Predicting sepsis-related mortality and ICU admissions from telephone triage information of patients presenting to out-of-hours GP cooperatives with acute infections: A cohort study of linked routine care databases.

BACKGROUND: General practitioners (GPs) often assess patients with acute infections. It is challenging for GPs to recognize patients needing immediate hospital referral for sepsis while avoiding unnecessary referrals. This study aimed to predict adverse sepsis-related outcomes from telephone triage information of patients presenting to out-of-hours GP cooperatives. METHODS: A retrospective cohort study using linked routine care databases from out-of-hours GP cooperatives, general practices, hospitals and mortality registration. We included adult patients with complaints possibly related to an acute infection, who were assessed (clinic consultation or home visit) by a GP from a GP cooperative between 2017-2019. We used telephone triage information to derive a risk prediction model for sepsis-related adverse outcome (infection-related ICU admission within seven days or infection-related death within 30 days) using logistic regression, random forest, and neural network machine learning techniques. Data from 2017 and 2018 were used for derivation and from 2019 for validation. RESULTS: We included 155,486 patients (median age of 51 years; 59% females) in the analyses. The strongest predictors for sepsis-related adverse outcome were age, type of contact (home visit or clinic consultation), patients considered ABCD unstable during triage, and the entry complaints"general malaise", "shortness of breath" and "fever". The multivariable logistic regression model resulted in a C-statistic of 0.89 (95% CI 0.88-0.90) with good calibration. Machine learning models performed similarly to the logistic regression model. A "sepsis alert" based on a predicted probability >1% resulted in a sensitivity of 82% and a positive predictive value of 4.5%. However, most events occurred in patients receiving home visits, and model performance was substantially worse in this subgroup (C-statistic 0.70). CONCLUSION: Several patient characteristics identified during telephone triage of patients presenting to out-of-hours GP cooperatives were associated with sepsis-related adverse outcomes. Still, on a patient level, predictions were not sufficiently accurate for clinical purposes.

The accuracy and feasibility of respiratory rate measurements in acutely ill adult patients by GPs: a mixed-methods study.

BACKGROUND: Tachypnoea in acutely ill patients can be an early sign of a life-threatening condition such as sepsis. Routine measurement of the respiratory rate by GPs might improve the recognition of sepsis. AIM: To assess the accuracy and feasibility of respiratory rate measurements by GPs. DESIGN & SETTING: Observational cross-sectional mixed-methods study in the setting of out-of-hours (OOH) home visits at three GP cooperatives in The Netherlands. METHOD: GPs were observed during the assessment of acutely ill patients, and semi-structured interviews were performed. The GP-assessed respiratory rate was compared with a reference measurement. In the event that the respiratory rate was not counted, GPs were asked to estimate the rate (dichotomised as ≥22 breaths per minute or <22 breaths per minute). RESULTS: Observations of 130 acutely ill patients were included, and 14 GPs were interviewed. In 33 patients (25%), the GP counted the respiratory rate. A mean difference of 0.27 breaths per minute (95% confidence interval [CI] = -5.7 to 6.3) with the reference measurement was found. At a cut-off point of ≥22 breaths per minute, a sensitivity of 86% (95% CI = 57% to 98%) was found when the GP counted the rate, and a sensitivity of 43% (95% CI = 22% to 66%) when GPs estimated respiratory rates. GPs reported both medical and practical reasons for not routinely measuring the respiratory rate. CONCLUSION: GPs are aware of the importance of assessing the respiratory rate of acutely ill adult patients, and counted measurements are accurate. However, in most patients the respiratory rate was not counted, and the rate was often underestimated when estimated.

Early experiences with quality-assured HbA1c and professional glucose point-of-care testing in general practice: a cross-sectional observational study among patients, nurses and doctors.

