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Open Access 01-12-2019 | Stroke | Research article

Contacting out-of-hours primary care or emergency medical services for time-critical conditions - impact on patient outcomes

Authors: Morten Breinholt Søvsø, Morten Bondo Christensen, Bodil Hammer Bech, Helle Collatz Christensen, Erika Frischknecht Christensen, Linda Huibers

Published in: BMC Health Services Research | Issue 1/2019

Abstract

Background

Out-of-hours (OOH) healthcare services in Western countries are often differentiated into out-of-hours primary healthcare services (OOH-PC) and emergency medical services (EMS). Call waiting time, triage model and intended aims differ between these services. Consequently, the care pathway and outcome could vary based on the choice of entrance to the healthcare system.

We aimed to investigate patient pathways and 1- and 1–30-day mortality, intensive care unit (ICU) stay and length of hospital stay for patients with acute myocardial infarction (AMI), stroke and sepsis in relation to the OOH service that was contacted prior to the hospital contact.

Methods

Population-based observational cohort study during 2016 including adult patients from two Danish regions with an OOH service contact on the date of hospital contact. Patients <18 years were excluded. Data was retrieved from OOH service databases and national registries, linked by a unique personal identification number. Crude and adjusted logistic regression analyses were performed to assess mortality in relation to contacted OOH service with OOH-PC as the reference and cox regression analysis to assess risk of ICU stay.

Results

We included 6826 patients. AMI and stroke patients more often contacted EMS (52.1 and 54.1%), whereas sepsis patients predominately called OOH-PC (66.9%). Less than 10% (all diagnoses) of patients contacted both OOH-PC & EMS. Stroke patients with EMS or OOH-PC & EMS contacts had higher likelihood of 1- and 1–30-day mortality, in particular 1-day (EMS: OR = 5.33, 95% CI: 2.82–10.08; OOH-PC & EMS: OR = 3.09, 95% CI: 1.06–9.01). Sepsis patients with EMS or OOH-PC & EMS contacts also had higher likelihood of 1-day mortality (EMS: OR = 2.22, 95% CI: 1.40–3.51; OOH-PC & EMS: OR = 2.86, 95% CI: 1.56–5.23) and 1–30-day mortality. Risk of ICU stay was only significantly higher for stroke patients contacting EMS (EMS: HR = 2.38, 95% CI: 1.51–3.75). Stroke and sepsis patients with EMS contact had longer hospital stays.

Conclusions

More patients contacted OOH-PC than EMS. Sepsis and stroke patients contacting EMS solely or OOH-PC & EMS had higher likelihood of 1- and 1–30-day mortality during the subsequent hospital contact. Our results suggest that patients contacting EMS are more severely ill, however OOH-PC is still often used for time-critical conditions.

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Langhelle A, Lossius HM, Silfvast T, Björnsson HM, Lippert FK, Ersson A, et al. International EMS systems: the Nordic countries. Resuscitation. 2004;61(1):9–21.CrossRef

Huibers L, Giesen P, Wensing M, Grol R. Out-of-hours care in western countries: assessment of different organizational models. BMC Health Serv Res. 2009;9:1–8.CrossRef

Munro J, Nicholl J, O’Cathain A. Impact of NHS Direct on demand for immediate care: Observational study [Internet]. Vol. 321, British Medical Journal. J. Munro, Medical Care Research Unit, University of Sheffield, Regent Court, Sheffield S1 4DA, United Kingdom. E-mail: j.f.munro@sheffield.ac.uk: BMJ Publishing Group (Tavistock Square, London WC1H 9JR, United Kingdom); 2000. p. 150–3. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=emed8&NEWS=N&AN=30447009.

Søvsø MB, Hermansen SB, Færk E, Lindskou TA, Ludwig M, Møller JM, et al. Diagnosis and mortality of emergency department patients in the North Denmark region. BMC Health Serv Res [Internet]. 2018 Jul;18(1):548. Available from: https://doi.org/10.1186/s12913-018-3361-x.

Doggen CJM, Zwerink M, Droste HM, Brouwers PJAM, van Houwelingen GK, van Eenennaam FL, et al. Prehospital paths and hospital arrival time of patients with acute coronary syndrome or stroke, a prospective observational study. BMC Emerg Med [Internet]. 2016;16:3. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=emex&NEWS=N&AN=616003708.

