Telephone triage by nurses in primary care out-of-hours services in Norway: an evaluation study based on written case scenarios

Background: The use of nurses for telephone-based triage in out-of-hours services is increasing in several countries. No investigations have been carried out in Norway into the quality of decisions made by nurses regarding our priority degree system. There are three levels: acute, urgent and non-urgent. Methods: Nurses working in seven casualty clinics in out-of-hours districts in Norway (The Watchtowers) were all invited to participate in a study to assess priority grade on 20 written medical scenarios validated by an expert group. 83 nurses (response rate 76%) participated in the study. A one-out-of-five sample of the nurses assessed the same written cases after 3 months (n¼18, response rate 90%) as a testeretest assessment. Results: Among the acute, urgent and non-urgent scenarios, 82%, 74% and 81% were correctly classified according to national guidelines. There were significant differences in the proportion of correct classifications among the casualty clinics, but neither employment percentage nor profession or work experience affected the triage decision. The mean intraobserver variability measured by the Cohen kappa was 0.61 (CI 0.52 to 0.70), and there were significant differences in kappa with employment percentage. Casualty clinics and work experience did not affect intrarater agreement. Conclusion: Correct classification of acute and nonurgent cases among nurses was quite high. Work experience and employment percentage did not affect triage decision. The intrarater agreement was good and about the same as in previous studies performed in other countries. Kappa increased significantly with increasing employment percentage

Understanding of and adherence to advice after telephone counselling by nurse: a survey among callers to a primary emergency out-of-hours service in Norway

<p>Abstract</p> <p>Background</p> <p>To investigate how callers understand the information given by telephone by registered nurses in a casualty clinic, to what degree the advice was followed, and the final outcome of the condition for the patients.</p> <p>Methods</p> <p>The study was conducted at a large out-of-hours inter-municipality casualty clinic in Norway during April and May 2010. Telephone interviews were performed with 100 callers/patients who had received information and advice by a nurse as a sole response. Six topics from the interview guide were compared with the telephone record files to check whether the caller had understood the advice. In addition, questions were asked about how the caller followed the advice provided and the patient's outcome.</p> <p>Results</p> <p>99 out of 100 interviewed callers stated that they had understood the nurse's advice, but interpreted from the telephone records, the total agreement for all six topics was 82.6%. 93 callers/patients stated that they followed the advice and 11 re-contacted the casualty clinic. 22 contacted their GP for the same complaints the same week, of whom five patients received medical treatment and one was hospitalised. There were significant difference between the native-Norwegian and the non-native Norwegian regarding whether they trusted the nurse (p = 0.017), and if they got relevant answers to their questions (p = 0.005).</p> <p>Conclusion</p> <p>Callers to the out-of-hours service seem to understand the advice given by the registered nurses, and a large majority of the patients did not contact their GP or other health services again with the same complaints.</p> <p>Practice Implication</p> <p>Medical and communicative training must be an important part of the continuous improvement strategy within the out-of-hour services.</p

Clinical practice patterns among native and immigrant doctors doing out-of-hours work in Norway: a registry-based observational study

Objectives: To evaluate whether immigrant and native Norwegian doctors differ in their practice patterns. Design: Observational study. Setting: Out-of-hours (OOH) emergency primary healthcare in Norway, 2008. Participants: All primary care physicians doing OOH work, altogether 4165 physicians. Main outcome measures: Number of patient contacts per doctor. Use of laboratory tests, minor surgery, sickness certification and length of consultations. Use of diagnoses related to psychiatric and sexual health. Choice of management strategy with psychiatric patients (psychotherapy or hospitalisation). Results: 21.4% of the physicians were immigrants, and they had 30.6% of the patient contacts. Immigrant doctors from Asia, Africa and Latin America had most patient contacts, 633 (95% CI 549 to 716), while native Norwegian doctors had 306 (95% CI 288 to 325). In multivariate analyses, immigrant physicians did not differ significantly from native Norwegians regarding use of laboratory tests, minor surgery or length of consultations, but immigrant doctors wrote more sickness certificates, OR 1.75 (95% CI 1.24 to 2.47) for immigrant doctors from Europe, North America and Oceania versus native Norwegian doctors and OR 1.56 (95% CI 1.15 to 2.11) for immigrant doctors from Asia, Africa and Latin America versus native Norwegians. Immigrant physicians from Europe, North America and Oceania used more diagnoses related to pregnancy, family planning and female genitals, OR 1.55 (95% CI 1.11 to 2.16), versus native Norwegian physicians. Immigrant doctors from Asia, Africa and Latin America used less psychiatric diagnoses, OR 0.71 (95% CI 0.53 to 0.95), versus native Norwegian doctors but did not differ significantly in their management of recognised psychiatric illness. Conclusions: Immigrant doctors make an important contribution to OOH emergency primary healthcare in Norway. The authors found only modest evidence that their clinical practice patterns are different from that of native Norwegian doctors.publishedVersio

