Search

Objective: 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 REFLECT mixed methods study. We defined out-of-hours discharge as 16:00 - 07:59h. We undertook 20 in-depth case record reviews where in-hospital death after ICU discharge had been judged ‘probably avoidable’ in previous retrospective structured judgement reviews, and 20 where patients survived. We conducted semi-structured 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 (FRAM). Setting: Three UK NHS 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 recognised or escalated appropriately. We identified five interdependent functions key to facilitating timely ICU discharge: multi-disciplinary team decision for discharge; patient prepared for discharge; bed meeting; bed manager allocation of beds; and ward bed made available. Conclusion: We identified significant limitations in out-of-hours care provision following overnight discharged 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.

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.

Clear evidence for a weekend effect was first demonstrated by Bell and Redelmeier1 who examined 3.8 million emergency admissions between 1988 and 1997 in an acute care hospital in Ontario. They had noted that staffing levels were lower in acute care hospitals at weekends and hypothesised that this might lead to poorer care and higher mortality. To test this hypothesis, they identified three conditions (ruptured abdominal aortic aneurysm, acute epiglottitis and pulmonary embolism) for which lower staffing on admission was expected to have consequences in outcomes, as well as three control conditions for which this would not be the case. In addition, they conducted an analysis without a prespecified hypothesis, examining the 100 conditions responsible for most deaths. After adjustment for illness severity, they found higher mortality for conditions expected to be affected by lower staffing and no increase for control conditions. From the 100 medical conditions examined, 23 had significantly increased mortality risk for weekend admissions. These two sets of findings provided strong evidence for a weekend effect, suggesting that for some conditions lower staffing on admission affected standards of care and thereby patient outcomes. Since then, dozens of studies of the weekend effect have been conducted, mostly in the UK and the USA.2 In Britain, the issue became much more high profile after an intervention in 2015 by the Secretary of State who suggested that 11 000 patients were unnecessarily dying at the weekend.3 4 This claim was challenged at the time,5 and many pointed out that the National Health Service (NHS) was already a 7-day service.6 7 However, concern about the weekend led eventually to the introduction of ‘7 day services’ in the NHS in England. A new set of 10 clinical standards was introduced to reduce differences between weekend and weekday services, including increased …

AIMS To investigate how diagnostic radiology on-call work is conducted by trainees out of hours, and to explore how this on-call experience may be improved from a trainee perspective. MATERIALS AND METHODS A nationwide online questionnaire was distributed to each radiology training scheme. A trainee on the diagnostic on-call rota completed the questionnaire on behalf of the scheme. Twenty-six questions spanning four domains were assessed exploring how radiology service provision is performed by trainees out of hours, and ways to improve it. RESULTS Forty schemes responded, representing the entire population size. Twenty-eight (70%) schemes formally assessed trainees prior to joining the on-call rota. Almost half (46%) of trainees start verifying reports independently at ST2. The most common combinations of imaging performed out of hours accounting for 32% each were: (1) computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, and radiography; and (2) CT, ultrasound and radiography. A majority of schemes (54%) had a fixed number of trainees across all shift types. CONCLUSION Radiology on-call provision by trainees varies considerably. Common factors between schemes include all trainees providing an on-call service on weekend day shifts. The most sought-after recommendation to improve the on-call experience was to introduce a collaborative reporting on-call hub set-up where trainees cross-cover multiple sites remotely as a team. Further analytical studies are needed to assess if any relationships between on-call set-up and trainee satisfaction exist.

Purpose The study aimed to investigate the association between out-of-hours surgery and postoperative mortality in hip fracture patients. Furthermore, internal fixation and arthroplasty were compared to determine if a difference could be observed in patients operated with these techniques at different times during the day. Methods All patients above 18 of age years in Sweden who underwent hip fracture surgery between 2008 and 2017 were eligible for inclusion. Pathological fractures, non-operatively managed fractures, or cases whose time of surgery was missing were excluded. The cohort was subdivided into on-hour (08:00–17:00) and out-of-hours surgery (17:00–08:00). Poisson regression with adjustments for confounders was used to evaluate the association between out-of-hours surgery and both 30-day and 90-day postoperative mortality. Results Out-of-hours surgery was associated with a 5% increase in the risk of both 30-day [adj. IRR (95% CI) 1.05 (1.00–1.10), p = 0.040] and 90-day [adj. IRR (95% CI) 1.05 (1.01–1.09), p = 0.005] mortality after hip fracture surgery compared to on-hour surgery. There was no statistically significant association between out-of-hours surgery and postoperative mortality among patients who received an internal fixation. Arthroplasties performed out-of-hours were associated with a 13% increase in 30-day postoperative mortality [adj. IRR (95% CI) 1.13 (1.04–1.23), p = 0.005] and an 8% increase in 90-day postoperative mortality [adj. IRR (95% CI) 1.08 (1.01–1.15), p = 0.022] compared to on-hour surgery. Conclusion Out-of-hours surgical intervention is associated with an increase in both 30- and 90-day postoperative mortality among hip fracture patients who received an arthroplasty, but not among patients who underwent internal fixation.

Background Effective management of trauma patients is dependent on pre-hospital triage systems and proper in-hospital treatment regardless of time of admission. We aim to investigate any differences in adjusted all-cause mortality between day vs. night arrival for adult trauma patients who were transported to the hospital via ground emergency medical services (GEMS) and helicopter emergency medical services (HEMS) and to determine if care/outcomes are inferior when admitted during the night shift as compared to the day shift. Methods Retrospective cohort analysis of adult blunt and penetrating injury patients requiring full team trauma activation at an American College of Surgeons Committee on Trauma (ACSCOT)-verified Level 1 trauma center from 2011 to 2019. Descriptive statistical analyses, chi-square analyses, independent-sample t-tests, and Fisher's exact tests were performed. Primary measurement outcome was adjusted observed/expected (O/E) mortality ratios utilizing TRISS methodology. Results 8370 patients with blunt injuries and 1216 patients with penetrating injuries were analyzed. There were no significant differences in day vs. night O/Es overall (blunt 0.65 vs. 0.59; p = 0.46) (penetrating 0.88 vs. 0.87; p = 0.97). There also were no significant differences when stratified by GEMS (blunt 0.64 vs. 0.55; p = 0.08) (penetrating 0.88 vs. 1.10; p = 0.09) and HEMS admissions (blunt 0.76 vs. 0.75; p = 0.91) (penetrating 0.88 vs. 0.91; p = 0.85). Conclusions At an ACSCOT-verified Level 1 Trauma Center, care/outcomes of patients admitted during the night shift were not inferior to those admitted during the day shift. Trauma Center verification by the ACSCOT and multidisciplinary collaboration may allow for consistent care despite injury type and time of day.

Background The extent to which patients with acute variceal bleeding (AVB) receive recommended care is largely unknown. Aim to evaluate the adherence of the 4 major Baveno VI recommendations [vasoactive agents, prophylactic antibiotic, esophagogastroduodenoscopy (EGD) within 12 hours, endoscopic variceal ligation (EVL)] as a marker of quality of an emergency model. Methods Retrospective evaluation of AVB admissions to a tertiary centre in which endoscopy was available 24hours-a-day, with a regional out-of-hours service at night (the furthest hospital is 200Km away). Patients were divided in directly admitted or transferred from other centres. Results 210 AVB patients were included; 101 (48.1%) were directly admitted. The majority of patients were submitted to vasoactive agents (85.7%) and prophylactic antibiotics (79%) before EGD. In 178 patients (84.8%) endoscopy was performed within 12h and EVL was the procedure of choice in 116 (74.8%) (only oesophageal varices). No significant differences were observed between directly admitted and transferred patients in adherence rates. Overall rebleeding rate was 8.6%, in-hospital mortality 11.4% and 6-week mortality 20%. Conclusion Adherence to quality metrics was high which might have played a vital role for reported outcomes. These results suggest that this model of care, provides accessibility and equity in access to urgent endoscopy.

