Paul Giesen

Out-of-hours care in western countries: assessment of different organizational models.

BackgroundInternationally, different organizational models are used for providing out-of-hours care. The aim of this study was to assess prevailing models in order to identify their potential strengths and weaknesses.MethodsAn international web-based survey was done in 2007 in a sample of purposefully selected key informants from 25 western countries. The questions concerned prevailing organizational models for out-of-hours care, the most dominant model in each country, perceived weaknesses, and national plans for changes in out-of-hours care.ResultsA total of 71 key informants from 25 countries provided answers. In most countries several different models existed alongside each other. The Accident and Emergency department was the organizational model most frequently used. Perceived weaknesses of this model concerned the coordination and continuity of care, its efficiency and accessibility. In about a third of the countries, the rota group was the most dominant organizational model for out-of-hours care. A perceived weakness of this model was lowered job satisfaction of physicians. The GP cooperative existed in a majority of the participating countries; no weaknesses were mentioned with respect to this model. Most of the countries had plans to change the out-of-hours care, mainly toward large scale organizations.ConclusionGP cooperatives combine size of scale advantages with organizational features of strong primary care, such as high accessibility, continuity and coordination of care. While specific patients require other organizational models, the co-existence of different organizational models for out-of-hours care in a country may be less efficient for health systems.

Safety of telephone triage in general practitioner cooperatives: do triage nurses correctly estimate urgency?

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

Quality of after-hours primary care in the Netherlands: a narrative review.

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

Patients either contacting a general practice cooperative or accident and emergency department out of hours: a comparison

Introduction: Lack of collaboration between general practice (GP) cooperatives and accident and emergency (A&E) departments and many self referrals may lead to inefficient out-of-hours care. Methods: We retrospectively analysed the records of all patients contacting the GP cooperative and all patients self referring to the A&E department out of hours in a region in the Netherlands. Results: 258 patients contacted the GP cooperative and 43 self referred to the A&E department per 1000 patients per year. A wide range of problems were seen in the GP cooperative, mainly related to infections (26.2%). The A&E department had a smaller range of problems, mainly related to trauma (66.1%). Relatively few urgent problems were seen in the GP cooperative (4.6%) or for self referrals in the A&E department (6.1%). Women, children, the elderly, and rural patients chose the GP cooperative significantly more often, as did men and patients with less urgent complaints, infections, and heart and airway problems. Discussion: The contact frequency of self referrals to the A&E department is much lower than that at the GP cooperative. Care is complementary: the A&E department focuses on trauma while the GP cooperative deals with a wide range of problems. The self referrals concern mostly minor, non-urgent problems and can generally be treated by the general practitioner, by a nurse, or by advice over the telephone, particularly in the case of optimal collaboration in an integrated care facility of GP cooperatives and A&E departments with one access point to medical care for all patients.

Safety of telephone triage in out-of-hours care: A systematic review

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

Validity of telephone and physical triage in emergency care: The Netherlands Triage System

BACKGROUND Due to emergency care overcrowding, right care at the right place and time is necessary. Uniform triage of patients contacting different emergency care settings will improve quality of care and communication between health care providers. OBJECTIVE Validation of the computer-based Netherlands Triage System (NTS) developed for physical triage at emergency departments (EDs) and telephone triage at general practitioner cooperatives (GPCs). METHODS Prospective observational study with patients attending the ED of a university-affiliated hospital (September 2008 to November 2008) or contacting an urban GPC (December 2008 to February 2009). For validation of the NTS, we defined surrogate urgency markers as best proxies for true urgency. For physical triage (ED): resource use, hospitalization and follow-up. For telephone triage (GPC): referral to ED, self-care advice after telephone consultation or GP advice after physical consultation. Associations between NTS urgency levels and surrogate urgency markers were evaluated using chi-square tests for trend. RESULTS We included nearly 10 000 patients. For physical triage at ED, NTS urgency levels were associated with resource use, hospitalization and follow-up. For telephone triage at GPC, trends towards more ED referrals in high NTS urgency levels and more self-care advices after telephone consultation in lower NTS urgency levels were found. The association between NTS urgency classification and GP advice was less explicit. Similar results were found for children; however, we found no association between NTS urgency level and GP advice. CONCLUSIONS Physically and telephone-assigned NTS urgency levels were associated with majority of surrogate urgency markers. The NTS as single triage system for physical and telephone triage seems feasible.

