop a model to predict these adverse neonatal outcomes., Results: Of 462,947 births, 227,672 (49.2%) occurred during off hours and had a comparable distribution in all maternity units, regardless of volume (<500 births per year: 50.3% during core time vs 49.7% during off hours; ≥500 births per year: 50.7% core time vs 49.3% off hours; perinatal tertiary center: 51.2% core time vs 48.8% off hours). Furthermore, most women (35.8-35.9%) gave birth between 2:00 and 5:59 am (night periods 3 and 4). After adjustment for covariates, we found that adverse neonatal outcomes also occurred more frequently during these night periods 3 and 4, in addition to the early morning period (night 3: odds ratio, 1.05; 95% confidence interval, 1.03-1.08; P < .001; night 4: odds ratio, 1.08; 95% confidence interval, 1.05-1.10; P < .001; early morning period: odds ratio, 1.05; 95% confidence interval, 1.02-1.08; P < .001). The adjusted odds for adverse outcomes were lowest for births between 6:00 and 7:59 pm (odds ratio, 0.96; 95% confidence interval, 0.93-0.99; P = .006)., Conclusion: There is an increased risk of adverse neonatal outcomes when giving birth between 2:00 and 7:59 am. The so-called working-hour phenomenon is an attainable target to improve neonatal outcomes. Health care providers should ensure an optimal organizational framework during this time period., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Standardized mortality rates are routinely used as measures of hospital performance and quality. Such metrics may, however, be biased if hospital admission thresholds differ and patient severity is not fully measured., Aim: To examine whether comparisons of hospital mortality rates suffer from selection bias due to variations in hospital admission rates, using the example of variations by day of the week., Data: 12,900,687 emergency department attendances and 3,418,446 unplanned admissions to all acute non-specialist hospitals of the National Health Service in England between 1 April 2013 and 28 February 2014., Methods: Population-based retrospective cohort study. Mortality within 30 days of attendance is modelled as a function of weekend or weekday attendance and hospital-level predictors of admission rates using patient-level risk-adjusted probit and bivariate Heckman selection models. Robustness is supported by the use of different hospital-level predictors., Results: When examining only the admitted population, patients admitted to hospital at weekends have a 0.206 percentage point higher risk of death within 30 days compared to patients admitted during the week. However, patients attending emergency departments at weekends have a 1.390 percentage point lower probability of being admitted to hospital. Once this selection bias is accounted for, the weekend effect in mortality is reduced by two-thirds to a 0.068 percentage point increase in the risk of death., Conclusions: Comparisons of standardized hospital mortality rates following unplanned admissions can be biased by variations in emergency department admission rates, leading to incorrect conclusions about quality. The use of mortality as a performance measure could therefore lead to misleading comparisons if admission rates vary and illness severity is not fully controlled for. Accounting for sample selection bias and dependence between admission and mortality rates is vital if accurate comparisons of hospital performance are to be made., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: Vascular laboratory (VL) venous duplex ultrasound is the "gold standard" for diagnosis of lower extremity deep venous thrombosis (DVT), which is linked to many morbid conditions. Decreasing night and weekend use of VL services in the emergency department (ED) represents a potentially viable means of reducing costs as skilled personnel must remain on call and receive a wage premium when activated. We investigated the effects of workflow changes that required ED providers to use a computerized decision-making tool, integrated into the electronic medical record, to calculate a Wells score for each patient considered for an after-hours venous duplex ultrasound study for suspected DVT., Methods: The rate of VL use and study positivity before and after implementation of the decision-making tool were examined in addition to measures of ED throughput, rate of concomitant pulmonary embolism, disposition of examined patients from the ED, observed thrombus distribution in duplex ultrasound studies positive for DVT, and calculated personnel costs of after-hours VL use., Results: A total of 391 after-hours, ED-initiated venous duplex ultrasound studies were obtained during the 4-year study period (n = 213 before intervention, n = 178 after intervention; P = .12). Whereas the period immediately after the start of the intervention saw a decrease in VL use, this was not sustained. Studies performed after the intervention were not more likely to be positive for acute DVT (12.2% vs 18%; P = .1179). The average Wells score was 2.8 (range, 0-6). VL personnel were called in 347 times during the 4-year period, with a total cost of $14,643.40. Nurse-ordered studies were significantly more likely to be positive, with 22% revealing acute DVT compared with 12% for physician-ordered studies (P = .042). The intervention resulted in significant improvements in ED throughput, with time between triage and study request falling from 226 minutes to 165 minutes (P < .001). Observed thrombus distribution revealed involvement of the most proximal external iliac system in a minority of cases (11%), whereas most thrombi (89%) were limited to the femoropopliteal, calf, and superficial venous systems., Conclusions: A requirement for ED providers to document a Wells score before obtaining an after-hours venous duplex ultrasound study resulted in only a transient decrease in VL use but improved ED throughput. Studies ordered by nurses were significantly more likely to be positive, possibly as a result of consistent protocol adherence compared with the physicians. Future studies may warrant investigation into this provider variance., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The primary purpose of this study was to determine which physical activity (PA) opportunity elicits the most moderate to vigorous PA (MVPA) in after-school programs. This study used a 3-group cross-over design in which participants were exposed to 3 variations of activity structures: free play, organized, or a mixture., Methods: PA was measured using ActiGraph GT3X+ accelerometers. All data were transformed into percentage of time spent sedentary or in MVPA. Repeated-measures mixed-effects models were used to examine differences in MVPA and sedentary among the 3 activity sessions. Participants included 197 unique children, aged 5-12 years, and were 53% male and 55% white., Results: Statistically significant differences were observed in the percentage of time boys spent in MVPA during free play and mixed compared with organized only sessions (35.8% and 34.8% vs 29.4%). No significant difference was observed in the percentage of time girls spent in MVPA during free play compared with organized or mixed (27.2% and 26.1% vs 26.1%). Both boys and girls experienced ∼10% less time sedentary during free play compared with the others., Conclusion: Offering free play during PA opportunities can help children attain as much if not more MVPA compared with only offering organized, adult-led games.

