Out Of Hours Research Articles

In-hospital delays to stroke thrombolysis: Out of hours versus regular hours and reduction in treatment times through the creation of a 24/7 mobile thrombolysis team

BackgroundThe main aim of this study was to evaluate the impact of the implementation of a mobile thrombolysis team (MTT) on time to thrombolysis treatment depending on patient admission time: regular hours (RH) or out of hours (OH). Methods504 consecutive patients treated with IV tPA or with combined IV tPA and mechanical thrombectomy for acute ischemic stroke were retrospectively included between 1st January 2013 and 31st December 2017. Three sub-periods were identified: 2013–2014, 2015–2016, and 2017 during which patients were treated with the usual care (UC), by the MTT or with UC according to their time of admission, or by the MTT, in the three time periods respectively. We compared in-hospital delays according to patient admission time. ResultsIn 2013–2014, 133 patients were included. Both median door-to-needle (DTN) and imaging to needle (ITN) times were shorter for patients admitted during RH than OH, respectively 75 min versus 85 min and 52 min versus 57 min (P < 0.05), and the proportion of patients with DTN ≤ 60 min was 23% versus 9% (P < 0.05), respectively. In 2015–2016, 223 patients were included. DTN and ITN times were shorter for patients admitted during RH and treated by the MTT than during OH with UC, respectively 54 min versus 78 min and 24 min versus 47 min (P < 0.001), and the proportion of patients with DTN ≤ 60 min was 64% versus 21% (P < 0.001), respectively. In 2017, there was no difference concerning in-hospital delays regardless of patient admission time (P > 0.05). DiscussionDTN time was significantly longer for patients admitted OH. We suggest that the implementation of an around-the-clock MTT would allow a reduction of in-hospital delays and similar times to thrombolysis treatment regardless of admission time.

The role and experiences of advanced nurse practitioners working in out of hours urgent care services in a primary care setting.

GPs' workload has increased significantly in recent years affecting their ability to provide high-quality services, and consequently there is increasing focus on nurses to provide a solution. There is little evidence of how advanced nurse practitioners (ANPs) experience their role in out of hours (OOH) services, and it is important to understand their perceptions of this and the challenges they may face in supporting service development and improvement. This article evaluates the role and experiences of ANPs working in an OOH urgent primary care service and identifies important factors that affect their roles. Positive factors enable job satisfaction, but challenges associated with knowledge base, perceptions, role definitions and isolation must be considered for quality and governance purposes. The article describes how supportive systems must be in place to enable mentorship, supervision programmes and development of this group of advanced practitioners.

Video-recording consultations for educational purposes in out-of-hours primary care: patients and physicians are willing to participate

Background Video-recordings of consultations are used by general practitioner (GP) trainees to enable reflection on aspects of knowledge, skills and attitudes. Typically, these recordings are made during office hours in general practice, but little is known about using video-recording during out of hours (OOH) care, which is an important and distinct part of a GP’s work. To be able to record consultations during OOH care (i.e. at the emergency department (ED) and at the General Practitioner Cooperative (GPC)), patients must be willing to cooperate and give informed consent. Therefore, it was of interest to investigate potential barriers in these OOH settings.Methods A questionnaire on demographics and attitudes regarding consent was administered to patients and physicians at the ED and at the GPC in Sint-Niklaas, Belgium.Results A total of 346 questionnaires were completed, 23 by physicians and 323 by patients. A majority of the patients (225/286 (79%)) would consent to video-recording the consultation, without physical examination. Almost all physicians (21/23) would agree to participate. Overall, 85% (260/323) of the patients agree when only the doctor was being recorded. Patients were neutral in recording in 79% (88/224) at the GPC and 57% (56/99) at the ED. Shyness or embarrassment was present in 32% (71/224), and 28% (28/99) at the GPC and ED, respectively. We did not find any significant differences in giving consent or feelings between patients at the GPC and ED.Conclusion A vast majority of both patients and physicians would consent to video-recording their consultation in OOH primary care settings (GPC and ED), with possible concerns about privacy, shame and discomfort.

