Factors associated with undertriage in patients classified by the need to visit a hospital by telephone triage: a retrospective cohort study

Background Prehospital telephone triage stratifies patients into five categories, “need immediate hospital visit by ambulance,” “need to visit a hospital within 1 hour,” “need to visit a hospital within 6 hours,” “need to visit a hospital within 24 hours,” and “do not need a hospital visit” in Japan. However, studies on whether present and past histories cause undertriage are limited in patients triaged as need an early hospital visit. We investigated factors associated with undertriage by comparing patient assessed to be appropriately triaged with those assessed undertriaged. Methods We included all patients classified by telephone triage as need to visit a hospital within 1 h and 6 h who used a single after-hours house call (AHHC) medical service in Tokyo, Japan, between November 1, 2019, and November 31, 2020. After home consultation, AHHC doctors classified patients as grade 1 (treatable with over-the-counter medications), 2 (requires hospital or clinic visit), or 3 (requires ambulance transportation). Patients classified as grade 2 and 3 were defined as appropriately triaged and undertriaged, respectively. Results We identified 10,742 eligible patients triaged as need to visit a hospital within 1 h and 6 h, including 10,479 (97.6%) appropriately triaged and 263 (2.4%) undertriaged patients. Multivariable logistic regression analyses revealed patients aged 16–64, 65–74, and ≥ 75 years (adjusted odds ratio [OR], 2.40 [95% confidence interval {CI} 1.71–3.36], 8.57 [95% CI 4.83–15.2], and 14.9 [95% CI 9.65–23.0], respectively; reference patients aged < 15 years); those with diabetes mellitus (2.31 [95% CI 1.25–4.26]); those with dementia (2.32 [95% CI 1.05–5.10]); and those with a history of cerebral infarction (1.98 [95% CI 1.01–3.87]) as more likely to be undertriaged. Conclusions We found that older adults and patients with diabetes mellitus, dementia, or a history of cerebral infarction were at risk of undertriage in patients triaged as need to visit a hospital within 1 h and 6 h, but further studies are needed to validate these findings.

Pre- and post-home visit behaviors after using after-hours house call (AHHC) medical services: a questionnaire-based survey in Tokyo, Japan

Background After-hours house call (AHHC) medical services have been implemented in Japan to reduce ambulance use, as well as overcrowding at the emergency department (ED). Examining the pre-and post-home visit behaviors of those using AHHC medical services will provide insights into the usefulness of these services and help develop strategies to reduce ED visits and ambulance use further. Methods This questionnaire-based study used data from anonymized medical records and internet-based questionnaires completed by patients who used AHHC medical services in Tokyo, Japan, between January 1 and December 31, 2019. The questionnaire comprised two questions: (1) What action would the patient have taken in the absence of AHHC services and (2) what action was taken within 3 days following the use of the AHHC services. In addition, following home consultations, AHHC doctors classified the patient’s illness severity as mild (treatable with over-the-counter medications), moderate (requires hospital or clinic visit), or severe (requires ambulance transportation). Results Of the 15,787 patients who used AHHC medical services during the study period, 2128 completed the questionnaire (13.5% response rate). Individuals aged ≤15 years and 16–64 years were the most common users of AHHC services (≤15 years, 71.4%; 16–64 years, 26.8%). Before using the AHHC service, 46.4% of the total respondents reported that they would have visited an ED had AHHC services not been available (≤15 years, 47.8%; 16–64 years, 42.8%; ≥65 years, 43.6%). The proportion of patients originally planning to call an ambulance was higher among those in the older age groups (≤15 years, 1.1%; 16–64 years, 6.0%; ≥65 years, 20.5%). After using the AHHC services, most patients (68.1%) did not visit a hospital within 3 days; however, the proportion of patients who visited an ED and called an ambulance within 3 days increased with the severity of illness. Conclusions Increasing AHHC medical services awareness among older adults and patients assessed as having severe illnesses regularly availing of AHHC services may help reduce ED visits and ambulance use.