Antihypertensive and lipid lowering treatment in 70–74 year old individuals – predictors for treatment and blood-pressure control: a population based survey. The Hordaland Health Study (HUSK)

BACKGROUND: In an elderly, community based population we aimed at investigating antihypertensive and lipid lowering medication use in relation to own and familiar cardiovascular morbidity and diabetes mellitus, as well as to lifestyle factors and general health. We also examined levels of blood pressure in untreated and treated residents, to investigate factors correlating with blood pressure control. METHODS: A health survey carried out in 1997-9 in the county of Hordaland, Norway included a self-administered questionnaire mailed to 4 338 persons born in 1925-7. Drug use the day prior to filling in the questionnaire was reported. A health check-up was carried out, where their systolic and diastolic blood pressure (SBP and DBP), body mass index (BMI), and serum-cholesterol level were recorded. RESULTS: One third of respondents used one or more antihypertensive drugs, while 13% of men and women were treated with a statin. Diabetes mellitus, own or relatives'cardiovascular disease, having quit smoking, physical inactivity, and overweight correlated with antihypertensive treatment. Mean blood pressure was lower in respondents not on treatment. Among those on treatment, 38% of men and 29% of women had reached a target BP-level of lower than 140/90 mm Hg. Own cardiovascular disease and a low BMI correlated with good BP-control. CONCLUSION: One third of 70–74 year old individuals living in the community used one or more antihypertensive drugs. Only around one third of those treated had reached a target BP-level of less than 140/90 mm Hg. Own cardiovascular disease and a low BMI correlated with good BP-control

Urinary incontinence associated with anxiety and depression: the impact of psychotropic drugs in a cross-sectional study from the Norwegian HUNT study

Background Anxiety and depression are in both cross-sectional and longitudinal studies associated with urinary incontinence (UI) in women, strongest for the urgency component of UI. The role of psychotropic drugs in this association, especially antidepressants, has been questioned, but not clarified. The present study aimed to explore the associations between UI and anxiety/depression and the possible impact of psychotropic drugs on these associations. Methods We conducted a cross-sectional, population-based study with questionnaire data from 21,803 women ≥20 years in the Norwegian Nord-Trøndelag Health Study merged with the Norwegian Prescription Database, which contains information on all dispensed prescriptions. We used multivariate logistic regression to investigate the association between UI (any UI, and by type and severity) and anxiety/depression (by different score on Hospital anxiety and depression scale), and the influence of psychotropic drugs on this association (by different volume of drug use). Results Compared with normal anxiety- and depression score, having moderate/severe anxiety or depression (HADS≥11) increased the prevalence of UI from 27.6 to 37.8% (OR 1.59 (1.40–1.81), p < 0.001) for anxiety and from 28.0 to 43.7% (OR 1.79 (1.46–2.21), p < 0.001) for depression. According to type of UI, mixed UI was most strongly associated with a high HADS-score with an odds ratio 1.84 (1.65–2.05) for anxiety and 1.85 (1.61–2.13) for depression. Compared to no UI, severe UI was associated with depression with odds ratios of 2.04 (1.74–2.40), compared with no UI. Psychotropic drug use did not influence the associations between UI and anxiety/depression. We found high prevalence of UI among users of various psychotropic drugs. After adjustments, only antidepressants were associated with UI, with OR 1.36 (1.08–1.71) for high defined daily dose of the drug. Anxiolytics were associated with less UI with OR 0.64 (0.45–0.91) after adjustments for anxiety. Conclusion This study showed that anxiety, depression and use of antidepressants are associated factors with UI, strongest for urgency and mixed type of UI, with increasing ORs by increasing severity of the conditions and increased daily dose of the medication. Use of antidepressants did not influence the associations between UI and anxiety/depression.publishedVersio

