Laboratory tests in out-of-hours services in Norway. Studies with special emphasis on use and consequences of C-reactive protein test in children

Background: Children with infections and respiratory symptoms have the highest contact rate with Norwegian out-of-hours (OOH) services, especially in the youngest age group, and during the winter season. Many contacts are non-urgent in a strict medical sense. Onsite measurement of C-reactive protein (CRP) is the most frequent laboratory test in Norwegian OOH, used in 60% of all contacts with children with infections and respiratory diseases. The aim of CRP is to differentiate between bacterial infections, viral and/or non-serious infections and to keep the use of antibiotics as low as possible. Nevertheless, the use of antibiotics has increased since the test was introduced as a point of care test until 2013. Several studies have investigated the diagnostic value of laboratory tests for children with fever, but not in primary health care where the prevalence of serious bacterial infections is low. Objective: Investigate the use of laboratory tests at Norwegian out-of-hours services and which characteristics of the doctor, patient, diagnoses and geography that affects it. Compare the RGPs’ rate of CRP use at daytime and at OOH in consultations with children. Evaluate if pre-consultation CRP screening affects the choice of treatment Identify predictors for prescription of antibiotics and referral to hospital for children at OOH services. Design/method: The first and second papers are from two cross-sectional registry based studies, based on electronic compensation claims from consultations in primary care. The third study (third paper) was a randomized controlled observational study at OOH-services in Norway, including children 20 mg/L, signs on ear examination and use of paracetamol during the previous 24 hours. A high respiratory rate, low oxygen saturation and signs of auscultation were predictors for referral to hospital. In addition, parents’ assessment of the seriousness was significantly associated with prescription of antibiotics and referral to hospital. Conclusion: Paper I and II: CRP is extensively used at Norwegian OOH services and the differences in use cannot be explained by different diagnoses. Paper III: CRP screening of children with fever or respiratory symptoms will not reduce the prescription of antibiotics. Paper IV: Predictors for prescription are signs on ear examination, slightly elevated CRP values and the parents’ assessment. Disturbed respiration is the most important sign predicting hospital admission

Use of laboratory tests in out-of-hours services in Norway

Objective: To investigate the use of laboratory tests and which factors influence the use in Norwegian out-of-hours (OOH) services. Design: Cross-sectional observational study. Setting: Out-of-hours services in Norway. Subjects: All electronic reimbursement claims from doctors at OOH services in Norway in 2007. Main outcome measures: Number of contacts and laboratory tests in relation to patients’ and doctors’ characteristics. Results: 1 323 281 consultations and home visits were reported. Laboratory tests were used in 31% of the contacts. C-reactive protein (CRP) was the most common test (27% of all contacts), especially in respiratory illness (55%) and infants (44%). Electrocardiogram and rapid strep A test were used in 4% of the contacts. Young doctors, female doctors, and doctors in central areas used laboratory tests more often. Conclusion: CRP is extensively used in OOH services, especially by young and inexperienced doctors, and in central areas. Further investigations are required to see if this extensive use of CRP is of importance for correct diagnosis and treatment.publishedVersio

Effect of an educational intervention for telephone triage nurses on out-of-hours attendance: a pragmatic randomized controlled study

