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

Ingrid Keilegavlen Rebnord, Geir Thue, Steinar Hunskår About the authors
Artikkel

In Norway, availability of medical services at all hours is a municipal responsibility, and each municipality is obliged to organize the service and provide premises, equipment and assisting personnel for the doctor on call. Prerequisites for good medical quality – in terms of availability and control of equipment – has not been investigated to a large extent. Type of equipment and personnel that should be available for a doctor on call has not been defined in any Norwegian regulation, national standard or agreement. We have therefore investigated availability of equipment, laboratory analyses and drugs (for diagnostics and treatment) and routines for cardiopulmonary resuscitation, laboratory work and handling of drugs.

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.

Equipment for diagnostics and treatment

Table 1 shows availability of various equipment for doctors on call. X-ray, ultrasound apparatus and alcometer are rarely available, while more than 90 % of OOH services have access to ECG, urine catheter, othoscope and ophthalmoscope, as well as equipment for suture, gynecologic examinations and intravenous access. Almost all services also had eye-rinsing fluid, pulverization apparatus, oxygen apparatus and a defibrillator.

Emergency bags and special luminous coats for use during emergency calls are less available at OOH services without shared premises. OOH services with shared premises are generally better equipped (especially the smaller ones) than those without shared premises.

Table 1  Availability of equipment by number and size of OOH districts and whether premises are shared or not

OOH services (N = 209)

Shared premises < 10 000 inhab. (n = 125)

Shared premises > 10 000 inhab. (n = 25)

Not shared premises (n = 59)

No.

(%)

ECG

207

(99)

125

25

57

Urine catheter

207

(99)

123

25

59

Ophthalmoscope/ othoscope

207

(99)

124

25

58

Intravenous canula

205

(98)

123

25

57

Equipment for wound suture

205

(98)

124

25

56

Gynecological equipment

203

(97)

122

25

56

Eye drops

201

(96)

119

25

57

Pulverization apparatus

201

(96)

122

24

55

Oxygen apparatus

199

(95)

120

24

55

Permanent urine catheter

199

(95)

119

24

56

Equipment for eye rinsing

196

(94)

117

24

55

Bag/mask for ventilation

196

(94)

117

23

56

Emergency bag

185

(89)

113

22

50

Defibrillator

183

(88)

113

23

48

Bacteriological media

179

(86)

115

22

42

Rectal thermometer

179

(86)

105

20

54

Vision chart

177

(85)

112

22

43

PEF equipment

174

(83)

111

19

44

Suction

167

(80)

103

19

45

Tonometer

166

(79)

109

23

34

Laryngeal tube

164

(78)

97

20

47

Sterilization equipment

160

(76)

91

22

47

Special luminous emergency coat

154

(74)

97

22

35

Microscope

153

(73)

100

17

36

Tamponade equipment

148

(71)

93

20

35

ECG interpretation module

146

(70)

89

17

40

Magnifying lamp

144

(69)

86

19

39

Rectoscope/ anoscope

145

(69)

105

20

20

Endotracheal tubes

142

(68)

91

19

32

Virological media

133

(64)

95

16

22

Oxymeter

134

(64)

83

9

42

Ear thermometer

128

(61)

67

14

47

Spirometer

119

(57)

94

16

9

Equipment for laryngoscopy

102

(48)

75

10

17

Equipment for gastric lavage

94

(45)

77

10

7

Equipment for casting

93

(44)

77

6

10

Heart monitoring system

89

(42)

59

5

25

Intraosseous canula

69

(33)

54

6

9

Equipment for suture of ligaments

54

(25)

38

4

12

Ultrasound apparatus

30

(14)

20

3

7

X-ray apparatus

28

(13)

16

4

8

Alcometer

11

(5)

5

0

6

Laboratory analyses

Six laboratory tests are available at almost all OOH services: CRP, blood sugar, urine stick, pregnancy test, streptococcus antigen test and haemoglobin (tab 2). Only a few OOH services have the possibility to do clinical chemical analyses such as potassium, ALAT and creatinine.

Quick tests for CK-MB, D-dimer and troponin are also rare. INR analysis is available in every fourth OOH service, i.e. mainly in those with shared premises (in which equipment is also shared with the GP office). Only 3 % (2/59) of OOH services without shared premises have the INR analysis. We see the same tendency for HbA1c and cell counts. The opposite is the case for diagnostic kits for mononucleosis and Chlamydia, which are common in OOH services without shared premises.

