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AbstractBackgroundAimMethodsResultsConclusionAntibiotic prescription rates can be affected by pandemic measures such as lockdowns, social distancing, and remote consultations in general practice. Therefore, such emergency states may negatively affect antimicrobial stewardship, specifically in out-of-hours (OOH) primary care. As contact patterns changed in the COVID-19 pandemic, it would be relevant to explore the impact on antimicrobial stewardship.To study the impact of the pandemic on antibiotic prescription rates in OOH primary care, overall and per age group.This cross-sectional register-based study used routine data from OOH primary care in the Central Denmark Region. We included all patient contacts in two equivalent time periods: pre-pandemic and pandemic period. The main outcome measure was defined as the number of antibiotic prescriptions per contact (antibiotic prescription rate).The overall antibiotic prescription rate decreased during the first year of the pandemic compared to the pre-pandemic period (RR = 0.97, 95%CI: 0.96–0.98). Likewise, the rate decreased for clinic consultations (RR = 0.63, 95%CI: 0.62–0.64). However, an increase was seen for telephone consultations (RR = 1.73, 95%CI: 1.70–1.76). The decline in clinic consultations was largest for consultations involving children aged 0–10 years (RR = 0.53, 95%CI: 0.51–0.56).Antibiotic prescription rates in Danish OOH primary care decreased during the first year of the COVID-19 pandemic, especially for young children. Prescription rates decreased in clinic consultations, whereas the rates increased in telephone consultations. Further research should explore if antibiotic prescription rates have returned to pre-pandemic levels, and if the introduction of video consultations has affected antibiotic prescription patterns in OOH primary care. [ABSTRACT FROM AUTHOR]

AbstractObjectiveDesignSettingSubjectsMain outcome measuresResultsConclusionImplications\nKEY POINTSTo describe and compare contacts regarding self-injurious thoughts and behaviours to other contacts to emergency primary care.Observational study.A sentinel network of seven emergency primary care centres throughout Norway.Initial contacts regarding patients 10 years and older during 12 consecutive months (11/2021–10/2022).Contacts due to self-injurious thoughts and behaviours.Self-injurious thoughts and behaviours were the reason for contact for 0.6% (n = 478) of initial contacts for patients aged 10 years or older (n = 77 344). When compared to other contacts, self-injurious thoughts and behaviours were associated with female gender, younger age, occurrence during evening and nighttime, higher urgency, and more physician consultations and call-outs. Of contacts about self-injurious thoughts and behaviours, 58.2% were regarding thoughts and 41.8% about behaviours, and in 75.0% a history of similar contacts was recorded. Contacts regarding thoughts often concerned threats (30.6%) and were more often handled by telephone advice than contacts regarding behaviours. Contacts regarding behaviours with suicidal intent were associated with higher urgency and more physician call-outs than contacts regarding non-suicidal behaviours.Self-injurious thoughts and behaviours are rare reasons for contact to emergency primary care but are assessed as more urgent than other contact reasons and trigger more extensive medical help. Many of the patients are known to the service through a history of similar contacts.The infrequency and severity of these encounters might necessitate training, decision support and procedures to compensate for the health care personnel’s limited exposure.Self-injurious thoughts and behaviours are major health concerns which are associated with need for immediate medical care. Within Norwegian emergency primary care, self-injurious thoughts and behaviours were rare but urgent contact reasons requiring relatively extensive medical help.Many patients with self-injurious thoughts and behaviours had a history of similar contacts indicating the need for integral care.Training, decision support and procedures may be needed to compensate for limited exposure in daily work.Within Norwegian emergency primary care, self-injurious thoughts and behaviours were rare but urgent contact reasons requiring relatively extensive medical help.Many patients with self-injurious thoughts and behaviours had a history of similar contacts indicating the need for integral care.Training, decision support and procedures may be needed to compensate for limited exposure in daily work. [ABSTRACT FROM AUTHOR]

Background Antibiotic prescription rates can be affected by pandemic measures such as lockdowns, social distancing, and remote consultations in general practice. Therefore, such emergency states may negatively affect antimicrobial stewardship, specifically in out-of-hours (OOH) primary care. As contact patterns changed in the COVID-19 pandemic, it would be relevant to explore the impact on antimicrobial stewardship.Aim To study the impact of the pandemic on antibiotic prescription rates in OOH primary care, overall and per age group.Methods This cross-sectional register-based study used routine data from OOH primary care in the Central Denmark Region. We included all patient contacts in two equivalent time periods: pre-pandemic and pandemic period. The main outcome measure was defined as the number of antibiotic prescriptions per contact (antibiotic prescription rate).Results The overall antibiotic prescription rate decreased during the first year of the pandemic compared to the pre-pandemic period (RR = 0.97, 95%CI: 0.96–0.98). Likewise, the rate decreased for clinic consultations (RR = 0.63, 95%CI: 0.62–0.64). However, an increase was seen for telephone consultations (RR = 1.73, 95%CI: 1.70–1.76). The decline in clinic consultations was largest for consultations involving children aged 0–10 years (RR = 0.53, 95%CI: 0.51–0.56).Conclusion Antibiotic prescription rates in Danish OOH primary care decreased during the first year of the COVID-19 pandemic, especially for young children. Prescription rates decreased in clinic consultations, whereas the rates increased in telephone consultations. Further research should explore if antibiotic prescription rates have returned to pre-pandemic levels, and if the introduction of video consultations has affected antibiotic prescription patterns in OOH primary care.

Objective To describe and compare contacts regarding self-injurious thoughts and behaviours to other contacts to emergency primary care.Design Observational study.Setting A sentinel network of seven emergency primary care centres throughout Norway.Subjects Initial contacts regarding patients 10 years and older during 12 consecutive months (11/2021–10/2022).Main outcome measures Contacts due to self-injurious thoughts and behaviours.Results Self-injurious thoughts and behaviours were the reason for contact for 0.6% (n = 478) of initial contacts for patients aged 10 years or older (n = 77 344). When compared to other contacts, self-injurious thoughts and behaviours were associated with female gender, younger age, occurrence during evening and nighttime, higher urgency, and more physician consultations and call-outs. Of contacts about self-injurious thoughts and behaviours, 58.2% were regarding thoughts and 41.8% about behaviours, and in 75.0% a history of similar contacts was recorded. Contacts regarding thoughts often concerned threats (30.6%) and were more often handled by telephone advice than contacts regarding behaviours. Contacts regarding behaviours with suicidal intent were associated with higher urgency and more physician call-outs than contacts regarding non-suicidal behaviours.Conclusion Self-injurious thoughts and behaviours are rare reasons for contact to emergency primary care but are assessed as more urgent than other contact reasons and trigger more extensive medical help. Many of the patients are known to the service through a history of similar contacts.Implications The infrequency and severity of these encounters might necessitate training, decision support and procedures to compensate for the health care personnel’s limited exposure.

Morten Breinholt Søvsø,1 Rasmine Birch Haurum,2 Trine Hagelskær Ebbesen,2 Ann Øster Rasmussen,2 Logan Morgan Ward,3 Mads Lause Mogensen,3 Erika Frischknecht Christensen,1 Tim Alex Lindskou1 1Centre for Prehospital and Emergency Research at Danish Centre for Health Services Research; Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, Gistrup, Denmark; 2Department of Health, Science and Technology, Aalborg University, Gistrup, Denmark; 3Treat Systems ApS, Aalborg, DenmarkCorrespondence: Tim Alex Lindskou, Centre for Prehospital and Emergency Research, Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, Selma Lagerløfs Vej 249, Gistrup, 9260, Denmark, Tel +45 23274523, Email tim.l@rn.dkIntroduction: Ambulance requests by general practitioners for primary care patients (GP-requested) are often omitted in studies on increased demand within emergency care but may comprise a substantial patient group. We aimed to assess acute severity, intensive care unit (ICU) admission, and diagnostic pattern, including comorbidity, and mortality among GP-requested ambulance patients, compared to emergency call ambulance patients. Our hypothesis was that emergency call patients had more severe health issues than GP-requested ambulance patients.Methods: Historic population-based cohort study of ambulance patients in the North Denmark Region, 2016– 2020. Hospital contact data including diagnoses, ambulance data, vital signs and vital status was linked using each patient’s unique identification number. Primary outcome measure was mortality within 1, 7, and 30 days. Secondary outcomes were disease severity expressed as modified National Early Warning Score (NEWS2), and ICU admission. Admission status and hospital diagnostic pattern, including comorbidity were described and compared.Results: We included 255,487 patients. GP-requested patients (N = 119,361, 46.7%) were older (median years [IQR] 73 [58– 83] versus 61 [37– 76]) and more had moderate/severe comorbidity (11.9%, N = 13,806 versus 4.9%, N = 6145) than the emergency call patients. Prehospital mNEWS2 median scores were lower for GP-requested patients. For both groups, mNEWS2 was highest among patients aged 66+. GP-requested patients had higher 30-day mortality (9.0% (95% CI: 8.8– 9.2), N = 8996) than emergency call patients (5.2% (95% CI: 5.1– 5.4), N = 6727). Circulatory (12.0%, 11,695/97,112) and respiratory diseases (11.6%, 11,219/97,112) were more frequent among GP-requested patients than emergency call patients ((10.7%, 12,640/118,102) and (5.8%, 6858/118,102)). The highest number of deaths was found for health issues ‘circulatory diseases’ in the emergency call group and ‘other factors’ followed by “respiratory diseases” in the GP-requested group.Conclusion: GP-requested patients constituted nearly half of the EMS volume, they were older, with more comorbidity, had serious conditions with substantial acute severity, and a higher 30-day mortality than emergency call patients.Keywords: emergency medical services, mortality, diagnoses, early warning scores, after-hours care, primary healthcare, general practitioners