BACKGROUND: Point-of-care testing (POCT) is increasingly used in primary care. The rapid availability of the test result during the patient encounter increases the potential for patients and care providers to make a direct and joint decision on disease management. Our aim was to get insight into the first experiences of patients and healthcare professionals after introducing quality-controlled HbA1c and professional glucose POCT in diabetes care in their own general practices. METHODS: A cross-sectional observational study using paper questionnaires for patients, nurses and general practitioners (GPs) in 13 general practices in the Netherlands. HbA1c and professional glucose POCT was introduced after training and under day-to-day quality control. Patients filled in the questionnaire immediately after the test; nurses and GPs after a minimum period of three months from the starting date. Descriptive data analyses were performed. RESULTS: A total of 1551 fingerstick blood POC tests were performed (1126 HbA1c; 425 Glucose). For HbA1c POCT, 84 patients, 29 nurses and 11 GPs filled in the questionnaires. For professional glucose POCT, 30 patients, 17 nurses and 8 GPs responded. Response rates varied between 24 and 56%. Patients, nurses and GPs were generally (very) satisfied with the novel POC tests. Patients were most positive about the location (in the GPs' office) and execution of the POC test (by their own nurse), and the speed of the test result. Almost all nurses indicated to have sufficient knowledge and skills to perform the test. Both nurses and GPs had confidence in the test results and indicated they experienced a higher patient satisfaction than with regular blood tests. Perceived disadvantages were the time required to regularly calibrate the devices and the extension of the consultation time because of the test. Patients, nurses and GPs generally expressed they wanted to continue performing these POC tests in routine diabetes care. CONCLUSIONS: Patients, nurses and GPs expressed (very) positive first experiences after introducing HbA1c and professional glucose testing on two high-quality POCT devices in their own general practices. Further research, with a random selection procedure of practices and patients and in other regions and countries, is recommended to confirm these findings.

New clinical prediction model for early recognition of sepsis in adult primary care patients: a prospective diagnostic cohort study of development and external validation.

BACKGROUND: Recognising patients who need immediate hospital treatment for sepsis while simultaneously limiting unnecessary referrals is challenging for GPs. AIM: To develop and validate a sepsis prediction model for adult patients in primary care. DESIGN AND SETTING: This was a prospective cohort study in four out-of-hours primary care services in the Netherlands, conducted between June 2018 and March 2020. METHOD: Adult patients who were acutely ill and received home visits were included. A total of nine clinical variables were selected as candidate predictors, next to the biomarkers C-reactive protein, procalcitonin, and lactate. The primary endpoint was sepsis within 72 hours of inclusion, as established by an expert panel. Multivariable logistic regression with backwards selection was used to design an optimal model with continuous clinical variables. The added value of the biomarkers was evaluated. Subsequently, a simple model using single cut-off points of continuous variables was developed and externally validated in two emergency department populations. RESULTS: A total of 357 patients were included with a median age of 80 years (interquartile range 71-86), of which 151 (42%) were diagnosed with sepsis. A model based on a simple count of one point for each of six variables (aged >65 years; temperature >38°C; systolic blood pressure ≤110 mmHg; heart rate >110/min; saturation ≤95%; and altered mental status) had good discrimination and calibration (C-statistic of 0.80 [95% confidence interval = 0.75 to 0.84]; Brier score 0.175). Biomarkers did not improve the performance of the model and were therefore not included. The model was robust during external validation. CONCLUSION: Based on this study's GP out-of-hours population, a simple model can accurately predict sepsis in acutely ill adult patients using readily available clinical parameters.

Reliability and validity of the Netherlands Triage Standard in emergency care settings: a case scenario study.