Competing Interests: Competing interests: None declared.

Introduction: The 'weekend effect' describes variation in outcomes of patients treated over the weekend compared with those treated during weekdays. This study examines whether a weekend effect exists for patients who undergo emergency laparotomy., Materials and Methods: Data entered into the National Emergency Laparotomy Audit between 2014 and 2017 at four NHS trusts in England and Wales were analysed. Patients were grouped into those admitted on weekdays and those on weekends (Friday 5pm to Monday 8am). Patient factors, markers of quality of care and patient outcomes were compared. Secondary analysis was performed according to the day of surgery., Results: After exclusion of patients who underwent laparotomy more than one week after admission to hospital, a total of 1717 patients (1138 patients admitted on weekdays and 579 admitted on weekends) were analysed. Age, preoperative lactate and P-POSSUM scores were not significantly different between the two groups. Time from admission to consultant review, decision to operate, commencement of antibiotics and theatre were not significantly different. Grades of operating surgeon were also similar in both groups. Inpatient 60-day mortality was 12.5% on weekdays and 12.8% on weekends ( P = 0.878). Median length of postoperative stay was 12 days in both groups. When analysed according to day of surgery, only number of hours from admission to antibiotics (12.8 weekday vs 9.4 weekend, P = 0.046) and number of hours to theatre (26.5 weekday vs 24.1 hours weekend, P = 0.020) were significantly different., Discussion: Quality of care and clinical outcomes for patients undergoing emergency laparotomy during the weekend are not significantly different to those carried out during weekdays.