Cholecystectomy is one of the most commonly performed abdominal operations. Rising demands on acute operating theater availability and resource utilization in the daytime have led to acute cholecystectomy being performed out-of-hours (in the evenings, at night, or on weekends), although it remains unknown whether outcomes differ between out-of-hours and in-hours (during the daytime on weekdays) acute cholecystectomy. This systematic review and meta-analysis aimed to compare outcomes following out-of-hours versus in-hours acute cholecystectomy.The study protocol was prospectively registered on PROSPERO (ID: CRD42021226127). MEDLINE, EMBASE, and Scopus databases were systematically searched for studies comparing outcomes following out-of-hours and in-hours acute cholecystectomy in adults with any acute benign gallbladder disease. The outcomes of interest were rates of bile leakage, bile duct injury, overall postoperative complications, conversion to open cholecystectomy, specific intraoperative and postoperative complications, length of stay, readmission, and mortality. Subgroup (evening/night-time vs. daytime, weekend vs. weekday, acute surgical unit [ASU]-only, non-ASU, and laparoscopic-only) and sensitivity analyses of adjusted multivariate regression analysis results was also performed.Eleven studies were included. There were no differences between out-of-hours and in-hours acute cholecystectomy for rates of bile leakage, bile duct injury, overall postoperative complications, conversion to open cholecystectomy, operative duration, readmission, mortality, and postoperative length of stay. Higher rates of postoperative sepsis (odds ratio, 1.58; 95% confidence interval, 1.04-2.41; p = 0.03) and pneumonia (odds ratio, 1.55; 95% confidence interval, 1.06-2.26; p = 0.02) were observed following out-of-hours acute cholecystectomy on univariate meta-analysis, but not after the adjusted multivariate meta-analysis. Higher conversion rates were observed when out-of-hours cholecystectomy was performed in centers without an ASU.This systematic review and meta-analysis has not shown an increased risk in overall or specific complications associated with out-of-hours compared with in-hours acute cholecystectomy. However, future studies should assess the potential impact of structural hospital factors, such as an ASU, on outcomes following out-of-hours acute cholecystectomy.Systematic Review and Meta-Analysis Study, Level IV.

AIM To assess safety and efficiency of the Cheshire & Merseyside Collaborative, the largest trainee led on-call service in the UK, based on discrepancy rates and time taken to issue reports. MATERIALS & METHODS All studies reported by the collaborative in a 4-week period were evaluated for discrepancy and the time taken to issue a report. These figures were compared against the Royal College of Radiologists (RCR) guidelines and a recent national audit of discrepancy rates. The time taken to report was measured against the National Institute of Health and Clinical Excellence (NICE) and Trauma Audit Research Network (TARN) guidelines. RESULTS The overall discrepancy rates for the collaborative were 2.5% for minor discrepancies and 2% for major discrepancies, which is within the RCR standard. The median time taken to issue a report was 30 min, which is within the NICE and TARN 1-h targets. CONCLUSIONS The Cheshire & Merseyside Collaborative can be deemed a safe and efficient way of delivering an out-of-hours radiology service.

Purpose: Quantify resident caseload during call and determine if there are consistent differences in call volumes for individuals or resident subgroups. Methods: Accession codes for after-hours computed tomography (CT) cases dictated by residents between July 1, 2012 and January 9, 2017 were reviewed. Case volumes by patient visits and body regions scanned were determined and categorized according to time period, year, and individual resident. Mean shift Relative Value Units (RVUs) were calculated by year. Descriptive statistics, linear mixed modeling, and linear regression determined mean values, differences between residents, associations between independent variables and outcomes, and changes over time. Consistent differences between residents were assessed as a measure of good or bad luck / karma on call. Results: During this time there were 23,032 patients and 30,766 anatomic regions scanned during 1,652 call shifts among 32 residents. Over the whole period, there were on average 10.6 patients and 14.3 body regions scanned on weekday shifts and 22.3 patients and 29.4 body regions scanned during weekend shifts. Annually, the mean number of patients, body regions, and RVUs scanned per shift increased by an average of 0.2 (1%), 0.4 (2%), and 1.2 (5%) (all p < 0.05) respectively in regression models. There was variability in call experiences, but only 1 resident had a disproportionate number of higher volume calls and fewer lower volume shifts than expected. Conclusions: Annual increases in scan volumes were modest. Although residents’ experiences varied, little of this was attributable to consistent personal differences, including luck or call karma.

Objectives:Due to the persistent primary care physicians shortage and the substantial increase in their workload, the organization of primary care calls during out-of-hours periods has become an everyday challenge. The SALOMON algorithm is an original nurse telephone triage tool allowing to dispatch patients to the best level of care according to their conditions. This study evaluated its reliability and criterion validity in rea-life settings. Methods:In this 5-year study, out-of-hours primary care calls were dispatched into four categories: Emergency Medical Services Intervention (EMSI), Emergency Department referred Consultation (EDRC), Primary Care Physician Home visit (PCPH), and Primary Care Physician Delayed visit (PCPD). We included data of patients' triage category, resources, and destination. Patients included into the primary care cohort were classified undertriaged if they had to be redirected to an emergency department (ED). Patients from the ED cohort were considered overtriaged if they did not require at least three diagnostic resources, one emergency-specific treatment or any hospitalization. In the ED cohort, only patients from the University Hospitals were considered. Results:10,207 calls were triaged using the SALOMON tool: 19.2% were classified as EMSI, 15.8% as EDRC, 62.8% as PCPH, and 2.2% as PCPD. The triage was appropriate for 85.5% of the calls with a 14.5% overtriage rate. In the PCPD/PCPH cohort, 96.9% of the calls were accurately triaged and 3.1% were undertriaged. SALOMON sensitivity and specificity reached 76.6% and 98.3%, respectively. Conclusion:SALOMON algorithm is a valid triage tool that has the potential to improve the organization of out-of-hours primary care work.

