An evaluation of the appropriateness of advice and healthcare contacts made following calls to NHS Direct Wales

Background: An evaluation of NHS Direct Wales (NHSDW), a national telephone-based healthcare advice and information service, was undertaken. A key objective was to describe the actions of callers and assess the appropriateness of advice and healthcare contacts made following calls, results of which are reported here. Methods: Postal questionnaires were sent to consecutive callers to NHSDW in May 2002 and February 2004 to determine 1) callers' actions following calls and 2) their views about the appropriateness of: advice given; and when to seek further care. An independent clinical panel agreed and applied a set of rules about healthcare sites where examinations, investigations, treatments and referrals could be obtained. The rules were then applied to the subsequent contacts to healthcare services reported by respondents and actions were classified in terms of whether they had been necessary and sufficient for the care received. Results: Response rates were similar in each survey: 1033/1897 (54.5%); 606/1204 (50.3%), with 75% reporting contacting NHSDW. In both surveys, nearly half of all callers reported making no further healthcare contact after their call to NHSDW. The most frequent subsequent contacts made were with GPs. More than four fifths of callers rated the advice given - concerning any further care needed and when to seek it - as appropriate (further care needed: survey 1: 673/729, 82.3%; survey 2: 389/421, 92.4%; when to seek further care - survey 1: 462/555, 83.2%; survey 2: n = 295/346, 85.3%). A similar proportion of cases was also rated through the rule set and backed up by the clinical panel as having taken necessary and sufficient actions following their calls to NHSDW (survey 1: 624/729, 80.6%; survey 2: 362/421, 84.4%), with more unnecessary than insufficient actions identified at each survey (survey 1: unnecessary 132/729, 17.1% versus insufficient 11/729, 1.4%; survey 2: unnecessary 47/421, 11.0% versus insufficient 14/421, 3.3%). Conclusion: Based on NHSDW caller surveys responses and applying a transparent rule set to caller actions a large majority of subsequent actions were assessed as appropriate, with insufficient contacts particularly infrequent. The challenge for NHSDW is to reduce the number of unnecessary contacts made following calls to the service, whilst maintaining safety.</p

Influence of socioeconomic factors on medically unnecessary ambulance calls

<p>Abstract</p> <p>Background</p> <p>Unnecessary ambulance use has become a socioeconomic problem in Japan. We investigated the possible relations between socioeconomic factors and medically unnecessary ambulance calls, and we estimated the incremental demand for unnecessary ambulance use produced by socioeconomic factors.</p> <p>Methods</p> <p>We conducted a self-administered questionnaire-based survey targeting residents of Yokohama, Japan. The questionnaire included questions pertaining to socioeconomic characteristics, dichotomous choice method questions pertaining to ambulance calls in hypothetical nonemergency situations, and questions on the city's emergency medical system. The probit model was used to analyze the data.</p> <p>Results</p> <p>A total of 2,029 out of 3,363 targeted recipients completed the questionnaire (response rate, 60.3%). Probit regression analyses showed that several demographic and socioeconomic factors influence the decision to call an ambulance. Male respondents were more apt than female respondents to state that they would call an ambulance in nonemergency situations (p < 0.05). Age was an important factor influencing the hypothetical decision to call an ambulance (p < 0.05); elderly persons were more apt than younger persons to state that they would call an ambulance. Possession of a car and hesitation to use an ambulance negatively influenced the hypothetical decision to call an ambulance (p < 0.05). Persons who do not have a car were more likely than those with a car to state that they would call an ambulance in unnecessary situations.</p> <p>Conclusion</p> <p>Results of the study suggest that several socioeconomic factors, i.e., age, gender, household income, and possession of a car, influence a person's decision to call an ambulance in nonemergency situations. Hesitation to use an ambulance and knowledge of the city's primary emergency medical center are likely to be important factors limiting ambulance overuse. It was estimated that unnecessary ambulance use is increased approximately 10% to 20% by socioeconomic factors.</p

Support and Assessment for Fall Emergency Referrals (SAFER 1): Cluster Randomised Trial of Computerised Clinical Decision Support for Paramedics

Objective: To evaluate effectiveness, safety and cost-effectiveness of Computerised Clinical Decision Support (CCDS) for paramedics attending older people who fall. Design: Cluster trial randomised by paramedic; modelling. Setting: 13 ambulance stations in two UK emergency ambulance services. Participants: 42 of 409 eligible paramedics, who attended 779 older patients for a reported fall. Interventions: Intervention paramedics received CCDS on Tablet computers to guide patient care. Control paramedics provided care as usual. One service had already installed electronic data capture. Main Outcome Measures: Effectiveness: patients referred to falls service, patient reported quality of life and satisfaction, processes of care. Safety: Further emergency contacts or death within one month. Cost-Effectiveness Costs and quality of life. We used findings from published Community Falls Prevention Trial to model cost-effectiveness. Results: 17 intervention paramedics used CCDS for 54 (12.4%) of 436 participants. They referred 42 (9.6%) to falls services, compared with 17 (5.0%) of 343 participants seen by 19 control paramedics [Odds ratio (OR) 2.04, 95% CI 1.12 to 3.72]. No adverse events were related to the intervention. Non-significant differences between groups included: subsequent emergency contacts (34.6% versus 29.1%; OR 1.27, 95% CI 0.93 to 1.72); quality of life (mean SF12 differences: MCS −0.74, 95% CI −2.83 to +1.28; PCS −0.13, 95% CI −1.65 to +1.39) and non-conveyance (42.0% versus 36.7%; OR 1.13, 95% CI 0.84 to 1.52). However ambulance job cycle time was 8.9 minutes longer for intervention patients (95% CI 2.3 to 15.3). Average net cost of implementing CCDS was £208 per patient with existing electronic data capture, and £308 without. Modelling estimated cost per quality-adjusted life-year at £15,000 with existing electronic data capture; and £22,200 without. Conclusions: Intervention paramedics referred twice as many participants to falls services with no difference in safety. CCDS is potentially cost-effective, especially with existing electronic data capture