Background: People with palliative care needs and their carers often rely on out-of-hours services to remain at home. Policymakers have recommended implementing telephone advice lines to ensure 24/7 access to support. However, the impact of these services on patient and carer outcomes, as well as the health care system, remains poorly understood. Aim: To evaluate the clinical- and cost-effectiveness of out-of-hours palliative care telephone advice lines, and to identify service characteristics associated with effectiveness. Design: Rapid systematic review (PROSPERO ID: CRD42023400370) with narrative synthesis. Data sources: Three databases (Medline, EMBASE and CINAHL) were searched in February 2023 for studies of any design reporting on telephone advice lines with at least partial out-of-hours availability. Study quality was assessed using the Mixed Methods Appraisal Tool, and quantitative and qualitative data were synthesised narratively. Results: Twenty-one studies, published 2000–2022, were included. Most studies were observational, none were experimental. While some evidence suggested that telephone advice lines offer guidance and reassurance, supporting care at home and potentially reducing avoidable emergency care use in the last months of life, variability in reporting and poor methodological quality across studies limit our understanding of patient/carer and health care system outcomes. Conclusion: Despite their increasing use, evidence for the clinical- and cost-effectiveness of palliative care telephone advice lines remains limited, primarily due to the lack of robust comparative studies. There is a need for more rigorous evaluations incorporating experimental or quasi-experimental methods and longer follow-up, and standardised reporting of telephone advice line models and outcomes, to guide policy and practice. [ABSTRACT FROM AUTHOR]

Purpose: Appendicitis is one of the most common acute surgical conditions globally, and hence appendectomy is a common procedure performed around the clock in many hospitals. The aim of the current study was to determine whether acute appendectomy due to acute appendicitis performed during day, evening, and night was equally safe, in terms of postoperative complications, readmission, death, and length of hospital stay. Methods: A retrospective single-center cohort study, using a local quality register of all consecutive acute appendectomies performed at the Department of Surgery, Södersjukhuset, Stockholm, Sweden. During the study period from December 2015 to August 2022, 4950 patients were included. Risk of complications, readmission, and death were determined using multivariable logistic regression models. Association with length of hospital stay was determined using multiple linear regression. Results: There was no significant difference in the associated risk of postoperative complications, readmission within 30 days, or death, regardless of when appendectomy was performed. Using daytime surgery as reference, hospital stay was shortened by 4.21 h (P = 0.008) for evening surgery and by 6.71 h (P < 0.001) for nightly surgery. Conclusion: Risks of postoperative complications, readmission, and death were similar regardless of when acute appendectomy was performed. However, surgery during evening and night was associated with shortened hospital stay, as compared to daytime surgery. [ABSTRACT FROM AUTHOR]

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

Background: Healthcare usage patterns change for people with life limiting illness as death approaches, with increasing use of out-of-hours services. How best to provide care out of hours is unclear. Aim: To evaluate the effectiveness and effect of enhancements to 7-day specialist palliative care services, and to explore a range of perspectives on these enhanced services. Design: An exploratory longitudinal mixed-methods convergent design. This incorporated a quasi-experimental uncontrolled pre-post study using routine data, followed by semi-structured interviews with patients, family carers and health care professionals. Setting/participants: Data were collected within specialist palliative care services across two UK localities between 2018 and 2020. Routine data from 5601 unique individuals were analysed, with post-intervention interview data from patients (n = 19), family carers (n = 23) and health care professionals (n = 33; n = 33 time 1, n = 20 time 2). Results: The mean age of people receiving care was 73 years, predominantly white (90%) and with cancer (42%). There were trends for those in the intervention (enhanced care) period to stay in hospital 0.16 days fewer, but be hospitalised 2.67 more times. Females stayed almost 3.5 more days in the hospital, but were admitted 2.48 fewer times. People with cancer had shorter hospitalisations (4 days fewer), and had two fewer admission episodes. Themes from the qualitative data included responsiveness (of the service); reassurance; relationships; reciprocity (between patients, family carers and staff) and retention (of service staff). Conclusions: Enhanced seven-day services provide high quality integrated palliative care, with positive experiences for patients, carers and staff. [ABSTRACT FROM AUTHOR]

Unscheduled care is a priority for the French Ministry of Health, which wants to improve the clarity of the care chain and the coordination of primary care providers. The SOS Médecins structure appears to be an important player in the urgent care of patients, whether relative or serious, as an alternative in the absence of the attending physician or hospital emergency services. The aim of this study is to analyze calls (number, type, schedule, referral), reasons for consultations and home visits, and diagnoses made between March 1 and March 31, 2022 in Saint-Étienne. [ABSTRACT FROM AUTHOR]

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

Sergiu Marian Cazacu,1,&ast; Adina Turcu-Stiolica,2,&ast; Dan Nicolae Florescu,1,&ast; Bogdan Silviu Ungureanu,1,&ast; Vlad Florin Iovanescu,1,&ast; Carmen Daniela Neagoe,3,&ast; Daniela Elena Burtea,1,&ast; Amelia Valentina Genunche-Dumitrescu,3,&ast; Taina Elena Avramescu,4,&ast; Sevastita Iordache1,&ast; 1Gastroenterology Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania; 2Biostatistics Department, University of Medicine and Pharmacy Craiova, Dolj County, Romania; 3Internal Medicine Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania; 4Individual Sports, and Medical Disciplines Departments, University of Craiova, Dolj County, Romania&ast;These authors contributed equally to this workCorrespondence: Carmen Daniela Neagoe, Tel +40723767106, Email dananeagoe2014@gmail.com; daniela.neagoe@umfcv.roBackground: In upper gastrointestinal bleeding (UGIB), admissions after normal working hours and during weekends may be associated with increased mortality.Aim: To assess the evolution of the after-hours and weekend effects during the COVID-19 pandemic as a result of progressive improved management despite management challenges during the pandemic.Methods: We performed an observational study of patients admitted for UGIB at a tertiary academic center between March 2020 and December 2021, compared to the corresponding timeframe before the pandemic. Admissions were assessed based on regular hours versus after-hours and weekdays versus weekends. We stratified patients based on demographic data, etiology, prognostic scores, the time between symptom onset and admission, as and between admission and endoscopy. The outcomes included mortality, rebleeding rate, the requirement for surgery and transfusion, and hospitalization days.Results: 802 cases were recorded during the pandemic, and 1006 cases before the pandemic. The overall mortality rate was 12.33%. Patients admitted after hours and during weekends had a higher mortality rate compared to those admitted during regular hours and weekdays (15.18% versus 10.22%, and 15.25% versus 11.16%), especially in cases of non-variceal bleeding. However, the difference in mortality rates was reduced by 2/3 during the pandemic, despite the challenges posed by COVID-19 infection. This suggests that there was an equalization effect of care in UGIB, regardless of the admission time. The differences observed in mortality rates for after-hours and weekend admissions seem to be primarily related to a higher proportion of patients who did not undergo endoscopy, while the proportion of severe cases remained similar. Blood requirements, hospital days, and rebleeding rate were similar between the two groups.Conclusion: Admissions during weekends and after-hours have been associated with increased mortality, particularly in cases of non-variceal bleeding. However, the impact of this association was significantly reduced during the pandemic.Keywords: gastrointestinal bleeding, after-hours care, COVID-19 pandemic

Abstract Background The amount of emergency medical service missions has increased internationally in recent years, and emergency departments are overcrowded globally. Previous evidence has shown that patients arriving at the emergency department during nighttime (20 − 08) have to wait longer, are more likely to leave without being seen, and often have non-urgent conditions compared to patients arriving during the day. The objective of this pilot study was to examine what kind of patient groups are conveyed as non-urgent to the hospital by emergency medical service during nighttime and what kind of diagnostic tests and medical interventions those patients receive before morning to identify patient groups that could be non-conveyed or directed to alternative points of care. Methods This was a retrospective register study where the information of patients conveyed to university hospital during nighttime (20 − 08) were analyzed. Frequencies of the dispatch codes presenting complaints, medical treatments, and diagnostic tests were calculated. Age significance (under/over 70 years) was also tested. Results 73.5% of the patients received neither medical treatment nor had diagnostic tests taken before morning. Most of these were patients with mental disorder(s), hip pain/complaint, or laceration/cut. Almost half of the patients with abdominal pain or fever had laboratory tests taken. Patients over 70 years old received more medications and had more diagnostic tests taken than younger patients. Conclusions Some of the low-acuity patients could be non-conveyed or referred to alternative pathways of care to avoid impolitic use of emergency medical service and to reduce the workload of emergency departments. Further research is needed to ensure patient safety for patients who are not conveyed at night.