The acute care surgery (ACS) model has been shown to improve patient, hospital and surgeon-specific outcomes. To date, however, little has been published on its impact on residency training. Our study compared the emergency general surgery (EGS) operative experiences of residents assigned to ACS versus elective surgical rotations.Resident-reported EGS case logs were prospectively collected over a 9-month period across 3 teaching hospitals. Descriptive statistics were tabulated and group comparisons were made using χ2 statistics for categorical data and t tests for continuous data.Overall, 1061 cases were reported. Resident participation exceeded 90%). Appendiceal and biliary disease accounted for 49.7% of EGS cases. Residents on ACS rotations reported participating in twice as many EGS cases per block as residents on elective rotations (12.64 v. 6.30 cases, p0.01). Most cases occurred after hours while residents were on call rather than during daytime ACS hours (78.8% v. 21.1%, p0.01). Senior residents were more likely than junior residents to report having a primary operator role (71.3% v. 32.0%, p0.01). Although the timing of cases made no difference in the operative role of senior residents, junior residents assumed the primary operator role more often during the daytime than after hours (50.0% v. 33.1%, p = 0.01).Despite implementation of the ACS model, residents in our program obtained most of their EGS operative experience after hours while on call. Although further research is needed, our study suggests that improved daytime access to the operating room may represent an opportunity to improve the quantity and quality of the EGS operative experience at our academic network.Il a été prouvé que le modèle de chirurgie en soins actifs (CSA) améliore les résultats pour le patient, l’hôpital et le chirurgien. Pour le moment, peu de publications s’intéressent aux effets de ce modèle sur les résidents. Notre étude compare l’expérience des chirurgies générales d’urgence (CGU) chez les résidents effectuant un stage en CSA et chez les résidents effectuant un stage optionnel en chirurgie.Les cas de CGU rapportés par les résidents ont été recueillis de manière prospective pendant 9 mois dans 3 hôpitaux universitaires. Les statistiques descriptives ont été compilées, et les 2 groupes ont été comparés à l’aide du test du χ2 pour les variables catégorielles et du test t pour les variables continues.En tout, 1061 cas ont été rapportés (la participation des résidents était de plus de 90 %). Les atteintes de l’appendice et de la vésicule biliaire représentaient 49,7 % des CGU. Les résidents en CSA ont indiqué participer à 2 fois plus de CGU que les résidents en stage optionnel (12,64 c. 6,30 cas, p0,01). La plupart des CGU se sont produites en dehors des heures normales, alors que les résidents étaient de garde, plutôt que pendant les heures de CSA (78,8 % c. 21,1 %, p0,01). Les médecins résidents finissants étaient plus susceptibles d'indiquer avoir tenu le rôle de chirurgien principal que les résidents en début de parcours (71,3 % c. 32,0 %, p0,01). Le moment des chirurgies ne faisait aucune différence pour ce qui est du rôle des résidents finissants, mais les résidents en début de parcours ont davantage assumé le rôle de chirurgien principal pendant les heures de CSA que pendant les périodes de garde (50,0 % c. 33,1 %, p0,01).Malgré l’adoption du modèle de CSA, les résidents de notre programme ont acquis la majorité de leur expérience en CGU en dehors des heures normales, alors qu’ils étaient de garde. Bien que d’autres études soient nécessaires, notre étude laisse croire qu’un meilleur accès aux salles d’opération pendant le jour pourrait augmenter la quantité et la qualité de l’expérience en CGU dans le réseau universitaire.

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.

To study variation in antibiotic prescribing rates among general practitioners (GP) in out-of-hours (OOH) primary care and to explore GP characteristics associated with these rates. Population-based observational registry study using routine data from the OOH primary care registration system on patient contacts and antibiotic prescriptions combined with national register data. OOH primary care of the Central Denmark Region. All patient contacts in 2014–2017. GPs’ tendency to prescribe antibiotics. Excess variation (not attributable to chance). We included 794,220 clinic consultations (16.1% with antibiotics prescription), 281,141 home visits (11.6% antibiotics), and 1,583,919 telephone consultations (5.8% antibiotics). The excess variation in the tendency to prescribe antibiotics was 1.56 for clinic consultations, 1.64 for telephone consultations, and 1.58 for home visits. Some GP characteristics were significantly correlated with a higher tendency to prescribe antibiotics, including ‘activity level’ (i.e. number of patients seen in the past hour) for clinic and telephone consultations, ‘familiarity with OOH care’ (i.e. number of OOH shifts in the past 180 days), male sex, and younger age for home visits. Overall, GP characteristics explained little of the antibiotic prescribing variation seen among GPs (Pseudo r2: 0.008–0.025). Some variation in the GPs’ tendency to prescribe antibiotics was found for OOH primary care contacts. Available GP characteristics, such as GPs’ activity level and familiarity with OOH care, explained only small parts of this variation. Future research should focus on identifying factors that can explain this variation, as this knowledge could be used for designing interventions.KEY POINTSCurrent awareness:Antibiotic prescribing rates seem to be higher in out-of-hours than in daytime primary care.Most important results:Antibiotic prescribing rates varied significantly among general practitioners after adjustment for contact- and patient-characteristics.This variation remained even after accounting for variation attributable to chance.General practitioners’ activity level and familiarity with out-of-hours care were positively associated with their tendency to prescribe antibiotics. Current awareness: Antibiotic prescribing rates seem to be higher in out-of-hours than in daytime primary care. Most important results: Antibiotic prescribing rates varied significantly among general practitioners after adjustment for contact- and patient-characteristics. This variation remained even after accounting for variation attributable to chance. General practitioners’ activity level and familiarity with out-of-hours care were positively associated with their tendency to prescribe antibiotics.

BACKGROUND A rapid trauma response is essential to provide optimal care for severely injured patients. However, it is currently unclear if the presence of an in-house trauma surgeon affects this response during call and influences outcomes. This study compares in-hospital mortality and process-related outcomes of trauma patients treated by a 24/7 in-house versus an on-call trauma surgeon. METHODS PubMed/Medline, Embase, and CENTRAL databases were searched on the first of November 2020. All studies comparing patients treated by a 24/7 in-house versus an on-call trauma surgeon were considered eligible for inclusion. A meta-analysis of mortality rates including all severely injured patients (i.e., Injury Severity Score of ≥16) was performed. Random-effect models were used to pool mortality rates, reported as risk ratios. The main outcome measure was in-hospital mortality. Process-related outcomes were chosen as secondary outcome measures. RESULTS In total, 16 observational studies, combining 64,337 trauma patients, were included. The meta-analysis included 8 studies, comprising 7,490 severely injured patients. A significant reduction in mortality rate was found in patients treated in the 24/7 in-house trauma surgeon group compared with patients treated in the on-call trauma surgeon group (risk ratio, 0.86; 95% confidence interval, 0.78-0.95; p = 0.002; I2 = 0%). In 10 of 16 studies, at least 1 process-related outcome improved after the in-house trauma surgeon policy was implemented. CONCLUSION A 24/7 in-house trauma surgeon policy is associated with reduced mortality rates for severely injured patients treated at level I trauma centers. In addition, presence of an in-house trauma surgeon during call may improve process-related outcomes. This review recommends implementation of a 24/7 in-house attending trauma surgeon at level I trauma centers. However, the final decision on attendance policy might depend on center and region-specific conditions. LEVEL OF EVIDENCE Systematic review/meta-analysis, level III.

