Violence towards personnel in out-of-hours primary care: a cross-sectional study

Objective

To investigate (1) the prevalence of occupational violence in out-of-hours (OOH) primary care, (2) the perceived cause of violence, and (3) the associations between occupation, gender, age, years of work, and occupational violence.

Design

A cross-sectional study using a self-administered postal questionnaire.

Setting

Twenty Norwegian OOH primary care centres.

Subjects

Physicians, nurses, and others with patient contact at OOH primary care centres, 536 responders (75% response rate).

Main outcome measures

Verbal abuse, threats, physical abuse, sexual harassment.

Results

In total, 78% had been verbally abused, 44% had been exposed to threats, 13% physically abused, and 9% sexually harassed during the last 12 months. Significantly more nurses were associated with verbal abuse (OR 3.85, 95% confidence interval 2.17–6.67) after adjusting for gender, age, and years in OOH primary care. Males had a higher risk for physical abuse (OR 2.36, CI 1.11–5.05) and higher age was associated with lower risk for sexual harassment (OR 0.28, CI 0.14–0.59), when adjusted for background variables. Drug influence and mental illness were the most frequently perceived causes for the last occurring episode of physical abuse, threats, and verbal abuse.

Conclusion

This first study on occupational violence in Norwegian OOH primary care found that a substantial number of health care workers experience occupational violence from patients or visitors. The employer should take action to prevent occupational violence in OOH primary care.Key Words: Cross-sectional studies, general practice, nurses, out-of-hours, physicians, prevalence, violenceThis study describes the prevalence of occupational violence among health workers in Norwegian out-of-hours primary care.

• One in three has been exposed to physical abuse during their working career in out-of-hours primary care.
• Nurses experience more verbal abuse than the other occupational groups.
• The perceived main causes of occupational violence are drug influence and mental illness.

     

Point-of-care ultrasonography in Norwegian out-of-hours primary health care

Objective: The objective of this study is to determine the extent of ultrasound availability in Norwegian casualty clinics and estimate the prevalence of its use.

Design: A retrospective study based on a national casualty clinic registry and data from reimbursement claims.

Setting: Out-of-hours primary health care in Norway.

Subjects: All Norwegian casualty clinics in 2016 and reimbursement claims from 2008 to 2015.

Main outcome measures: Percent of casualty clinics with ultrasound, types of ultrasound devices and probes, reasons for/against ultrasound access, characteristics of clinics with/without ultrasound, frequency of five ultrasound indications and characteristics of the physicians using/not using ultrasound.

Results: Out of 182 casualty clinics, 41 (23%) reported access to ultrasound. Mobile (49%) and stationary (44%) devices were most frequent. Physician request was the most common cited reason for ultrasound access (66%). Neither population served by the casualty clinic nor distance to hospital showed any clear association with ultrasound access. All of the five ultrasound reimbursement codes showed a substantial increase from 2008 to 2015 with 14.1 ultrasound examinations being performed per 10,000 consultations in 2015. Only 6.5% of physicians performed ultrasound in 2015 and males were significantly more likely to use ultrasound than females (OR 1.85, 95% CI: 1.38–2.47, p?Conclusions: Although the use of ultrasound is increasing in out-of-hours Norwegian primary health care, most casualty clinics do not have access and only a minority of physicians use ultrasound.     

Age-related differences in motives for contacting out-of-hours primary care: a cross-sectional questionnaire study in Denmark

Abstract

Objective

Demands for out-of-hours primary care (OOH-PC) services are increasing. Many citizens call because of non-urgent health problems. Nevertheless, the patients’ motives for requesting medical help outside office hours remains an understudied area. This study aimed to examine motives for calling OOH-PC services in various age groups.     

