Efficiency and safety of ‘Unwell for no clear reason’ (table 1)
For the period of January 2018 to June 30 2018, 11622 calls were registered. 756 (6,6%) of these calls were allocated to the protocol ‘unwell for no clear reason’ of which a random sample of 180 calls was extracted and re-listened. 16 calls were excluded because of technical data base errors. In total 164 calls were included in the data-analysis. 60 (37%) calls took place in the morning, 45 (26,8%) in the afternoon, 44 (27%) in the evening and 15 (9,1%) during the night.
The label ‘fail to recognize keyword’ was allocated to 51 calls (31%), the label ‘correct protocol’ was allocated to 44 (27%) calls and the label ‘missing protocol’ to 37 (23%) calls . The label ‘fail of the operator’ was allocated to 23 (17%) calls of which 18 calls were labelled as ‘communication problem’. No call was labelled as ‘impossible to refer’.
When assessing the efficiency of allocation to a protocol, 104(64%) calls were labelled by the researchers as ‘unwell for no clear reason’. Eight calls (5%) were allocated to the protocol ‘dizziness’, six calls to the protocol ‘skin problems’ and five (3%) calls to ‘airway problems’. All other calls (n=41) were allocated less than five times to another protocol.
135 (82%) calls were referred to the out of hours primary care services and 23 (14%) calls were urgently referred to this care level. Planned care was advised in four (3%) calls. Two (1%) calls were referred to ‘ambulance intervention’.
When assessing the safety of referral, the researchers referred 111 (68%) calls to the same level of care as the operator did and 53 calls were referred to another care level. 36 (22% of total) of these calls were recognized as ‘over triage’. 17 (10% of total) calls were recognized as ‘under triage.
The allocation to an inappropriate protocol led in 25 (15%) calls to a discordance of the referral to a care level between the operator and the researcher. In 12 calls the referral was labelled as ‘over-triage’ and the referral of 13 calls was recognized as ‘under triage’. In 2 calls there was an ‘under triage’ of 2 levels.
The efficiency and safety of (referral to) the specific primary care protocols (tables 2)
For each of the 18 primary care protocols 15 calls were randomly selected for assessment. For seven protocols, less than 15 calls were available. In total, the researchers assessed 202 calls. 75 (37%) of the calls was recorded in the morning, 65 (32%) in the afternoon, 49 (24%) in the evening and 13 (7%) at night. The researchers assessed 126 (62%) calls as ‘correct protocol’, 13 (6%) calls as ‘missing protocol’, 48 (24%) as ‘fail to recognize keyword’, 12 (6%) as ‘fail of the operator’, 3 (2%) as ‘communication problem’. To determine the efficiency of the PCP the researchers assessed the referral to a protocol. 76 (37%) calls were referred to another protocol than the operators did: 16 (27%) calls were allocated to ‘unwell for no clear reason’, 10 (16%) to ‘child with fever’, 6 (10%) to ‘wounds’ 5 (8%) to ‘abdominal pain’ and 4 (7%) to both ‘ear-nose-throat’ and ‘allergic reaction’. 31 (15%) calls were referred less than three times to other protocols.
To determine the safety of referral to the PCP, the researchers assessed the allocation to the level of care. 175 calls (87%) were allocated to ‘out of hours primary care services’, 19 calls (9%) to ‘urgent out of hours primary care services’, 7 calls (3%) to ‘ambulance’ and 1 (1%) call to ‘planned care’. The researchers referred 46 (23%) calls to another care level: in 22 (11%) calls there was under-triage and in 24 (12%) over-triage. The researchers disagreed about the appropriate level of care in 10 calls. These calls were re-listened and discussed until the team reached consensus: two calls remained undetermined due to a language issue and due to missing administration of referral. The researchers labelled 99 (50%) calls as ‘correct protocol and correct care level’ and 27 (13%) calls as inappropriate protocol and correct care level’. 57 (28%) calls were labelled as ‘incorrect protocol’ but correct care level. In 19 (9%) cases, the researchers labelled a call as ‘inappropriate protocol and inappropriate care level’.
To determine the safety of referral to a care level using the PCP, 325 allocated patients received an assessment by the GP on duty (table 3). Seven assessments were incomplete and 68 assessments were completed after clinical judgement. In total 75 assessments were excluded for further analysis. 102 included assessments took place in the first weekend and 148 in the second weekend.
After assessment by the GP on duty, in the summer weekend the following reasons for encounter were withheld: 24 (23%) wound/skin problem, 15 (15% )stomach-intestines, 10 (10%) ear-nose-throat, 7 (7%) uro-genital, 6 (6%) allergic reaction/insect bite, 40 (39%) all other problems less than 2% prevalent. In the winter weekend prevalence of reason for encounter was in 45 cases (32%) ear-nose-throat, 19 (12%) lung, 15 (10%) stomach-intestines, 14 (9%) unwell for no clear reason, 10 (7%) uro-genital and 45 (30%) other reasons.
Of all patients presenting at the guard post, the operator allocated 184 (73%) cases to a regular consultation, 47 (19%) to regular home visit and 29 (8%) to urgent home visit. In summer versus winter 6 (5%) respectively 13 (9%) cases concerned an urgent home visit, 25 (25%) respectively 22 (15%) a regular home visit, 71 (70%) respectively 113 (76%) a regular consultation.
After assessment by the GP on duty, 236 (94,4%) calls were correctly referred with a small non-significant difference between summer and winter. In two (0.8%) cases the patients needed referring to a higher level of care and in 12 (5%) cases a lower level of care.