Background: Telephone triage has been established in many countries as a response to the challenge of non-urgent use of out-of-hours primary care services. However, limited evidence is available regarding the effect of training interventions on clinicians’ telephone consultation skills and patient outcomes. Methods: This was a pragmatic randomized controlled educational intervention for telephone triage nurses in 59 Norwegian out-of-hours general practitioners’ (GPs) cooperatives, serving 59% of the Norwegian population. Computer-generated randomization was performed at the level of out-of-hours GP cooperatives, stratified by the population size. Thirty-two out-of-hours GP cooperatives were randomized to intervention. One cooperative did not accept the invitation to participate in the educational programme, leaving 31 cooperatives in the intervention group. The intervention comprised a 90-minute e-learning course and 90-minute group discussion about respiratory tract infections (RTIs), telephone communication skills and local practices. We aimed to assess the effect of the intervention on out-of-hours attendance and describe the distribution of RTIs between out-of-hours GP cooperatives and list-holding GPs. The outcome was the difference in the number of doctor’s consultations per 1000 inhabitants between the intervention and control groups during the winter months before and after the intervention. A negative binomial regression model was used for the statistical analyses. The model was adjusted for the number of nurses who had participated in the e-learning course, the population size and patients’ age groups, with the out-of-hours GP cooperatives defined as clusters. Results: The regression showed that the intervention did not change the number of consultations for RTIs between the two groups of out-of-hours GP cooperatives (incidence rate ratio 0.99, 95% confidence interval 0.91–1.07). The winter season’s out-of-hours patient population was younger and had a higher proportion of RTIs than the patient population in the list-holding GP offices. Laryngitis, sore throat, and pneumonia were the most common diagnoses during the out-of-hours primary care service. Conclusions: The intervention did not influence the out-of-hours attendance. This finding may be due to the intervention’s limited scope and the intention-to-treat design. Changing a population’s out-of-hours attendance is complicated and needs to be targeted at several organizational levels.publishedVersio

Factors predicting antibiotic prescription and referral to hospital for children with respiratory symptoms: secondary analysis of a randomised controlled study at out-of-hours services in primary care

Objective: Acute respiratory infections and fever among children are highly prevalent in primary care. It is challenging to distinguish between viral and bacterial infections. Norway has a relatively low prescription rate of antibiotics, but it is still regarded as too high as the antimicrobial resistance is increasing. The aim of the study was to identify predictors for prescribing antibiotics or referral to hospital among children. Design: Secondary analysis of a randomised controlled study. Setting: 4 out-of-hours services and 1 paediatric emergency clinic in Norwegian primary care. Participants: 401 children aged 0–6 years with respiratory symptoms and/or fever visiting the out-of-hours services. Outcomes: 2 main outcome variables were registered: antibiotic prescription and referral to hospital. Results: The total prescription rate of antibiotics was 23%, phenoxymethylpenicillin was used in 67% of the cases. Findings on ear examination (OR 4.62; 95% CI 2.35 to 9.10), parents' assessment that the child has a bacterial infection (OR 2.45; 95% CI 1.17 to 5.13) and a C reactive protein (CRP) value >20 mg/L (OR 3.57; 95% CI 1.43 to 8.83) were significantly associated with prescription of antibiotics. Vomiting in the past 24 hours was negatively associated with prescription (OR 0.26; 95% CI 0.13 to 0.53). The main predictors significantly associated with referral to hospital were respiratory rate (OR 1.07; 95% CI 1.03 to 1.12), oxygen saturation 20 mg/L, findings on ear examination, use of paracetamol and no vomiting in the past 24 hours were significantly associated with antibiotic prescription. Affected respiration was a predictor for referral to hospital. The parents' assessment was also significantly associated with the outcomes.publishedVersio

Preparedness and management during the first phase of the COVID-19 outbreak - a survey among emergency primary care services in Norway

Background The emergency primary care (EPC) services in Norway have been at the frontline of the COVID-19 pandemic. Knowledge about the EPC services’ management of the COVID-19 outbreak can be used to prepare for future outbreaks and improve patient management. The objectives of this study were to identify pandemic preparedness and management strategies in EPC centres in Norway during the COVID-19 outbreak. Methods Questions regarding patient management of the COVID-19 outbreak were included in data collection for the National Out-Of-Hours Services Registry. The data collection was web-based, and an invitation was sent by email to the managers of all EPC services in Norway in June 2020. The EPC services were asked questions about pre-pandemic preparedness, access to personal protective equipment (PPE), organizational measures taken, and how staffing was organized during the onset of the pandemic. Results There were 169 municipal and inter-municipal EPC services in Norway in 2020, and all responded to the questionnaire. Among the EPC services, 66.7% (n = 112) had a pandemic plan, but only 4.2% had performed training for pandemic preparedness. Further, fewer than half of the EPC centres (47.5%) had access to supplies of PPE, and 92.8% answered that they needed extra supplies of PPE. 75.3% of the EPC services established one or more respiratory clinics. Staffing with other personnel than usual was done in 44.6% (n = 74) of the EPC services. All EPC services except one implemented new strategies for assessing patients, while about half of the wards implemented new strategies for responding to emergency calls. None of the largest EPC services experienced that their pandemic plan was adequate, while 13.3% of the medium-sized EPC services and 48.9% of the small EPC services reported having an adequate pandemic plan. Conclusions Even though the EPC services lacked well-tested plans and had insufficient supplies of PPE at the outbreak of the COVID-19 pandemic, most services adapted to the pandemic by altering the ways they worked and by hiring health care professionals from other disciplines. These observations may help decision makers plan for future pandemics.publishedVersio