BACKGROUND: The Netherlands Triage Standard (NTS) is a triage system that can be used by different types of emergency care organisations. Our objective was to determine the interrater reliability and construct validity of the NTS when applied to self-presenting patients. METHODS: We performed a cross-sectional case scenario study consisting of two parts: (1) paediatric triage in January-February 2019 and (2) adult triage in October-November 2020. In each part, we invited nurse triagists from three general practitioner cooperatives, three ambulance dispatching centres and three hospital emergency departments in the Netherlands to participate. We used 40 case scenarios involving paediatric patients and 41 involving adult patients who could self-present to any emergency care organisation. In advance, an expert panel determined the urgency (six levels) of the case scenarios (reference standard). The main outcome for reliability was the intraclass correlation coefficient (ICC) for urgency level. The main outcomes for validity were degree of agreement with the reference standard, for urgency level, and sensitivity and specificity for high versus low urgency. We used descriptive statistics and logistic multilevel modelling with both case and triagist as random effects. RESULTS: 218 out of 240 invited triagists participated. The ICC among all triagists was 0.73 for paediatric cases and 0.88 for adult cases and was highest in general practitioner cooperatives. For paediatric cases, there was 62.3% agreement with the reference standard about urgency, 17.4% underestimation and 20.2% overestimation. The sensitivity of the NTS for identifying highly urgent paediatric cases was 85.2%; the specificity was 89.7%. For adult cases, there was 68.3% agreement, 13.7% underestimation and 18.0% overestimation. The sensitivity of triage for high urgency in adults was 94.5% and the specificity 83.3%. CONCLUSION: NTS appears to have good reliability and construct validity for estimating the urgency of health complaints of non-referred patients presenting themselves in emergency care.

Effects of access to radiology in out-of-hours primary care on patient satisfaction and length of stay.

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.

Vital signs of the systemic inflammatory response syndrome in adult patients with acute infections presenting in out-of-hours primary care: A cross-sectional study.

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.

[The Netherlands Triage Standard applied to paediatric patients in emergency medicine: is it reliable and valid?] / Toepassing van de Nederlandse Triage Standaard bij kinderen in de spoedzorg.

OBJECTIVE: To determine the inter-rater reliability and validity of the Netherlands Triage Standard (NTS) for paediatric triage. DESIGN: A cross-sectional study using fictional cases for telephone and physical triage. METHOD: An expert panel established in advance the urgency of 40 cases concerning emergency help requests from non-referred children (the reference standard). These requests were presented in an online survey to triagists from three general practitioner (GP) out-of-hours practices, three ambulance dispatching centres and three hospital emergency departments. Triagists assessed all cases, using the NTS. We determined the agreement on degrees of urgency between different triagists and compared them with the reference standard. The outcome measure for inter-rater reliability was the intraclass correlation coefficient (ICC). The outcome measures for validity were the degree of agreement with the reference standard, under-triage and over-triage, and sensitivity and specificity in identifying high-urgency (U0-U2) versus low-urgency cases (U30U5). RESULTS: In total, 116 triagists participated in the study (response: 86%). The ICC was 0.73 among all triagists, and was highest in the out-of-hours GP cooperatives. There was 62.3% agreement with the reference standard, 17.4% under-triage and 20.2% over-triage. Of the divergent urgencies, 77% differed by only one urgency category. The sensitivity was 85.2% and the specificity 89.7%. The sensitivity and specificity of triage by the GP out-of-hours practices (82.7% and 92.7%, respectively) were almost the same as that by the hospital emergency departments (79.6% and 92.5%, respectively). Triage by the ambulance dispatching centres had relatively high sensitivity (93%), but relatively low specificity (82.4%). CONCLUSION: The results of the study contribute to the evidence that the NTS is a reliable and valid triage standard for paediatric patients. The urgency assessments by triagists in the GP out-of-hours practices, ambulance dispatching centres and hospital emergency departments were broadly in agreement. Results were limited by cases being on paper and triage only on anamnestic characteristics.

Out-of-hours primary care in 26 European countries: an overview of organizational models.