Purpose: To evaluate the impact of time of birth on adverse neonatal outcome in singleton term hospital births., Materials and Methods: Medical Birth Register Data in Finland from 2005 to 2009. Study population was all hospital births (n = 263,901), excluding multiple pregnancies, preterm births <37 weeks, major congenital anomalies or birth defects, and antepartum stillbirths. Main outcome measures were either 1-minute Apgar score 0-3, 5-minute Apgar score 0-6, or umbilical artery pH <7.00, and intrapartum and early neonatal mortality. We calculated risk ratios (ARRs) adjusted for maternal age and parity, and 95% confidence intervals (CIs) to indicate the probability of adverse neonatal outcome outside of office hours in normal vaginal delivery, in vaginal breech delivery, in instrumental vaginal delivery, and in elective and nonelective cesarean sections. We analyzed different size-categories of maternity hospitals and different on-call arrangements., Results: Instrumental vaginal delivery had increased risk for mortality (ARR 3.31, 95%CI; 1.01-10.82) outside office hours. Regardless of hospital volume and on-call arrangement, the risk for low Apgar score or low umbilical artery pH was higher outside office hours (ARR 1.23, 95%CI; 1.15-1.30). Intrapartum and early neonatal mortality increased only in large, nonuniversity hospitals outside office hours (ARR 1.51, 95%CI; 1.07-2.14)., Conclusions: Compared to office hours, babies born outside office hours are in higher risk for adverse outcome. Demonstration of more detailed circadian effects on adverse neonatal outcomes in different subgroups requires larger data.

Introduction: Two areas of controversy in the management of bleeding pelvic fractures are the need to perform angioembolization (AE) in patients with a retroperitoneal hematoma (RPH) but no contrast extravasation (CE) on Computerized Tomography (CT) and/or angiography, and the delay to AE. Our main objective was to assess whether there had been differences in the percentage and delay to AE between patients admitted on weekdays versus off-hours (weekends and admission after 3pm) at our hospital. Our hypothesis was that angiography and AE would be more frequent on weekdays, and the time delay would be longer during off-hours, with a higher mortality in this latter group for a similar overall severity. A secondary objective was to assess the correlation between CE on CT scan and angiography., Methods: Retrospective review of two cohorts of patients with RPH from a pelvic fracture during a period of 24 years. Patients were divided depending on the time of arrival (Group A: weekdays, and Group B: off-hours). The decision to perform angiography and AE was made by the general surgeons on call, in consensus with the interventional radiologist. We analyzed demographics, mechanism of injury, associated injuries, physiologic and anatomic trauma scores, CE on CT scan, need of AE, Intensive Care Unit (ICU) stay and mortality., Results: 104 patients were admitted with RPH from a pelvic fracture. We performed AE in 63 cases (61%). The groups were comparable in the variables analyzed. In 70% of patients in group A, angiography was done, vs 57% in group B, with the same median time delay. CE on CT scan was seen in 53 out of 96 patients and confirmed by angiography in 45 (85%) of them. No significant differences were found in mortality between the two groups., Conclusions: There was a short delay from admission to AE, even during off-hours, and a good correlation of CE on CT scan and angiography., (Copyright © 2019 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objectives: Assess restricted antimicrobials acquired after standard working hours for adherence to antimicrobial stewardship (AMS) and identify factors associated with increased likelihood of adherence at the time of acquisition, and the next standard working day., Methods: All documented antimicrobials acquired from a paediatric hospital after-hours drug room from 1 July 2014 to 30 June 2015 were reconciled with records of AMS approval, and documented AMS review in the medical record., Key Findings: Of the 758 antimicrobial acquisitions from the after-hours drug room, 62.3% were restricted. Only 29% were AMS adherent at the time of acquisition, 15% took place despite documented request for approval by a pharmacist. Antimicrobials for respiratory patients (OR 3.10, 95% CI 1.68-5.5) and antifungals (2.48, 95% CI 1.43-4.30) were more likely to be AMS adherent. Half of the acquisitions that required review the next standard working day were adherent to AMS (51.8%, 129/249). Weekday acquisitions (2.10, 95% CI 1.20-3.69) and those for patients in paediatric intensive care (2.26, 95% CI 1.07-4.79) were associated with AMS adherence. Interactions with pharmacists prior to acquisition did not change the likelihood of AMS adherence the next standard working day. Access to restricted antimicrobial held as routine ward stock did not change the likelihood of AMS adherence at the time of acquisition, or the next standard working day., Conclusion: Restricted antimicrobials acquired after-hours are not routinely AMS adherent at the time of acquisition or the next standard working day, limiting opportunities for AMS involvement., (© 2018 Royal Pharmaceutical Society.)

