Out Of Hours Research Articles

G238 Make Love Not War: Bridging the Gap Between Primary and Secondary Paediatric Care

AimTo determine the number of presentations to a new Children’s Emergency Department (CED) that could have been managed in primary care.MethodsAll Patients were assessed to determine the appropriateness of attendance....

PTU-041 Dedicated GI Bleed Services Result in a Significant Difference in Inpatient Mortality: a South Yorkshire Experience

IntroductionAcute upper GI bleeding (AUGIB) is a common gastrointestinal problem associated with significant mortality.1 Whilst numerous factors have been shown to influence mortality in these individuals including co-morbidity and time...

USE OF OUT-OF-HOURS SERVICES: THE PATIENT’S POINT OF VIEW ON CO-PAYMENT A MIXED METHODS APPROACH

Introduction: In many countries out of hours (OOH) care is offered by different health care services. General practitioners (GP) tend to offer services in competition with emergency departments (ED). Patients behaviour depends on a number of factors. In this study, we highlight the knowledge and ideas of patients concerning the co-payment system.Methods: We used a mixed methods design, combining quantitative and qualitative research. During two weekends in January 2005, all patients using the ED or the GP OOH service, were invited for an interview with a structured questionnaire. A stratified random sample of patients participated in a semi-structured interview. Both methods add complementary data to answer the research questions.Results: Most mentioned reasons for seeking help at the ED are: accessibility (15.0%), proximity (6.4%) and competence of the staff (5.6%). Reasons for choosing the GP are: GP is easy to find, minor medical problem or anxiety and confidence in the GP. The odds of not knowing the co-payment system are significantly higher in patients visiting the ED (OR 1.783; 95% CI: 1.493-2.129). Mostly GP users recognize the problem of ED overuse. They suggested especially to provide clear information about the tasks of the different services and about the payment system, to reduce ED overuse.Conclusion and discussion: When intending to shift from ED to GP services for minor medical problems, aiming at just one measure is no option. Information campaigns aiming to address the entire population, can clarify the role of each player in out-of-hours care.

Implementation of a combined Cardiopulmonary Resuscitation and Treatment Escalation Plan document in a District General Hospital.

Documentation of appropriate escalation of treatment was identified as a problem for junior doctors and Critical Care Outreach Nurses at Musgrove Park Hospital. An audit of resuscitation and escalation documentation of all wards found that of the patients who were not for Cardiopulmonary resuscitation (and therefore not for full escalation of care), 78.4% had no documentation of the appropriate level of escalation of treatment should they deteriorate. The majority of junior doctors had experienced cases where they felt that inappropriate treatment had been given, where no escalation plan was documented.Using several Plan, Do, Study, Act (PDSA) cycles, drawing tools used in other trusts and departments, and the views of clinicians, we developed a treatment escalation plan (TEP) tool, to be included in the resuscitation form. This included consideration of referral to critical care, ward based non-invasive ventilation, and appropriate use of intravenous or oral antibiotics. This then prompted the responsible clinician to consider and document appropriate escalation of treatment.The CPR-TEP form was trialed using a quasi-experiment design allowing the aim to be tested using two groups - intervention and control. All patients in the intervention group were not for CPR and therefore had their TEP-CPR form filled in fully (n=68). The control group consisted of patients who were not for CPR but who did not have a TEP form filled in (n=36).The appropriateness of OOH (out of hours) treatment in those patients who experienced clinical deterioration was judged by questionnaire-based feedback from the in-hours team the following morning. Levels of inappropriate treatment between the two groups were compared to test the aim.At the end of the study period, questionnaire feedback indicated that 11.1% of patients in the group with the new CPR-TEP document had received inappropriate OOH care compared to 44.4% of patients in the group without the document.Using the TEP alongside resuscitation documentation prompts the responsible clinician to consistently consider and document the appropriate escalation of care for their patient, improving communication with the out of hours team and appropriate escalation of care in the event of patient deterioration.

PWE-193 Out of hours GI bleeder service: the Leicester experience

IntroductionThe incidence of upper gastrointestinal bleeds is 50–150 cases per 100 000.1 The introduction of the CROMES: “Scope for improvement” toolkit2 has focused on the need for provision of a...

Clinical decision making in a high-risk primary care environment: a qualitative study in the UK

ObjectiveExamine clinical reasoning and decision making in an out of hours (OOH) primary care setting to gain insights into how general practitioners (GPs) make clinical decisions and manage risk in...

Evaluating the impact of nurse independent prescribing within a weekend CNS service

IntroductionNurse independent prescribing (NIP) is a development of the nursing role that has been long awaited by both the Royal College of Nursing and the Nursing and Midwifery Council and...

Evaluation of a current 24/7 service provided by a community palliative care team

IntroductionThe ‘End of Life Care Strategy’ recommends the importance of 24/7 community support enabling people to be cared for in their place of choice. The hospice has provided this service...

Introducing an electronic palliative care summary: patient, carer and professional perspectives

Introduction and aimsThe electronic Palliative Care Summary (ePCS) is being introduced throughout Scotland to provide out of hours (OOH) staff with up to date records of medications, decisions regarding treatment...

