Background
Theme | Feature |
---|---|
General | Out-of-hours primary care is provided by large-scale general practitioner cooperatives (GPC) |
Out-of-hours is defined as daily from 5 p.m. to 8 a.m. the entire weekend, and public holidays. | |
Participation of 50–250 GPs per cooperative with a mean of 4 h on call per week | |
Population consists of 100,000 to 500,000 patients | |
At present there are 121 GPCs with yearly about 4 million contacts. 200.000 self-referral contacts a year are registered at the GPCs (5%). | |
Location | Distance of patients to GPC maximally 30 km |
56% of GPCs is co-located with the ED of a hospital, forming an Emergency Care Access Point, 7% is located on the site of the hospital premises (without collaboration), 11% in the vicinity of the hospitals and 26% elsewhere | |
Accessibility | Access generally via regional telephone number. First contact is mostly telephonic with a triage nurse (90–95%), infrequently as self-referral. |
Telephone triage by nurses supervised by GPs: contacts are divided into telephone advice (38%), centre consult (52%), or GP home visit (10%). | |
Triage outcomes (NTS: Dutch Triage Guidelines): Life threatening (U1) 2%; Acute (U2) 15%: Urgent (U3) 38%; Routine (U4) 18%; Advice (U5) 27% | |
The GPC in an ECAP is mostly responsible for the face-to-face triage of self-referrals (54%). The ED is responsible for face-to-face triage in 21%. In 15% the triage is performed according to the patients choice. The remaining 10% has a deviant organisation. | |
In the Netherlands, adult patients have to make an annual deductible (€385,- in 2016) for hospital care and diagnostics. GP and GPC care is fully covered, without a co-payment. | |
Facilities | Glucose testing and urine examination can be performed at all GPCs. An ECG is available in 26%, conventional radiology in 19% and routine laboratory test in 37–65%. |
Methods
Design and population
Data collection
-
Patient characteristics: gender, age, living area, urgency, eventual diagnosis (ICPC).
-
Care characteristics: diagnostics, treatment, referral to ED, reason for referral, subsequent advice.
-
Follow-up: follow-up contacts, complementary diagnostics, alterations in diagnostics or treatment by the GP or specialist, possible complications.
-
Urgency: adequacy of triage in retrospect, using the urgency categories of the Dutch NHG-Triage Index [13].
-
Guidelines: applicability of guidelines formulated by the Dutch College of General Practitioners [14].
-
Clinical management: appropriateness of the diagnostics, treatment and referral according to guidelines (if applicable) or common medical practice.
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Adverse events: unintended harm to the patient and preventability.
Ethics and privacy
Analyses
Results
Inclusion and exclusion
Agreement
Objective characteristics
Patient characteristics
Characteristic | Number | Percent |
---|---|---|
Gender (n = 783) | ||
• Male | 459 | (58.6) |
• Female | 324 | (41.4) |
Age (n = 783) | ||
• 0–15 years | 184 | (23.5) |
• 16–45 years | 361 | (46.1) |
• 46–65 years | 150 | (19.1) |
• 65 > years | 88 | (11.2) |
Living area (n = 783) | ||
• Urban | 509 | (65.0) |
• rural area | 274 | (35.0) |
Urgency (n = 533)a,b
| ||
• U1: Life-threatening | 0 | (0) |
• U2: Acute | 25 | (4.7) |
• U3: Urgent | 344 | (64.5) |
• U4: Routine | 164 | (30.8) |
Diagnosis (ICPC) (n = 783) | ||
Trauma
|
463
|
(59.1)
|
• Wound | 186 | (23.8) |
• suspicion of fracture of extremity | 122 | (15.6) |
• contusion/distortion of musculoskeletal system | 106 | (13.5) |
• multiple injury after trauma | 26 | (3.3) |
• traumatic nose injury | 14 | (1.8) |
• traumatic cranial injury | 9 | (1.1) |
Non trauma
|
320
|
(40.9)
|
• abdominal complaints | 41 | (5.2) |
• ocular complaints | 34 | (4.3) |
• musculoskeletal (non-traumatic) | 27 | (3.4) |
• myogenic complaints | 20 | (2.6) |
• skin complaints | 20 | (2.6) |
• thoracic pain | 17 | (2.2) |
• respiratory complaints | 14 | (1.8) |
• other | 147 | (18.8) |
Clinical management
Clinical management | Number | % total | % within category | |
---|---|---|---|---|
Treatment by GPC | 380 | 49 | ||
Medication | 156 | 20 | ||
• analgesics | 54 | 7 | 35 | |
• oral antibiotics | 32 | 4 | 20 | |
• other | 70 | 9 | 45 | |
Suture, wound glue, skin closure | 132 | 17 | ||
• including tetanus toxoid or antibiotics | 34 | 4 | 26 | |
• excluding tetanus toxoid or antibiotics | 98 | 13 | 74 | |
Activity | 92 | 12 | ||
• bandage | 48 | 6 | 52 | |
• imprecisely defined (possibly with medication) | 44 | 6 | 48 | |
Other | 11 | 1 | ||
Conservative | 200 | 26 | ||
• explanation and advice | 114 | 15 | 57 | |
• wait and see (without explanation and advice mentioned) | 86 | 11 | 43 | |
Referral to ED | 192 | 24 | ||
Referral to the ED after GP consultation | 157 | 20 | 82 | |
Direct referral to the ED based on triage | 35 | 4 | 18 | |
Reason for referral (after GP consultation) | ||||
• X-ray diagnostics needed | 102 | 13 | 53 | |
• specialist assessment needed | 37 | 5 | 19 | |
• acute assessment needed | 10 | 1 | 5 | |
• other | 8 | 1 | 4 | |
Total | 783 | 100 |
Follow-up
Subjective characteristics
Adequacy of triage
Urgency | Incorrect triage | |||||
---|---|---|---|---|---|---|
Under triage | Over triage | Total | ||||
n | (%) | n | (%) | n | (%) | |
U1 Life-threatening (n = 0) | – | – | – | |||
U2 Acute (n = 25) | 2 | (8.0) | 7 | (28.0) | 9 | (36.0) |
U3 Urgent (n = 344) | 15 | (4.4) | 42 | (12.2) | 57 | (16.6) |
U4aRoutine (n = 164) | 46 | (28.0) | - | - | 46 | (28.0) |
Totalb
| 63 | (11.8) | 49 | (9.2) | 112 | (21.1) |