Background: Nocturnists (overnight hospitalists) are commonly implemented in US teaching hospitals to adhere to per-resident patient caps and improve care but are rare in Canada, where patient caps and duty hours are comparatively flexible. Our objective was to assess the impact of a newly implemented nocturnist program on perceived quality of care, code status documentation and patient outcomes. Methods: Nocturnists were phased in between June 2018 and December 2019 at Toronto General Hospital, a large academic teaching hospital in Toronto, Ontario. We performed a quality-improvement study comparing rates of code status entry into the electronic health record at admission, in-hospital mortality, the 30-day readmission rate and hospital length of stay for patients with cancer admitted by nocturnists and by residents. Surveys were administered in June 2019 to general internal medicine faculty and residents to assess their perceptions of the impact of the nocturnist program. Results: From July 2018 to June 2019, 30 nocturnists were on duty for 241/364 nights (66.5%), reducing the mean maximum overnight per-resident patient census from 40 (standard deviation [SD] 4) to 25 (SD 5) (p < 0.001). The rate of admission code status entry was 35.3% among patients admitted by residents (n = 133) and 54.9% among those admitted by nocturnists (n = 339) (p < 0.001). The mortality rate was 10.5% among patients admitted by residents and 5.6% among those admitted by nocturnists (p = 0.06), the 30-day readmission rate was 8.3% and 5.9%, respectively (p = 0.4), and the mean acute length of stay was 7.2 (SD 7.0) days and 6.4 (SD 7.8) days, respectively (p = 0.3). Surveys were completed by 15/24 faculty (response rate 62%), who perceived improvements in patient safety, efficiency and trainee education; however, only 30/102 residents (response rate 29.4%) completed the survey. Interpretation: Although implementation of a nocturnist program did not affect patient outcomes, it reduced residents’ overnight patient census, and improved faculty perceptions of quality of care and education, as well as documentation of code status. Our results support nocturnist implementation in Canadian teaching hospitals.

Cardiogenic shock (CS) is associated with high mortality and often requires involvement of a multidisciplinary provider team to deliver timely care. Care coordination is more difficult on weekends, which may lead to a delay in care. We sought to assess the effect of weekend admissions on outcomes in patients admitted with CS. Patients admitted with CS were identified from 2005 to 2014 in the National Inpatient Sample using ICD9 code 785.51. Baseline demographics, in-hospital procedures, and outcomes were obtained and compared by day of admission. A multivariable model was used to assess the impact of weekend admission on in-hospital mortality. A total of 875,054 CS admissions were identified (age 67.4 ± 15.1 years, 40.2% female, 72.1% Caucasian), with 23% of patients being admitted on weekends. Baseline co-morbidities were similar between groups. Weekend admissions were associated with higher in-hospital mortality (40.6% vs 37.5%) and cardiac arrest (20.3% vs 18.1%, p < 0.001 for both) consistently over the study period. Use of temporary and permanent mechanical support devices and heart transplantation were slightly less common for weekend admissions. In a multivariable model adjusting for relevant confounders, weekend admission was associated with a 10% increased mortality in patients with CS. In conclusion, patients with CS admitted on weekends had higher in-hospital mortality and were slightly less likely to receive mechanical support and advanced therapies compared with those admitted on weekdays. Future studies and health system initiatives should focus on rectifying these disparities with around-the-clock multidisciplinary coordinated care for CS.

Objective To explore the interactional implications of either/or-questions on the interaction between people who call out-of-hours services in primary care (OHS-PC) and triage nurses who use a decision support tool called the ‘Netherlands Triage Standard’ (NTS) during telephone triage. Methods A qualitative study of 68 triage conversations at six Dutch OHS-PC. Patients called the OHS-PC with symptoms, e.g. chest discomfort, suggestive of acute coronary syndrome. Using conversation analysis, we identified two categories of multiple-choice either/or-questions that indicated interactional difficulties, shown in hesitation markers within callers’ responses. Results Our analysis shows that interactional difficulties mainly arise when (i) questions are poorly designed by the triage nurse; or (ii) when the caller’s complaints are ambiguously presented reflecting patient’s difficulties to verbalize them (e.g. “not feeling well”). Conclusion The way NTS displays key diagnostic options encourages triage nurses to use multiple-choice either/or-questions. More awareness among triage nurses is needed on undesirable implications of either/or-questions on the interaction. Practice implications We recommend changing the NTS display of diagnostic options and to use questions with fewer options in order to decrease the chance of formulating ambiguous questions soliciting unclear responses. Furthermore, asking content questions when complaints are ambiguously formulated may specify the presentation of complaints.

Background In 2015, the Veterans Health Administration (VHA) incorporated nurse practitioners (NPs) into remote triage call centers to supplement registered nurse (RN)–handled calls. Objective To assess 7-day healthcare use following telephone triage by NPs compared to RNs. We hypothesized that NP clinical decision ability may reduce follow-up healthcare. Design Retrospective observational comparative effectiveness study of clinical and administrative databases. NP routed calls were matched to RN calls based on chief complaint with propensity score matching and multivariate count data models, adjusting for differences in call severity and patient comorbidity. Participants Callers to a VHA regional call center, April 2015 to March 2019. Main Measures Primary care, specialty care, and emergency department (ED) visits plus hospitalizations within 7 days. Key Results NP-handled calls (N = 1554) were matched to RN calls (N = 48,024) for the same chief complaint. NP-handled calls, compared to RNs, had lower comorbidities, fewer hospitalizations, and less urgent complaints. Seven-day healthcare use was lower for NP compared to RN calls for specialty care (0.15 vs. 0.20 visits per person [VPP]; p < 0.001), ED (0.11 vs. 0.27 VPP; p < 0.001), and hospitalizations (0.01 vs. 0.04 VPP; p < 0.001), but not primary care (0.43 vs. 0.42 VPP; p = 0.80). In adjusted analyses, estimated avoided in-person visits per 100 calls routed to NPs were 0.7 primary care visits (95% confidence interval [CI] 0.4, 1.0), 2.6 specialty care visits (95% CI 0.0, 5.1), 5.9 ED visits (95% CI 2.7, 9.1), and 1.4 hospital stays (95% CI 0.1, 2.6). Propensity score–matched models comparing NP (N = 1533) to RN (N = 2646) calls had adjusted odds ratios for 7-day healthcare use of 0.75 (primary care), 0.75 (specialty care), and 0.73 (ED) (all p < 0.003). Conclusion Incorporating NPs into a call center was associated with lower in-person healthcare use in the subsequent 7 days compared to routine RN-triaged calls.

BACKGROUND: Access to primary care outside of regular working hours is limited in many countries. This study investigates the relation between the after-hours premium, an incentive for primary care physicians to provide services after hours, and less-urgent visits to the emergency department in Ontario, Canada. METHODS: We analyzed a retrospective cohort of a random sample of Ontario residents from April 2002 to March 2006, and a subcohort of patients followed from April 2005 to March 2016. We linked patient and primary care physician data with emergency department visit data. We used fixed-effects regression models to analyze the association between the introduction of the after-hours premium, as well as subsequent increases in the value of the premium, and the number of monthly emergency department visits. RESULTS: The sample consisted of 586 534 patients between 2002 and 2006, and 201 594 patients from 2005 to 2016. After controlling for patient and physician characteristics, seasonality and time-invariant patient confounding factors, introduction of the after-hours premium was associated with a reduction of 1.26 less-urgent visits to the emergency department per 1000 patients per month (95% confidence interval −1.48 to −1.04). Most of this reduction was observed in after-hours visits. Sensitivity analysis showed that the monthly reduction in less-urgent visits to the emergency department was in the range of −1.24 to −1.16 per 1000 patients. Subsequent increases in the after-hours premium were associated with a small reduction in less-urgent visits to the emergency department. INTERPRETATION: Ontario’s experience suggests that incentivizing physicians to improve access to after-hours primary care reduces some less-urgent visits to the emergency department. Other jurisdictions may consider incentives to limit less-urgent visits to the emergency department.