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

Incidence of emergency contacts (red responses) to Norwegian emergency primary healthcare services in 2007 – a prospective observational study

<p>Abstract</p> <p>Background</p> <p>The municipalities are responsible for the emergency primary health care services in Norway. These services include casualty clinics, primary doctors on-call and local emergency medical communication centres (LEMC). The National centre for emergency primary health care has initiated an enterprise called "The Watchtowers", comprising emergency primary health care districts, to provide routine information (patients' way of contact, level of urgency and first action taken by the out-of-hours services) over several years based on a minimal dataset. This will enable monitoring, evaluation and comparison of the respective activities in the emergency primary health care services. The aim of this study was to assess incidence of emergency contacts (potential life-threatening situations, red responses) to the emergency primary health care service.</p> <p>Methods</p> <p>A representative sample of Norwegian emergency primary health care districts, "The Watchtowers" recorded all contacts and first action taken during the year of 2007. All the variables were continuously registered in a data program by the attending nurses and sent by email to the National Centre for Emergency Primary Health Care at a monthly basis.</p> <p>Results</p> <p>During 2007 the Watchtowers registered 85 288 contacts, of which 1 946 (2.3%) were defined as emergency contacts (red responses), corresponding to a rate of 9 per 1 000 inhabitants per year. 65% of the instances were initiated by patient, next of kin or health personnel by calling local emergency medical communication centres or meeting directly at the casualty clinics. In 48% of the red responses, the first action taken was a call-out of doctor and ambulance. On a national basis we can estimate approximately 42 500 red responses per year in the EPH in Norway.</p> <p>Conclusion</p> <p>The emergency primary health care services constitute an important part of the emergency system in Norway. Patients call the LEMC or meet directly at casualty clinics with medical problems that initially are classified as a potentially life-threatening situation, a red response.</p

The epidemiology of medical emergency contacts outside hospitals in Norway - a prospective population based study

<p>Abstract</p> <p>Introduction</p> <p>There is a lack of epidemiological knowledge on medical emergencies outside hospitals in Norway. The aim of the present study was to obtain representative data on the epidemiology of medical emergencies classified as "red responses" in Norway.</p> <p>Method</p> <p>Three emergency medical dispatch centres (EMCCs) were chosen as catchment areas, covering 816 000 inhabitants. During a three month period in 2007 the EMCCs gathered information on every situation that was triaged as a red response, according to The Norwegian Index of Medical Emergencies (Index). Records from ground ambulances, air ambulances, and the primary care doctors were subsequently collected. International Classification of Primary Care - 2 symptom codes (ICPC-2) and The National Committee on Aeronautics (NACA) Score System were given retrospectively.</p> <p>Results</p> <p>Total incidence of red response situations was 5 105 during the three month period. 394 patients were involved in 138 accidents, and 181 situations were without patients, resulting in a total of 5 180 patients. The patients' age ranged from 0 to 107 years, with a median age of 57, and 55% were male. 90% of the red responses were medical problems with a large variation of symptoms, the remainder being accidents. 70% of the patients were in a non-life-threatening situation. Within the accident group, males accounted for 61%, and 35% were aged between 10 and 29 years, with a median age of 37 years. Few of the 39 chapters in the Index were used, A10 "Chest pain" was the most common one (22% of all situations). ICPC-2 symptom codes showed that cardiovascular, syncope/coma, respiratory and neurological problems were most common. 50% of all patients in a sever situation (NACA score 4-7) were > 70 years of age.</p> <p>Conclusions</p> <p>The results show that emergency medicine based on 816 000 Norwegians mainly consists of medical problems, where the majority of the patients have a non-life-threatening situation. More focus on the emergency system outside hospitals, including triage and dispatch, and how to best deal with "everyday" emergency problems is needed to secure knowledge based decisions for the future organization of the emergency system.</p