Time to implement a national referral pathway for suspected cauda equina syndrome: review and outcome of 250 referrals

Introduction: Cauda equina syndrome (CES) is a condition with significant implications and medico-legal profile. The literature still lacks large primary studies to provide strong evidence for a robust management pathway. Statements from Neurosurgical and Spinal societies support early diagnosis and imaging but this has not resulted in any noticeable shift in referral pattern. We strongly feel the need for a nationally agreed, evidence-based referral pathway in practice. We present our large series and in-depth analysis of the referral pathway to provide strong evidence for more robust referrals and management.Methods: We reviewed 250 referrals of suspected CES (sCES) to the regional neurosurgical unit, evaluating the importance of clinical findings and the imaging pathway.Results: After clinico-radiological evaluation only 32 (13%) had confirmed CES requiring urgent surgery. There was no significant difference in terms of clinical presentation between these true cases of CES (tCES) and false cases (fCES). Imaging was therefore the key rate-limiting step. MRI was the most common investigation used. 73 patients presented without imaging out of hours (OOH). In this group, investigation was delayed to the next day in 60/73 (82%) patients while only 13 (18%) patients underwent OOH MRI. Only 2 (3%) were able to have this at their local hospital.Conclusions: As with previous studies we conclude that signs/symptoms are insufficient to identify tCES. Taking into consideration the improved outcome with early diagnosis, the importance of early scanning in diagnosing tCES, and the poor availability of OOH MRI scanning outside of neurosurgical units, we recommend a national policy of 24/7 MRI availability for cases of sCES at all hospitals with MRI scanners. This would remove the 87% of patients not requiring urgent surgery from an unnecessary and distracting referral process.

National audit investigating Oral and Maxillofacial Surgery out of hours ward cover senior house officer background, experience and training

Introduction/Aims: Senior House Officer (SHO) level cover in Oral and Maxillofacial Surgery (OMFS) is provided by dentally or medically qualified staff. Variations in training and experience between these two groups may have implications for patient safety out of hours(OOH).We aimed to assess background of OMFS SHOs providing OOH cover nationally and to evaluate levels of training and experience in medical problems/emergencies and non-surgical practical skills.

Role of out of hours primary care service in limiting inappropriate access to emergency department.

Out of hours (OOH) doctors can have an important gate-keeping role over the access to the emergency department (ED), but the outcome and the quality of their ED referrals have been poorly studied. We aimed to investigate the outcome of patients referred to ED from OOH service and the determinants of admission or short-stay dispositions. We collected retrospectively data about referrals to ED from a local OOH service in the north-east of Italy using the OOH paper register and the ED electronic database, over the period of 01/10/2012 to 31/03/2013. Out of 5217 patients accessing the OOH service, 408 referrals were included in our analysis. 45.3% (185) of the referrals were admitted to hospital or the short-stay unit, 26 patients (=6.4%) were discharged as non-urgent outgoing codes after no specialist consultation or test, suggesting inappropriate referrals, and, of the remaining 197 (=48%), only 10 did not undergo any investigation or consultation. Significant determinants of admission were: age ≥65years (OR=2.619; 95% CI 1.528-4.491, p<0.0001), domiciliary examination (OR=2.168; 95% CI 1.353-3.476, p=0.001), nursing home/palliative care setting (OR=2.563; 95% CI 1.228-5.351, p=0.012) and OOH triage code, ranging from an OR of 7.47 (95% CI 3.028-18.433) for minor urgencies to an OR of 26.835 (95% CI 6.761-106.508, p<0.0001) for emergencies, in comparison to no urgent codes. OOH service seems to play an effective gate-keeping role limiting ED access. Determinants of admission to hospital suggest some simple interventions that could improve the adequacy of ED referral from OOH service.

Out of hours workload management: Bayesian inference for decision support in secondary care.