BACKGROUND: Various models exist to organize out-of-hours primary care (OOH-PC). We aimed to provide an up-to-date overview of prevailing organizational models in the European Union (EU), implemented changes over the last decade and future plans. This baseline overview may provide information for countries considering remodelling their OOH-PC system. METHODS: A cross-sectional web-based questionnaire among 93 key informants from EU countries, Norway and Switzerland. Key informants with expertise in the field of primary health care were invited to participate. Themes in the questionnaire were the existing organizational models for OOH-PC, model characteristics, major organizational changes implemented in the past decade and future plans. RESULTS: All 26 included countries had different coexisting OOH-PC models, varying from 3 to 10 models per country. 'GP cooperative was the dominant model in most countries followed by primary care centre and rota group'. There was a large variation in characteristics between the models, but also within the models, caused by differences between countries and regions. Almost all countries had implemented changes over the past 10 years, mostly concerning the implementation of telephone triage and a change of organizational model by means of upscaling and centralization of OOH-PC. Planned changes varied from fine-tuning the prevailing OOH-PC system to radical nationwide organizational transitions in OOH-PC. CONCLUSIONS: Different organizational models for OOH-PC exist on international and national level. Compared with a decade ago, more primary care-oriented organizational models are now dominant. There is a trend towards upscaling and centralization; it should be evaluated whether this improves the quality of health care.

Acute rule-out of non-ST-segment elevation acute coronary syndrome in the (pre)hospital setting by HEART score assessment and a single point-of-care troponin: rationale and design of the ARTICA randomised trial.

INTRODUCTION: Because of the lack of prehospital protocols to rule out a non-ST-segment elevation acute coronary syndrome (NSTE-ACS), patients with chest pain are often transferred to the emergency department (ED) for thorough evaluation. However, in low-risk patients, an ACS is rarely found, resulting in unnecessary healthcare consumption. Using the HEART (History, ECG, Age, Risk factors and Troponin) score, low-risk patients are easily identified. When a point-of-care (POC) troponin measurement is included in the HEART score, an ACS can adequately be ruled out in low-risk patients in the prehospital setting. However, it remains unclear whether a prehospital rule-out strategy using the HEART score and a POC troponin measurement in patients with suspected NSTE-ACS is cost-effective. METHODS AND ANALYSIS: The ARTICA trial is a randomised trial in which the primary objective is to investigate the cost-effectiveness after 30 days of an early rule-out strategy for low-risk patients suspected of a NSTE-ACS, using a modified HEART score including a POC troponin T measurement. Patients are included by ambulance paramedics and 1:1 randomised for (1) presentation at the ED (control group) or (2) POC troponin T measurement (intervention group) and transfer of the care to the general practitioner in case of a low troponin T value. In total, 866 patients will be included. Follow-up will be performed after 30 days, 6 months and 12 months. ETHICS AND DISSEMINATION: This trial has been accepted by the Medical Research Ethics Committee region Arnhem-Nijmegen. The results of this trial will be disseminated in one main paper and in additional papers with subgroup analyses. TRIAL REGISTRATION NUMBER: Netherlands Trial Register (NL7148).

Substitution of general practitioners by nurse practitioners in out-of-hours primary care home visits: A quasi-experimental study.