Introduction: Recent improvements in pediatric intensive care units (PICUs) were achieved through trained personnel and better technology, leading to an increase in patient care, survival rates and good prognosis. Nevertheless the quality of care varies according to the availability of human and technical resources., Objective: The aim was to determine the correlation of mortality rates with daytime shifts compared to other shift periods (off-hours)., Methods: Work hours were defined as week days between 8:00 a.m. and 5:00 p.m., with in-house attendance of senior staff, and off-hours as week days between 5:00 p.m. and 8:00 a.m., weekends and public holidays, with one resident covering the PICU and senior staff directly available only on-call. Mortality causes in children hospitalized in the intensive care unit were classified., Results: During this period, a total of 2,187 patients were hospitalized in the PICU. A total of 394 patients died; 151 were girls (38.3 %) and 243 boys (61.7 %). Evaluating time of mortality showed that death occurred mostly at out-off hours: 244 (61.9 %) vs. 150 (38.1 %) during the daytime shift, which was statistically significant (p < 0.05). In addition, age, gender and the length of stay in the PICU were not significant (p > 0.05) when daytime was compared to out-off hours. The conditions which accompanied death were evaluated, the relationship between working hours and death was also significant (p < 0.05). More conditions related to mortality were encountered at off-hours., Conclusion: Off-hours without 24 hour attendance of senior staff, was associated with higher mortality., (Sociedad Argentina de Investigación Odontológica.)

