Summary
Almost one per cent of patients required urgent admission to secondary care within 3 days of an initial consultation in this UK OOH primary care service. Patients who were older, had used the service more often, and presented to the service at times of low calls were at higher risk. Over two-thirds of the patients who required escalation of care after re-attending within 3 days were initially discharged with either no follow-up or advice to contact their own GP.
Patients presenting with social, mental health, gastrointestinal, and cardiac problems were at highest risk of requiring delayed escalation of care. The social descriptor is often used to indicate a functional decline, which means that the patient can no longer manage in their usual home environment without a clear medical cause. This may indicate that acute illness can initially present as a functional decline, particularly for frail, older patients with multimorbidity, and a medical diagnosis can become more manifest over ensuing days.
Implications for research and practice
The present analysis suggests a number of measures that could reduce the number of patients who have delayed escalation to secondary care, which could be applied either separately or in combination.
Presentation at times of low call volume for the OOH service was associated with higher risk of ‘delayed escalation’. Periods of low call volume are commonly covered by smaller numbers of clinicians. Therefore, the pressures of the service may lead to deferred decision-making by telephone triage until more staff are available, for example, to offer a home visit the following day. Norwegian OOH GPs described the challenges of balancing practical issues and clinical need when offering home visits with limited clinician resources.14 The GP’s tolerance of risk has been shown to be an important factor for decisions about admission from OOH care. GPs self-rating as cautious refer more often than those rating themselves as good at living with risk and uncertainty.6 GPs choosing to work in overnight OOH shifts, which are considered to be more pressured, may be a selected group of clinicians who have higher risk tolerance. Increasing the number of clinicians available in this time period may allow more timely review of higher-risk patient groups and encourage more clinicians to consider these shifts.
Over two-thirds of the ‘delayed escalation’ population were discharged at their initial consultation and just 3.5% were offered follow-up by the OOH service. Active followup could allow OOH services to detect deterioration earlier, and offer the potential for enhanced input to meet clinical need without an emergency admission. The patient group targeted for follow-up should include older patients, particularly those presenting with unexplained functional decline, patients initially presenting overnight, and patients with mental health, cardiac, and gastrointestinal problems where there is diagnostic doubt. A records-based follow-up list, with a planned telephone review period of 12 or 24 hours, could be employed. This would be particularly beneficial over the weekend, when the OOH service has continuity of care, and could also allow secondary care to highlight patients requiring community follow-up after discharge.
Patients who had contacted the OOH service previously were more likely to require escalation of care within 3 days. In European OOH services these patients have been shown to have higher occurrences of chronic disease and psychiatric illness;15,16 these are populations in which the decision to admit is likely to be more challenging. Enhanced sharing of information with the in-hours GP practice could facilitate shared management plans and reduce the risk of deterioration out-of-hours. Similarly, the present finding that 14.7% of the ‘delayed escalation’ population had been referred to secondary care at their initial consultation suggests that feedback on the outcomes of admissions from the OOH service would be highly beneficial in informing further management of these challenging patients. At present, OOH clinicians have no access to feedback on the decisions they make regarding referral. They would not learn about subsequent referral to secondary care, an immediate discharge following an admission, or even, unless it was particularly noteworthy, a death. Without such feedback, clinicians are unable to learn from their experiences in this higher risk setting.
Improving the detection and management of patients who are on a declining trajectory requires research to understand the presenting features, the final diagnosis, and the outcome of escalation of care in this patient group. Improving care delivery through support for decision-making and follow-up models requires research into the type of clinicians used in OOH care pathways, availability of diagnostic testing, staffing levels at the time of assessment, and optimal timing of clinical review. This will allow OOH follow-up to be targeted at the highest-risk patients, and will enable development of decision support such as use of point-of-care testing, which could identify conditions notoriously difficult to detect clinically at an early stage (for example, acute kidney injury), as well as reduce inappropriate referral decisions. This will allow understanding of the impact of clinician experience and pressure on referral decisions and evaluation of whether the admissions were clinically justified or could have been prevented with alternative management strategies.
The present findings need to be confirmed and extended through multicentre studies or collaborations between different OOH service providers covering different UK populations that share data on re-attendance and escalation. Furthermore, definitive clinical outcome data after escalation to secondary care will be most efficiently gathered through local data-sharing partnerships between an OOH provider and secondary care organisations to enable linkage of patient data. New models of care incorporating active review by the OOH service will also need to be evaluated alongside routine care from different OOH service providers to assess their clinical-and cost-effectiveness. It is appreciated that increasing the number of GPs available in OOHs services, however desirable, is not easy at the present time. Understanding how to support decision-making by different healthcare professionals assessing patients in an OOH service, focusing more directly on those patients who are particularly at risk of missing a needed referral, and putting in place more active follow-up when such patients are seen, are potential strategies, however, to improve the safety of OOH primary care.