Thylén I, Ericsson M, Hellström Ängerud K, Isaksson RM, Sederholm LS. First medical contact in patients with STEMI and its impact on time to diagnosis; an explorative cross-sectional study. BMJ Open. 2015;5(4):1–7.CrossRef

Devon HA, Rosenfeld A, Steffen AD, Daya M. Sensitivity, specificity, and sex differences in symptoms reported on the 13-item acute coronary syndrome checklist. J Am Heart Assoc. 2014;3(2):1–9.CrossRef

Goldstein LB, Simel DL. CLINICIAN ’ S CORNER is this patient having a stroke ? EXAMINATION OF PATIENTS WITH SUSPECTED STROKE. Jama. 2008;293(19):2391–402.CrossRef

Van Der Wekken LCW, Alam N, Holleman F, Van Exter P, Kramer MHH, Nanayakkara PWB. Epidemiology of sepsis and its recognition by emergency medical services personnel in the Netherlands. Prehospital Emerg Care. 2016;20(1):90–6.CrossRef

10.

Latten GHP, Claassen L, Jonk M, Cals JWL, Muris JWM, Stassen PM. Characteristics of the prehospital phase of adult emergency department patients with an infection: a prospective pilot study. PLoS One. 2019;14(2):1–10.CrossRef

11.

Faiz KW, Sundseth A, Thommessen B, Rønning OM. Prehospital path in acute stroke. Tidsskr Den Nor Laegeforening Tidsskr Prakt Med Ny Raekke [Internet] 2017;137(11):798–802. Available from: http://ezproxy.lib.umb.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=28597634&site=ehost-live

12.

World Health Organization. International Statistical Classification of Diseases and Related Health Problems 10th Revision [Internet]. 2016 [cited 2016 Feb 5]. Available from: http://apps.who.int/classifications/icd10/browse/2016/en

13.

Gradel KO, Nielsen SL, Pedersen C, Knudsen JD, Østergaard C, Arpi M, et al. Low completeness of bacteraemia registration in the Danish National Patient Registry. PLoS One. 2015;10(6):1–19.CrossRef

14.

Schmidt M, Pedersen L, Sørensen HT. The Danish civil registration system as a tool in epidemiology. Eur J Epidemiol. 2014;29(8):541–9.CrossRef

15.

Schmidt M, Schmidt SAJ, Sandegaard JL, Ehrenstein V, Pedersen L, Sorensen HT, et al. The Danish National Patient Registry: a review of content, data quality, and research potential. Clin Epidemiol [Internet] 2015;7:449–90. Available from: https://www.dovepress.com/getfile.php?fileID=28043

16.

Andersen JS, Olivarius NDF, Krasnik A. The Danish National Health Service Register. Scand J Public Health 2011;39(7 Suppl):34–7.CrossRef

17.

STROBE group. index @ strobe-statement.org [Internet]. [cited 2016 Nov 30]. Available from: http://strobe-statement.org/index.php?id=strobe-home

18.

von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies. Int J Surg [Internet]. 2014 Dec 1 [cited 2019 Jun 13];12(12):1495–9. Available from: https://www.sciencedirect.com/science/article/pii/S174391911400212X?via%3Dihub

19.

Statistics Denmark. Danmarks Statistik [Internet]. [cited 2016 Aug 29]. Available from: http://www.statistikbanken.dk/statbank5a/default.asp?w=1440

20.

Regioner D. Dansk Indeks for Akuthjælp; 2014.

21.

Andersen MS, Johnsen SP, Sørensen JN, Jepsen SB, Hansen JB, Christensen EF. Implementing a nationwide criteria-based emergency medical dispatch system: A register-based follow-up study. Scand J Trauma Resusc Emerg Med [Internet]. 2013;21(1):53. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3708811&tool=pmcentrez&rendertype=abstract

22.

Olesen F, Jolleys J V. Out of hours service: the Danish solution examined. BMJ [Internet]. 1994;309(6969):1624–6. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2542018&tool=pmcentrez&rendertype=abstract

23.

Region Hovedstaden. Afrapportering af akut og præhospital indsats i Region Hovedstaden [Internet]. 2013. Available from: https://www.regionh.dk/om-region-hovedstaden/Den-Praehospitale-Virksomhed/om-akutberedskabet/publikationer/Documents/Aarsrapport 2013_April 2014_Endelig.pdf.

24.

Keizer E, Christensen MB, Carlsen AH, Smits M, Wensing M, Senn O, et al. Factors related to out-of-hours help-seeking for acute health problems: a survey study using case scenarios 11 medical and health sciences 1117 public health and health services. BMC Public Health. 2019;19(1):1–12.CrossRef

25.

Franks P, Gold MR, Fiscella K. Sociodemographics, self-rated health, and mortality in the US. Soc Sci Med. 2003;56(12):2505–14.CrossRef

26.

Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J chronic dis [internet]. 1987;40(5):373–83. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3558716.CrossRef

27.