Introduction: Access to after‐hours care (AHC) is an important aspect of general practice service provision. Objective: To establish the prevalence and associations of early‐career GPs' provision of AHC. Design: An analysis of data from the New alumni Experiences of Training and independent Unsupervised Practice (NEXT‐UP) cross‐sectional questionnaire‐based study. Participants were early‐career GPs (6‐month to 2‐year post‐Fellowship) following the completion of GP vocational training in NSW, the ACT, Victoria or Tasmania. The outcome factor was 'current provision of after‐hours care'. Associations of the outcome were established using multivariable logistic regression. Findings: Three hundred and fifty‐four early‐career GPs participated (response rate 28%). Of these, 322 had responses available for analysis of currently performing AHC. Of these observations, 128 (40%) reported current provision of AHC (55% of rural participants and 32% of urban participants). On multivariable analysis, participants who provided any AHC during training were more likely to be providing AHC (odds ratio (OR) 5.51, [95% confidence interval (CI) 2.80–10.80], p < 0.001). Current rural location and in‐training rural experience were strongly associated with currently providing AHC in univariable but not multivariable analysis. Discussion: Early‐career GPs who provided AHC during training, compared with those who did not, were more than five times more likely to provide after‐hours care in their first 2 years after gaining Fellowship, suggesting participation in AHC during training may have a role in preparing registrars to provide AHC as independent practitioners. Conclusion: These findings may inform future GP vocational training policy and practice concerning registrars' provision of AHC during training. [ABSTRACT FROM AUTHOR]

Background: Healthcare assistants working in hospice at home settings have a pivotal role in supporting people dying at home and their family caregivers. Some healthcare assistants are working alone in patients' homes, which magnifies some of the issues reported for those working closely with other team members. There is a dearth of evidence in terms of education, training and support needs for healthcare assistants when working alone. Aim: To explore the role of newly employed lone working healthcare assistants delivering palliative care in the community, and their support and educational needs. Design: Qualitative exploratory study using semi-structured interviews. Setting/participants: Healthcare assistants (n = 16) employed less than 12 months by a national non-profit hospice and palliative care provider located across the UK. Results: Analysis of interviews identified three main themes: (1) Healthcare assistants have a unique and complex role catering for holistic needs of patients and their family caregivers in the home environment; (2) preparation for the complex role requires focus on experiential learning and specific training to support holistic care provision; (3) lone workers experience loneliness and isolation and identify peer support as a key intervention to support their wellbeing. Conclusions: Given the complexities of their role within community palliative care teams, there are key learning points in relation to healthcare assistant preparation. Education and support networks should be prioritised to reduce isolation and support ongoing learning and development of newly employed healthcare assistants; all of which is vital to ensure safety and quality of care for the growing number of people they support in the community. [ABSTRACT FROM AUTHOR]

Objective: With the increase in the preterm birth rate, the factors influencing mortality and morbidity in very-low-birth weight neonates have gained importance in recent years. The results of available studies on the influence of birth hour on the mortality and morbidity rates of preterm infants are contradictory. Moreover, no study on this topic has been conducted in our region. Materials and Methods: This retrospective cohort study was conducted on 127 very-low-birth weight newborns based on birth hour. The newborns were divided into 2 groups, the first born during working hours (7:00 am to 11:59 pm) and the second born during after-hours care (12-6:59 am). Mortality and major diseases were compared using Statistical Package for the Social Sciences by Fisher’s exact tests, Pearson's chi-squared test, and independent t-tests. The statistical significance level for all analyses was set at P < .05 and the CI at 95%. Results: Based on the results of this study in terms of neonatal mortality and major morbidities such as intraventricular hemorrhage and the need for prolonged mechanical ventilation, no significant difference was found between the 2 groups, but the difference in appearance, pulse, grimace, activity, respiration (APGAR) score at the fifth minute was statistically significant and was lower at the working hours. Conclusion: The results of the study may be due to appropriate allocation of resources, assignment of tasks, and professionalism of care in our study area. Further study is needed to determine the differences in clinical care processes that cause these results. [ABSTRACT FROM AUTHOR]

Background: The amount of emergency medical service missions has increased internationally in recent years, and emergency departments are overcrowded globally. Previous evidence has shown that patients arriving at the emergency department during nighttime (20 − 08) have to wait longer, are more likely to leave without being seen, and often have non-urgent conditions compared to patients arriving during the day. The objective of this pilot study was to examine what kind of patient groups are conveyed as non-urgent to the hospital by emergency medical service during nighttime and what kind of diagnostic tests and medical interventions those patients receive before morning to identify patient groups that could be non-conveyed or directed to alternative points of care. Methods: This was a retrospective register study where the information of patients conveyed to university hospital during nighttime (20 − 08) were analyzed. Frequencies of the dispatch codes presenting complaints, medical treatments, and diagnostic tests were calculated. Age significance (under/over 70 years) was also tested. Results: 73.5% of the patients received neither medical treatment nor had diagnostic tests taken before morning. Most of these were patients with mental disorder(s), hip pain/complaint, or laceration/cut. Almost half of the patients with abdominal pain or fever had laboratory tests taken. Patients over 70 years old received more medications and had more diagnostic tests taken than younger patients. Conclusions: Some of the low-acuity patients could be non-conveyed or referred to alternative pathways of care to avoid impolitic use of emergency medical service and to reduce the workload of emergency departments. Further research is needed to ensure patient safety for patients who are not conveyed at night. [ABSTRACT FROM AUTHOR]

AbstractObjective To describe the development over time of the use of C-reactive protein (CRP) and rapid streptococcal detection test (RADT) point-of-care tests (POCT) in Danish general practice and to explore associations between patient characteristics and POCT use (i.e. CRP and RADT).Design and settings A register-based study including all general practice clinic consultations in daytime and out-of-hours (OOH) settings in Denmark between 2003 and 2018.Subjects All citizens who had at least one clinic consultation in daytime or OOH general practice within the study period.Main outcome measures We estimated the total and relative use of CRP and RADT POCTs and described the development over time. Crude and adjusted proportion ratios (PRs) were calculated to explore associations between patient characteristics and POCT use.Results Overall, the relative use of CRP POCTs increased. At OOH, a steep increase was noticed around 2012. The relative use of RADT decreased. Patient age 40–59 years and existing comorbidity were significantly associated with a higher use of CRP testing in both settings. A significantly lower use of CRP testing was found for patients with higher educational level. We found a significantly higher use of RADT testing for patients aged 0–19 years and with higher household educational level, whereas comorbidity was associated with a lower use of RADT testing.Conclusion The use of CRP POCT increased over time, whereas the use of RADT POCT decreased. Perhaps the success of implementing CRP as a tool for reducing antibiotic use has reached it limit. Future studies should focus on how and when POCT are used most optimal.Key pointsCRP POC tests and RADT POCTs are frequently used diagnostic tools in general practice, both in daytime and in the out-of-hours setting.There was an increased use of CRP POCTs, particularly in out-of-hours general practice, whereas the use of RADT POCTs declined between 2003 and 2018.CRP POCTs were associated with age of 40–59 years and co-morbidity, while the use of RADT was mostly associated with younger age.

To describe the development over time of the use of C-reactive protein (CRP) and rapid streptococcal detection test (RADT) point-of-care tests (POCT) in Danish general practice and to explore associations between patient characteristics and POCT use (i.e. CRP and RADT). A register-based study including all general practice clinic consultations in daytime and out-of-hours (OOH) settings in Denmark between 2003 and 2018. All citizens who had at least one clinic consultation in daytime or OOH general practice within the study period. We estimated the total and relative use of CRP and RADT POCTs and described the development over time. Crude and adjusted proportion ratios (PRs) were calculated to explore associations between patient characteristics and POCT use. Overall, the relative use of CRP POCTs increased. At OOH, a steep increase was noticed around 2012. The relative use of RADT decreased. Patient age 40–59 years and existing comorbidity were significantly associated with a higher use of CRP testing in both settings. A significantly lower use of CRP testing was found for patients with higher educational level. We found a significantly higher use of RADT testing for patients aged 0–19 years and with higher household educational level, whereas comorbidity was associated with a lower use of RADT testing. The use of CRP POCT increased over time, whereas the use of RADT POCT decreased. Perhaps the success of implementing CRP as a tool for reducing antibiotic use has reached it limit. Future studies should focus on how and when POCT are used most optimal. CRP POC tests and RADT POCTs are frequently used diagnostic tools in general practice, both in daytime and in the out-of-hours setting. There was an increased use of CRP POCTs, particularly in out-of-hours general practice, whereas the use of RADT POCTs declined between 2003 and 2018. CRP POCTs were associated with age of 40–59 years and co-morbidity, while the use of RADT was mostly associated with younger age. [ABSTRACT FROM AUTHOR]