Table 2  Availability of laboratory analyses by number and size of OOH districts and whether premises are shared or not

OOH services (N = 209)

Shared premises < 10 000 inhab. (n = 125)

Shared premises > 10 000 inhab. (n = 25)

Not shared premises (n = 59)

No.

(%)

CRP

207

(99)

123

25

59

Urine strip

200

(96)

119

24

57

Glucose

200

(96)

118

23

59

Urine-HCG

194

(93)

118

20

56

Strep test

193

(92)

113

22

58

Haemoglobin

190

(91)

113

21

56

Blood in faeces

157

(75)

99

17

41

Urine cultivation

121

(58)

83

18

20

Mononucleosis test

116

(56)

57

14

45

Urine microscope

102

(48)

68

11

23

SR

69

(33)

57

6

6

Chlamydia test

55

(26)

29

6

20

INR

52

(25)

45

5

2

HbA1c

32

(15)

27

4

1

Cell counter

28

(13)

21

5

2

Leucocytes

22

(11)

16

4

2

Trombocytes

19

(9)

13

4

2

D-dimer

13

(6)

9

1

3

Troponin

12

(6)

7

0

5

ALAT

8

(4)

4

1

3

Creatinine

8

(4)

4

1

3

Influenza test

8

(4)

5

1

2

GT

7

(3)

4

0

3

Urate

6

(3)

3

0

3

Potassium

5

(2)

2

1

2

CK-MB

4

(2)

2

0

2

Cholesterol

3

(2)

2

0

1

Helicobacter pylori

4

(2)

4

0

0

Sodium

3

(1)

1

0

2

Drugs

All OOH services have some drugs available, and most of them have a broad spectre of drugs on stock (tab 3). The OOH services usually buy and store the drugs themselves, only 5 % of them state that doctors on call are responsible for providing necessary drugs. 44 % of OOH services that buy drugs for their own use buy single doses meant to be sufficient until the pharmacy opens. 48 % of the services also have small packages of drugs for sale, while a few of them only have drugs for internal use. Concerning availability of drugs, OOH services with shared premises were only slightly different from those that did not share premises.

Table 3  Availability of drugs by number and size of OOH districts and whether premises are shared or not

OOH districts (N = 209)

Shared premises < 10 000 inhab. (n = 125)

Shared premises > 10 000 inhab. (n = 25)

Not shared premises (n = 59)

No.

(%)

Drugs for injection

Adrenalin

206

(98)

124

25

58

Hydrocortisone

203

(97)

124

24

55

Metoclopramide

199

(95)

124

23

51

Diphtheria-/tetanusvaccine

198

(95)

118

25

55

Opioids

195

(93)

122

22

51

Diclophenac

194

(93)

115

25

54

Diazepam

193

(92)

122

20

51

Naloxone

192

(92)

117

23

52

Atropine

188

(90)

117

24

47

Glucose 50 %

186

(89)

119

22

45

Furosemide

186

(88)

122

22

42

Ringer-acetate

185

(88)

117

21

47

Terbutaline

176

(84)

114

21

41

Aminophylline

176

(84)

114

21

43

NaCl for infusion

164

(78)

106

19

39

Dexchlorpheniramine

162

(77)

99

18

45

Antipsychotics

159

(76)

108

20

31

Glucagon

157

(75)

104

20

33

Penicillin G

157

(75)

118

15

24

Glucose for infusion

150

(71)

98

17

35

Verapamil

138

(66)

95

16

27

Insulin

125

(59)

82

12

31

Flumazenil

106

(50)

71

11

24

Antithrombotic drugs

92

(44)

73

4

15

Amiodarone

88

(42)

63

10

15

Chloramphenicol

72

(34)

63

4

5

Hepatitis B-vaccine

43

(20)

30

1

12

Tiamine

28

(13)

25

2

1

Hepatitis B-immunoglobulin

18

(9)

9

0

9

Drugs for oral use

Nitroglycerin

207

(99)

124

25

58

Acetylsalicylic acid

206

(98)

123

25

58

Penicillin V

204

(97)

124

24

56

Macrolids

201

(96)

122

23

56

Doxycycline

200

(96)

123

22

55

NSAID drugs

200

(96)