Objective: To explore how out-of-hours primary healthcare services (OOHS) are represented in UK national newspapers, focusing on content and tone of reporting and the use of personal narratives to frame stories., Design: A retrospective cross-sectional quantitative content analysis of articles published in 2005, 2010 and 2015., Data Sources: Nexis database used to search 10 UK national newspapers covering quality, middle-market and tabloid publications., Inclusion/exclusion Criteria: All articles containing the terms 'out-of-hours' (≥3 mentions per article) or ('NHS 24' OR 'NHS 111' OR 'NHS Direct') AND 'out-of-hours' (≥1 mention per article) were included. Letters, duplicate news items, opinion pieces and articles without a substantial portion of the story (>50% of an article's word count, as judged by researchers) concerning OOHS were excluded., Results: 332 newspaper articles were identified: 113 in 2005 (34.1%), 140 in 2010 (42.2%) and 79 in 2015 (23.8%). Of these, 195 (58.7%) were in quality newspapers, 99 (29.8%) in middle-market and 38 (11.3%) in tabloids. The most commonly reported themes were OOHS organisation, personal narratives and telephone triage. Stories about service-level crises and personal tragedy, including unsafe doctors and missed or delayed identification of rare conditions, predominated. The majority of articles (252, 75.9%) were negative in tone. This was observed for all included newspapers and by publication genre; middle-market newspapers had the highest percentage of negative articles (Pearson χ 2 =35.72, p<0.001). Articles presented little supporting contextual information, such as call rates per annum, or advice on how to access OOHS., Conclusion: In this first reported analysis of UK national newspaper coverage of OOHS, media representation is generally negative in tone, with frequent reports of 'negative exemplars' of OOHS crises and fatal individual patient cases with little or no contextualisation. We present recommendations for the future reporting of OOHS, which could apply to the reporting of healthcare services more generally., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Purpose: This resident-driven quality improvement project was undertaken to assess the effectiveness of structured reporting to reduce revision rates for afterhours reports dictated by residents., Methods: The first part of the study assessed baseline revision rates for head and neck CT angiography (CTA) examinations dictated by residents during afterhours call. A structured report was subsequently created based on templates on the RSNA informatics reporting website and critical findings that should be assessed for on all CTA examinations. The template was made available to residents through the speech recognition software for all head and neck CTA examinations for a duration of 2 months. Report revision rates were then compared with and without use of the structured template., Results: The structured template was found to reduce revision rates by approximately 50% with 10/41 unstructured reports revised and 2/17 structured reports revised., Conclusions: We believe that structured reporting can help reduce reporting errors, particularly in term of typographical errors, train residents to evaluate complex examinations in a systematic fashion, and assist them in recalling critical findings on these examinations., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To develop a valid and reliable assessment tool able to measure quality of communication, patient safety and efficiency in out-of-hours (OOH) telephone triage conducted by both general practitioners (GP) and nurses., Design: The Dutch KERNset tool was translated into Danish and supplemented with items from other existing tools. Face validity, content validity and applicability in OOH telephone triage (OOH-TT) were secured through a two-round Delphi process involving relevant stakeholders. Forty-eight OOH patient contacts were assessed by 24 assessors in test-retest and inter-rater designs., Setting: OOH-TT services in Denmark conducted by GPs, nurses or doctors with varying medical specialisation., Patients: Audio-recorded OOH patient contacts., Main Outcome Measures: Test-retest and inter-rater reliability were analysed using ICC agreement , Fleiss' kappa and percent agreement., Results: Major adaptations during the Delphi process were made. The 24-item assessment tool (Assessment of Quality in Telephone Triage - AQTT) measured communicative quality, health-related quality and four overall quality aspects. The test-retest ICC agreement reliability was good for the overall quality of communication (0.85), health-related quality (0.83), patient safety (0.81) and efficiency (0.77) and satisfactory when assessing specific aspects. Inter-rater reliability revealed reduced reliability in ICC agreement and in Fleiss' kappa. Percent agreement revealed satisfactory agreements when differentiating between 'poor' and 'sufficient' quality)., Conclusion: The AQTT demonstrated high face, content and construct validity, satisfactory test-retest reliability, reduced inter-rater reliability, but satisfactory percent agreement when differentiating between 'poor' and 'sufficient' quality. The AQTT was found feasible and clinically relevant for assessing the quality of GP- and nurse-led OOH-TT. KEYPOINTS Comparative knowledge is sparse regarding quality of out-of-hours telephone triage conducted by general practitioners and nurses. The assessment tool (AQTT) enables assessment of quality in OOH telephone triage conducted by nurses and general practitioners AQTT is feasible and clinically relevant for assessment of communication, patient safety and efficiency. AQTT can be used to identify areas for improvement in telephone triage.

Aim: To measure the effectiveness of advanced nurse practitioners (ANPs) against national quality requirements for out-of-hours (OOH) care, to compare ANP effectiveness with that of doctors working in the same service, and to evaluate the impact of ANPs on the service., Background: There is little documented evidence of ANPs undertaking urgent home visits in the OOH setting. This study advances current knowledge of this aspect of the OOH service and makes recommendations for the management of the ANP urgent home visiting service., Methods: Analysis of 1,539 ANP home-visit patient electronic case notes over a 12-month period, a focus group of eight GPs, and interviews with six ANPs., Results: Advanced nurse practitioners are as effective as GPs in undertaking urgent home visits. Their documentation is more consistent and their refer-on rate to secondary care is less than that of GP colleagues., Conclusion: Advanced nurse practitioners can provide equivalent clinical outcomes to GPs when undertaking urgent home visits., Implications for Nursing Management: This study adds to the body of evidence for the positive impact of ANPs on OOH service delivery and managers can be assured that they are practising at a level that makes them effective and safe to undertake this role., (© 2018 John Wiley & Sons Ltd.)