Abstract Background The effect of ICU admission time on patient outcomes has been shown to be controversial in several studies from a number of countries. The imbalance between ICU staffing and medical resources during off-hours possibly influences the outcome for critically ill or injured patients. Here, we aimed to evaluate the association between ICU admission during off-hours and in-hospital mortality in Japan. Methods This study was an observational study using a multicenter registry (Japanese Intensive care PAtient Database). From the registry, we enrolled adult patients admitted to ICUs from April 2015 to March 2019. Patients with elective surgery, readmission to ICUs, or ICU admissions only for medical procedures were excluded. We compared in-hospital mortalities between ICU patients admitted during off-hours and office-hours, using a multilevel logistic regression model which allows for the random effect of each hospital. Results A total of 28,200 patients were enrolled with a median age of 71 years (interquartile range [IQR], 59 to 80). The median APACHE II score was 18 (IQR, 13 to 24) with no significant difference between patients admitted during off-hours and those admitted during office-hours. The in-hospital mortality was 3399/20,403 (16.7%) when admitted during off-hours and 1604/7797 (20.6%) when admitted during office-hours. Thus, off-hours ICU admission was associated with lower in-hospital mortality (adjusted odds ratio 0.91, [95% confidence interval, 0.84–0.99]). Conclusions ICU admissions during off-hours were associated with lower in-hospital mortality in Japan. These results were against our expectations and raised some concerns for a possible imbalance between ICU staffing and workload during office-hours. Further studies with a sufficient dataset required for comparing with other countries are warranted in the future.

Background and Aims: Policy makers and health system managers are seeking evidence on the risks involved for patients associated with after‐hours care. This study of approximately 1 million patients who were admitted to the 25 largest public hospitals in Queensland Australia sought to quantify mortality and readmission differences associated with after‐hours hospital admission. Methods: Logistic regression was used to assess whether there were any differences in mortality and readmissions based on the time inpatients were admitted to hospital (after‐hours versus within hours). Patient and staffing data, including the variation in physician and nursing staff numbers and seniority were included as explicit predictors within patient outcome models. Results: After adjusting for case‐mix confounding, statistically significant higher mortality was observed for patients admitted on weekends via the hospital's emergency department compared to within hours. This finding of elevated mortality risk after‐hours held true in sensitivity analyses which explored broader definitions of after‐hours care: an "Extended" definition comprising a weekend extending into Friday night and early Monday morning; and a "Twilight" definition comprising weekends and weeknights. There were no significant differences in 30‐day readmissions for emergency or elective patients admitted after‐hours. Increased mortality risks for elective patients was found to be an evening/weekend effect rather than a day‐of‐week effect. Workforce metrics that played a role in observed outcome differences within hours/after‐hours were more a time of day rather than day of week effect, i.e. staffing impacts differ more between day and night than the weekday versus weekend. Conclusion: Patients admitted after‐hours have significantly higher mortality than patients admitted within hours. This study confirms an association between mortality differences and the time patients were admitted to hospital, and identifies characteristics of patients and staffing that affect those outcomes. [ABSTRACT FROM AUTHOR]

Background: People with advanced cancer frequently use the GP out-of-hours (GPOOH) service. Considerable amounts of routine GPOOH data are uncoded. Therefore, these data are omitted from existing healthcare datasets. Aim: To conduct a free-text analysis of a GPOOH dataset, to identify reasons for attendance and care delivered through GPOOH to people with advanced cancer. Design and setting: An analysis of a GPOOH healthcare dataset was undertaken. It contained all coded and free- text information for 5749 attendances from a cohort of 2443 people who died from cancer in Tayside, Scotland, from 2013–2015. Method: Random sampling methods selected 575 consultations for free-text analysis. Each consultation was analysed by two independent reviewers to determine the following: assigned presenting complaints; key and additional palliative care symptoms recorded in free text; evidence of anticipatory care planning; and free-text recording of dispensed medications. Inter-rater reliability concordance was established through Kappa testing. Results: More than half of all coded reasons for attendance (n = 293; 51.0%) were 'other' or 'missing'. Free-text analysis demonstrated that nearly half (n = 284; 49.4%) of GPOOH attendances by people with advanced cancer were for pain or palliative care. More than half of GPOOH attendances (n = 325; 56.5%) recorded at least one key or additional palliative care symptom in free text, with the commonest being breathlessness, vomiting, cough, and nausea. Anticipatory care planning was poorly recorded in both coded and uncoded records. Uncoded medications were dispensed in more than one- quarter of GPOOH consultations. Conclusion: GPOOH delivers a substantial amount of pain management and palliative care, much of which is uncoded. Therefore, it is unrecognised and under-reported in existing large healthcare data analyses. [ABSTRACT FROM AUTHOR]

Abstract Background In the Netherlands, General Practitioners (GP) are usually the first point of contact with a health professional for most health problems. Out-of-hours (OOH) primary care is provided by regional OOH services. Changes in consultation rates at OOH services may be regarded as a warning system for failures elsewhere in the healthcare system. Therefore in this study, we investigated how the COVID-19 pandemic changed the use of primary care OOH services during the first year of the pandemic. Methods Routine electronic health records data were used from 60% of OOH services in the Netherlands, collected by the Nivel Primary Care Database. We compared consultation rates per week (2020) for COVID-19-like symptoms and other health problems (e.g. small traumas, urinary tract infections), for different age groups, the proportion of remote consultations, and different levels of urgency during the pandemic compared to the same period in 2019. Results The number of consultations for COVID-19-like symptoms peaked at the start of the COVID-19 pandemic, while consultations for other health problems decreased. These changes in consultation rates differed between age groups. Remote consultations took place more frequently for all health problems, while the proportion of non-urgent health problems increased. Conclusion There were significant changes in the number of consultations and the proportion that were remote for COVID-19-like symptoms and other health problems. Especially care for babies and young children decreased, while the number of consultations for older adults remained stable. The continued use of OOH services by older adults suggests there were unmet care needs elsewhere in our healthcare system.

Abstract Background and Aims Policy makers and health system managers are seeking evidence on the risks involved for patients associated with after‐hours care. This study of approximately 1 million patients who were admitted to the 25 largest public hospitals in Queensland Australia sought to quantify mortality and readmission differences associated with after‐hours hospital admission. Methods Logistic regression was used to assess whether there were any differences in mortality and readmissions based on the time inpatients were admitted to hospital (after‐hours versus within hours). Patient and staffing data, including the variation in physician and nursing staff numbers and seniority were included as explicit predictors within patient outcome models. Results After adjusting for case‐mix confounding, statistically significant higher mortality was observed for patients admitted on weekends via the hospital's emergency department compared to within hours. This finding of elevated mortality risk after‐hours held true in sensitivity analyses which explored broader definitions of after‐hours care: an “Extended” definition comprising a weekend extending into Friday night and early Monday morning; and a “Twilight” definition comprising weekends and weeknights. There were no significant differences in 30‐day readmissions for emergency or elective patients admitted after‐hours. Increased mortality risks for elective patients was found to be an evening/weekend effect rather than a day‐of‐week effect. Workforce metrics that played a role in observed outcome differences within hours/after‐hours were more a time of day rather than day of week effect, i.e. staffing impacts differ more between day and night than the weekday versus weekend. Conclusion Patients admitted after‐hours have significantly higher mortality than patients admitted within hours. This study confirms an association between mortality differences and the time patients were admitted to hospital, and identifies characteristics of patients and staffing that affect those outcomes.

Aim: This study aimed to identify publicly reported access characteristics for episodic primary care in BC and provided a clinic-level comparison between walk-in clinics and UPCCs. Background: Walk-in clinics are non-hospital-based primary care facilities that are designed to operate without appointments and provide increased healthcare access with extended hours. Urgent and Primary Care Centres (UPCCs) were introduced to British Columbia (BC) in 2018 as an additional primary care resource that provided urgent, but not emergent care during extended hours. Methods: This cross-sectional study used publicly available data from all walk-in clinics and UPCCs in BC. A structured data collection form was used to record access characteristics from clinic websites, including business hours, weekend availability, attachment to a longitudinal family practice, and provision of virtual services. Findings: In total, 268 clinics were included in the analysis (243 walk-in clinics, 25 UPCCs). Of those, 225 walk-in clinics (92.6%) and two UPCCs (8.0%) were attached to a longitudinal family practice. Only 153 (63%) walk-in clinics offered weekend services, compared to 24 (96%) of UPCCs. Walk-in clinics offered the majority (8,968.6/ 78.4%) of their service hours between 08:00 and 17:00, Monday to Friday. UPCCs offered the majority (889.3/ 53.7%) of their service hours after 17:00. Conclusion: Most walk-in clinics were associated with a longitudinal family practice and provided the majority of clinic services during typical business hours. More research that includes patient characteristics and care outcomes, analyzed at the clinic level, may be useful to support the optimization of episodic primary healthcare delivery. [ABSTRACT FROM AUTHOR]