Air ambulance flights in northern Norway 2002-2008. Increased number of secondary fixed wing (FW) operations and more use of rotor wing (RW) transports

Air ambulance service in Norway has been upgraded during the last years. European regulations concerning pilots’ working time and new treatment guidelines/strategies have called for more resources. The objective was to describe and analyse the two supplementary air ambulance [fixed wing (FW) and rotor wing (RW)] alternatives’ activity during the study period (2002-2008). Furthermore we aimed to compare our findings with reports from other north European regions. This is a retrospective analysis. The air ambulance fleet’s activity according to the electronic patient record database of “Luftambulansetjenesten ANS” (LABAS) was analysed. The subject was the fleet’s operations in northern Norway, logistics, and patients handled. Type of flight, distances, frequency, and patients served were the main outcome measures. A significant increase (45%) in the use of RW and a shift in FW operations (less primary and more secondary) were revealed. The shift in FW operations reflected the centralisation of several health care services [i.e. percutaneous cardiac intervention (PCI), trauma, and cancer surgery] during the study period. Cardiovascular disease (CVD) and injuries were the main diagnoses and constituted half of all operations. CVD was the most common cause of FW operations and injuries of the RW ones. The number of air ambulance operations was 16 per 1,000 inhabitants. This was more frequent than in other north European regions. The use of air ambulances and especially RW was significantly increased during the study period. The change in secondary FW operations reflected centralisation of medical care. When health care services are centralised, air ambulance services must be adjusted to the new settings

Implementation and use of computerised clinical decision support (CCDS) in emergency pre-hospital care: a qualitative study of paramedic views and experience using Strong Structuration Theory

Computerised clinical decision support (CCDS) has been shown to improve processes of care in some healthcare settings, but there is little evidence related to its use or effects in pre-hospital emergency care. CCDS in this setting aligns with policies to increase IT use in ambulance care, enhance paramedic decision-making skills, reduce avoidable emergency department attendances and improve quality of care and patient experience. This qualitative study was conducted alongside a cluster randomised trial in two ambulance services of the costs and effects of web-based CCDS system designed to support paramedic decision-making in the care of older people following a fall. Paramedics were trained to enter observations and history for relevant patients on a tablet, and the CCDS then generated a recommended course of action which could be logged. Our aim was to describe paramedics' experience of the CCDS intervention and to identify factors affecting its implementation and use. We invited all paramedics who had been randomly allocated to the intervention arm of the trial to participate in interviews or focus groups. The study was underpinned by Strong Structuration Theory, a theoretical model for studying innovation based on the relationship between what people do and their context. We used the Framework approach to data analysis. Twenty out of 22 paramedics agreed to participate. We developed a model of paramedic experience of CCDS with three domains: context, adoption and use, and outcomes. Aspects of context which had an impact included organisational culture and perceived support for non-conveyance decisions. Experience of adoption and use of the CCDS varied between individual paramedics, with some using it with all eligible patients, some only with patients they thought were 'suitable' and some never using it. A range of outcomes were reported, some of which were different from the intended role of the technology in decision support. Implementation of new technology such as CCDS is not a one-off event, but an ongoing process, which requires support at the organisational level to be effective. ISRCTN Registry 10538608 . Registered 1 May 2007. Retrospectively registered

A patient survey of out-of-hours care provided by Emergency Care Practitioners

© 2007 Halter et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens

Predictive Capability of Anorectal Physiologic Tests for Unfavorable Outcomes Following Biofeedback Therapy in Dyssynergic Defecation

The purpose of this study is to evaluate the predictive capability of anorectal physiologic tests for unfavorable outcomes prior to the initiation of biofeedback therapy in patients with dyssynergic defecation. We analyzed a total of 80 consecutive patients who received biofeedback therapy for chronic idiopathic functional constipation with dyssynergic defecation. After classifying the patients into two groups (responders and non-responders), univariate and multivariate analyses were performed to determine the predictors associated with the responsiveness to biofeedback therapy. Of the 80 patients, 63 (78.7%) responded to biofeedback therapy and 17 (21.3%) did not. On univariate analysis, the inability to evacuate an intrarectal balloon (P=0.028), higher rectal volume for first, urgent, and maximal sensation (P=0.023, P=0.008, P=0.007, respectively), and increased anorectal angle during squeeze (P=0.020) were associated with poor outcomes. On multivariate analysis, the inability to evacuate an intrarectal balloon (P=0.018) and increased anorectal angle during squeeze (P=0.029) were both found to be independently associated with a lack of response to biofeedback therapy. Our data show that the two anorectal physiologic test factors are associated with poor response to biofeedback therapy for patients with dyssynergic defecation. These findings may assist physicians in predicting the responsiveness to therapy for this patient population