Competing Interests: Competing interests: None declared.

Background: The increased mortality risk associated with weekend admission to hospital (the 'weekend effect') has been reported across many health systems. More recently research has focused on causal mechanisms. Variations in the organisation and delivery of in-hospital care between weekends and weekdays have been identified, but this is not always to the detriment of weekend admissions, and the impact on mortality is uncertain. The insights of frontline staff and patients have been neglected. This article reports a qualitative study of patients and clinicians, to explore their views on quality and safety of care at weekends., Methods: We conducted focus groups and interviews with clinicians and patients with experience of acute medical care, recruited from three UK hospital Trusts. We analysed the data using a thematic analysis approach, aided by the use of NVivo, to explore quality and safety of care at weekends., Results: We held four focus groups and completed six in-depth interviews, with 19 clinicians and 12 patients. Four threats to quality and safety were identified as being more prominent at weekends, relating to i) the rescue and stabilisation of sick patients; ii) monitoring and responding to deterioration; iii) timely accurate management of the therapeutic pathway; iv) errors of omission and commission., Conclusions: At weekends patients and staff are well aware of suboptimal staffing numbers, skill mix and access to resources at weekends, and identify that emergency admissions are prioritised over those already hospitalised. The consequences in terms of quality and safety and patient experience of care are undesirable. Our findings suggest the value of focusing on care processes and systems resilience over the weekends, and how these can be better supported, even in the limited resource environment that exists in many hospitals at weekends.

Background: Patient complaints can provide valuable insights into the quality and safety of clinical care. Studies examining the epidemiology of complaints in out-of-hours general practice internationally are limited., Aim: To characterise patient complaints in an out-of-hours general practice setting., Design and Setting: Retrospective cohort study of patient complaints to an out-of-hours service provider in Dublin, Ireland, over a 5-year period (2011-2016). This comprises nurse-led telephone triage and GP consultations for patients with urgent problems., Method: A modified version of the UK Healthcare Complaints Analysis Tool (HCAT) was utilised to code complaints, which were reviewed independently in duplicate by two academic GPs., Results: Of 445 598 telephone contacts, 303 085 resulted in face-to-face GP consultations. Of 234 patients who made 298 complaints, 185 (79%) related to GP care. The remainder related to nurse triage, other staff, and management issues. A total of 109 (46%) related to children aged ≤18 years, and 134 (58%) of complainants were female. There were 0.61 complaints per 1000 GP consultations. Most complaints ( n = 126, 42%) were in relation to clinical care problems, largely diagnosis and prescribing. Common themes included unmet management expectations and clinical examination dissatisfaction. Inter-rater reliability was 90% (κ statistic 0.84, 95% confidence interval = 0.80 to 0.88). Following internal investigation, 158 (85%) of GP-related complaints were managed effectively by the out-of-hours service., Conclusion: The majority of complaints related to clinical care problems and were successfully managed locally. Expectation management may be an important way to mitigate the risk of complaints., (© British Journal of General Practice 2018.)

Academic medical centers have long relied on radiology residents to provide after-hours coverage, which means that they essentially function with autonomy. In this approach, attending radiologist review of resident interpretations occurs the following morning, often by subspecialist faculty. In recent years, however, this traditional coverage model in academic radiology departments has been challenged by an alternative model, the 24-hour attending radiologist coverage. Proponents of this new model seek to improve patient care after hours by increasing report accuracy and the speed with which the report is finalized. In this article, we review the traditional and the 24-hour attending radiologist coverage models. We summarize previous studies that indicate that resident overnight error rates are sufficiently low so that changing to an overnight attending model may not necessarily provide a meaningful increase in report accuracy. Whereas some centers completely replaced overnight residents, we note that most centers use a hybrid model, and overnight residents work alongside supervising attending radiologists, much as they do during the day. Even in this hybrid model, universal double reading and subspecialist final review, typical features of the traditional autonomous resident coverage model, are generally sacrificed. Because of this, changing from resident coverage to coverage by an attending radiologist that is 24 hours/day, 7 days/week may actually have detrimental effects to patient safety and quality of care provided. Changing to an overnight attending radiologist model may also have negative effects on the quality of radiology resident training, and it significantly increases cost., (© RSNA, 2018 See also the editorial by Meltzer in this issue.)