Emergency departments in The Netherlands.

Emergency medicine in The Netherlands is faced with an increasing interest by politicians and stakeholders in health care. This is due to crowding, increasing costs, criticism of the quality of emergency care, restructuring of out-of-hours services in primary care and the introduction of a training programme for emergency physicians in 2000. A comprehensive search was conducted of published research, policy reports and updated Dutch websites on acute care. Publications were included in this review if these referred to emergency care, including emergency departments (ED), general practitioner (GP) cooperatives and emergency medical services in The Netherlands and were written in English or Dutch. The literature search identified 14 eligible papers. The manual search identified 11 additional papers. Seven reports and two PhD theses were also included. Given the lack of relevant empirical research the review was liberal in its inclusion, but the analysis focused on research when available. ED in The Netherlands are in different stages of development. However, it is obvious that the presence of emergency physicians is increasing and more ED will be staffed by emergency physicians. Although this seems an important step, it does not necessarily imply a good position of the emergency physician in the ED. What the characteristics of the future patient of the Dutch ED will be is dependent on the development of different ED levels of care and GP cooperatives. The lack of empirical research also points out the need for research on quality of care in Dutch ED.

Patient safety in out-of-hours primary care: a review of patient records

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

Hoe urgent is de gepresenteerde morbiditeit op de Centrale Huisartsenpost

SamenvattingGiesen PHJ, Mokkink HGA, Ophey G, Drijver CR, Grol RPTM, Van den Bosch WJHM. Hoe urgent is de gepresenteerde morbiditeit op de Centrale Huisartsenpost? Huisarts Wet 2005;48(5):207-10.Doel Explorerend onderzoek naar de mate van urgentie en de aard van de hulpvragen waarmee patiënten bij een huisartsenpost komen.Methoden Dwarsdoorsnedenonderzoek waarbij in de computer geregistreerde gegevens over patiëntencontacten van een huisartsenpost werden ingedeeld naar ICPC-code en mate van urgentie (U1-4).Resultaten Van de 20.471 patiëntencontacten werd 0,7% van de gevallen als levensbedreigend (U1) en 76,9% als niet-urgent (U4) ingeschat. Indien er sprake was van urgente klachten (U1-3), dan bleek de urgentie zoals ingeschat op basis van de diagnose (E-regel) 29% lager uit te vallen dan de urgentie-inschatting op basis van de klacht (S-regel). Problemen in de hoogste urgentiecategorieën werden vooral bepaald door hart-, luchtweg- en bewustzijnsstoornissen; bij de niet-urgente klachten ging het vooral om infecties en klachten van het bewegingsapparaat.Conclusie Het aantal als urgent ingeschatte patiëntencontacten op deze huisartsenpost is klein. Het grootste deel van de klachten wordt als niet-urgent beoordeeld.

EurOOHnet—the European research network for out-of-hours primary health care

Abstract Background and rationale: European countries face similar challenges in the provision of health care. Demographic factors like ageing, population growth, changing patient behaviour, and lack of work force lead to increasing demands, costs, and overcrowding of out-of-hours (OOH) care (i.e. primary care services, emergency departments (EDs), and ambulance services). These developments strain services and imply safety risks. In the last few decades, countries have been re-organizing their OOH primary health care services. Aim and scope of the network: We established a European research network for out-of-hours primary health care (EurOOHnet), which aims to transfer knowledge, share experiences, and conduct research. Combining research competencies and integrating results can generate a profound information flow to European researchers and decision makers in health policy, contributing towards feasible and high-quality OOH care. It also contributes to a more comparable performance level within European regions. Conducted research projects: The European research network aims to conduct mutual research projects. At present, three projects have been accomplished, among others concerning the diagnostic scope in OOH primary care services and guideline adherence for diagnosis and treatment of cystitis in OOH primary care. The future: Future areas of research will be organizational models for OOH care; appropriate use of the OOH services; quality of telephone triage; quality of medical care; patient safety issues; use of auxiliary personnel; collaboration with EDs and ambulance care; and the role of GPs in OOH care.