In this paper, we aim to evaluate the use of electronic technologies in out of hours (OoH) task-management for assisting the design of effective support systems in health care; targeting local facilities, wards or specific working groups. In addition, we seek to draw and validate conclusions with relevance to a frequently revised service, subject to increasing pressures. We have analysed 4 years of digitised demand-data extracted from a recently deployed electronic task-management system, within the Hospital at Night setting in two jointly coordinated hospitals in the United Kingdom. The methodology employed relies on Bayesian inference methods and parameter-driven state-space models for multivariate series of count data. Main results support claims relating to (i) the importance of data-driven staffing alternatives and (ii) demand forecasts serving as a basis to intelligent scheduling within working groups. We have displayed a split in workload patterns across groups of medical and surgical specialities, and sustained assertions regarding staff behaviour and work-need changes according to shifts or days of the week. Also, we have provided evidence regarding the relevance of day-to-day planning and prioritisation. The work exhibits potential contributions of electronic tasking alternatives for the purpose of data-driven support systems design; for scheduling, prioritisation and management of care delivery. Electronic tasking technologies provide means to design intelligent systems specific to a ward, speciality or task-type; hence, the paper emphasizes the importance of replacing traditional pager-based approaches to management for modern alternatives.

Are subcutaneous palliative medicines available and accessible: an out of hours (OOH) audit in sheffield

IntroductionNICE quality standards (2011) state palliative care drugs should be fully accessible 24/7. National drug shortages, insufficient local stockholdings and prescriptions for items not on the recommended palliative list can make this problematic especially out of hours (OOH). There is little research on referral patterns for accessing subcutaneous medicines OOH.ObjectivesDetermine if subcutaneous palliative medicines are fully available OOH Investigate whether supplies vary between hospital and community pharmaciesUnderstand referral patterns to access medicationMethodA 12 month retrospective audit of GP OOH supplies from a hospital pharmacy with a prospective 4 week audit and carer survey in a large community pharmacy providing OOH supplies.ResultsLocally derived standards from commissioned service set at 100% (n = 68 in GP OOH/hospital, n = 21 in community pharmacy).100% of core subcutaneous medicines were available 24/7. Use of midazolam, diamorphine and hyoscine butylbromide similar across both settings; however levomepromazine was more common in the community following a national shortage of haloperidol. See table 1.29% of community pharmacy issues were for formulations not on the recommended palliative list.80% (4/5) patient referrals were made to the community pharmacy; 20% (1/5) going to more than one pharmacy.Abstract 61 Table 1Subcutaneous palliative care drug suppliesDrug nameGP OOH/hospital pharmacy suppliesNo. (%)Community pharmacy suppliesNo. (%)Midazolam Injection (various strengths)19 (28)5 (24)Diamorphine Injection (various strengths)17 (25)8 (38)Haloperidol Injection 5 mg5 (7)1 (5)Hyoscine Butylbromide Injection 20 mg13 (19)4 (19)Levomepromazine Injection 25 mg1 (1)3 (14)Morphine Injection 10 mg3 (4)0 (0)Oxycodone Injection (various strengths)6 (9)0 (0)Other Injections4 (6)0 (0)Total6821ConclusionSubcutaneous palliative care drugs are fully available in the OOH setting however further research should be undertaken to assess referral patterns.ReferenceNational Institute for Health and Care Excellence (NICE). Quality Standard 13 End of life care for adults. London: NICE; 2011

Use of a service evaluation and lean thinking transformation to redesign an NHS 111 refer to community Pharmacy for Emergency Repeat Medication Supply Service (PERMSS)

ObjectivesTo demonstrate the contribution of community pharmacy from NHS 111 referrals out of hours (OOH) for emergency supply repeat medication requests via presentation of service activity, community pharmacist feedback and...

OC-036 International Assessment of Outcome of Upper GI Haemorrhage at Weekends: Abstract OC-036 Table 1

Introduction Weekend admissions have been associated with higher mortality. For upper gastrointestinal haemorrhage (UGIH) some studies show significantly increased mortality and less early endoscopy while the UK UGIH audit reported no difference. We studied whether out of hours (OOH) admissions were sicker and/or had higher mortality. Methods Prospective study over 12 months (from March 2014) from 2 UK and 2 international centres. Admission time, demographics, pulse, BP, lab results, endoscopy findings, further procedures and 30 d mortality were recorded. 3 pre-endoscopy scores (Glasgow Blatchford (GBS), AIMS65 and admission Rockall scores) and 2 post-endoscopy scores (PNED and full Rockall scores) were determined. Chi-squared, Fisher’s exact and Kruskal-Wallis tests were used as appropriate. A two-tailed significance level of 5% was used. Results 2118 pconsecutive atients, 60% male, median age 66 years were seen. There were no significant differences in mortality, need for endoscopic therapy, surgery/embolisation or rebleeding in both UK and non-UK centres. There were no differences in comorbidity, mean ASA 2.3, pulse or BP although weekday admissions had a lower Hb (110 g/l vs 118 g/l (weeknight) vs 117 g/l (weekend) p 2118 consecutive patients admitted March 2014-March 2015 from Glasgow (600), Truro (544), Odense (541) and Singapore (433). Data shown are mean [95% CI] or number (%). Conclusion There is no difference in mortality in patients admitted with UGIH OOH compared to weekday admissions. The severity of UGIH was not related to time of admission. Similar findings were noted in the 2 UK centres and internationally. Disclosure of Interest None Declared

