Parents' beliefs and expectations when presenting with a febrile child at an out-of-hours general practice clinic.
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On the basis of structured interviews with 146 parents, this study describes why and when parents of acutely ill children seek the out-of-hours service, what actions they might have taken beforehand, and their expectations as to the outcome of the consultation. A total of 46% of the parents did not consider their child's condition to be serious, but 12% throught that their child was very ill. Parents sought medical advice because of what they perceived to be a lack of control of the condition (49%), fear of a serious disease (17%), and for symptom relief (34%). All except three parents expected there to be an examination of their child, and 79% expected an explanation or a diagnosis. Only 13% spontaneously mentioned that they expected a prescription. It is clinical and communicative skills that prevail in promoting successful consultations in this setting. (+info)
Surgical OGD--a dying art?
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INTRODUCTION: Reductions in surgical training and the increases in medical gastroenterology have raised concerns that surgeons may not be adequately trained in upper gastrointestinal (GI) endoscopy. METHOD: To evaluate this problem, a questionnaire was sent to all current surgical specialist registrars (SpRs) in the South Thames East Region. RESULTS: There was an 82% (52/63) response rate. Only 50% (26/52) of trainees had received more than 6 months' training in upper GI endoscopy. 83% (43/52) were in posts which did not provide adequate elective exposure for training. 50% (26/52) were required to provide an emergency service, despite a paucity of experience and less than 50% were able to perform therapeutic injection. In the main, emergency endoscopy is performed with substandard equipment, poor facilities, and untrained staff. CONCLUSIONS: Surgical trainees are poorly trained and do not have the necessary skills to provide an emergency service for upper GI haemorrhage. Emergency endoscopy facilities are severely under resourced. (+info)
Effect of NHS walk-in centre on local primary healthcare services: before and after observational study.
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OBJECTIVE: To assess the effect of an NHS walk-in centre on local primary and emergency healthcare services. DESIGN: Before and after observational study. SETTING: Loughborough, which had an NHS walk-in centre, and Market Harborough, the control town. PARTICIPANTS: 12 general practices. MAIN OUTCOME MEASURES: Mean daily rate of emergency general practitioner consultations, mean number of half days to the sixth bookable routine appointment, and attendance rates at out of hours services, minor injuries units, and accident and emergency departments. RESULTS: The change between the before and after study periods was not significantly different in the two towns for daily rate of emergency general practice consultations (mean difference -0.02/1000 population, 95% confidence interval -0.75 to 0.71), the time to the sixth bookable routine appointment (-0.24 half-days, -1.85 to 1.37), and daily rate of attendances at out of hours services (0.07/1000 population, -0.06 to 0.19). However, attendance at the local minor injuries unit was significantly higher in Loughborough than Market Harborough (rate ratio 1.22, 1.12 to 1.33). Non-ambulance attendances at accident and emergency departments fell less in Loughborough than Market Harborough (rate ratio 1.17, 1.03 to 1.33). CONCLUSIONS: The NHS walk-in centre did not greatly affect the workload of local general practitioners. However, the workload of the local minor injuries unit increased significantly, probably because it was in the same building as the walk-in centre. (+info)
Impact of NHS walk-in centres on the workload of other local healthcare providers: time series analysis.
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OBJECTIVES: To assess the impact of NHS walk-in centres on the workload of local accident and emergency departments, general practices, and out of hours services. DESIGN: Time series analysis in walk-in centre sites with no-treatment control series in matched sites. SETTING: Walk-in centres and matched control towns without walk-in centres in England. PARTICIPANTS: 20 accident and emergency departments, 40 general practices, and 14 out of hours services within 3 km of a walk-in centre or the centre of a control town. MAIN OUTCOME MEASURES: Mean number (accident and emergency departments) or rate (general practices and out of hours services) of consultations per month in the 12 month periods before and after an index date. RESULTS: A reduction in consultations at emergency departments (-175 (95% confidence interval -387 to 36) consultations per department per month) and general practices (-19.8 (-53.3 to 13.8) consultations per 1000 patients per month) close to walk-in centres became apparent, although these reductions were not statistically significant. Walk-in centres did not have any impact on consultations on out of hours services. CONCLUSION: It will be necessary to assess the impact of walk-in centres in a larger number of sites and over a prolonged period, to determine whether they reduce the demand on other local NHS providers. (+info)
Use of out of hours services: a comparison between two organisations.
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OBJECTIVES: To investigate differences in numbers and characteristics of patients using primary or emergency care because of differences in organisation of out of hours care. BACKGROUND: Increasing numbers of self referrals at the accident and emergency (A&E) department cause overcrowding, while a substantial number of these patients exhibit minor injuries that can be treated by a general practitioner (GP). METHODS: Two different organisations of out of hours care in two Dutch cities (Heerlen and Maastricht) were investigated. Important differences between the two organisations are the accessibility and the location of primary care facility (GP cooperative). The Heerlen GP cooperative is situated in the centre of the city and is respectively 5 km and 9 km away from the two A&E departments situated in the area of Heerlen. This GP cooperative can only be visited by appointment. The Maastricht GP cooperative has free access and is located within the local A&E department. During a three week period all registration forms of patient contacts with out of hours care (GP cooperative and A&E department) were collected and with respect to the primary care patients a random sample of one third was analysed. RESULTS: For the Heerlen and Maastricht GP cooperative the annual contact rate, as extrapolated from our data, per 1000 inhabitants per year is 238 and 279 respectively (chi(2)((1df))=4.385, p=0.036). The contact rate at the A&E departments of Heerlen (n=66) and Maastricht (n=52) is not different (chi(2)((1df))=1.765, p=0.184). Some 51.7% of the patients attending the A&E department in Heerlen during out of hours were self referred, compared with 15.9% in Maastricht (chi(2)((1df))=203.13, p<0.001). CONCLUSIONS: The organisation of out of hours care in Maastricht has optimised the GP's gatekeeper function and thereby led to fewer self referrals at the A&E department, compared with Heerlen. (+info)
A systematic review of the effect of different models of after-hours primary medical care services on clinical outcome, medical workload, and patient and GP satisfaction.