Background Signs of the systemic inflammatory response syndrome (SIRS) - fever (or hypothermia), tachycardia and tachypnoea - are used in the hospital setting to identify patients with possible sepsis. Objectives To determine how frequently abnormalities in the vital signs of SIRS are present in adult out-of-hours (OOH) primary care patients with suspected infections and assess the association with acute hospital referral. Methods We conducted a cross-sectional study at the OOH GP cooperative in Nijmegen, the Netherlands, between August and October 2015. GPs were instructed to record the body temperature, heart rate and respiratory rate of all patients with suspected acute infections. Vital signs of SIRS, other relevant signs and symptoms, and referral state were extracted from the electronic registration system of the OOH GP cooperative retrospectively. Logistic regression analysis was used to evaluate the association between clinical signs and hospital referral. Results A total of 558 patients with suspected infections were included. At least two SIRS vital signs were abnormal in 35/409 (8.6%) of the clinic consultations and 60/149 (40.3%) of the home visits. Referral rate increased from 13% when no SIRS vital sign was abnormal to 68% when all three SIRS vital signs were abnormal. Independent associations for referral were found for decreased oxygen saturation, hypotension and rapid illness progression, but not for individual SIRS vital signs. Conclusion Although patients with abnormal vital signs of SIRS were referred more often, decreased oxygen saturation, hypotension and rapid illness progression seem to be most important for GPs to guide further management.

Background Direct access to hospital radiology facilities by general practitioner (GP) cooperatives is known to decrease the number of emergency department referrals, but the effects on length of stay (LOS; time from patient arrival at GP cooperative till departure to home) and patient experiences are unclear. Objectives To provide insight into the LOS and experiences of trauma patients with an indication for radiology at GP cooperatives with and without access to radiology. Methods A multi-methods observational study in April 2014–October 2015 at six GP cooperatives in The Netherlands, covering three organisational models for access to radiology: no direct access, limited access and unlimited access. Patient experiences were measured with a questionnaire. Patient records were analysed for background characteristics, radiology outcomes, referral and LOS. Results In total 657 patients were included, 232 no direct access model, 307 limited access model and 118 unlimited access model. The mean LOS was 99 minutes, with a significant difference between GP cooperatives without access to radiology (121 minutes), with limited access (86 minutes), and with unlimited access (90 minutes). The differences were larger for patients without radiological abnormalities. On a ten-point scale, patients rated GP cooperatives with unlimited access to radiology higher (8.62) than those without access (8.36) or with limited access (8.39). Conclusion Access to radiology by GP cooperatives seems to reduce the length of stay and is slightly more appreciated by patients. GP cooperatives with unlimited access seem to provide the most efficient and best-valued care, contributing to more patient-centred care.

BACKGROUND: Rotavirus is a common cause of acute gastroenteritis in young children in the Netherlands, where rotavirus vaccination has not yet been implemented.OBJECTIVES: To evaluate a difference in illness severity course depending on the presence of rotavirus infection and assess the prevalence of viruses and the referral rate in children with acute gastroenteritis.METHODS: A prospective cohort of children aged 6 months to 6 years presenting with acute gastroenteritis to a primary care out-of-hours service from October 2016 to March 2018. Faeces were sampled and sent to a laboratory where viral pathogens were identified and quantified by real-time polymerase chain reaction. Severe course of acute gastroenteritis was defined as a Modified Vesikari Score of ≥11. In addition, we assessed referral rates. Chi-square tests were used to evaluate differences between groups.RESULTS: We included 75 children (34 boys) with a median age of 1.5 years (interquartile range, 0.9-2.0 years). The prevalence of rotavirus was 65.3% (95% confidence interval, 53.5-76.0) with a median cycle threshold of 16.0. Severe course of acute gastroenteritis was present in 31 of 71 children (4 were lost to follow-up). Those with rotavirus (20/47) did not have a severe course more often than those without (11/24): odds ratio, 0.88 (95% confidence interval, 0.33-2.36). Referral rates were comparable for rotavirus (15.2%) and non-rotavirus (14.3%).CONCLUSION: In out-of-hours primary care, rotavirus is common but not associated with increased severity and higher referral rates in children with acute gastroenteritis.

BackgroundTelephone triage is used to facilitate efficient and adequate acute care allocation, for instance in out-of-hours primary care services (OPCSs). Remote assessment of health problems is challenging and could be impeded by a patient’s ambiguous formulation of his or her healthcare need. Socioeconomically vulnerable patients may experience more difficulty in expressing their healthcare need. We aimed to assess whether income differences exist in the patient’s presented symptoms, assessed urgency and allocation of follow-up care in OPCS.MethodData were derived from Nivel Primary Care Database encompassing electronic health record data of 1.3 million patients from 28 OPCSs in 2017 in the Netherlands. These were linked to sociodemographic population registry data. Multilevel logistic regression analyses (contacts clustered in patients), adjusted for patient characteristics (eg, age, sex), were conducted to study associations of symptoms, urgency assessment and follow-up care with patients’ income (standardised for household size as socioeconomic status (SES) indicator).ResultsThe most frequently presented symptoms deduced during triage slightly differed across SES groups, with a larger relative share of trauma in the high-income groups. No SES differences were observed in urgency assessment. After triage, low income was associated with a higher probability of receiving telephone advice and home visits, and fewer consultations at the OPCS.ConclusionsSES differences in the patient’s presented symptom and in follow-up in OPCS suggest that the underlying health status and the ability to express care needs affect the telephone triage process . Further research should focus on opportunities to better tailor the telephone triage process to socioeconomically vulnerable patients.

Supplemental digital content is available in the text., Objectives Serious adverse events at out-of-hours services in primary care (OHS-PC) are rare, and the most often concern is missed acute coronary syndrome (ACS). Previous studies on serious adverse events mainly concern root cause analyses, which highlighted errors in the telephone triage process but are hampered by hindsight bias. This study compared the recorded triage calls of patients with chest discomfort contacting the OHS-PC in whom an ACS was missed (cases), with triage calls involving matched controls with chest discomfort but without a missed ACS (controls), with the aim to assess the predictors of missed ACS. Methods A case-control study with data from 2013 to 2017 of 9 OHS-PC in the Netherlands. The cases were matched 1:8 with controls based on age and sex. Clinical, patient, and call characteristics were univariably assessed, and general practitioner experts evaluated the triage while blinded to the final diagnosis or the case-control status. Results Fifteen missed ACS calls and 120 matched control calls were included. Cases used less cardiovascular medication (38.5% versus 64.1%, P = 0.05) and more often experienced pain other than retrosternal chest pain (63.3% versus 24.7%, P = 0.02) compared with controls. Consultation of the supervising general practitioner (86.7% versus 49.2%, P = 0.02) occurred more often in cases than in controls. Experts rated the triage of cases more often as “poor” (33.3% versus 10.9%, P = 0.001) and “unsafe” (73.3% versus 22.5%, P < 0.001) compared with controls. Conclusions To facilitate learning from serious adverse events in the future, these should also be bundled and carefully assessed without hindsight bias and within the context of “normal” clinical practice.