Background: Tachypnoea in acutely ill patients can be an early sign of a life-threatening condition such as sepsis. Routine measurement of the respiratory rate by GPs might improve the recognition of sepsis. Aim: To assess the accuracy and feasibility of respiratory rate measurements by GPs. Design & setting: Observational cross-sectional mixed-methods study in the setting of out-of-hours (OOH) home visits at three GP cooperatives in The Netherlands. Method: GPs were observed during the assessment of acutely ill patients, and semi-structured interviews were performed. The GP-assessed respiratory rate was compared with a reference measurement. In the event that the respiratory rate was not counted, GPs were asked to estimate the rate (dichotomised as ≥22 breaths per minute or <22 breaths per minute). Results: Observations of 130 acutely ill patients were included, and 14 GPs were interviewed. In 33 patients (25%), the GP counted the respiratory rate. A mean difference of 0.27 breaths per minute (95% confidence interval [CI] = -5.7 to 6.3) with the reference measurement was found. At a cut-off point of ≥22 breaths per minute, a sensitivity of 86% (95% CI = 57% to 98%) was found when the GP counted the rate, and a sensitivity of 43% (95% CI = 22% to 66%) when GPs estimated respiratory rates. GPs reported both medical and practical reasons for not routinely measuring the respiratory rate. Conclusion: GPs are aware of the importance of assessing the respiratory rate of acutely ill adult patients, and counted measurements are accurate. However, in most patients the respiratory rate was not counted, and the rate was often underestimated when estimated. [ABSTRACT FROM AUTHOR]

Background: Almost half of Australian after-hours emergency department (ED) presentations are rated as 'non-urgent' by clinicians and are suggested to be managed by community-based services, such as general practice (GP). This paper reports patient reasons for presenting for medical care after hours, and reasons for selection of specific services across a health system. Methods: A cross-sectional survey was conducted across the Australian Capital Territory. Patients voluntarily completed questionnaires in waiting rooms during the after-hours periods of one weekday and one weekend in 2019 at 28/51 extended hours GPs, 3/3 medical deputising services (MDS), 3/3 nurse-led walk-in-clinics (WICs), and 2/2 public emergency departments (EDs). Results: Of 3371 presentations, 1992 patients completed a survey, with 58% from GPs (n = 1149), 16% from WIC (n = 317), 10% from MDS (n = 193), and 17% from EDs (n = 333). Most patients presented with self-rated new issues (n = 987, 49.5%) and were uncertain of the urgency of their issues (n = 723, 36.7%). Common reasons for presenting to WIC, MDS, and EDs included the problem occurring after hours, and patients concern about the issue. Common reasons for presenting to GP were related to personal preference for after-hours care. Conclusions: Patients present to after-hours medical services for both perceived need and convenience. Most patients appear to be self-selecting after-hours services appropriately aligned with advertised services; except for GP patients who were attending after hours for care that is often non-urgent and could be seen in usual working hours. This study should be replicated to account for local health systems, and coronavirus disease 2019 (COVID-19)-related changes to health care. Almost half of Australian after-hours emergency department (ED) presentations are rated as 'non-urgent' by clinicians and are suggested to be managed by community-based services, such as general practice (GP). Our survey shows that patient-perceived urgency and need for care are drivers towards ED and other community services. In contrast, most patients chose after-hours GP for convenience. Public messaging could be adapted to encourage appropriate and timely access to care after hours. [ABSTRACT FROM AUTHOR]

Abstract Background During the cluster randomised TRIAGE-trial, a nurse advised 13% of low-risk patients presenting at an emergency department in Belgium to visit the adjacent general practitioner cooperative. Patients had the right to refuse this advice. This exploratory study examines the characteristics of refusers by uncovering the determinants of non-compliance and its impact on costs, as charged on the patient’s invoice. Methods Bivariate analyses with logistic regressions and T-tests were used to test the differences in patient characteristics, patient status, timing characteristics, and costs between refusers and non-refusers. A chi-square automatic interaction detection analysis was used to find the predictors of non-compliance. Results 23.50% of the patients refused the advice to visit the general practitioner cooperative. This proportion was mainly influenced by the nurse on duty (non-compliance rates per nurse ranging from 2.9% to 52.8%) and the patients’ socio-economic status (receiving increased reimbursement versus not OR 1.37, 95%CI: 0.96 to 1.95). Additionally, non-compliance was associated (at the 0.10 significance level) with being male, not living nearby and certain reasons for encounter. Fewer patients refused when the nurse perceived crowding level as quiet relative to normal, and more patients refused during the evening. The mean cost was significantly higher for patients who refused, which was a result of more extensive examination and higher out-of-pocket expenses at the ED. Conclusions The nurse providing the advice to visit the general practitioner cooperative has a central role in the likelihood of patients’ refusal. Interventions to reduce non-compliance should aim at improving nurse-patient communication. Special attention may be required when managing patients with a lower socio-economic status. The overall mean cost was higher for refusers, illustrating the importance of compliance. Trial registration The trial was registered on registration number NCT03793972 on 04/01/2019.

Abstract Background General practitioners (GPs) and out-of-hours (OOH) doctors are gatekeepers to acute hospital admissions in many healthcare systems. The aim of the present study was to investigate the whole range of reasons for acute referrals to somatic hospitals from GPs and OOH doctors and referral rates for the most common reasons. We wanted to explore the relationship between some common referral diagnoses and the discharge diagnosis, and associations with patient’s gender, age, and GP or OOH doctor referral. Methods A registry-based study was performed by linking national data from primary care in the physicians’ claims database with hospital services data in the Norwegian Patient Registry (NPR). The referring GP or OOH doctor was defined as the physician who had sent a claim for the patient within 24 h prior to an acute hospital stay. The reason for referral was defined as the ICPC-2 diagnosis used in the claim; the discharge diagnoses (ICD-10) came from NPR. Results Of all 265,518 acute hospital referrals from GPs or OOH doctors in 2017, GPs accounted for 43% and OOH doctors 57%. The overall referral rate per contact was 0.01 from GPs and 0.11 from OOH doctors, with large variations by referral diagnosis. Abdominal pain (D01) (8%) and chest pain (A11) (5%) were the most frequent referral diagnoses. For abdominal pain and chest pain referrals the most frequent discharge diagnosis was the corresponding ICD-10 symptom diagnosis, whereas for pneumonia-, appendicitis-, acute myocardial infarction- and stroke referrals the corresponding disease diagnosis was most frequent. Women referred with chest pain were less likely to be discharged with ischemic heart disease than men. Conclusions The reasons for acute referral to somatic hospitals from GPs and OOH doctors comprise a wide range of reasons, and the referral rates vary according to the severity of the condition and the different nature between GP and OOH services. Referral rates for OOH contacts were much higher than for GP contacts. Patient age, gender and referring service influence the relationship between referral and discharge diagnosis.

OBJECTIVES:As the largest acute heart failure (AHF) trial conducted to date, the global ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure) trial database presented an opportunity to systematically describe the relationship among time of hospital presentation, clinical profile, inpatient management, and outcomes among patients admitted with AHF. BACKGROUND:Time of hospital presentation has been shown to impact outcomes among patients hospitalized with many conditions. However, the association among time of presentation and patient characteristics, management, and clinical outcomes among patients hospitalized with AHF has not been well characterized. METHODS:A post hoc analysis of the ASCEND-HF trial was performed, which enrolled 7,141 patients hospitalized for AHF. Patients were divided based on when they presented to the hospital; regular hours were defined as 9 am to 5 pm, Monday through Friday, and off hours were defined as 5 pm to 9 am, Monday through Friday and weekends. Clinical characteristics and outcomes were compared by time of presentation. RESULTS:Overall, 3,298 patients (46%) presented during off hours. Off-hour patients were more likely to have orthopnea (80% vs. 74%, respectively) and rales (56% vs. 49%, respectively) than regular-hour patients. Off-hour patients were more likely to receive intravenous (IV) nitroglycerin (18% vs. 11%, respectively) and IV loop diuretics (92% vs. 86%, respectively) as initial therapy and reported greater relief from dyspnea at 24 h (odds ratio [OR]: 1.14; 95% confidence interval [CI]: 1.04 to 1.24; p = 0.01) than regular-hour patients. After adjustment, off-hour presentation was associated with significantly lower 30-day mortality (OR: 0.74; 95% CI: 0.57 to 0.96; p = 0.03) and 180-day mortality (hazard ratio [HR]: 0.82; 95% CI: 0.72 to 0.94; p = 0.01) but similar 30-day rehospitalization rates (p = 0.40). CONCLUSIONS:In this AHF trial, patients admitted during off hours exhibited a distinct clinical profile, experienced greater dyspnea relief, and had lower post-discharge mortality than regular-hour patients. These findings have implications for future AHF trials.