BACKGROUND: General practitioners experience a high workload during out-of-hours care. A possible solution is the shifting of care to nurse practitioners. OBJECTIVES: To provide insight into patient- and care characteristics, safety, efficiency, and patient satisfaction of substituting general practitioners with nurse practitioners for home visits by out-of-hours primary care services. DESIGN: Quasi-experimental non-randomised study comparing home visits by nurse practitioners (intervention group; one out-of-hours care service) with home visits by general practitioners (control group; two out-of-hours care services) for 24 protocolised health problems. SETTING: Three out-of-hours primary care services in the East of the Netherlands. PARTICIPANTS: 1601 patients who received a home visit by a nurse practitioner (N = 386) or a general practitioner (N = 1215). Of these patients, 639 gave informed consent to be included in the protocol adherence assessment and follow-up record review (nurse practitioner: N = 358; general practitioner: N = 281). METHODS: Five nurse practitioners with experience in ambulance care were recruited and trained. From September 2016 to March 2017 the nurse practitioners took over home visits under supervision of a general practitioners. This was evaluated using: (1) data-extraction from the patient registration system, (2) follow-up record review in the patients' general practices, and (3) patient satisfaction survey. Two general practitioners independently assessed protocol adherence based on the extracted registration data. RESULTS: Nurse practitioners prescribed medication significantly less often than general practitioners (19.9% versus 30.6%), and referred patients significantly more often to the hospital (24.1% versus 15.9%). The mean length of the home visit was significantly longer for nurse practitioners (34.1 versus 21.1 min). Nurse practitioners adhered to the protocol significantly more often than general practitioners (84.9% versus 76.2%) and their medication prescribing was significantly more often appropriate (93.7% versus 79.5%). There were no differences in the number of missed diagnoses and complications. The number of follow-up contacts was also similar in both groups. Patient satisfaction was generally high and significantly higher for nurse practitioners on several items. CONCLUSIONS: Nurse practitioners with experience in ambulance care can safely, efficiently, and satisfactorily perform low complex out-of-hours primary care home visits. It is recommended to study the safety and efficiency of nurse practitioners' home visits in other regions and with nurse practitioners with different educational levels and different specialisations. In addition, we recommend to evaluate the cost-effectiveness and if it leads increased quality of care.

[Migrants' motives and expectations for contacting out-of-hours primary care]. / Gebruik van de huisartsenpost door migranten.

BACKGROUND: Migrants relatively often use out-of-hours primary care. The objective of this study is to examine the motives and expectations of migrants for contacting out-of-hours primary care. METHODS: We used data from a survey study of 11,483 patients who contacted a General Practitioner (GP) cooperative in the Netherlands between 2009 and 2014 (response rate 45.6%). Logistic regression analysis was used to test differences in motives and expectations between non-western and western migrants and native Dutch patients. RESULTS: The most frequently mentioned motives and expectation of migrants to contact out-of-hours primary care were similar to Dutch patients. The main motives for respectively non-western and western migrants were an urgent need for a GP (54.9%/52.4%), worry (49.3%/43.0%), and a need for medical information (21.3%/26.2%). Compared to natives, non-western migrants more often perceived an urgent need for a GP (OR 1.65), less often needed information (OR 0.59), and like western migrants, more often experienced problems contacting their own GP during office hours (OR 1.71(non-western/1.38(western)). Most non-western and western migrants expected to see a doctor (46.2%/46.6%) or get advice (39.6%/41.5%). Non-western migrants expected more often to get physical examinations (OR 1.53), and prescriptions (OR 1.37). CONCLUSION: The main motives and expectations of migrants are similar to native Dutch patients, yet non-western migrants more often want action from the GP (e.g. examinations or prescriptions). At the same time, migrants experience problems accessing their own GP. We recommend education about the purpose of a GP cooperative, and examination and improvement of accessibility of daytime primary care.

Management of sepsis in out-of-hours primary care: a retrospective study of patients admitted to the intensive care unit.