Background Antibiotic resistance is a threat to our health and health systems. Up to 70% of antibiotics are prescribed in general practice. In Ireland, Out-of-hours (OOH) services are mostly provided by co-operatives of GPs and the 11 main OOH centres cover up to 90% of the population. More than 80% of GPs are involved in OOH care in their area, which provides an opportunity to deliver education and awareness through this centralised system. Objectives To analyse the change in the quality of antibiotic prescribing after the introduction of an educational intervention categorising antibiotics into a red (avoid) and green (preferred) panel. Methods Educational information for the GP was developed based on the national prescribing guidelines. A particular focus was to reduce co-amoxyclav prescribing. An electronic pop-up message to record whether an antibiotic was prescribed, was displayed at the end of each consultation in the patient management software of the OOH-centre, after the decision of prescribing was made. Antibiotic prescribing was compared for a 13-week period (week 47–week 7) in 2016/2017 with 2017/2018. Results Pre-intervention prescribing of red antibiotics was 44% which reduced to 17% after the intervention. The mean percentage of co-amoxyclav, the most prescribed non-firstline prescription, was 33% of all antibiotic prescriptions which dropped to 10%. Conclusion Our intervention implemented in the OOH GP service categorised antibiotics into red prescriptions and green (firstline) prescriptions, which was recorded through an electronic pop-up message, resulted in an absolute reduction of 27% in red prescriptions and more than 23% in co-amoxyclav prescriptions.

Background Low socioeconomic position (SEP) is related to higher healthcare use in out-of-hours primary care services (OPCSs). We aimed to determine whether inequalities persist when taking the generally poorer health status of socioeconomically vulnerable individuals into account. To put OPCS use in perspective, this was compared with healthcare use in daytime general practice (DGP). Methods Electronic health record (EHR) data of 988 040 patients in 2017 (251 DGPs, 27 OPCSs) from Nivel Primary Care Database were linked to socio-demographic data (Statistics, The Netherlands). We analyzed associations of OPCS and DGP use with SEP (operationalized as patient household income) using multilevel logistic regression. We controlled for demographic characteristics and the presence of chronic diseases. We additionally stratified for chronic disease groups. Results An income gradient was observed for OPCS use, with higher probabilities within each lower income group [lowest income, reference highest income group: odds ratio (OR) = 1.48, 95% confidence interval (CI): 1.45–1.51]. Income inequalities in DGP use were considerably smaller (lowest income: OR = 1.17, 95% CI: 1.15–1.19). Inequalities in OPCS were more substantial among patients with chronic diseases (e.g. cardiovascular disease lowest income: OR = 1.60, 95% CI: 1.53–1.67). The inequalities in DGP use among patients with chronic diseases were similar to the inequalities in the total population. Conclusions Higher OPCS use suggests that chronically ill patients with lower income had additional healthcare needs that have not been met elsewhere. Our findings fuel the debate how to facilitate adequate primary healthcare in DGP and prevent vulnerable patients from OPCS use.

Background The aim of this article is to describe the courses of vomiting, diarrhea, fever, and clinical deterioration, in children with uncomplicated gastroenteritis at presentation. This study was performed as a 7-day prospective follow-up study in an out-of-hours primary care service. The course of vomiting, diarrhea, and fever was analyzed by generalized linear mixed modeling. Because young children (≤ 12 months) and children with severe vomiting are at increased risk of dehydration, the potentially more complicated courses of these groups are described separately. The day(s) most frequently associated with deterioration and the symptoms present in children who deteriorated during follow-up were also described. Results In total, 359 children presented with uncomplicated acute gastroenteritis to the out-of-hours primary care service. Of these, 31 (8.6%) developed a complicated illness and needed referral or hospitalization. All symptoms decreased within 5 days in most children (> 90%). Vomiting and fever decreased rapidly, but diarrhea decreased at a somewhat slower pace, especially among children aged 6–12 months. Children who deteriorated during follow-up had a higher frequency of vomiting at presentation and higher frequencies of vomiting and fever during follow-up. Conclusions The frequency of vomiting, not its duration, appears to be the more important predictor of deterioration. When advising parents, it is important to explain the typical symptom duration and to focus on alarm symptoms. Clinicians should be vigilant for children with higher vomiting frequencies at presentation and during follow-up because these children are more likely to deteriorate.

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.

Excess in-hospital mortality following out-of-hours ICU discharge has been reported worldwide. From preliminary data, we observed that magnitude of difference may be reduced when patients discharged for end-of-life care or organ donation are excluded. We speculated that these patients may be disproportionately discharged out-of-hours, biasing results. We now compare in-hospital mortality and ICU readmission rates following discharge in-hours and out-of-hours over 3 years, excluding discharges for organ donation or end-of-life care. This single-centre retrospective study includes patients discharged alive following ICU admission between 01/07/2015–31/07/2018, excluding readmissions and discharges for end-of-life care/organ donation. A multiple logistic regression model was fitted to estimate adjusted odds ratio of death following out-of-hours versus in-hours discharge. Characteristics and outcomes for both groups were compared. 4678 patients were included. Patients discharged out-of-hours were older (62 vs 59 years, p

Background Increased opioid prescribing has raised concern, as the benefits of pain relief not always outweigh the risks. Acute and chronic pain is often treated in a primary care out-of-hours (OOH) setting. This setting may be a driver of opioid use but the extent to which opioids are prescribed OOH is unknown. We aimed to investigate weak and strong opioid prescribing at OOH primary care services (PCS) in Flanders (Northern, Dutch-speaking part of Belgium) and the Netherlands between 2015 and 2019. Methods We performed a retrospective cross sectional study using data from routine electronic health records of OOH-PCSs in Flanders and the Netherlands (2015–2019). Our primary outcome was the opioid prescribing rate per 1000 OOH-contacts per year, in total and for strong (morphine, hydromorphone, oxycodone, oxycodone and naloxone, fentanyl, tapentadol, and buprenorphine and weak opioids (codeine combinations and tramadol and combinations) and type of opioids separately. Results Opioids were prescriped in approximately 2.5% of OOH-contacts in both Flanders and the Netherlands. In Flanders, OOH opioid prescribing went from 2.4% in 2015 to 2.1% in 2017 and then increased to 2.3% in 2019. In the Netherlands, opioid prescribing increased from 1.9% of OOH-contacts in 2015 to 2.4% in 2017 and slightly decreased thereafter to 2.1% of OOH-contacts. In 2019, in Flanders, strong opioids were prescribed in 8% of the OOH-contacts with an opioid prescription. In the Netherlands a strong opioid was prescribed in 57% of these OOH-contacts. Two thirds of strong opioids prescriptions in Flanders OOH were issued for patients over 75, in the Netherlands one third was prescribed to this age group. Conclusion We observed large differences in strong opioid prescribing at OOH-PCSs between Flanders and the Netherlands that are likely to be caused by differences in accessibility of secondary care, and possibly existing opioid prescribing habits. Measures to ensure judicious and evidence-based opioid prescribing need to be tailored to the organisation of the healthcare system.

Background: Unscheduled care is used increasingly during the last year of life by people known to have significant palliative care needs. Aim: To document the frequency and patterns of use of unscheduled healthcare by people in their last year of life and understand the experiences and perspectives of patients, families and professionals about accessing unscheduled care out-of-hours. Design: A mixed methods, multi-stage study integrating a retrospective cohort analysis of unscheduled healthcare service use in the last year of life for all people dying in Scotland in 2016 with qualitative data from three regions involving service users, bereaved carers and general practitioners. Setting: Three contrasting Scottish Health Board regions and national datasets for the whole of Scotland. Results: People who died in Scotland in 2016 ( n = 56,407) had 472,360 unscheduled contacts with one of five services: telephone advice, primary care, ambulance service, emergency department and emergency hospital admission. These formed 206,841 individual continuous unscheduled care pathways: 65% starting out-of-hours. When accessing healthcare out-of-hours, patients and carers prioritised safety and a timely response. Their choice of which service to contact was informed by perceptions and previous experiences of potential delays and whether the outcome might be hospital admission. Professionals found it difficult to practice palliative care in a crisis unless the patient had previously been identified. Conclusion: Strengthening unscheduled care in the community, together with patient and public information about how to access these services could prevent hospital admissions of low benefit and enhance community support for people living with advanced illness.