122

23

55

Prednisolone

198

(95)

121

23

54

Mecillinam

198

(95)

121

22

55

Paracetamol

198

(95)

121

23

54

Antihistamine

196

(94)

119

23

54

Broad-spectred penicillin

194

(92)

120

21

53

Trimethoprim

190

(91)

118

20

52

Diuretics

183

(88)

118

21

44

Paracetamol/codeine

182

(87)

117

22

43

Anxiolytics

176

(84)

116

19

41

Antipsychotic drugs

171

(82)

111

18

42

Dicloxacillin, clindamycine

165

(79)

110

15

40

Hypnotic drugs

155

(74)

108

15

32

Betamethasone

153

(73)

98

18

37

Opiates

151

(72)

106

16

29

H2-blocker

147

(70)

93

16

37

Trimethoprim-sulpha

146

(69)

92

13

41

Loperamide

140

(66)

91

15

34

Laxative

127

(61)

88

10

29

Migraine drugs

118

(57)

77

8

33

Carbamazepine

96

(46)

65

6

25

Warfarin

63

(30)

55

3

5

Drugs for inhalation

Terbutaline/salbutamol

202

(96)

120

24

58

Ipratropium bromide

183

(87)

110

21

52

Racemic adrenalin

165

(78)

101

20

44

Drugs for local use

Fusidin/antiseptic drugs

198

(95)

120

25

53

Chloramphenicol

204

(97)

122

25

57

Flamazine

198

(95)

119

25

54

More than 90 % of OOH services have the following drugs for injection (tab 3): adrenaline, hydrocortisone, metoclopramide, tetanus-/diphtheria vaccine, opiates, diclophenac, diazepam, naloxone and atropine. In general, small OOH services with shared premises are best equipped, while those that do not share premises have fewest drugs for injection – larger OOH services with shared premises come in a position between the two first. Antibiotics for injection, antiarrhythmic drugs and antithrombotic drugs indicated in heart attack are far more prevalent in services with shared premises, especially in the smaller ones.

Many OOH services have a large choice of drugs for oral use. Small services have a broader offer than the two other types of services. Typical drugs on offer are anxiolytics such as diazepam, antipsychotic drugs, hypnotics and opiates, but also antibiotics (e.g. dicloxacillin and clindamycin), laxatives and warfarin, and to a certain extent carbamazepin and drugs against migraine attacks (tab 3).

Some routines in OOH services

52 % of doctors are offered regular (at least once a year) training in advanced cardiopulmoary resuscitation, 31 % practice less than this and 17 % never practice. At OOH services with shared premises, 55 % of the assisting personnel practice cardiopulmoary resuscitation annually or more often, while this is the case for 60 % of doctors – i.e. quite similar frequencies. In OOH services without shared premises the assisting personnel practice more often than the doctors; 74 % at least annually, versus only 40 % of doctors.

In small OOH services with shared premises doctors on call take the samples and do the analyses themselves in 88 % of cases, versus 56 % at larger OOH services with shared premises. Assisting personnel in the OOH service are responsible for internal and external quality assurance in almost all cases. In 90 % of OOH services without shared premises (n = 59) employed assisting personnel do the sampling and analyze blood samples. Nurses do internal quality assurance in 86 % of OOH services, but also ambulance workers are involved in this (in 10 % of the OOH services without shared premises). Interal quality control is done regulary in 71 % of the OOH services, sporadically or less often than every other week in 16 % of them, in 4 % of them upon suspicion of a mistake, while in 8 % of cases there are no routines in place for such controls. 73 % of the OOH services without shared premises have external quality control throught their own membership in NOKLUS.

85 % of OOH services state that all their employees have access to guidelines for all equipment and that new employees are trained and shown how to use it. Laboratory binders from NOKLUS are available in 68 % of the OOH services. Samples are sent with a messenger in 24 % of the OOH services and by normal post in 58 % of the services, while 10 % deliver themselves.

67 % of OOH services have written routines for handling of blood contamination and cuts, in 19 % of services the doctor on call decides the measures to be taken; in 7 % the doctor in charge (medically responsible) takes responsibility, while 7 % of OOH services have no routines for this. 64 % of OOH services offer employed health personnel (not those on short-term contracts) vaccination against hepatitis B; the services without shared premises offer such vaccination to the highest proportion of employees (78 %).

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.

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