Patient safety culture in Norwegian primary care: A study in out-of-hours casualty clinics and GP practices

Objective. This study aimed to investigate patient safety attitudes amongst health care providers in Norwegian primary care by using the Safety Attitudes Questionnaire, in both out-of-hours (OOH) casualty clinics and GP practices. The questionnaire identifies five major patient safety factors: Teamwork climate, Safety climate, Job satisfaction, Perceptions of management, and Working conditions. Design. Cross-sectional study. Statistical analysis included multiple linear regression and independent samples t-tests. Setting. Seven OOH casualty clinics and 17 GP practices in Norway. Subjects. In October and November 2012, 510 primary health care providers working in OOH casualty clinics and GP practices (316 doctors and 194 nurses) were invited to participate anonymously. Main outcome measures. To study whether patterns in patient safety attitudes were related to professional background, gender, age, and clinical setting. Results. The overall response rate was 52%; 72% of the nurses and 39% of the doctors answered the questionnaire. In the OOH clinics, nurses scored significantly higher than doctors on Safety climate and Job satisfaction. Older health care providers scored significantly higher than younger on Safety climate and Working conditions. In GP practices, male health professionals scored significantly higher than female on Teamwork climate, Safety climate, Perceptions of management and Working conditions. Health care providers in GP practices had significant higher mean scores on the factors Safety climate and Working conditions, compared with those working in the OOH clinics. Conclusion. Our study showed that nurses scored higher than doctors, older health professionals scored higher than younger, male GPs scored higher than female GPs, and health professionals in GP practices scored higher than those in OOH clinics – on several patient safety factors.Key Words: Adverse events, general practice, medical errors, Norway, out-of-hours, patient safety culture, primary care, Safety Attitudes QuestionnairePatient safety culture is how leader and staff interaction, attitudes, routines, and practices in a group setting may protect patients from adverse events.

• In out-of-hours clinics, nurses scored higher than doctors, and older health professionals scored higher than younger on patient safety factors.
• Male professionals in GP practices scored significantly higher than female on four of the patient safety factors.
• Health care providers in GP practices had higher patient safety factor scores than those working in out-of-hours clinics.

     

Short-term effects of a pay-for-performance programme for diabetes in a primary care setting: an observational study

Objective A pay-for-performance (P4P) programme for primary care was introduced in 2011 by a Swedish county (with 1.6 million inhabitants). Effects on register entry practice and comparability of data for patients with diabetes mellitus were assessed.Design and setting Observational study analysing short-term outcomes before and after introduction of a P4P programme in the study county as compared with a reference county.Subjects A total of 84 053 patients reported to the National Diabetes Register by 349 primary care units.Main outcome measures Completeness of data, level and target achievement of glycated haemoglobin (HbA1c), blood pressure (BP), and LDL cholesterol (LDL).Results In the study county, newly recruited patients who were entered during the incentive programme were less well controlled than existing patients in the register – they had higher HbA1c (54.9 [54.5–55.4] vs. 53.7 [53.6–53.9] mmol/mol), BP, and LDL. The percentage of patients with entry of BP, HbA1c, LDL, albuminuria, and smoking increased in the study county but not in the reference county (+26.3% vs –1.5%). In the study county, with an incentive for BP < 130/80 mmHg, BP data entry behaviour was altered with an increased preference for sub-target BP values and a decline in zero end-digit readings (38.3% vs. 33.7%, p < 0.001).Conclusion P4P led to increased register entry, increased completeness of data, and altered BP entry behaviour. Analysis of newly added patients and data shows that missing patients and data can cause performance to be overestimated. Potential effects on reporting quality should be considered when designing payment programmes.

Key points

• A pay-for-performance programme, with a focus on data entry, was introduced in a primary care region in Sweden.
• Register data entry in the National Diabetes Register increased and registration behaviour was altered, especially for blood pressure.
• Newly entered patients and data during the incentive programme were less well controlled.
• Missing data in a quality register can cause performance to be overestimated.