OBJECTIVES: Timely recognition and treatment of sepsis is essential to reduce mortality and morbidity. Acutely ill patients often consult a general practitioner (GP) as the first healthcare provider. During out-of-hours, GP cooperatives deliver this care in the Netherlands. The aim of this study is to explore the role of these GP cooperatives in the care for patients with sepsis. DESIGN: Retrospective study of patient records from both the hospital and the GP cooperative. SETTING: An intensive care unit (ICU) of a general hospital in the Netherlands, and the colocated GP cooperative serving 260 000 inhabitants. PARTICIPANTS: We used data from 263 patients who were admitted to the ICU due to community-acquired sepsis between January 2011 and December 2015. MAIN OUTCOME MEASURES: Contact with the GP cooperative within 72 hours prior to hospital admission, type of contact, delay from the contact until hospital arrival, GP diagnosis, initial vital signs and laboratory values, and hospital mortality. RESULTS: Of 263 patients admitted to the ICU, 127 (48.3%) had prior GP cooperative contacts. These contacts concerned home visits (59.1%), clinic consultations (18.1%), direct ambulance deployment (12.6%) or telephone advice (10.2%). Patients assessed by a GP were referred in 64% after the first contact. The median delay to hospital arrival was 1.7 hours. The GP had not suspected an infection in 43% of the patients. In this group, the in-hospital mortality rate was significantly higher compared with patients with suspected infections (41.9% vs 17.6%). Mortality difference remained significant after correction for confounders. CONCLUSION: GP cooperatives play an important role in prehospital management of sepsis and recognition of sepsis in this setting proved difficult. Efforts to improve management of sepsis in out-of-hours primary care should not be limited to patients with a suspected infection, but also include severely ill patients without clear signs of infection.

[Early recognition of sepsis; a diagnostic challenge for the general practitioner]. / Vroege herkenning van sepsis.

Early recognition and treatment of sepsis is essential to prevent morbidity and mortality. Many sepsis patients are initially assessed by a general practitioner (GP). Delay can be prevented if patients are referred to the hospital as soon as possible. However, signs and symptoms of sepsis can be subtle or aspecific, complicating the distinction between patients who need urgent care and patients who can be safely treated at home. We describe three patients who were admitted to the intensive care after repeated assessment by GPs in an out-of-hours setting: a 76-year-old man who was diagnosed with urosepsis, an 86-year-old man who was diagnosed with pneumosepsis and a 49-year-old man who was admitted after cardiopulmonary resuscitation due to sepsis. In all cases risk factors and signs of sepsis were present, but the sepsis had not been recognized until presentation to the hospital.

Availability of Dutch General Practitioners for After-Hours Palliative Care.

BACKGROUND: Continuity of care is important for palliative patients in their end of life. In the Netherlands, after-hours primary care for palliative patients is either provided by large-scale general practitioner (GP) cooperatives or GPs choose to give palliative care by themselves while they are not on duty. AIM: To examine the availability of, perceived problems by, and attitude of Dutch GPs regarding providing palliative care for their own patients outside office hours. DESIGN AND SETTING: Cross-sectional observational study among 1772 GPs from 10 Dutch regions. METHOD: Online questionnaire among GPs affiliated with 10 GP cooperatives. RESULTS: Five hundred twenty-four (29.6%) eligible questionnaires were returned. Of the GPs, 60.8% were personally available outside office hours for their own palliative patients on their own private cell phone and performed home visits if needed. In 33.0%, GPs were willing to make home visits in private time instigated by the GP cooperative and 26.8% were only accessible for telephone consultation by the GP cooperative. In 12.2%, the GP delegated after-hours palliative care completely to the GP cooperative. The GPs predominantly reported "time pressure" problems (17.3%) as a barrier and 61.7% stated that after-hours palliative care is the responsibility of the own GP. CONCLUSION: The large majority of Dutch GPs is personally available for telephone consultation and/or willing to provide palliative care for their own patients outside office hours. For the future, it is important to maintain the willingness of GPs to remain personally available for their palliative patients.

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.

Ambulance dispatch versus general practitioner home visit for highly urgent out-of-hours primary care.