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BACKGROUND: The organization of after-hours primary medical care services is changing in many countries. Increasing demand, economic considerations and changes in doctors' attitudes are fueling these changes. Information for policy makers in this field is needed. However, a comprehensive review of the international literature that compares the effects of one model of after-hours care with another is lacking. OBJECTIVE: The aim of this study was to carry out a systematic review of the international literature to determine what evidence exists about the effect of different models of out-of-hours primary medical care service on outcome. METHODS: Original studies and systematic reviews written since 1976 on the subject of 'after-hours primary medical care services' were identified. Databases searched were Medline/Premedline, CINAHL, HealthSTAR, Current Contents, Cochrane Reviews, DARE, EBM Reviews and EconLit. For each paper where the optimal design would have been an interventional study, the 'level' of evidence was assessed as described in the National Health and Medical Research Council Handbook. 'Comparative' studies (levels I, II, III and IV pre-/post-test studies) were included in this review. RESULTS: Six main models of after-hours primary care services (not mutually exclusive) were identified: practice-based services, deputizing services, emergency departments, co-operatives, primary care centres, and telephone triage and advice services. Outcomes were divided into the following categories: clinical outcomes, medical workload, and patient and GP satisfaction. The results indicate that the introduction of a telephone triage and advice service for after-hours primary medical care may reduce the immediate medical workload. Deputizing services increase immediate medical workload because of the low use of telephone advice and the high home visiting rate. Co-operatives, which use telephone triage and primary care centres and have a low home visiting rate, reduce immediate medical workload. There is little evidence on the effect of different service models on subsequent medical workload apart from the finding that GPs working in emergency departments may reduce the subsequent medical workload. There was very little evidence about the advantages of one service model compared with another in relation to clinical outcome. Studies consistently showed patient dissatisfaction with telephone consultations. CONCLUSIONS: The rapid growth in telephone triage and advice services appears to have the advantage of reducing immediate medical workload through the substitution of telephone consultations for in-person consultations, and this has the potential to reduce costs. However, this has to be balanced with the finding of reduced patient satisfaction when in-person consultations are replaced by telephone consultations. These findings should be borne in mind by policy makers deciding on the shape of future services. (+info)
Outcome of primary angioplasty for acute myocardial infarction during routine duty hours versus during off-hours.
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OBJECTIVES: We sought to investigate the impact of circadian patterns in the onset of acute myocardial infarction (AMI) on the practice of primary angioplasty. BACKGROUND: A circadian variation in the time of onset of AMI with a peak in the morning hours has been described. METHODS: We studied 1,702 consecutive patients with acute ST-segment elevation myocardial infarction treated with primary angioplasty. We observed circadian variation in frequency of symptom onset, hospital admission, and first balloon inflation. Circadian patterns of symptom onset, hospital admission, and balloon inflation are similar. RESULTS: A majority of patients have symptom onset (53%), hospital admission (53%), and first balloon inflation (52%) during routine duty hours (0800 to 1800 h). There were no differences in baseline clinical characteristics or treatment delays between routine duty hours and off-hours patients. Hospital admission between 0800 and 1800 was associated with an angioplasty failure rate of 3.8%, compared with 6.9% between 1800 and 0800, p < 0.01. Thirty-day mortality was 1.9% in patients with hospital admission between 0800 and 1800, compared with 4.2% in patients with hospital admission between 1800 and 0800, p < 0.01. CONCLUSIONS: Circadian variations may have a profound effect on the practice of primary angioplasty. A majority of patients are treated during routine duty hours. Patients treated during off-hours have a higher incidence of failed angioplasty and consequently a worse clinical outcome than patients treated during routine duty hours. (+info)
After-hour home care service provided by a hospice in Singapore.
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A home care Hospice programme was set up to provide care to the patients with advanced diseases and their families in Singapore. After office-hour, the service is managed by a doctor on weekdays, with the assistance of a nurse during daytime on Saturdays, Sundays and public holidays. The doctor on-call made an average of 3.1 phone calls and 1.3 visits each weekday evening. Over the weekends and public holidays, there were a mean of 16.7 phone calls and 6 visits each day. More than half of the visits (50.3%) were made for certification of death. The commonest symptoms that prompted visits were dyspnoea (20%) and pain (12.2%). The busiest period during weekdays was between 6.00 pm and 11.00 pm, when our doctors did most of their visits. The workload of the hospice home care service is likely to increase and resources such as family health physicians can be explored to help to meet this increasing demand. This can be achieved through the provision of comprehensive training and easy accessibility to medical records which are kept with patients. (+info)