To assess the impact on specialty trainee (ST) experience of out-of-hours (OOH) working, focusing on what might be improved with both patient safety and staff wellbeing in mind.The number of acute computed tomography (CT) examinations reported OOH over the last 15 years (2007-2021) at Oxford University Hospitals NHS Foundation Trust was analysed. Qualitative data from the radiology STs participating in the acute OOH rotas were obtained using questionnaires during winter months in 2019 and 2021, before and after the introduction of an OOH CT outsourcing service in 2020.Overnight acute CT has increased over 10-fold over the last decade to almost 50 CT examinations in 2021, and similar increases were observed during evening and weekend shifts. The option to outsource acute CT on an ad hoc basis was introduced in 2020 to manage the increase in demand. This resulted in a statistically significant improvement in the STs' level of reported satisfaction for OOH shifts (p0.018), despite significantly increased perception of how busy the shifts were (p0.035).OOH acute CT reporting at Oxford NHS Foundation Trust has increased dramatically over the previous 15 years. Working patterns and resources have changed incrementally to absorb this increase in demand, most recently with the option for outsourcing at times of peak demand. The trend for increasing OOH CT demand has considerable implications for future resource planning.

Percutaneous coronary intervention (PCI) performed during non-work hours is believed to have inferior outcomes because of operator fatigue, differences in baseline patient characteristics, and fewer on-call catheterization laboratory staff. We aimed to analyze a cohort of patients who underwent PCI (all comers) at our tertiary-care center between January 1, 2006, and December 31, 2018, and compare procedural and in-hospital outcomes between 2 groups defined by whether PCI was performed during normal work hours (7:00 A.M. to 7:00 PM) versus non-work hours (7:01 P.M. to 6:59 A.M. weekdays; all hours weekends and holidays). Finally, we examined temporal changes throughout the 24-hour weekday. Primary outcomes were unadjusted in-hospital adverse outcomes (composite death, recurrent myocardial infarction, emergent coronary artery bypass grafting, and target lesion revascularization). We identified 21,848 patients who underwent PCI at our institution. The proportions of ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) were higher during non-work hours. Overall, unadjusted in-hospital adverse outcomes were higher during non-work hours than during normal work hours (8.80% vs 2.00%; p

Root cause analyses of serious adverse events (SAE) in out-of-hours primary care (OHS-PC) often point to errors in telephone triage. Such analyses are, however, hampered by hindsight bias. We assessed whether experts, blinded to the outcome, recognize (un)safety of triage of patients with chest discomfort, and we quantified inter-rater reliability.This is a case-control study with triage recordings from 2013-2017 at OHS-PC. Cases were missed acute coronary syndromes (ACSs, considered as SAE). These cases were age- and gender-matched 1:8 with the controls, sampled from the remainder of people calling for chest discomfort. Fifteen experts listened to the recordings and rated the safety of triage. We calculated sensitivity and specificity of recognizing an ACS and the intraclass correlation.In total, 135 calls (15 SAE, 120 matched controls) were relistened. The experts identified ACSs with a sensitivity of 0.86 (95% CI: 0.71-0.95) and a specificity of 0.51 (95% CI: 0.43-0.58). Cases were rated significantly more often as unsafe than the controls (73.3% vs. 22.5%, P0.001). The inter-rater reliability for safety was poor: ICC 0.16 (95% CI: 0.00-0.32).Blinded experts rated calls of missed ACSs more often as unsafe than matched control calls, but with a low level of agreement among the experts.

Objective We sought to compare clinical outcomes in patients with acute type A aortic dissection that undergone surgical repair during in-hours (IH) versus out-of-hours (OOH). Methods An electronic literature search was done till March 2020 to include studies with comparative cohorts of IH versus OOH. Primary outcomes were 30-day mortality, stroke, and reoperation for bleeding; secondary outcomes were acute kidney injury, total hospital stay, and intensive care unit stay. Results Six articles with a total of 3744 patients met the inclusion criteria. Mean age was similar, 60 ± 12 versus 60 ± 13 in IH versus OOH (p = .25). Aortic root and total arch replacement were similar in both cohorts, 22% in IH versus 25% in OOH (risk ratio [RR], 1.10; 95% confidence interval [CI: 0.78, 1.55]; p = .58) and 29% in IH versus 32% in OOH (RR, 0.96; 95% CI [0.89, 1.04], p = .37) respectively. Reoperation for bleeding and stroke rate were similar, with 18% in IH versus 23% in OOH (RR, 0.89; 95% CI [0.73, 1.08]; p = .24), and 12% in IH versus 13% in OOH (RR, 0.83; 95% CI [0.66, 1.03]; p = .09) respectively. Thirty-day mortality was significantly lower in IH (RR, 0.81; 95% CI [0.72, 0.90]; p = .0001). Conclusion There was higher 30-day mortality rate during OOH surgery, yet this difference diminished following sensitivity analysis. There were no significant differences in major postoperative outcomes. Therefore, operating on such cases should be decided on clinical priority without delay.

OBJECTIVE: To determine whether after-hours presentation to EDs is associated with differences in 7-day and 30-day mortality. The influence of patient case-mix and workforce staffing differences are also explored. METHODS: We conducted a retrospective observational study of 3.7 million ED episodes across 30 public hospitals in Queensland, Australia during May 2013-September 2015 using routinely collected hospital data linked to hospital staffing data and the death registry. Episodes were categorised as within/after-hours using time of presentation. Staffing was derived from payroll records and explored by defining 11 staffing ratios. RESULTS: Weekend presentation was slightly more associated (7-day mortality odds ratio 1.05, 95% confidence interval [CI] 1.01-1.10) or no more associated (30-day mortality odds ratio 1.01, 95% CI 0.98-1.03) with death than weekday presentation. When weeknights are included in the 'after-hours' period, odds ratios are smaller, so that after-hours presentation is no more associated (7-day mortality odds ratio 1.03, 95% CI 0.99-1.08) or less associated (30-day mortality odds ratio 0.95, 95% CI 0.93-0.97) with death. No significant after-hours patient case-mix differences were observed between weekday and weekend presentations for 7-day mortality. In other combinations of outcome and after-hours definition, some differences (especially measures relating to severity of presenting condition) were found. Staffing ratios were not strongly associated with any within/after-hours differences in ED mortality. CONCLUSIONS: After-hours presentation on the weekend to an ED is associated with higher 7-day mortality even after controlling for case-mix.