Background: Patients with life-threatening conditions who contact out-of-hours primary care either receive a home visit from a GP of a GP cooperative (GPC) or are handed over to the ambulance service. Objective: The objective of this study was to determine whether highly urgent visits, after a call to the GPC, are delivered by the most appropriate healthcare provider: GPC or ambulance service. Methods: We performed a cross-sectional study using patient record data from a GPC and ambulance service in an urban district in The Netherlands. During a 21-month period, all calls triaged as life-threatening (U1) to the GPCs were included. The decision to send an ambulance or not was made by the triage nurse following a protocolized triage process. Retrospectively, the most appropriate care was judged by the patient's own GP, using a questionnaire. Results: Patient and care characteristics from 1081 patients were gathered: 401 GPC visits, 570 ambulance responses and 110 with both ambulance and GPC deployment. In 598 of 1081 (55.3%) cases, questionnaires were returned by the patients' own GP. About 40% of all visits could have been carried out with a lower urgency in retrospect, and almost half of all visits should have received a different type of care or different provider. In case of ambulance response, 60.7% concerned chest pain. Conclusion: Research should be done on the process of triage and allocation of care to optimize labelling complaints with the appropriate urgency and to deploy the appropriate healthcare provider, especially for patients with chest pain.

Effects of access to radiology in out-of-hours primary care in the Netherlands: a prospective observational study.

Background: In the Netherlands, out-of-hours primary care is provided in general-practitioner-cooperatives (GPCs). These are increasingly located on site with emergency departments (ED), forming Emergency-Care-Access-Points (ECAP). A more efficient and economical organization of out-of-hours primary emergency care could be realized by increased collaboration at an ECAP. In this study, we compared the effects of different models with respect to access to (hospital) radiology by the GPC. We investigated patient and care characteristics, indication for diagnostics and outcomes at GPCs with and without access to radiology. Methods: A prospective observational record review study of patients referred for conventional radiology for trauma by one of five GPCs in the period April 2014-October 2015, covering three organizational models. Results: The mean age was 31 years and 56% was female. Extremities were predominately involved (91%). There was a medical indication for radiology in 85% and the assessed risk by requesting GPs on abnormalities was high in 66%. There was a significant difference in outcomes between models. Radiological abnormalities (fractures/luxations) were present in 51% without direct access and in 35% with partial and unlimited access. Overall, 61% of the included patients were referred to the ED; 100% in the models without access and 38% in the models with (partial) access. Conclusions: GPC access to radiology is beneficial for patients and professionals. The diagnostics were adequately used. With access to radiology, unnecessary referrals and specialist care are prevented. This may lead to a decrease in ED attendance and overcrowding.

Development and testing of the KERNset: an instrument to assess the quality of telephone triage in out-of-hours primary care services.

BACKGROUND: Telephone triage is a core but vulnerable part of the care process at out-of-hours general practitioner (GP) cooperatives. In the Netherlands, different instruments have been used for assessing the quality of telephone triage. These instruments focussed mainly on communicational aspects, and less on the medical quality of triage decisions. Our aim was to develop and test a minimum set of items to assess the quality of telephone triage. METHODS: A national survey among all GP cooperatives in the Netherlands was performed to examine the most important aspects of telephone triage. Next, corresponding items from existing instruments were searched on these topics. Subsequently, an expert panel judged these items on importance, completeness and formulation. The concept KERNset consisted of 24 items about the telephone conversation: 13 medical, ten communicational and one regarding both types. It was pilot tested on measurement characteristics, reliability, validity and variation between triagists. In this pilot study, 114 anonymous calls from four GP cooperatives spread across the Netherlands were judged by three out of eight raters, both internal and external raters. RESULTS: Cronbach's alpha was .94 for the medical items and .75 for the communicational items. Inter-rater reliability: complete agreement between the external raters was 45% and reasonable agreement 73% (difference of maximally one point on the five-point scale). Intra-rater reliability: complete agreement within raters was 55% and reasonable agreement 84%. There were hardly any differences between internal and external raters, but there were differences in strictness between individual raters. The construct validity was confirmed by the high correlation between the general impression of the call and the items of the KERNset. Of the differences within items 19% could be explained by differences between triage nurses, which means the KERNset is able to demonstrate differences between triage nurses. CONCLUSIONS: The KERNset can be used to assess the quality of telephone triage. The validity is good and differences between calls and between triage nurses can be measured. A more intensive training for raters could improve the reliability.