Background: Tachypnoea in acutely ill patients can be an early sign of a life-threatening condition such as sepsis. Routine measurement of the respiratory rate by GPs might improve the recognition of sepsis. Aim: To assess the accuracy and feasibility of respiratory rate measurements by GPs. Design & setting: Observational cross-sectional mixed-methods study in the setting of out-of-hours (OOH) home visits at three GP cooperatives in The Netherlands. Method: GPs were observed during the assessment of acutely ill patients, and semi-structured interviews were performed. The GP-assessed respiratory rate was compared with a reference measurement. In the event that the respiratory rate was not counted, GPs were asked to estimate the rate (dichotomised as ≥22 breaths per minute or

Background: The effect of ICU admission time on patient outcomes has been shown to be controversial in several studies from a number of countries. The imbalance between ICU staffing and medical resources during off-hours possibly influences the outcome for critically ill or injured patients. Here, we aimed to evaluate the association between ICU admission during off-hours and in-hospital mortality in Japan. Methods: This study was an observational study using a multicenter registry (Japanese Intensive care PAtient Database). From the registry, we enrolled adult patients admitted to ICUs from April 2015 to March 2019. Patients with elective surgery, readmission to ICUs, or ICU admissions only for medical procedures were excluded. We compared in-hospital mortalities between ICU patients admitted during off-hours and office-hours, using a multilevel logistic regression model which allows for the random effect of each hospital. Results: A total of 28,200 patients were enrolled with a median age of 71 years (interquartile range [IQR], 59 to 80). The median APACHE II score was 18 (IQR, 13 to 24) with no significant difference between patients admitted during off-hours and those admitted during office-hours. The in-hospital mortality was 3399/20,403 (16.7%) when admitted during off-hours and 1604/7797 (20.6%) when admitted during office-hours. Thus, off-hours ICU admission was associated with lower in-hospital mortality (adjusted odds ratio 0.91, [95% confidence interval, 0.84–0.99]). Conclusions: ICU admissions during off-hours were associated with lower in-hospital mortality in Japan. These results were against our expectations and raised some concerns for a possible imbalance between ICU staffing and workload during office-hours. Further studies with a sufficient dataset required for comparing with other countries are warranted in the future. [ABSTRACT FROM AUTHOR]

Background: Community services for palliative patients outside normal working hours are variable and the best evidence-based models of care have not been determined. Aim: To establish expert consensus on the most important components of out-of-hours community palliative care services. Design: Delphi study. The first round listed 68 components generated from systematic literature reviewing, focus groups with healthcare professionals and input from the project's patient and public involvement advisory group. The components deemed 'essential' by over 70% of participants in the first round were refined and carried forward to a second round, asking participants to rank each on a five-point Likert scale (5 highest to 1 lowest). The consensus threshold was median of 4 to 5 and interquartile range of ⩽1. Participants: Community specialist palliative care health professionals, generalist community health professionals and patients and family carers with experience of receiving care out-of-hours at home. Results: Fifty-four participants completed round 1, and 44 round 2. Forty-five components met the threshold as most important for providing out-of-hours care, with highest consensus for: prescription, delivery and administration of medicines; district and community nurse visits; and shared electronic patient records and advance care plans. Conclusions: The Delphi method identified the most important components to provide community palliative care for patients out-of-hours, which are often provided by non-specialist palliative care professionals. The importance placed on the integration and co-ordination with specialist palliative care through shared electronic records and advance care plans demonstrates the reassurance for patients and families of being known to out-of-hours services. [ABSTRACT FROM AUTHOR]

Introduction: Telephone triage is pivotal for evaluating the urgency of patient care, and in the Netherlands, the Netherlands Triage Standard (NTS) demonstrates moderate discrimination for chest pain. To address this, the Safety First Prediction Rule (SFPR) was developed to improve the safety of ruling out acute coronary syndrome (ACS) during telephone triage., Methods: We conducted an external validation of the SFPR using data from the TRACE study, a retrospective cohort study in out-of-hours primary care. We evaluated the diagnostic accuracy assessment for ACS, major adverse cardiovascular events (MACE), and major events within 6 weeks. Moreover, we compared its performance with that of the NTS algorithm., Results: Among 1404 included patients (57.3% female, 6.8% ACS, 8.6% MACE), the SFPR demonstrated good discrimination for ACS (C-statistic: 0.79; 95%-CI: 0.75-0.83) and MACE (C-statistic: 0.79; 95%-CI: 0.0.76-0.82). Calibration was satisfactory, with overestimation observed in high-risk patients for ACS. The SFPR (risk threshold 2.5%) trended toward higher sensitivity (95.8% vs. 86.3%) and negative predictive value (99.3% vs. 97.6%) with a lower negative likelihood ratio (0.10 vs. 0.34) than the NTS algorithm., Conclusion: The SFPR proved robust for risk stratification in patients with acute chest pain seeking out-of-hours primary care in the Netherlands. Further prospective validation and implementation are warranted to refine and establish the rule's clinical utility., (© The Author(s) 2024. Published by Oxford University Press.)

Objectives: Physician burnout in the US has reached crisis levels, with one source identified as extensive after-hours documentation work in the electronic health record (EHR). Evidence has illustrated that physician preferences for after-hours work vary, such that after-hours work may not be universally burdensome. Our objectives were to analyze variation in preferences for after-hours documentation and assess if preferences mediate the relationship between after-hours documentation time and burnout., Materials and Methods: We combined EHR active use data capturing physicians' hourly documentation work with survey data capturing documentation preferences and burnout. Our sample included 318 ambulatory physicians at MedStar Health. We conducted a mediation analysis to estimate if and how preferences mediated the relationship between after-hours documentation time and burnout. Our primary outcome was physician-reported burnout. We measured preferences for after-hours documentation work via a novel survey instrument (Burden Scenarios Assessment). We measured after-hours documentation time in the EHR as the total active time respondents spent documenting between 7 pm and 3 am., Results: Physician preferences varied, with completing clinical documentation after clinic hours while at home the scenario rated most burdensome (52.8% of physicians), followed by dealing with prior authorization (49.5% of physicians). In mediation analyses, preferences partially mediated the relationship between after-hours documentation time and burnout., Discussion: Physician preferences regarding EHR-based work play an important role in the relationship between after-hours documentation time and burnout., Conclusion: Studies of EHR work and burnout should incorporate preferences, and operational leaders should assess preferences to better target interventions aimed at EHR-based contributors to burnout., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Introduction: In patients suspected of stroke or transient ischemic attack (TIA), rapid triaging is imperative to improve clinical outcomes. For this purpose, balance-eye-face-arm-speech-time (BEFAST) items are used in out-of-hours primary care (OHS-PC). We explored the risk of stroke and TIA among BEFAST positive patients calling to the OHS-PC, and assessed whether additional predictors could improve risk stratification., Methods: This is a cross-sectional study of retrospectively gathered routine care data from telephone triage tape-recordings of patients calling the OHS-PC with neurological deficit symptoms, classified as BEFAST positive. Four models-with the predictors age, sex, a history of cardiovascular or cerebrovascular disease, and cardiovascular risk factors-were fitted using logistic regression to predict the outcome stroke or TIA. Likelihood ratio testing was used to select the best model, which was subsequently internally validated., Results: The risk of stroke or TIA diagnosis was 52% among 1,289 BEFAST positive patients, median age 72 years, 56% female sex. Of patients with the outcome stroke/TIA, 24% received a low urgency allocation, while 92% had signs or symptoms when calling. Only the addition of age and sex improved predicting stroke or TIA (internally validated c-statistic 0.72, 95%CI 0.69-0.75). The predicted risk of stroke or TIA remained below 20% in those aged below 40. Females aged 70 or over and males aged 55 or over, had a predicted risk above 50%., Discussion: Urgency allocation appears to be suboptimal in BEFAST positive patients calling the OHS-PC. Risk stratification could be improved in this setting by adding age and sex., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 van Royen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Out-of-hours primary care (OOH-PC) has emerged as a promising solution to improve efficiency, accessibility, and quality of care and to reduce the strain on emergency departments. As this modality gains traction in diverse healthcare settings, it is increasingly important to fully assess its societal value-for-money and conduct thorough process evaluations. However, current economic evaluations mostly emphasise direct- and short-term effect measures, thus lacking a broader societal perspective., Aim: This study offers a comprehensive overview of current effect measures in OOH-PC evaluations and proposes additional measures from the evaluation of integrated care programmes., Approach and Development: First, we systematically identified the effect measures from published cost-effectiveness studies and classified them as process, outcome, and resource use measures. Second, we elaborate on the incorporation of 'productivity gains', 'health promotion and early intervention', and 'continuity of care' as additional effects into economic evaluations of OOH-PC. Seeking care affects personal and employee time, potentially resulting in decreased productivity. Challenges in taking time off work and limited access to convenient care are often cited as barriers to accessing primary care. As such, OOH-PC can potentially reduce opportunity costs for patients. Furthermore, improving access to healthcare is important in determining whether people receive promotional and preventive services. Health promotion involves empowering people to take control of their health and its determinants. Given the unscheduled nature and the fragmented or rotational care in OOH-PC, the degree to which interventions and modalities provide continuity should be monitored, assessed, and included in economic evaluations. Continuity of care in primary care improves patient satisfaction, promotes adherence to medical advice, reduces reliance on hospitals, and reduces mortality., Conclusion: Although it is essential to also address local settings and needs, the integration of broader scope measures into OOH-PC economic evaluations improves the comprehensive evaluation that aligns with welfare gains.