Despite the need to develop a non-medical out-of-hours (OOHs) workforce to address increasing healthcare demands and to support a strained GP workforce, there is no consensus on the required training and clinical competencies needed for nurses and paramedics to be developed as safe OOH practitioners. This paper presents the development and evaluation of one programme delivered in 2017 to paramedics seeking to work in OOHs services. Details of the course delivery are outlined and the mixed-methods evaluation presented. Following successful university ethical approval, student and staff experiences were reviewed through interviews, questionnaires and graded feedback of completed electronic patient case records. The findings provided useful learning that can be transferred to other organisations seeking to develop such training. In particular, the findings suggest the course was able to provide the students with the skills, knowledge and confidence to become safe practitioners in the OOHs service. Challenges in course delivery were highlighted. It was suggested that course organisation, duration and scope require careful consideration to enable students to complete and practise successfully.

Background: End-of-life care (EoLC) is an experience that touches the lives of everyone. Dying in an acute hospital is a common occurrence in developed countries across the world. Previous studies have shown that there is wide variation in EoLC and at times is experienced as being of poor quality. Assessing and measuring the quality of care provided is a key component of all healthcare systems. This paper reports on the qualitative analysis of open-ended free text questions that were asked as part of a post-bereavement survey conducted in two adult acute hospitals in Ireland., Methods: This was a quantitative descriptive post-bereavement postal survey, gathering data retrospectively from relatives or friends of patients who died, utilising an adapted version of the VOICES (Views of Informal Carers - Evaluation of Services) questionnaire. VOICES MaJam has 29 core questions, seven questions requesting personal demographic information and four open-ended questions gathering descriptive data about the care experience during the patient's last admission to hospital. A total of 356 valid questionnaires were returned. Qualitative data were managed, coded and analysed with NVivo 10, using a template analysis framework approach., Results: Three quarters (75%: n = 268) responded to at least one of the open-ended questions. Several key themes emerged, indicating areas that require particular attention in EoLC. Two themes relate to how care needs are met and how the hospital environment has a critical influence on EoLC experiences. The remaining three themes relate more to the interpersonal context including whether patients are treated with dignity and respect, the psychological, emotional and spiritual needs of patients and their family members and communication., Conclusions: Acute hospitals need to ensure that patients and their relatives receive high quality EoLC. Seeking the views of bereaved relatives should be considered by all hospitals and healthcare settings to ascertain the quality of care at end of life. This study contributes to our understanding and knowledge of what good EoLC looks like and where care can be improved, thus enabling hospitals to direct and inform quality improvement.

Background: Primary care patients are often cited as a cause of Emergency Department overcrowding (ED). The aim of this study was to evaluate a physician led redirection procedure of selected patients towards an out of hours general practice (OHGP) in an Emergency Department with 55,000 admissions per year., Methods: Observational monocentric study over a period of 2 months. Every patient redirected to the OHGP was included and subsequently contacted by telephone to answer a standardized questionnaire, in order to measure: Redirection rate over the entire period and during weekdays or weekends/holiday Rate of redirected patients who went to the OHGP Rate of redirected patients who consulted in an ED in the next 72 h for the same reason Redirected patients' satisfaction rate RESULTS: During the study period 9551 patients presented to the ED, of which 288 were redirected towards the OHGP (3%). The redirection rate was 1.9% during weekdays and 5.7% during weekends/holiday (p < 0.001). Of the redirected patients, 77% answered the telephone interview. Ninety percent of these patients consulted the OHGP. The main reasons for not consulting were: unduly long wait, opening hours not suitable, too costly. The rate of redirected patients who consulted in an ED in the following 72 h for the same reason was 4.1%. The satisfaction rate was 79.6% among interviewed patients., Conclusions: A physician led procedure to redirect selected patients from the ED towards an OHGP results in a low redirection rate, unlikely to have a significant effect on ED patient flow. However, the procedure is safe and well accepted by a majority of patients.

