Equipment, laboratory analyses and drugs in out-of-hours services in Norwegian municipalities

Material and method

The National Centre of Emergency Primary Health Care has established a registry for all Norwegian OOH (out-of-hours) services (the Primary Care Registry) (1, 2). In spring 1982, a questionnaire was sent to 282 host municipalities that either had their own OOH service or participated in an intermunicipal medical emergency cooperative (according to the registry). One reminder was sent.

The questionnaire had multiple-choice answers and some space for additional information, and consisted of four parts. Knowledge about equipment and routines at GP offices and some larger OOH services formed the basis for developing the response options. The managers were requested to take responsibility for completing the form. In the first part of the form they had to check off for type of equipment available for doctors on call during evenings and nights. We also asked about how often doctors and assisting personnel practiced cardiopulmonary resuscitation.

In the second part of the form we asked about types of laboratory analyses performed by the OOH service, types of personnel who do the sampling and analyses and how samples were transported to an external laboratory. The third part of the form was about which routines the OOH service had for training personnel in use of laboratory equipment and for quality control of the equipment, and if the OOH service was a member of NOKLUS (Norwegian Quality Improvement of Primary Care Laboratories). They were also asked about routines for cuts and blood contamination and if the employees were offered hepatitis B vaccination. In the last part of the form we asked about routines for storage and distribution of drugs. Drugs available in the OOH service were to be checked off from a list consisting of 30 drugs for intravenous use, 27 for oral use, three for inhalation and three for local use.

Based on information from the Primary Care Registry (1), the OOH services were grouped according to whether they had more or less than 10 000 inhabitants in their district. OOH districts with more than 10 000 inhabitants have often employed assisting personnel part of the time or around the clock – how many depend on the number of inhabitants they serve. The analyses also take into account whether the OOH services shared premises and assisting personnel with GP offices or emergency care units or did not share premises or assisting personnel with anyone. SPSS version 13.0 was used to make simple cross-table presentations and frequency analyses.

Results

261 of the 282 municipalities in the registry study had their own OOH service in evenings and nights. 223 of the 261 municipalities responded, rendering a response rate of 85. The service offered in evenings was about the same as that offered during nights. 14 of the OOH services shared premises with emergency care units and thereby had access to other services and equipment than the others, they are therefore not further described. The OOH services without shared premises all serve at least 10 000 inhabitants. Services that share premises with GP offices were divided into two groups according to number of inhabitants they serve (more or less than 10 000 inhabitants). Data from these three groups (n = 209) are presented.

Discussion

In this study we have investigated type of equipment, drugs and laboratory analyses that doctors on call in Norwegian OOH services can expect to be available for them. A response rate of 85 % provides us with a representative sample from OOH services organized in different ways. We have not investigated skills or whether the equipment has been used correctly, only the availabilty of equipment. The overview provided is just a reflection of reality and should not be regarded as recommended standards for properly equipped OOH services. It also remains unknown whether less equipped GP offices or OOH services can lead to erroneous medical diagnoses or prehospital treatment. This should be investigated in follow-up studies.

The study shows that Norwegian OOH services share premises with GP offices to a large extent and that the repertoire of equipment and analyses are determined by whether premises are shared or not. OOH services without shared premises have a narrower repertoire. This may be explained by the fact that many of the larger OOH services have a central location with a short distance to ambulance, hospital and pharmacy (2). Types of equipment requiring much competence, and expensive machines – such as ultrasound and X-ray – are not readily available in Norwegian OOH services. Some equipment is mainly available because it is used in the GP office; e.g. rectoscope/anoscope, spirometer and equipment for indirect laryngoscopy. However, equipment used for casting, gastric lavage and intraosseous needle, is used most often when there is a certain distance to hospital; i.e. in smaller OOH services and in rural districts. In certain OOH districts the health trust is responsible for all patients calls with the priority grade «red response» (1); this can be explained by the lower availability of equipment for medical emergencies and drugs found at OOH services that do not share premises with others. We also found that A and B drugs are less available in these services. This may have several explanations; the most likely is that strict requirements for handling, storage and prescription of these drugs cause OOH services that consider they can manage without them to not have them on stock. When open-around-the clock pharmacies are in the vicinity, the patients can get the drugs there.

Laboratory analyses are used in connection with one third of patient consultations, according to NAV (the Norwegian Labour and Welfare Administration) statistics from 2006. CRP-analyses are used most often, as shown by fees for CRP being included in 93 % of remuneration cards for laboratory analyses (3). In our study we see that a large majority of OOH services use tests that are simple and quick, while few of them use more costly and time-consuming equipment and tests – such as those needed for clinical chemical analyses and cell counts.

Some of the differences we have found can be explained by centrality of the service and whether or not premises are shared, but lack of requirements on availability of equipment indicate that economical factors should also be taken into account. National guidelines on types of equipment required in the OOH services would dimish these differences. The general advice provided in «Handbook for OOH services» is closest to what could be regarded as national guidance. It is not known to what extent the OOH services use this Handbook or other guidelines, so meaningful comparisons cannot be made between our findings and available recommendations. National guidelines that outline the types of required equipment and the level of competence for health personnel working in OOH services should therefore be developed.

In OOH services with shared premises, the regular personnel at the GP office usually perform quality controls (external and internal) of the laboratory equipment that is also used by personnel working in the OOH services (including different doctors on call). In general, nurses and doctors on call have little training and experience with laboratory work. All Norwegian GP offices are members of NOKLUS, but this study shows that more than one fourth of OOH services without shared premises are not part of the quality assurance system of NOKLUS. Some also do not have access to guidelines for laboratory equipment or the NOKLUS folders. It should be investigated further whether this reduces the quality of analyses from the OOH services.

The information we have collected about hepatitis B vaccination provides little information about vaccination coverage, as most of those educated the last years have been vaccinated and doctors on call are their own employers (not employees of the OOH services). However, it does show that most OOH services emphasize safety for their employees, even though many of them still let vaccination be optional.

The frequency of training in advanced cardiopulmonary resuscitation is highly variable; it is lowest for doctors on call in larger OOH services without shared premises, while that for assisting personnel increases with the size of the service provider. This probably reflects that larger OOH services, with assisting and administrative personnel in a larger professional environment, have a better ability to organize systematic training. It is difficult to organize systematic training for all personnel in intermunicipal OOH services, because the doctors who take on duties are often not familiar with the district; many of them live in other municipalities and some of them work in hospitals in more densely populated areas and take on extra duties (4 – 6). The fact that many doctors practice cardiopulmoary resuscitation less often than once a year, can make it difficult to maintain the necessary competence over time (7, 8). Cooperation with ambulance personnel and other health professionals may also suffer because of this.

Conclusion

Available equipment and repertoire of analyses is highly dependant on whether the OOH service shares premises with a GP office, but also on the distance to ambulance, hospital and pharmacy. It may be unfortunate that much laboratory equipment is used by personnel with little experience in using it, this should be investigated further. Municipal OOH services should put more emphasis on regular training in cardiopulmonary resuscitation.