     

Harm caused by adverse events in primary care: a clinical observational study

Rationale, aims and objectives  Patient safety in primary care is important, but not well studied. The aim of our study was to determine the actual and potential harm caused by adverse events in primary care.
Method  Observational study in two general practices, including the patients of five doctors. Two methods were used to identify adverse events; (1) a prospective registration of adverse events by the general practitioner and (2) a retrospective audit of medical records. Actual harm was registered and a clinical analysis was made to estimate potential harm.
Results  A total of 31 adverse events were collected and analysed. The adverse events were spread over different adverse event categories. About half of the events did not have health consequences, but a third led to worsening of symptoms and a few resulted in unplanned hospital admission. Potential negative health consequences were likely in three-quarters of the events.
Conclusions  The identified adverse events had some impact on health outcomes, but a risk for harm existed in a majority of the events. Patient safety programmes in primary care should focus on adverse events and not just on harm.     

Minor troponin T elevation in patients 6 months after acute myocardial infarction: an observational study

Background  Troponin elevation in patients with stable coronary heart disease is associated with adverse outcome and prognosis. However, the mechanism is not yet clearly understood. Our objectives were to examine the prevalence and range of cardiac troponin T (cTnT) in stable patients, 6 months after acute myocardial infarction (AMI) using a new high sensitive cTnT assay and to investigate the association of minor cTnT elevation in these patients to clinical variables, NT-proBNP and cardiac MRI-findings. Study design and methods  cTnT was measured in 98 patients 6 months after AMI with a precommercial assay by electrochemiluminescence methods (Roche Diagnostics, Mannheim, Germany). cTnT values were correlated with clinical and angiographic variables, NT-proBNP concentrations and with cardiac MRI-findings. Results  Minor cTnT concentrations were detectable in 90% of the entire cohort, of whom 16% had cTnT values above the 99th percentile (>12 ng/L). These patients were also significantly older, suffered more frequently from hypertension, had a higher New York Heart Association class and received more often diuretics at follow up. Patients with cTnT elevation had a more impaired left ventricular ejection fraction (P = 0.02) but did not have an increased infarct size (P = 0.73). Conclusions  Elevated minor cTnT levels are frequently detectable in patients 6 months after AMI. Increased cTnT level were associated with clinical parameter for heart failure, impaired ejection fraction and higher NT-proBNP levels suggesting that myocardial dysfunction is a main cause for cTnT elevation in these patient group.     

Contacts related to mental illness and substance abuse in primary health care: A cross-sectional study comparing patients' use of daytime versus out-of-hours primary care in Norway

Objective

To investigate prevalence, diagnostic patterns, and parallel use of daytime versus out-of-hours primary health care in a defined population (n = 23,607) in relation to mental illness including substance misuse.

Design

Cross-sectional observational study.

Setting

A Norwegian rural general practice cooperative providing out-of-hours care (i.e. casualty clinic) and regular general practitioners’ daytime practices (i.e. rGP surgeries) in the same catchment area.

Subjects

Patients seeking medical care during daytime and out-of-hours in 2006.

Main outcome measures

Patients’ diagnoses, age, gender, time of contact, and parallel use of the two services.

Results

Diagnoses related to mental illness were given in 2.2% (n = 265) of encounters at the casualty clinic and in 8.9% (n = 5799) of encounters at rGP surgeries. Proportions of diagnoses related to suicidal behaviour, substance misuse, or psychosis were twice as large at the casualty clinic than at rGP surgeries. More visits to the casualty clinic occurred in months with fewer visits to rGP surgeries. Most patients with a diagnosis related to mental illness at the casualty clinic had been in contact with their rGP during the study period.

Conclusion

Psychiatric illness and substance misuse have lower presentation rates at casualty clinics than at rGP surgeries. The distribution of psychiatric diagnoses differs between the services, and more serious mental illness is presented out-of-hours. The casualty clinic seems to be an important complement to other medical services for some patients with recognized mental problems.Key Words: After-hours care, emergency medical services, family practice, physician''s practice patterns, primary health care, psychiatryMost mentally ill patients in Norway are dealt with by the primary health care system, and out-of-hours GP services are the main source of acute referrals to psychiatric wards. Differences between daytime and out-of-hours services regarding relative prevalence, diagnostic challenges, and parallel use have previously been unknown.