Purpose: The Royal College of Surgeons recognises patient handover as the point at which patients are collectively at their most vulnerable. Concerns were raised in a London teaching hospital surgical department regarding an unstructured handover system, poor access to relevant clinical information, and inadequate weekend staffing. A quality improvement programme was designed and implemented to respond to these concerns and improve patient safety. The paper aims to discuss these issues., Design/methodology/approach: A structured questionnaire was distributed to staff and results used to construct a diagram outlining the main factors influencing weekend patient safety. This framework was used to design changes, including a new electronic handover tool, regular handover meetings and additional weekend staff. Regular staff training was provided, and success was assessed in a continuous audit cycle with the results fed back to team leaders., Findings: Over a three-month period, the handover meeting recorded an attendance rate consistently above 80 per cent. The electronic handover entries were scored according to seven criteria (correct layout; key information, i.e.: patient location, clinical priority, active issues, resuscitation status, test results and weekend plan), averaging between 42.2 and 92.9 per cent, with progressive improvement seen over the assessment period. Weekend staffing was increased by 50 per cent, allowing a dedicated team to care for stable inpatients and to oversee discharges., Originality/value: This improvement programme delivered lasting and significant change in response to staff concerns. It resulted in a more structured and reliable weekend system and established key mechanisms for dynamic performance feedback.

On-call physicians encounter a diverse aggregate of interfaces with sundry persons concerning patient care that may surface potential legal peril. The duties and obligations of an on-call physician, who must act as a fiduciary to all patients, create a myriad of circumstances where there is a risk of falling prey to legal ambiguities. The understanding of the doctor-patient relationship, the obligations of physicians under the Emergency Medical Treatment and Labor Act, the meaning of medical informed consent and the elements of negligence will help physicians avoid the legal risk associated with the various encounters of being on call. After introducing the legal concepts, we will explore the interactions that may put physicians at legal risk and outline how to mitigate that risk. Being on call is time consuming and arduous. While on call, physicians have a duty to act morally and ethically in the best interest of the patients., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Aim: To assess the influence of time, intensity, and trainee seniority on radiology registrars' major and minor discrepancy rates during weekend reporting at a university teaching hospital., Materials and Methods: A 12-month retrospective review was performed of out-of-hours trainee provisional reports for computed tomography (CT) and magnetic resonance imaging (MRI) in a university teaching hospital. From Friday 9.00 pm to Sunday 9.00 pm, the out-of-hours service is provided by a single registrar rotating every 12 hours. A busy shift was defined as more than 24 reports issued during the shift. A senior trainee was defined as having more than 2 years' experience on the on-call rota. Reports were compared to subsequent subspecialist consultant review with all discrepancies collected. Discrepancy rates were calculated for junior/senior registrars, time of shift, and for busy/less busy shifts., Results: The total discrepancy rate was 11.1%, with a major discrepancy rate of 3%. Junior registrars had a lower total discrepancy rate (9.7% versus 12.2%, p=0.0065). Although there was no difference between major discrepancies, junior trainees made fewer minor discrepancies (7.1% versus 8.93%, p=0.03). The discrepancy rate was higher at night (12.3% versus 10.4%, p=0.0418). On a less busy shift, more discrepancies were made (12.8% versus 10%, p=0.0001)., Conclusion: The major discrepancy rate of trainees is low. More discrepancies are made at night, and trainee seniority does not mitigate this problem. Night shifts are less busy in comparison to day shifts, which may explain why less busy shifts appear to yield more mistakes., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)