Health alliance for prudent prescribing and yield of antibiotics in a patient-centred perspective (HAPPY PATIENT): a before-and-after intervention and implementation study protocol

Background Excessive and inappropriate use of antibiotics is the most important driver of antimicrobial resistance. The aim of the HAPPY PATIENT project is to evaluate the adaptation of European Union (EU) recommendations on the prudent use of antimicrobials in human health by evaluating the impact of a multifaceted intervention targeting different categories of healthcare professionals (HCPs) on common community-acquired infectious diseases, especially respiratory and urinary tract infections. Methods/design HAPPY PATIENT was initiated in January 2021 and is planned to end in December 2023. The partners of this project include 15 organizations from 9 countries. Diverse HCPs (doctors, nurses, pharmacists, and pharmacy technicians) will be audited by the Audit Project Odense (APO) method before and after an intervention in four different settings: general practice, out of hours services, nursing homes and community pharmacies in four high antibiotic prescribing countries (France, Poland, Greece, and Spain) and one low prescribing country (Lithuania). About 25 individuals from each professional group will be recruited in each country, who will register at least 25 patients with community-acquired infections during each audit period. Shortly before the second registration participants will undertake a multifaceted intervention and will receive the results from the first registration to allow the identification of possible quality problems. At these meetings participants will receive training courses on enhancement of communication skills, dissemination of clinical guidelines with recommendations for diagnosis and treatment, posters for the waiting rooms, and leaflets for patients. The results of the second registration will be compared with those obtained in the first audit. Discussion HAPPY PATIENT is an EU-funded project aimed at contributing to the battle against antibiotic resistance through improvement of the quality of management of common community-acquired infections based on interventions by different types of HCPs. It is hypothesized that the use of multifaceted strategies combining active intervention will be effective in reducing inappropriate prescribing and dispensing of antibiotics.publishedVersio

Laboratory tests in out-of-hours services in Norway. Studies with special emphasis on use and consequences of C-reactive protein test in children

Background: Children with infections and respiratory symptoms have the highest contact rate with Norwegian out-of-hours (OOH) services, especially in the youngest age group, and during the winter season. Many contacts are non-urgent in a strict medical sense. Onsite measurement of C-reactive protein (CRP) is the most frequent laboratory test in Norwegian OOH, used in 60% of all contacts with children with infections and respiratory diseases. The aim of CRP is to differentiate between bacterial infections, viral and/or non-serious infections and to keep the use of antibiotics as low as possible. Nevertheless, the use of antibiotics has increased since the test was introduced as a point of care test until 2013. Several studies have investigated the diagnostic value of laboratory tests for children with fever, but not in primary health care where the prevalence of serious bacterial infections is low. Objective: Investigate the use of laboratory tests at Norwegian out-of-hours services and which characteristics of the doctor, patient, diagnoses and geography that affects it. Compare the RGPs’ rate of CRP use at daytime and at OOH in consultations with children. Evaluate if pre-consultation CRP screening affects the choice of treatment Identify predictors for prescription of antibiotics and referral to hospital for children at OOH services. Design/method: The first and second papers are from two cross-sectional registry based studies, based on electronic compensation claims from consultations in primary care. The third study (third paper) was a randomized controlled observational study at OOH-services in Norway, including children 20 mg/L, signs on ear examination and use of paracetamol during the previous 24 hours. A high respiratory rate, low oxygen saturation and signs of auscultation were predictors for referral to hospital. In addition, parents’ assessment of the seriousness was significantly associated with prescription of antibiotics and referral to hospital. Conclusion: Paper I and II: CRP is extensively used at Norwegian OOH services and the differences in use cannot be explained by different diagnoses. Paper III: CRP screening of children with fever or respiratory symptoms will not reduce the prescription of antibiotics. Paper IV: Predictors for prescription are signs on ear examination, slightly elevated CRP values and the parents’ assessment. Disturbed respiration is the most important sign predicting hospital admission