Improving care and support for people with progressive illness in primary care

Introduction and aimsThe Palliative Care Directed Enhanced Service (DES) was introduced in Scotland in 2008/2009 to stimulate anticipatory care by GP practice teams. We aimed to evaluate how practices were...

Improving care and support for people with progressive illness in primary care

Introduction and aimsThe Palliative Care Directed Enhanced Service (DES) was introduced in Scotland in 2008/2009 to stimulate anticipatory care by GP practice teams. We aimed to evaluate how practices were...

The need to improve the interface between in-hours and out-of-hours GP care, and between out-of-hours care and self-care

considerable changes have occurred over the last 5 years in the organization of out-of-hours care in the UK. Users' experiences of their care are an important part of 'quality of care' and are valuable for identifying areas for improvement. to identify strengths and weaknesses of out-of hours service provision in Wales. The design of the study is a cross-sectional survey. The setting of the study is nine GP services, three Accident and Emergency units and NHS Direct in Wales. survey using the validated Out-of-Hours questionnaire. We identified the four most and least favourably rated items regarding users' experience of care. These were analysed by type of care provided, telephone advice, treatment centre and home visit groups. eight hundred and fifty-five of 3250 users responded (26% response rate). Across providers and types of care, consistent strengths were the 'manner of treatment by call operator' and the 'explanation of the next step by call operator'. Consistent weaknesses were the 'speed of call back by the clinician', the 'information provided by the GP', 'getting medication after the consultation' and 'when to contact the (in-hours) GP'. users of out-of-hours care identify clear and consistent strengths and weaknesses of service provision across Wales. Specific areas for improvement concern the interface between in-hours care and out-of-hours care and between out-of-hours care and self-care. GP surgeries need to give better information on how to access the out-of-hours services. Out-of-hours providers should improve their advice on how and when to access in-hours surgeries and also improve the availability of medicines after out-of-hours consultations.

Factors influencing emergency hospital admissions from nursing and residential homes: positive results from a practice-based audit

Emergency admissions of frail older people in care homes, many of whom have dementia, are critical events which should be avoided if possible. To identify and influence factors related to emergency admissions and place of death. Completed audit cycle. Jenner Health Centre patients in six local care homes. Data collection over 12 months in 05/6, repeated in 08/9. Emergency admissions, admitting health professional, assessment prior to admission, length of hospital stay, annual visit workload and place of death. Admission numbers fell from 91 (194 patients) in 05/6 to 52 (183 patients) in 08/9, related to a fall in admissions by general practitioners (GPs) and out of hours (OOH). The proportion of admissions by care home staff doubled. There was a highly significant difference (P < 0.001), between GPs and OOH in patients visited prior to admission in 05/6 which persisted in 08/9 (P < 0.01). A hospital stay >72 hours was significantly more likely if patients were visited prior to admission. In 05/6, 55% of deaths occurred in the care home rising to 75.5% in 08/9 (total numbers deaths unchanged). There was a highly significant difference (P < 0.001 05/6 and 08/9), between deaths in nursing compared with residential homes. GP visits to nursing home patients rose by 10.3% but visits to residential home patients fell by 5.4%. The aims of the audit were achieved with a 43% reduction in emergency admissions and a 45% reduction in deaths in hospital but at the expense of a 12% increase in visits. Improved anticipatory planning and increased medical and nursing support for patients and staff in residential homes may help to further reduce emergency admissions and deaths in hospital in future.

123 Comparison of outcomes of patients treated within hours vs out of hours by PPCI for STEMI: Abstract 123 Table 1

Background Primary percutaneous coronary intervention (PPCI) is the treatment of choice for ST-segment elevation myocardial infarction (STEMI) provided PPCI is performed in a timely manner. There is conflicting data regarding the outcomes of patients treated in-hours vs out of-hours, we sought to determine whether in-hospital and long-term outcomes are different among in-hours vs out of hours PPCI patients. Method Clinical information was analysed from a prospective data base on 1692 STEMI patients who underwent Primary PCI between January 2004 and March 2009 at a London centre. Information was entered at the time of procedure and outcome assessed by all-cause mortality information provided by the Office of National Statistics via the BCIS/CCAD national audit. In hours (IH) was defined as PPCI occurring on weekdays from 0800 to 1700 and out of hours (OFH) was defined as PPCI occurring from 1701 to 0759 during weekdays and anytime on weekends. Results Of the 1692 patients in the study, 46% (779/1692) underwent out of hours PPCI and 54% (913/1692) in hours. There were no differences in baseline clinical or angiographic characteristics between the two groups (see Abstract 123 Table 1). In the overall study group, door-to-balloon times (D2B) were not different (66 min±26 vs 68 min±34, p=0.77). The out of hours patients tended to present later with significantly longer symptom to balloon times (p=0.007). There was a significant difference in MACE between the two groups in favour of those patients treated in hours (7% OFH vs 4% IH, p=0.03) at 30 days, at 1 year (12% OFH vs 7% IH, p=0.002) and at 3 years (13% vs 9%, p=0.02) MACE was driven by increase in mortality, myocardial infarction and TVR in the out of hours group. Conclusion STEMI patients have worse clinical outcomes if treated out of hours by PPCI. This observation does not appear related to PCI centre door to balloon times. Further research is needed to understand and improve the causes of the worse outcomes out of hours.