Background: There is a deficiency in the evidence from rural and regional centres in Australia on the weekend effect following presentation with acute stroke., Objective: To estimate the association between admission over a weekend/holiday and all-cause mortality 3-day, 7-day, 14-day, 1-month, 3-month, 6-month, and 12-month following acute stroke., Methods: The records of stroke patients admitted to a main regional hospital in Australia from 2010 to 2020 were linked with the National Death Index. Time to death following ischaemic, haemorrhagic, and total stroke at different time points was modelled using Weibull, Exponential, or Gompertz regression based on best model fit determined by Akaike's information criterion., Results: Of 1669 patients, 1273 (76.3%) were admitted on a weekday, and 396 (23.7%) on a weekend/ or holiday. After adjusting for age, sex, and Charlson Comorbidity Index, stroke type and country of birth, admissions over a weekend/holiday following total stroke were significantly associated with an increased risk of dying within three days from admission [hazard ratio (HR): 1.59, 95% confidence interval: 1.01-2.50]. In haemorrhagic stroke, increased risk of death was significantly higher at three days (HR: 2.19, 95% confidence interval: 1.17-4.08), 14 days (HR: 1.73, 95% confidence interval: 1.02-2.93), and 1 month (HR: 1.82, 95% confidence interval: 1.09-3.03) following admission on the weekend/ or holiday compared to those admitted during the weekdays., Conclusions: This study reports a short-term adverse weekend/holiday effect following admission for haemorrhagic stroke or total stroke. No significant weekend/holiday effect was found in ischaemic stroke., Competing Interests: Declaration of competing interest The 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 The Author(s). Published by Elsevier Inc. All rights reserved.)

A patient is told he will have to wait overnight for emergency care from an on-call specialist and his team.

Objectives: Out-of-hours discharge from ICU to the ward is associated with increased in-hospital mortality and ICU readmission. Little is known about why this occurs. We map the discharge process and describe the consequences of out-of-hours discharge to inform practice changes to reduce the impact of discharge at night.Design: This study was part of the REcovery FoLlowing intensive CarE Treatment mixed methods study. We defined out-of-hours discharge as 16:00 to 07:59 hours. We undertook 20 in-depth case record reviews where in-hospital death after ICU discharge had been judged "probably avoidable" in previous retrospective structured judgment reviews, and 20 where patients survived. We conducted semistructured interviews with 55 patients, family members, and staff with experience of ICU discharge processes. These, along with a stakeholder focus group, informed ICU discharge process mapping using the human factors-based functional analysis resonance method.Setting: Three U.K. National Health Service hospitals, chosen to represent different hospital settings.Subjects: Patients discharged from ICU, their families, and staff involved in their care.Interventions: None.Measurements and Main Results: Out-of-hours discharge was common. Patients and staff described out-of-hours discharge as unsafe due to a reduction in staffing and skill mix at night. Patients discharged out-of-hours were commonly discharged prematurely, had inadequate handover, were physiologically unstable, and did not have deterioration recognized or escalated appropriately. We identified five interdependent function keys to facilitating timely ICU discharge: multidisciplinary team decision for discharge, patient prepared for discharge, bed meeting, bed manager allocation of beds, and ward bed made available.Conclusions: We identified significant limitations in out-of-hours care provision following overnight discharge from ICU. Transfer to the ward before 16:00 should be facilitated where possible. Our work highlights changes to help make day time discharge more likely. Where discharge after 16:00 is unavoidable, support systems should be implemented to ensure the safety of patients discharged from ICU at night. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to investigate the prevalence, nature, and management of post‐surgical emergency after‐hours calls in a dental school setting with predoctoral students, graduate students/residents, and faculty providers. Methods: A patient chart review (March 2018–February 2020) for post‐surgical calls through the emergency after‐hours pager system was conducted at the Marquette University School of Dentistry. The total number of surgical procedures, procedure type, the timing of call, operator experience, concern, and recommendation given during the call were documented. Results: During the review period, 83 calls (from 75 patients) were recorded after 8,487 surgical procedures (1% of procedures). Patients called 5.4 ± 0.8 days postoperatively. Procedure type affected call prevalence (p = 0.04), with most calls made after extractions (69.9% of all calls; 1% of extractions; 58/5,725), implant placement (6%; 0.9% of implant placements; 5/530) and periodontal plastic surgery (6%; 3.1% of all plastic surgeries; 5/161). The most common concern was pain (72.3%), then swelling (36.1%), bleeding (12%), and infection (9.6%). Operator experience did not affect call prevalence. Recommendations given were next business day follow‐up (79.5%), reinforcement of already given postoperative instructions (51.8%), prescription (15.7%), and hospital emergency department (ED) visit (7.2%). Conclusions: Post‐surgical emergency after‐hours calls in a dental school setting occur within the first postoperative week and are rare, unrelated to operator experience, typically prompted by pain, and rarely resulting in referral to hospital ED. The use of a pager system is adequate for the management of after‐hours emergencies and may reduce self‐referrals to the hospital ED. [ABSTRACT FROM AUTHOR]

Background: The prehospital emergency system in Norway involves out-of-hours (OOH) services with on-call physicians. Helicopter emergency medical service (HEMS) are used in cases of severe illness or trauma that require rapid transport and/or an anesthesiologist's services. In recent years, on-call primary care physicians have been less available for call-outs in Norway, and HEMS may be requested for missions that could be adequately handled by on-call physicians. Here, we investigated how different availability of an on-call physician to attend emergency patients at site (call-out) impacted requests and use of HEMS.Methods: Our analysis included all acute medical missions in an urban and nearby rural OOH district, which had different approach regarding physician call-outs from the OOH service. For this prospective observational study, we used data from both HEMS and the OOH service from November 1st 2017 until November 30th 2018. Standard descriptive statistical analyses were used.Results: The rates of acute medical missions in the urban and rural OOH districts were similar (30 and 29 per 1000 inhabitants per year, respectively). The rate of HEMS requests was significantly higher in the rural OOH district than in the urban district (2.4 vs. 1.7 per 1000 inhabitants per year, respectively). Cardiac arrest and trauma were the major symptom categories in more than one half of the HEMS-attended patients, in both districts. Chest pain was the most frequent reason for an OOH call-out in the rural OOH district (21.1%). An estimated NACA score of 5-7 was found in 47.7% of HEMS patients from the urban district, in 40.0% of HEMS patients from the rural OOH district (p = 0.44), and 12.8% of patients attended by an on-call physician in the rural OOH district (p < 0.001). Advanced interventions were provided by an anesthesiologist to one-third of the patients attended by HEMS, of whom a majority had an NACA score of ≥ 5.Conclusions: HEMS use did not differ between the two compared areas, but the rate of HEMS requests was significantly higher in the rural OOH district. The threshold for HEMS use seems to be independent of on-call primary care physician involvement. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether practice rurality and rural training pathway are associated with general practitioner registrars' participation in their practice's after‐hours care roster. Design: A cross‐sectional analysis of data (2017‐2019) from the Registrar Clinical Encounters in Training study, an ongoing inception cohort study of Australian general practitioner registrars. The principal analyses used logistic regression. Setting: Three national general practitioner regional training organisations across 3 Australian states. Participants: General practitioner registrars in training within regional training organisations. Main outcome measure: Involvement in practice after‐hours care was indicated by a dichotomous response on a 6‐monthly Registrar Clinical Encounters in Training study questionnaire item. Results: 1576 registrars provided 3158 observations (response rate 90.3%). Of these, 1574 (48.6% [95% confidence interval: 46.8‐50.3]) involved registrars contributing to their practice's after‐hours roster. In major cities, 40% of registrar terms involved contribution to their practice's after‐hours roster; in regional and remote practices, 62% contributed to the after‐hours roster. On multivariable analysis, both level of rurality of practice (odds ratio(OR) 1.75, P =.007; and OR 1.74, P =.026 for inner regional and outer regional/remote locations, respectively, versus major city) and rural training pathway of registrar (OR 1.65, P =.008) were significantly associated with more after‐hours roster contribution. Other associations were registrars' later training stage, larger practices and practices not routinely bulk billing. Significant regional variability in after‐hours care was identified (after adjusting for rurality). Conclusion: These findings suggest that registrars working rurally and those training on the rural pathway are more often participating in practice after‐hours rosters. This has workforce implications, and implications for the educational richness of registrars' training environment. [ABSTRACT FROM AUTHOR]