• Prevalence of diagnoses related to mental illness is lower at out-of-hours services compared with daytime services. However, suicidal behaviour, substance misuse, and psychosis are more prevalent out-of-hours than during the daytime.
• Use of out-of-hours services increases in periods with low use of daytime services.
• Most patients with diagnoses related to mental illness out-of-hours had also seen their regular general practitioner during the study period.

Norway has a two-tier public health care system where regular general practitioners (rGPs) serve as gatekeepers for all specialized health services including psychiatric health care [1,2]. Most patients with mental illness are therefore dealt with by the primary health care system, with relatively few patients referred to psychiatrists [3,4].Local municipalities (Norwegian kommuner) are responsible for providing all primary health care, including access to an rGP and 24-hour access to emergency health care [5,6]. Although optional, almost all Norwegians are listed with an rGP in their residing municipality. The rGPs provide emergency care to their listed patients during office hours. Out-of-hours, most municipalities organize the emergency care with one or more GPs on call, usually based in a casualty clinic. Depending on the size of the municipality and the population served, the casualty clinic might be cooperatively shared between several municipalities [1]. Henceforth casualty clinic is used as a general term for out-of-hours services, and rGP surgeries refer to rGPs’ work during normal office hours. At a national level, approximately 66% of inhabitants annually have at least one appointment with their rGP and 16% contact the casualty clinics [7].International studies indicate that psychiatric patients are frequent users of emergency medical health services [12–14]. In Norway, however, diagnoses related to mental illness are given in only 2–5% of patient contacts with casualty clinics [7,9,10,15], while mental illness accounts for 5–12% of consultations at rGP surgeries [7–11]. Nevertheless, casualty clinics are the major source of acute referrals to psychiatric wards [16]. This raises the possibility that patients’ use of the two primary health care services may differ, and that casualty clinics mainly deal with more severe mental illness.In this study we compared a defined population''s use of daytime rGP appointments versus their use of the out-of-hours casualty clinic in relation to mental illness. Main measures were relative prevalence and diagnostic differences. We also studied patients’ parallel use of these two services.     

Patient safety culture in out-of-hours primary care services in the Netherlands: a cross-sectional survey

Objective: To examine patient safety culture in Dutch out-of-hours primary care using the safety attitudes questionnaire (SAQ) which includes five factors: teamwork climate, safety climate, job satisfaction, perceptions of management and communication openness.

Design: Cross-sectional observational study using an anonymous web-survey. Setting Sixteen out-of-hours general practitioner (GP) cooperatives and two call centers in the Netherlands. Subjects Primary healthcare providers in out-of-hours services. Main outcome measures Mean scores on patient safety culture factors; association between patient safety culture and profession, gender, age, and working experience.

Results: Overall response rate was 43%. A total of 784 respondents were included; mainly GPs (N?=?470) and triage nurses (N?=?189). The healthcare providers were most positive about teamwork climate and job satisfaction, and less about communication openness and safety climate. The largest variation between clinics was found on safety climate; the lowest on teamwork climate. Triage nurses scored significantly higher than GPs on each of the five patient safety factors. Older healthcare providers scored significantly higher than younger on safety climate and perceptions of management. More working experience was positively related to higher teamwork climate and communication openness. Gender was not associated with any of the patient safety factors.

Conclusions: Our study showed that healthcare providers perceive patient safety culture in Dutch GP cooperatives positively, but there are differences related to the respondents’ profession, age and working experience. Recommendations for future studies are to examine reasons for these differences, to examine the effects of interventions to improve safety culture and to make international comparisons of safety culture.

• Key Points

• Creating a positive patient safety culture is assumed to be a prerequisite for quality and safety. We found that:

• ??healthcare providers in Dutch GP cooperatives perceive patient safety culture positively;

• ??triage nurses scored higher than GPs, and older and more experienced healthcare professionals scored higher than younger and less experienced professionals – on several patient safety culture factors; and

• ??within the GP cooperatives, safety climate and openness of communication had the largest potential for improvement.