Use of endoscopy for management of acute upper gastrointestinal bleeding in the UK: results of a nationwide audit

ObjectivesTo examine the use of endoscopy in the UK for acute upper gastrointestinal bleeding (AUGIB) and compare with published standards.To assess the organisation of endoscopy services for AUGIB in the...

Periodic Variation and Its Effect on Management and Prognosis of Korean Patients With Acute Myocardial Infarction

The characteristics of the periodic variation in acute myocardial infarction (AMI) and the subsequent effect on management and prognosis have not been fully investigated in a large number of Asian populations. From a prospective, observational multicenter online registry, 4,573 patients diagnosed as AMI in Korea from January to December 2006 were included. The highest incidence of AMI was between 8 a.m. and noon. The number of cases was highest in the winter and lowest in the autumn (13.6 vs 11.4 patients per day, P<0.001). Patients with symptom onset during working hours had a shorter time to first medical contact (203+/-288 min) compared with out-of-hours onset (230+/-288 min, P=0.003). In patients who underwent primary angioplasty, out-of hours symptom onset was associated with a greater time delay in both the patient's and the medical facility's response (door-to-balloon time out-of hours vs working hours: 101+/-54 min vs 84+/-44 min, P<0.001). In patients with ST-segment elevation myocardial infarction, symptoms to first medical contact showed a significant relationship to in-hospital mortality (for every 10 min of symptoms to first medical contact, odds ratio 1.006, 95% confidence interval 1.001-1.012, P=0.018) Circadian and periodic variation in AMI exists in Korean patients, which resulted in different patient behavior, hospital management and outcomes.

A retrospective investigation of the clinical management of patients attending an out of hours dental clinic in Merseyside under the new NHS dental contract

To investigate the clinical management of patients attending for emergency dental treatment. A retrospective analysis of clinical record cards. Information was collected from patient record cards concerning the patient's reason for attendance and their management at an emergency dental clinic in South Sefton, Liverpool. Over a nine month period, 1,718 patients attended the clinic; 1,472 record cards were analysed. Over 80% of the patients attending the out of hours (OOH) clinic had pain associated with a localised dental infection or dental abscess. Where a diagnosis was recorded, only 67% of patients received appropriate treatment. Over 50% of patients received antibiotics alone with no other definitive treatment provided. The principal antibiotic prescribed for both adult and child patients was amoxicillin. The current study has highlighted that GDPs working within the OOH services are not adhering to current clinical and best practice guidelines with respect to patient examination, diagnosis, management, in particular the correct prescribing of antibiotics for dental infections, and clinical record keeping.

Applying value-sensitive design and quality function deployment to healthcare ICT: the case of Dutch primary care unit dossiers

This paper aims to combine the Value Sensitive Design approach with more formalised QFD (Quality Function Deployment) methods for requirements engineering. As a case illustration we use a regional Dutch Electronic Out-of hours Record pilot, which is part of a nationwide roadmap towards Electronic Health Records. The combined approach aims at early phase requirements engineering and provides a high level situation analysis before proceeding to more solution oriented phases. We combine stakeholder analysis, value scenarios, QFD for multiple stakeholders and a consideration of systemic effects. The case illustrates several limits of existing approaches, pointing to an important and challenging area for future research. Advantages of the combined approach are: user centeredness, increased design decision transparency, considering not only service concepts and service processes but also systemic effects, combining moral exploration (VSD) with prioritisation and decisioning (QFD) and making innovation decisions more 'future-proof' by considering longer time horizons.

What determines a patient’s treatment? Evidence from out of hours primary care co-op data in the Republic of Ireland

This study explores consistency in healthcare. It investigates whether vulnerable groups in the population receive the most appropriate care. This is achieved by considering the case study of individuals who present to out of hours (OOH) primary care services in the Republic of Ireland with gastroenteritis. Specifically an individual can potentially receive four services; nurse advice, doctor advice, a treatment centre consultation or a home visit. Results show that service choice is influenced by patient, call and seasonal characteristics to varying degrees. Patient symptoms are the primary driver of the type of service the patients receives. Results also indicate that the OOH primary care facilities individual characteristics do not affect service choice. This suggests a degree of consistent care across these organisations. It also provides evidence that service choice is exogenous to the organisation.

Out-of-hours medical cover in community hospitals: implications for palliative care

The new General Medical Services contract in England means many GPs have transferred out-of hours work to their primary care organization, with implications for continuity of palliative care in community hospitals. To examine existing arrangements for out-of-hours medical cover in community hospitals, focusing on palliative care. Telephone survey of community hospital managers/senior nurses across England and Wales. Interviews (n = 62) revealed nursing staff were satisfied with existing out-of-hours care. Concern was expressed about the future of out-of-hours medical care from GPs as new services will cover larger areas, meaning unknown doctors may attend, taking longer to arrive. Arrangements for out-of-hours medical cover in community hospitals are in transition, threatening the continuity of care for dying patients.