Audit of emergent and urgent surgery for acutely ill pediatric patients: is access timely?

There is a paucity of literature about wait times for urgent/emergent surgeries in Canada. Delays and performance of non-emergent operations overnight increase morbidity and mortality. The study aim was to determine patterns of delays and performance of less-emergent surgery overnight. MethodsA retrospective analysis (June 2011–December 2013) of emergent/urgent surgeries was conducted using the ORSOS database (prospective patient and operative data). Surgeries were classified: class 1, 2A, 2B, and 3: target times of 1, 6, 24 and 72h. In hours (IH)=7:45AM–3:30PM, M-F; others were out of hours (OOH) and overnight =2300–0700. ResultsThere were 4668 operations: class 1 (5.8%), 2A (29.1%), 2B (42.1%), and 3(23%). For class 1, 2A, 2B, and 3 surgeries, mean in-room times were 2, 4.7, 15.4, and 54h respectively; 59.2% (class 1), 81.9% (class 2A), 81.2% (class 2B) and 74.4%(class 3) were performed in target. OOH occurred for 73.2% (class 1), 71.5%(class 2A), 54.7% (class 2B), and 27.7% (class 3). There were 37 class 2B and 3 surgeries overnight. There was a significant increase surgeries IH: 41.8% to 49.6%. ConclusionThe majority of urgent/emergent surgery occurred OOH and the most unstable patients are least likely to have their operation within target.Level of evidence: 4

Primary Care Access, Emergency Department Visits, and Unplanned Short Hospitalizations in the UK.

Demand for unplanned hospital services is rising, and children are frequent users, especially where access to primary care is poor. In England, universal health care coverage entitles parents to see a general practitioner (GP) for first-contact care. However, access to GP appointments is variable, and few patients can see their own regular GP out of hours (OOH). The goal of this study explored the association between access to GPs , emergency department (ED) visits and short hospitalizations (<2 days) in children in England. ED visit and short hospitalization rates were investigated in 9.5 million children aged <15 years registered with English family practices between April 2011 and March 2012 by using administrative hospital data. Six access categories ranked all practices according to patients' reported ability to schedule GP appointments; from national GP Patient Survey data. GP consulting hours were 8:00 am to 6:30 pm on weekdays. There were 3 074 616 ED visits (56% OOH) and 470 752 short hospitalizations over the 12 months studied. Children registered with practices in the highest access group compared with the lowest were 9% less likely to visit an ED (adjusted rate ratio: 0.91 [95% confidence interval: 0.89-93]), particularly OOH compared with consulting hours (10% vs 7%). Children in the highest access groups were equally likely to be admitted for a short stay. Increasing GP accessibility might alleviate the burden of ED visits from children, particularly during peak times OOH. Short hospitalizations may be more sensitive to other aspects of health systems.