     

Early stroke care in Italy--a steep way ahead: an observational study

Objectives

To measure the performance of selected Italian emergency medical system (EMS) dispatch centres managing calls for patients suffering from stroke. Data on outcome and on early treatment in the ED were collected.

Methods

Prospective data collection for a trimester from interventions for a suspected stroke in 13 EMS dispatch centres over five Italian regions.

Results

Altogether, 1041 calls for a suspected stroke were analysed. Mean intervals of the sequential phases were 2.3±2 minutes between call and ambulance dispatch, 8.4±5.5 minutes to reach the patient, 14.5±8.5 minutes on the scene, and 40.2±16.2 minutes between call and arrival at the ED. Interventions were performed in 56% of cases by a basic life support (BLS) crew, advanced life support (ALS) crews intervened in 28% of cases, and a combination of ALS and BLS in the remaining 16%. Mean diagnostic interval was 99±85 minutes between emergency system call and the first CT scan. This was performed 71±27 minutes after ED admission. Only 1.6% were admitted to a stroke unit. One month outcome according to GCS was good recovery in 32%, moderate disability in 28%, severe disability in 14%, and death in 25% of the patients.

Conclusions

Mean times show a rapid response of the selected EMS dispatch centres to calls for a suspected stroke. Nevertheless, mean times of the ED phase are still unacceptable according to international guidelines such as Brain Attack Coalition and American Stroke Association guidelines. Efforts should be spent to reduce the time between the arrival and the CT scan and more patients should be admitted to a stroke unit.     

Patterns of elderly spousal caregiving in dementia care: an observational study

AIM: The aim of this study was to describe which caring activities eight spouses performed when caring for a partner with dementia, and in what way these activities were carried out. BACKGROUND: Family caregivers are recognized as being the primary source of care for the community's older people. The largest group is comprised of spouses, with wives as the predominant caregivers. This informal care seems to be more or less invisible and performed in silence within the family. Despite the wealth of studies, the essence of family caregiving is not well understood. METHODS: Data collection was conducted by observing the dyads in their homes. A qualitative approach inspired by grounded theory was chosen to discover qualities and describe patterns of spousal caregiving in dementia care. RESULTS: The analysis yielded four broad themes, which included nine categories. Findings from the study shed some light on the invisible aspects besides the traditional hands-on caregiving. CONCLUSION: The elderly carers were engaged in demanding and time-consuming care ranging from supervision to heavy physical responsibility. They were caring for as well as about their partners. The study also showed that spouses were successful in managing their situation in different ways. The results reported in this article are unique as they come from direct observations in family home settings where a spouse cared for a partner with dementia. Knowledge about family caregiving is valuable for nurses as there is an emphasis on collaboration between family caregivers and professionals.     

Assessing the accuracy of a computerized decision support system for digoxin dosing in primary care: an observational study

BACKGROUND: This study was carried out as part of a European Union funded project (PharmDIS-e+), to develop and evaluate software aimed at assisting physicians with drug dosing. A drug that causes particular problems with drug dosing in primary care is digoxin because of its narrow therapeutic range and low therapeutic index. OBJECTIVES: To determine (i) accuracy of the PharmDIS-e+ software for predicting serum digoxin levels in patients who are taking this drug regularly; (ii) whether there are statistically significant differences between predicted digoxin levels and those measured by a laboratory and (iii) whether there are differences between doses prescribed by general practitioners and those suggested by the program. METHODS: We needed 45 patients to have 95% Power to reject the null hypothesis that the mean serum digoxin concentration was within 10% of the mean predicted digoxin concentration. Patients were recruited from two general practices and had been taking digoxin for at least 4 months. Exclusion criteria were dementia, low adherence to digoxin and use of other medications known to interact to a clinically important extent with digoxin. RESULTS: Forty-five patients were recruited. There was a correlation of 0.65 between measured and predicted digoxin concentrations (P < 0.001). The mean difference was 0.12 microg/L (SD 0.26; 95% CI 0.04, 0.19, P = 0.005). Forty-seven per cent of the patients were prescribed the same dose as recommended by the software, 44% were prescribed a higher dose and 9% a lower dose than recommended. CONCLUSION: PharmDIS-e+ software was able to predict serum digoxin levels with acceptable accuracy in most patients.     