Background: There are substantial differences in hospital referrals between general practitioners (GPs); however, there is little research on the consequences for patient safety and further healthcare use.Objective: To investigate associations between out-of-hours GP characteristics, unplanned hospital admissions, and patient safety.Methods: This cohort study included all Norwegian out-of-hours services contacts from 2008 to 2016, linked to registry data on patient characteristics, healthcare use and death, and GP age, sex, specialist status, out-of-hours service experience, and prior admission proportion. We estimated the impact from GP characteristics on (i) immediate unplanned hospital admissions for "all conditions," (ii) immediate unplanned hospital admissions for "critical conditions," (iii) 30-day unplanned hospital admissions, (iv) 30-day hospital costs, and (v) 30-day risk of death. To limit confounding, we matched patients in groups by age, time, and location, with an assumption of random assignment of GPs to patients with this design.Results: Patients under the care of older and male GPs had fewer immediate unplanned hospital admissions, but the effects on cumulative 30-day unplanned hospital admissions and costs were small. The GPs' prior admission proportion was strongly associated with both immediate and 30-day unplanned hospital admissions. Higher prior admission proportion was also associated with admitting more patients with critical conditions. There was little evidence of any associations between GP characteristics and 30-day risk of death.Conclusions: GPs' prior admission proportion was strongly associated with unplanned hospital admissions. We found little effects on 30-day mortality, but more restrictive referral practices may threaten patient safety through missing out on critical cases. [ABSTRACT FROM AUTHOR]

Background: Recognising patients who need immediate hospital treatment for sepsis while simultaneously limiting unnecessary referrals is challenging for GPs.Aim: To develop and validate a sepsis prediction model for adult patients in primary care.Design and Setting: This was a prospective cohort study in four out-of-hours primary care services in the Netherlands, conducted between June 2018 and March 2020.Method: Adult patients who were acutely ill and received home visits were included. A total of nine clinical variables were selected as candidate predictors, next to the biomarkers C-reactive protein, procalcitonin, and lactate. The primary endpoint was sepsis within 72 hours of inclusion, as established by an expert panel. Multivariable logistic regression with backwards selection was used to design an optimal model with continuous clinical variables. The added value of the biomarkers was evaluated. Subsequently, a simple model using single cut-off points of continuous variables was developed and externally validated in two emergency department populations.Results: A total of 357 patients were included with a median age of 80 years (interquartile range 71-86), of which 151 (42%) were diagnosed with sepsis. A model based on a simple count of one point for each of six variables (aged >65 years; temperature >38°C; systolic blood pressure ≤110 mmHg; heart rate >110/min; saturation ≤95%; and altered mental status) had good discrimination and calibration (C-statistic of 0.80 [95% confidence interval = 0.75 to 0.84]; Brier score 0.175). Biomarkers did not improve the performance of the model and were therefore not included. The model was robust during external validation.Conclusion: Based on this study's GP out-of-hours population, a simple model can accurately predict sepsis in acutely ill adult patients using readily available clinical parameters. [ABSTRACT FROM AUTHOR]

Background: In the Netherlands, General Practitioners (GP) are usually the first point of contact with a health professional for most health problems. Out-of-hours (OOH) primary care is provided by regional OOH services. Changes in consultation rates at OOH services may be regarded as a warning system for failures elsewhere in the healthcare system. Therefore in this study, we investigated how the COVID-19 pandemic changed the use of primary care OOH services during the first year of the pandemic.Methods: Routine electronic health records data were used from 60% of OOH services in the Netherlands, collected by the Nivel Primary Care Database. We compared consultation rates per week (2020) for COVID-19-like symptoms and other health problems (e.g. small traumas, urinary tract infections), for different age groups, the proportion of remote consultations, and different levels of urgency during the pandemic compared to the same period in 2019.Results: The number of consultations for COVID-19-like symptoms peaked at the start of the COVID-19 pandemic, while consultations for other health problems decreased. These changes in consultation rates differed between age groups. Remote consultations took place more frequently for all health problems, while the proportion of non-urgent health problems increased.Conclusion: There were significant changes in the number of consultations and the proportion that were remote for COVID-19-like symptoms and other health problems. Especially care for babies and young children decreased, while the number of consultations for older adults remained stable. The continued use of OOH services by older adults suggests there were unmet care needs elsewhere in our healthcare system. [ABSTRACT FROM AUTHOR]

Background: Excessive and inappropriate use of antibiotics is the most important driver of antimicrobial resistance. The aim of the HAPPY PATIENT project is to evaluate the adaptation of European Union (EU) recommendations on the prudent use of antimicrobials in human health by evaluating the impact of a multifaceted intervention targeting different categories of healthcare professionals (HCPs) on common community-acquired infectious diseases, especially respiratory and urinary tract infections. Methods/design: HAPPY PATIENT was initiated in January 2021 and is planned to end in December 2023. The partners of this project include 15 organizations from 9 countries. Diverse HCPs (doctors, nurses, pharmacists, and pharmacy technicians) will be audited by the Audit Project Odense (APO) method before and after an intervention in four different settings: general practice, out of hours services, nursing homes and community pharmacies in four high antibiotic prescribing countries (France, Poland, Greece, and Spain) and one low prescribing country (Lithuania). About 25 individuals from each professional group will be recruited in each country, who will register at least 25 patients with community-acquired infections during each audit period. Shortly before the second registration participants will undertake a multifaceted intervention and will receive the results from the first registration to allow the identification of possible quality problems. At these meetings participants will receive training courses on enhancement of communication skills, dissemination of clinical guidelines with recommendations for diagnosis and treatment, posters for the waiting rooms, and leaflets for patients. The results of the second registration will be compared with those obtained in the first audit. Discussion: HAPPY PATIENT is an EU-funded project aimed at contributing to the battle against antibiotic resistance through improvement of the quality of management of common community-acquired infections based on interventions by different types of HCPs. It is hypothesized that the use of multifaceted strategies combining active intervention will be effective in reducing inappropriate prescribing and dispensing of antibiotics. Study registration: EU Health programmes project database https://webgate.ec.europa.eu/chafea%5fpdb/health/projects/900024/summary; date of registration: 1 January 2021. [ABSTRACT FROM AUTHOR]

Abstract Background High demands create pressure on acute care services, such as emergency medical services (EMS), emergency departments (ED) and out-of-hours primary care (OOH-PC) services. A variety of patient- and organisational factors have been discussed as reasons why especially non-western migrants more frequently contact an ED or OOH-PC service than native born. We aim to investigate whether persons with a non-western and western migrant background more often contact an acute care service than native born and how this relates to the number of contacts with their general practitioners (GPs). In addition, we aim to explore how possible differences in acute care use by migrants can be explained. Methods We performed secondary analysis of data collected for the EurOOHnet survey on OOH help-seeking behaviour in Denmark, the Netherlands and Switzerland. Differences in self-reported acute care use (sum of number of contacts with OOH-PC, the ED and 1–1-2/1–4-4) between non-western and western migrants and native born were tested with a quasi Poisson regression analysis. Mediation analyses were performed to examine the impact of factors related to help-seeking on the relation between self-reported acute care use and migrant background. Results Non-western migrants had more acute care contacts than native born (adjusted IRR 1.74, 95% CI 1.33–2.25), whereas no differences were found between western migrants and native born. Migrants who regularly contacted OOH-PC or the ED also regularly contacted their GP. Mediation analyses showed that the factors employment, anxiety, attitude towards use of OOH-PC and problems in accessing the own GP could partly explain the higher acute care use of non-western migrants. Conclusion The higher use of acute care services by non-western migrants compared with native born could partly be explained by feeling fewer barriers to contact these services, feeling more anxiety, more unemployment and problems making an appointment with the GP. Increasing awareness and improving GP access could help migrants in navigating the healthcare system.

BACKGROUND: There has been a rapid scale up of HIV services and access to anti-retroviral therapy in Africa over the last 10 years as a result of multilateral donor funding mechanisms. However, in order to continue to expand and to sustain these services it is important that in country options are explored. This study sought to explore attitudes and perceptions of people living with HIV (PLHIV) and health care staff towards using a fee-based after hours clinic (AHC) at the Infectious Diseases Institute (IDI) in Kampala, Uganda. METHODS: A cross-sectional study design, using qualitative methods for data collection was used. A purposeful sample of 188 adults including PLHIV accessing care at IDI and IDI staff were selected. We conducted 14 focus group discussions and 55 in-depth interviews. Thematic content analysis was conducted and Nvivo Software Version 10 was used to manage data. RESULTS: Findings suggested that some respondents were willing to pay for consultation, brand-name drugs, laboratory tests and other services. Many were willing to recommend the AHC to friends and/or relatives. However, there were concerns expressed of a risk that the co-pay model may lead to reduction in quality or provision of the free service. Respondents agreed that, as a sign of social responsibility, fees for service could help underprivileged patients. CONCLUSION: The IDI AHC clinic is perceived as beneficial to PLHIV because it provides access to HIV services at convenient times. Many PLHIV are willing to pay for this enhanced service. Innovations in HIV care delivery such as quality private-public partnerships may help to improve overall coverage and sustain quality HIV services in Uganda in the long term.