Statistics Denmark. About Us - Statistics Denmark [Internet]. [cited 2016 Aug 29]. Available from: http://www.dst.dk/en/OmDS#.

28.

Thygesen SK, Christiansen CF, Christensen S, Lash TL, Sørensen HT. The predictive value of ICD-10 diagnostic coding used to assess Charlson comorbidity index conditions in the population-based Danish National Registry of Patients. BMC Med Res Methodol [Internet]. 2011;11(1):83. Available from: http://www.biomedcentral.com/1471-2288/11/83

29.

Schmidt M, Schmidt SAJ, Sandegaard JL, Ehrenstein V, Pedersen L, Sørensen HT. The Danish National Patient Registry: a review of content, data quality, and research potential. Clin Epidemiol [Internet]. 2015 Nov;7:449. Available from: https://www.dovepress.com/the-danish-national-patient-registry-a-review-of-content-data-quality%2D%2Dpeer-reviewed-article-CLEP

30.

Koshy S, Kean C, Fuchs BD. Severe sepsis cohorts derived from claims-based strategies appear to be biased towards a more severely ill patient population. Crit Care Med [Internet] 2014;41(4):1–15. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3810475/

31.

Faiz KW, Sundseth A, Thommessen B, Rønning OM. Prehospital delay in acute stroke and TIA. Emerg Med J. 2013;30(8):669–74.CrossRef

32.

Lehm KK, Andersen MS, Riddervold IS. Non-urgent emergency callers: characteristics and prognosis. Prehospital Emerg Care [Internet] 2017 Mar 4;21(2):166–73. Available from: https://www.tandfonline.com/doi/full/10.1080/10903127.2016.1218981.

33.

Sun BC, Hsia RY, Weiss RE, Zingmond D, Liang L-J, Han W, et al. Effect of emergency department crowding on outcomes of admitted patients NIH public access author manuscript. Ann Emerg Med [Internet] 2011;61(6):605–11. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3690784/pdf/nihms-445308.pdf.CrossRef

34.

Singer AJ, Thode HC, Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011;18(12):1324–9.CrossRef

35.

Freitas A, Silva-Costa T, Lopes F, Garcia-Lema I, Teixeira-Pinto A, Brazdil P, et al. Factors influencing hospital high length of stay outliers. BMC Health Serv Res. 2012;12(1).

36.

Hamilton BH, Sheth A, McCormack RT, McCormack RP. Imaging of frequent emergency department users with alcohol use disorders. J Emerg Med. 2014;46(4):582–7.CrossRef

37.

Seymour CW, Kahn JM, Martin-Gill C, Callaway CW, Yealy DM, Scales D, et al. Delays from first medical contact to antibiotic administration for sepsis. Crit Care Med. 2017;45(5):759–65.CrossRef

38.

Loots FJ, Smits M, van Steensel C, Giesen P, Hopstaken R, van Zanten AR. Management of sepsis in out-of-hours primary care: a retrospective study of patients admitted to the intensive care unit. Br J Gen Pract. 2018;68(suppl 1):e022832. bjgp18X696653.CrossRef

39.

Meischke H, Ho MT, Eisenberg MS, Schaeffer SM, Larsen MP. Reasons patients with chest pain delay or do not call 911. Ann Emerg Med. 1995.

40.

Lozzi L, Carstensen S, Rasmussen H, Nelson G. Why do acute myocardial infarction patients not call an ambulance? An interview with patients presenting to hospital with acute myocardial infarction symptoms. Intern Med J. 2005;35(11):668–71.CrossRef

41.

Mackian S, Bedri N, Lovel H. Up the garden path and over the edge: where might health-seeking behaviour take us? Health Policy Plan. 2004;19(3):137–46.CrossRef

42.

Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank Mem fund Q health Soc [internet]. 1973;51(1):95–124. Available from: http://www.ncbi.nlm.nih.gov/pubmed/4198894.CrossRef

Title: Contacting out-of-hours primary care or emergency medical services for time-critical conditions - impact on patient outcomes
Authors: Morten Breinholt Søvsø
Morten Bondo Christensen
Bodil Hammer Bech
Helle Collatz Christensen
Erika Frischknecht Christensen
Linda Huibers
Publication date: 01-12-2019
Publisher: BioMed Central
Keywords: Stroke
Septicemia
Septicemia
Care
Myocardial Infarction
Published in: BMC Health Services Research / Issue 1/2019
Electronic ISSN: 1472-6963
DOI: https://doi.org/10.1186/s12913-019-4674-0

At a glance: The STEP trials

Springer Medicine

Contacting out-of-hours primary care or emergency medical services for time-critical conditions - impact on patient outcomes

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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