Venous thromboembolic disease: an observational study in medical-surgical intensive care unit patients

Purpose: Acute and chronic illness, immobility, and procedural and pharmacologic interventions may predispose patients in the intensive care unit (ICU) to venous thromboembolic (VTE) disease. The purpose of this study was to observe potential risk factors and diagnostic tests for VTE, and prophylaxis against VTE in medical-surgical ICU patients. Materials and Methods: In a prospective observational study, 93 consecutive patients admitted to a mixed medical-surgical ICU were followed. We recorded demographics, admitting diagnoses, APACHE II score, VTE risk factors, antithrombotic, anticoagulant and thrombolytic agents, diagnostic tests for deep venous thrombosis (DVT) and pulmonary embolus (PE), and clinical outcomes. Results: Patients were 65.5 (15.5) years old with an APACHE II score of 21.1 (9.0); 44 (47.3%) were female. Admission diagnoses were medical (58, 67.4%) and surgical (35, 37.6%). The duration of ICU stay was 3 days (interquartile range: 1, 8.5 days) and the ICU mortality rate was 20.4% (19 of 93). We observed 8 VTE events among 5 of 93 patients (incidence 5.4% [0.8 to 10.0]); 2 patients had DVT and PE before admission, 1 had DVT as an admitting diagnosis, 1 had DVT on day 2 and PE on day 3, and 1 had PE on day 2. Over 804 ICU patient-days, 2 of 5 ultrasound examinations diagnosed DVT and 2 of 3 ventilation-perfusion lung scans diagnosed PE. Of 64 patients in whom heparin was not contraindicated and who were not anticoagulated, subcutaneous heparin prophylaxis was prescribed for 40 (62.5%) patients. ICU-acquired VTE risk factors were mechanical ventilation (odds ratio [OR] 1.56), immobility (OR 2.14), femoral venous catheter (OR 2.24), sedatives (OR 1.52), and paralytic drugs (OR 4.81), whereas VTE heparin prophylaxis (OR 0.08), aspirin (OR 0.42), and thromboembolic disease stockings (OR 0.63) were associated with a lower risk. Only warfarin (OR 0.07, P = .01) and intravenous heparin (OR 0.04, P < .01) were associated with a significantly decreased risk of VTE. Conclusions: Several ICU-acquired risk factors for VTE were documented in this medical-surgical ICU. VTE prophylaxis was underprescribed, and VTE diagnostic tests were infrequent. Further research is required to determine the incidence, predisposing factors, attributable morbidity, mortality, and costs of VTE in medical-surgical ICU patients, the optimal diagnostic test strategies, and the most cost-effective approaches of prophylaxis. Copyright © 2000 by W.B. Saunders Company     

Podiatric care for diabetic patients with foot problems: an observational study

The aims of this study were to describe podiatric care for diabetic patients with foot problems and to explore the changes in knowledge, self-care behaviour and physical functioning after podiatric care. The treatment characteristics of 26 diabetic patients referred to podiatry were assessed. Prior to the first podiatric visit (T1) and 20 weeks later (T2) these patients filled in a structured questionnaire and performed a six-minute walking test. In half the number of patients preventive goals were set and strived for by general education about the diabetic foot and advice on footwear and self-care behaviour. With regard to treatment, reduction of pain was the most frequently selected goal. To achieve this reduction, a variety of interventions was applied. After podiatric care, patients reported having less severe foot pain and some improvements in functional ability and self-care behaviour were found. This study offers clues to start controlled clinical trials on the effectiveness of podiatry for diabetic patients. Trials should not only be directed to (the role of podiatry in) ulcer healing; it may be even more significant to study its effectiveness for the purpose of prevention and treatment of early-stage diabetic foot symptoms.