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

PURPOSE Previous work has demonstrated that home care patients have an increased risk of visiting the emergency department after a home nursing visit on the same day. We investigated whether this association is modified by greater access to after-hours primary care. METHODS We conducted a population-based case-crossover study of home care patients in Ontario, Canada in 2014-2016. Emergency department visits after 5:00 pm were selected as case periods and matched, within the same patient, to control periods within the previous week. The association between home nursing visits and same-day emergency department visits was estimated with conditional logistic regression. Access to after-hours primary care, measured on the patient and practice level, was tested for effect modification using an interaction term approach. Analysis was performed separately for all emergency department visits and a less urgent subset not admitted to hospital. RESULTS A total of 11,840 patients contributed cases to the analysis. Patients with a history of after-hours primary care use had a smaller increased risk of a same-day after-hours emergency department visit (OR = 1.18; 95% CI, 1.06-1.30) compared with patients with no after-hours care (OR = 1.31; 95% CI, 1.25-1.39). The modifying effect was stronger among emergency department visits not admitted to hospital (OR = 1.11; 95% CI, 0.97-1.28 vs OR = 1.41; 95% CI, 1.31-1.51). CONCLUSION Greater access to after-hours primary care reduced the risk of less-urgent emergency department use associated with home nursing visits. These findings suggest increasing access to after-hours primary care could prevent some less-urgent emergency department visits.

Purpose To understand patient attitudes, access toward video calling to enhance efficiency of after-hours triage calls. Methods We surveyed patients aged 18 to 89 years. Questions included demographics, preferences, access to video calling devices, and perceived advantages and disadvantages of this technology. Answers were entered into Qualtrics database and analyzed using JMP 11 (SAS, Cary, NC). Results Two hundred ninety-eight patients agreed to participate. Mean age was 47.9 years; 71.6% were female; and 75.1% had access to video calling device. Device proficiency was inversely related to age and greatest in 18-to-32-years group (χ2 = 71.18, P Conclusions Patients seem to have access and interest in video communication for after-hours calls. Further studies are needed to evaluate whether addition of video component to after-hours triage calls will help reduce unnecessary emergency department visits.

Purpose: The aim of this national survey was to assess the overall impact of the coronavirus disease 2019 (COVID-19) pandemic on the provision of interventional radiology (IR) services in Canada. Methods: An anonymous electronic survey was distributed via national and regional radiology societies, exploring (1) center information and staffing, (2) acute and on-call IR services, (3) elective IR services, (4) IR clinics, (5) multidisciplinary rounds, (6) IR training, (7) personal protection equipment (PPE), and departmental logistics. Results: Individual responses were received from 142 interventional radiologists across Canada (estimated 70% response rate). Nearly half of the participants (49.3%) reported an overall decrease in demand for acute IR services; on-call services were maintained at centers that routinely provide these services (99%). The majority of respondents (73.2%) were performing inpatient IR procedures at the bedside where possible. Most participants (88%) reported an overall decrease in elective IR services. Interventional radiology clinics and multidisciplinary rounds were predominately transitioned to virtual platforms. The vast majority of participants (93.7%) reported their center had disseminated an IR specific PPE policy; 73% reported a decrease in case volume for trainees by at least 25% and a proportion of trainees will either have a delay in starting their careers as IR attendings (24%) or fellowship training (35%). Conclusion: The COVID-19 pandemic has had a profound impact on IR services in Canada, particularly for elective cases. Many centers have utilized virtual platforms to provide multidisciplinary meetings, IR clinics, and training. Guidelines should be followed to ensure patient and staff safety while resuming IR services.

Objective To assess whether there is a relationship between evening, night, and weekend births and severe unexpected neonatal morbidity in low-risk term singleton births. Methods We conducted a population-based, cross-sectional analysis. Severe unexpected neonatal morbidity as defined by the National Quality Forum specification 0716 was derived from linked birth certificate and hospital discharge summaries for 1,048,957 low-risk singleton term Californian births during 2011 through 2013. The association between the nursing shift (7 am-3 pm vs 3-11 pm and 11 pm -7 am) and weekday compared with weekend birth and the risk of severe unexpected neonatal morbidity was estimated using mixed effects logistic regression models. Results Severe unexpected neonatal morbidity was higher among births during the 3-11 pm evening shift (2.1%) and the 11 pm-7 am night shift (2.1%), compared with those during the 7 am-3 pm day shift (1.8%). The adjusted odds ratios (ORs) were 1.10 (95% CI 1.06-1.13) for the evening shift and 1.15 (1.11-1.19) for the night shift. The adjusted ORs of severe unexpected neonatal morbidity were increased only on Sunday, as compared with other days (adjusted OR 1.08, 95% CI 1.02-1.14). When our analysis was by perinatal region, the increase was seen in four of the nine perinatal regions. Conclusion After risk adjustment, the risk of severe unexpected morbidity in the low-risk singleton California birth cohort was significantly increased on Sundays and births during evening and night shifts. These elevations were detected in only four of California's nine perinatal regions. Further analysis at the individual hospital level is warranted.

Objective To describe antibiotic prescriptions in out-of-hour (OOH) service in primary care setting in Iceland and to study the indications for prescriptions. Design A population based retrospective study, using electronic data from the OOH registration system. Setting OOH primary care setting in Reykjavik capital area in Iceland. Subjects All patients that received a prescription for oral antibiotic drug at an OOH service in Reykjavik capital area over a one-year period. Main outcome measures Number of oral antibiotic prescriptions and diagnosis connected to the prescriptions according to age and sex. Results There were 75,582 contacts with the OOH primary care of which 25,059 contacts resulted in prescription of an oral antibiotic (33%). The most common antibiotic prescribed in total, and for the diagnosis studied, was amoxicillin with clavulanic acid. It was most often prescribed for acute otitis media. Of those diagnosed with otitis media 50% were treated with amoxicillin with clavulanic acid and 40% of those diagnosed with pneumonia received that treatment. The second most prescribed antibiotic was amoxicillin. Most often it was prescribed for sinusitis, in 47% of cases with that diagnosis. Conclusion Antibiotics are often prescribed in OOH primary care in Iceland and a substantial number of the patients diagnosed in OOH primary care with acute otitis media or pneumonia are prescribed broad-spectrum antibiotics.Key pointsAntibiotic prescription rate is high and broad-spectrum drugs often prescribed in OOH primary care service in Iceland.The results should encourage general practitioners in Iceland to review antibiotic prescriptions in OOH service.

Introduction UK and European guidelines recommend consideration of a self-expandable metallic stent (SEMS) as an alternative to emergency surgery in left-sided colonic obstruction. However, there is no clear consensus on stenting owing to concern for complications and long-term outcomes. Our study is the first to explore SEMS provision across England. Methods All colorectal surgery department leads in England were contacted in 2018 and invited to complete an objective multiple choice questionnaire pertaining to service provision of colorectal stenting (including referrals, time, location and specialty). Results Of 182 hospitals contacted, 79 responded (24 teaching hospitals, 55 district general hospitals). All hospitals considered stenting, with 92% performing stenting and the remainder referring. The majority (93%) performed fewer than four stenting procedures per month. Most (96%) stented during normal weekday hours, with only 25% stenting out of hours and 23% at weekends. Compared with district general hospitals, a higher proportion of teaching hospitals stented out of hours and at weekends. Stenting was performed in the radiology department (64%), the endoscopy department (44%) and operating theatres (15%), by surgeons (63%), radiologists (60%) and gastroenterologists (48%). A radiologist was present in 66% of cases. Of 14 hospitals that received referrals, 3 had a protocol, 3 returned patients the same day and 4 returned patients for management in the event of failure. Conclusions All responding hospitals in England consider the use of SEMS in colonic obstruction. Nevertheless, there is great variation in stenting practices, and challenges in terms of access and expertise. Centralisation and regional referral networks may help maximise availability and expertise but more work is needed to support this.