Phone triage nurses’ assessment of respiratory tract infections – the tightrope walk between gatekeeping and service providing. A qualitative study

Background Phone nurses triage callers to Norwegian out-of-hours cooperatives to estimate the appropriate urgency and level of care for the caller. Many callers with mild symptoms of respiratory tract infections receive a doctor’s consultation, which may lead to busy sessions and in turn impair clinical decisions. Objective This study explores how phone triage nurses assess callers with mild-to-moderate symptoms of respiratory tract infections and their views and experiences on triaging and counselling these callers. Methods We conducted four focus groups with 22 nurses (five men and 17 women aged 24–66 years) in three different locations in Norway. The interviews were transcribed verbatim and analysed by systematic text condensation. Results The informants were reluctant to call themselves gatekeepers. However, their description of their work indicates that they practice such a role. When nurses and callers disagreed about the right level of care, the informants sought consensus through strategies and negotiations. The informants described external factors such as organisational or financial issues as decisive for the population’s use of out-of-hours services. They also described callers’ characteristics, such as language deficiency and poor ability to describe symptoms, as determining their own clinical assessments

Phone triage nurses’ assessment of respiratory tract infections–the tightrope walk between gatekeeping and service providing. A qualitative study

Aim To measure change in service user involvement in secure mental health units, before and after the implementation of recovery-oriented practice. Design Quasi-experimental study pretest–posttest design with non-equivalent comparison groups. Methods Data were collected from May 2018 to December 2019 in four medium-/high-security units in Norway. Two intervention units that implemented recovery-oriented practice were compared with two comparison units that did not. Data were obtained using anonymous questionnaires at baseline and at 6-month follow-up. For intervention units, data were also obtained at a 12-month follow-up to measure sustainability of improvements over time. Twenty inpatients (‘patients’; intervention group: 10, comparison group: 10) and 141 members of frontline staff (‘service providers’; intervention group: 92, comparison group: 49) participated at baseline. Mann–Whitney U-tests and independent sample t-tests were applied at the group-level to analyse changes in mean scores in groups. Results Among patients in the intervention units, findings indicated no improvements after 6 months, but significant improvements after 12 months in terms of patients’ opportunities to participate in formulating their individual care plans, to influence decision-making about therapy and to receive information about complaint procedures. Opportunities to participate in discussions about medication and treatment regimens did not improve. After 6 months, service providers in the intervention units reported an increase in democratic patient involvement, patient collaboration and management support, but not in carer involvement and assisted patient involvement. The improvements in democratic patient involvement and management support were sustained over time. No changes were found in the comparison groups. Conclusion The patients and the service providers reported a higher degree of service user involvement after implementing recovery-oriented practice. Specific work is needed to ensure patients’ involvement in all domains

Use of laboratory tests in out-of-hours services in Norway

Objective: To investigate the use of laboratory tests and which factors influence the use in Norwegian out-of-hours (OOH) services. Design: Cross-sectional observational study. Setting: Out-of-hours services in Norway. Subjects: All electronic reimbursement claims from doctors at OOH services in Norway in 2007. Main outcome measures: Number of contacts and laboratory tests in relation to patients’ and doctors’ characteristics. Results: 1 323 281 consultations and home visits were reported. Laboratory tests were used in 31% of the contacts. C-reactive protein (CRP) was the most common test (27% of all contacts), especially in respiratory illness (55%) and infants (44%). Electrocardiogram and rapid strep A test were used in 4% of the contacts. Young doctors, female doctors, and doctors in central areas used laboratory tests more often. Conclusion: CRP is extensively used in OOH services, especially by young and inexperienced doctors, and in central areas. Further investigations are required to see if this extensive use of CRP is of importance for correct diagnosis and treatment