Patients’ impressions of after-hours house-call services during the COVID-19 pandemic in Japan: a questionnaire-based observational study

Background Access to healthcare has been strongly affected by the coronavirus disease 2019 (COVID-19) pandemic, which has raised concerns about the increased risk of delays in receiving medical care. This study aimed to assess the patients’ impressions of after-hour house-call (AHHC) medical services during the COVID-19 pandemic using a patient questionnaire. Methods This was a cross-sectional observational study of anonymized medical record data and internet-based questionnaires from patients who used AHHC medical services from April 2020 to January 2021. We summarized the patients’ impressions of AHHC medical services during the COVID-19 pandemic stratified by patient characteristics. The questions of the questionnaire were as follows: (i) Did you use the AHHC medical services because you suspected you had COVID-19 infection? (ii) Do you feel that the use of AHHC medical services has helped prevent transmission of COVID-19? (iii) What action would you have taken in the absence of AHHC medical services? Results A total of 1802 patients responded to the questionnaire (response rate: 11.3%). First, 700 (40.8%) of the responders indicated that they had used AHHC medical services because of suspicion of COVID-19. Second, most responders (88.8%) felt that AHHC medical services prevented transmission of COVID-19. Third, 774 (43.0%) of the responders considered that they would have visited an emergency department or called an ambulance if AHHC medical services had not been used. Furthermore, 411 (22.8%) of the responders indicated that they would remain at home or wait until working hours if AHHC medical services were not available despite having a condition that required emergency attention. Conclusions AHHC medical services may be one of the strategies for those who refrain from seeking healthcare services, thus reducing the risk of delayed hospital visits during emergencies. Furthermore, AHHC medical services may also contribute to preventing transmission of COVID-19 by avoiding contact with other patients in the hospital.

Changes in the proportion and severity of patients with fever or common cold symptoms utilizing an after-hours house call medical service during the COVID-19 pandemic in Tokyo, Japan: a retrospective cohort study

Background Trends in the characteristics and disease severity of patients using an after-hours house call (AHHC) medical service changed during the coronavirus disease (COVID-19) pandemic. However, there have been no reports on this issue since the start of the COVID-19 pandemic. This study aimed to investigate patients’ tendencies to utilize an AHHC medical service for fever or common cold symptoms during the COVID-19 pandemic. Methods This retrospective cohort study compared the characteristics and disease severity of patients with fever or common cold symptoms utilizing an AHHC medical service offered by a single large company between the control period (December 1, 2018 to April 30, 2019) and the COVID-19 pandemic exposure period (December 1, 2019 to April 30, 2020). We also assessed the proportion of these patients in relation to all patients calling the service for any reason. Results During the control and COVID-19 pandemic exposure periods, a total of 6462 and 10,003 patients consulted the AHHC medical service, respectively. Of these, 5335 (82.6%) and 7423 (74.2%) patients had fever and common cold symptoms, respectively, during the control and COVID-19 pandemic exposure periods (P < 0.001). The corresponding median (interquartile range) ages were 8 (3–11) and 10 (4–33) years, respectively. The distribution of disease severity differed between the groups. The proportions of patients with mild, moderate, and severe illness were 71.1, 28.7, and 0.2% in the control period and 42.3, 56.7, and 0.9% in the COVID-19 pandemic exposure period, respectively (P < 0.001). Conclusions During the COVID-19 pandemic, the proportion of patients with fever or common cold symptoms was lower than that in the control period, but disease severity was significantly higher.

Pre- and Post-home Visit Behaviors using an after-hours House Call (AHHC) Medical Services: A Questionnaire-based Survey in Tokyo, Japan