G454(P) Retrospective survey of child protection case characteristics in an acute and community setting

Aim The first principle of safeguarding services stated in the Munro report 2010 1 places the quality of experience and views of the child at the centre. Lord Laming’s review in 2009 2 recommended minimum requirements to be met during the safeguarding process. Safeguarding assessments for children occur in both an outpatient (OP) clinic setting and in an acute out of hours (OOH) setting. The aim of this survey was to compare the number, type and outcome of safeguarding assessments between these two settings. Method Retrospective case–notes review of all cases where a safeguarding examination was completed due to Section 47 concerns from January to March 2013. Those that were referred due to accidental incidents or where there was found to be no safeguarding concern were excluded. Data was obtained on documentation of the process and timeline for assessment as well as the types of case assessed. Outcomes one year later included children remaining with biological family and children remaining on a child protection plan. Results A total of 67 safeguarding cases were seen during that period of time. 78% were seen in an OP setting. Median age =5 yrs 7 months (IQR 2 to 9 years). OOH median age = 20 months (IQR –12 to 35 months). Median waiting times and type of abuse were similar. Twenty eight percent were on a child protection plan (CPP) at the time of referral to the OP service versus 9% for OOH referrals. Fractures and burns were more often seen in the OOH setting whereas no injury seen was more often documented in the OP setting. Conclusions The type of safeguarding cases seen do differ between acute and community settings in the age of presentation, the type of injury seen, the presence of history taking from the child and the numbers on a child protection plan at the point of referral. However the type of abuse, whether physical, neglect or sexual is similar. Further work needs to be done on standardising safeguarding practice across acute and community settings. References The Munro Review of Child protection. Department of Education. 2011 The Protection of Children in England: A Progress Report. Department of Education. 2009

Simultaneous computerised activation of the primary percutaneous coronary intervention pathway reduces out-of-hours door-to-balloon time but not mortality

BackgroundIn 2009 activation of out of hours (OOH) primary percutaneous coronary intervention (PPCI) in our institution changed from separate telephone calls to a simultaneous computerised alert. We assessed the impact of this protocol change on door-to-balloon (DTB) time, in hospital and 1year mortality. MethodsRetrospective survey of our Myocardial Ischaemia National Audit Project (MINAP) database. OOH patients were categorised — pre- (Group 1) and post- (Group 2) introduction of the computerised alert protocol. ResultsOOH PPCI was performed for 793 patients (mean age 61, 73.4% male) — 295 in Group 1 and 498 in Group 2. Median DTB times were 92min (interquartile range [IQR] 75–111) for Group 1 and 76min (IQR 64–97) for Group 2 (p<0.0001). Forty-eight percent achieved DTB in ≤90min in Group 1 compared to 70% in Group 2 (p<0.0001). Computerised alert was associated with a shorter DTB time on multivariate analysis (beta coefficient −0.09, p=0.03 for linear regression and OR 2.8, 95% CI 1.6–5.0, p<0.0001 for logistic regression). In hospital mortality was 4.1% in Group 1 and 5% in Group 2 (p=0.60). All-cause mortality at 1year was 6.1% in Group 1 and 9.9% in Group 2 (p=0.09). ConclusionsSimultaneous computerised activation for OOH PPCI reduced DTB times, increased the number of patients achieving target DTB times but did not affect mortality.

A survey-based cross-sectional study of doctors’ expectations and experiences of non-technical skills for Out of Hours work

ObjectivesThe skill set required for junior doctors to work efficiently and safely Out of Hours (OoH) in hospitals has not been established. This is despite the OoH period representing 75%...

Outcome of emergency general surgery in a university hospital

Outcome of emergency general surgery in a university hospital

CSF xanthochromia: correlation with brain imaging and its usefulness as an out-of-hours test

BackgroundSubarachnoid haemorrhage (SAH) is a spontaneous bleed into the subarachnoid space which is investigated by CT head and cerebrospinal fluid (CSF) xanthochromia. The aim of this study was to compare...

HANDOVER OF PALLIATIVE PATIENTS TO OUT OF HOURS CARE

BackgroundCancer patients spend 90% of the last year of their life at home. At least two thirds of the working week is out of hours. The Gold Standards Framework aims...

Discontinuity of care at end of life: a qualitative exploration of OOH end of life care

ObjectiveThis study aimed to understand the experiences of palliative care patients when accessing or making decisions about out of hours (OOH) services. It also aimed to illuminate barriers and enablers...

PTH-168 Organisation of an Acute upper Gastrointestinal Bleed Service in an average District General Hopsital

IntroductionAcute Upper Gastrointestinal Bleed (AUGIB) continues to carry appreciable morbidity and mortality. Organisation and deliverance of emergency care incorporating therapeutic endoscopy is pivotal in the management of AUGIB. Recent British...