Background: To reduce the burden caused by emergency department (ED) visits and ambulance use, after-hours house call (AHHC) medical services have been implemented. Examining the pre-and post-home visit behaviors of those who use AHHC medical services, stratified by age and illness severity, may help determine the populations these services should target effectively to reduce ED visits and ambulance use.Methods: This questionnaire-based study used data from anonymized medical records and internet-based questionnaires completed by patients who used AHHC medical services in Tokyo, Japan, between January 1 and December 31, 2019. The questionnaire consisted of two questions: what action would the patient have taken in the absence of AHHC services, and what action was taken within three days following the use of the AHHC services.Results: Of the 15,787 patients who used AHHC medical services during the study period, 2,128 completed the questionnaire (13.5% response rate). Individuals aged <15 years and 16–64 years were the most common users of AHHC services (≤15 years, 71.4%; 16–64 years, 26.8%). Before using the AHHC service, the majority of patients in each patient age group would have visited the ED if the AHHC service had not been available (≤15 years, 47.8%; 16–64 years, 42.8%; ≥65 years, 43.6%), and the proportion of patients originally planning to call an ambulance was higher among those in higher age groups (≤15 years, 1.1%; 16–64 years, 6.0%; ≥65 years, 20.5%). After using AHHC services, the majority of patients (68.1%) did not visit a hospital within three days, but the proportion of patients who visited an ED and called an ambulance within that time increased as their illness severity increased.Conclusions: Increasing AHHC medical services awareness among older adults and encouraging repeated use of AHHC services for patients with severe illnesses may help reduce ED visits and ambulance use.

Changes in The Use of After-Hour House-Call Medical Services For Fever or Common Cold Symptoms During The COVID-19 Pandemic in Tokyo, Japan: A Descriptive Study

BackgroundThe trend in the characteristics of patients using an after-hour house-call (AHHC) medical service changed the coronavirus disease of 2019 (COVID-19) pandemic, but there has been no report on this issue since the start of the COVID-19 pandemic. The aim of this study was to investigate patients’ tendencies to seek an AHHC medical service for fever or common cold symptoms during the COVID-19 pandemic.MethodsThis cohort study compared the characteristics of patients with fever or symptoms of the common cold utilizing an AHHC medical service offered by a single large company between the control period (December 1, 2018 to April 30, 2019) and the COVID-19 pandemic exposure period (December 1, 2019 to April 30, 2020). It also assessed the proportion of these patients in relation to all patients calling for the service for any reason. ResultsDuring the control and COVID-19 pandemic exposure periods, 6,462 (median age: 8 [interquartile range {IQR}: 3, 11], males: 48.2%) and 10,003 (median age: 10 [IQR: 4, 33], males: 48.3%) patients, respectively, called for the AHHC medical service. Of these, 5,335 (82.6%) and 7,423 (74.2%) patients had fever or common cold symptoms, respectively. The disease severity was differently distributed between the groups: the proportions of people with severe, moderate, and mild illness were 0.3%, 28.7%, and 71.0% in the control period and 1.1%, 54.8%, and 44.1% in the COVID-19 pandemic exposure period (p < 0.001), respectively. The AHHC medical service identified six individuals with COVID-19.ConclusionsDuring the COVID-19 pandemic, the proportion of patients with fever or symptoms of the common cold was lower than that in the control period, but the illness severity was substantially higher.

A Prospective Observational Study Comparing Effects of Call Schedules on Surgical Resident Sleep and Physical Activity Using the Fitbit

ABSTRACT Background Surgical residency training has an extended tradition of long hours. Residency programs use a variety of call schedules to combat resident fatigue and sleep deprivation while maintaining adherence to duty hour restrictions. Nonetheless, there is a paucity of data regarding objective measurements of sleep during the different call schedules included in general surgery training. Objective The primary objective of this study was to compare the quantity of sleep in 24-hour time frames across all types of shifts worked by general surgery residents at our institution. The secondary objective was to measure activity level in total steps during various time frames. Methods This prospective observational study was performed between April 4 and August 26, 2018, with general surgery residents. Each resident was assigned a Fitbit Charge 2 to wear during all rotations, including general surgery and subspecialty services. Results Twenty-six out of 31 residents voluntarily participated in the study (84%). In-house call (IHC) had significantly less sleep in a 24-hour time frame than home call and night float (144 vs 283 vs 246 minutes, P &lt; .001 and P &lt; .028). IHC had significantly more steps than home call (11 245 vs 8756 steps, P = .039). The smallest number of steps was obtained when residents were not working (7904 steps). Conclusions Our data demonstrate that surgical residents on IHC have significantly less sleep compared to all other types of on-call time frames. Residents on IHC have the most steps across all time frames.