Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Involvement in emergency situations by primary care doctors on-call in Norway - a prospective population-based observational study

BMC Emergency Medicine201010:5

DOI: 10.1186/1471-227X-10-5

Received: 26 June 2009

Accepted: 6 March 2010

Published: 6 March 2010

Abstract

Background

Primary care doctors on-call in the emergency primary health care services in Norway are, together with the ambulances, the primary resources for handling emergencies outside hospitals. There is a lack of reliable data for Norway on how often the primary care doctors are alerted and on their responses in the most urgent emergency cases. The aim of this study was to investigate how doctors on-call are involved in red responses (highest priority), using three different emergency medical communication centres (EMCC) as catchment area for a prospective population-based study.

Methods

In the period from October to December 2007 three dispatch centres covering approximately 816 000 inhabitants prospectively recorded all acute emergency cases. Ambulance records, air ambulance records and records from the doctors on-call were collected. NACA score was used to define the severity of the emergencies.

Results

5 105 cases were classified as red responses during the period. We have complete basic recordings (AMIS forms) from all and resaved ambulance records, air ambulance records and records from doctors on-call in 89% of the cases. Ambulances were alerted in 96% and doctors on-call in 47% of the cases, but there were large differences between the three EMCCs. Doctors on-call responded with call-out in 42% of the alerted cases. 28% of all patients were taken to a casualty clinic, 46% were admitted to hospital by a doctor and 24% were taken directly to hospital by ambulances. In total, primary care doctors on-call took active part in 42% of all red response cases, and together with GPs' daytime activity the primary health care services were involved in 50% of the cases. 29% of the cases were classified as life-threatening. Call-out by doctors on-call were found to be more frequent in life-threatening situations compared with not life-threatening situations.

Conclusion

Doctors on-call and GPs on daytime were involved in half of all red responses. There were large differences between the EMCCs in the frequency of doctors alerted. The inhabitants in the three EMMCs were thus offered different levels of professional competency in emergency situations outside hospitals.

Background

The primary resources in the Norwegian pre-hospital emergency care system are the ambulances and the primary care doctors. Ambulance personnel and primary care doctors on-call thus constitute a major part in the "chain of survival", the doctors being especially present as an important resource in rural areas [1].

In Norway, the municipalities are responsible for the emergency primary healthcare system, including the out-of-hours services, primary care doctors on-call, casualty clinics and local emergency medical communication centres (LEMC) [2]. The doctors have an obligation to take part in the restricted and nationwide medical radio network (radio) used as the national standard for communication between doctors on-call, ambulance personnel and the emergency medical communication centres (EMCC) (dispatch centrals) [3].

The central government is responsible for the secondary health care system; hospitals, EMCCs, ground and boat ambulances and the national air ambulance service, staffed with anaesthetists. An important principle in the health care system in Norway is the gatekeeper function exerted by the primary care doctors; patients cannot meet directly at hospitals without being referred by a doctor. However, in a severe emergency situation the ambulance may drive directly to hospital without a doctor's confirmation, but then only in agreement with health personnel in the EMCCs.

A national three digits emergency number (113) to an EMCC is used when medical emergencies occur. All EMCCs use a software system called Acute Medical Information System (AMIS) to record the cases, and they use the Norwegian Index of Medical Emergencies (Index) [4] as a decision tool for level of emergency. Based on the Index the EMCC nurses will classify the call as a "red response", with highest priority; "yellow response", urgent but not acute; or "green response", with lowest priority. If Index prescribes a red response, a radio alarm alert shall be sent simultaneously to the doctor on-call and the ambulances in the actual geographical area.

Ambulance personnel have argued that primary care doctors on-call leave the responsibility of the emergency patients more frequently to them, compared to earlier [1]. Only half of the out-of-hours districts in Norway had doctors who always used the radio in 2005 [5]. A study found geographical differences in the involvement of Norwegian doctors on-call in pre-hospital emergencies, but the study was limited to situations where the air ambulances were alerted as well [6]. Two studies have investigated rGPs'experiences with emergency situations, though not red responses in particular, through the EMCC system [7, 8]. On a national basis the EMCCs in Norway alerted doctors on-call in about 50% of the red response cases [9]. A recent study describes difficulties in cooperation between doctors on-call and ambulance personnel [10].

The aim of this study was to investigate how red response situations are administrated with special focus on the primary care doctors on-call, using three different EMCCs as catchment area for a prospective population-based study.

Methods

For data collection we chose the EMCCs at Haugesund, Stavanger and Innlandet hospitals. Together they cover 69 581 km2 (21% of total area of Norway), 816 000 inhabitants (18% of total) and 85 municipalities (20% of total). The out-of-hours districts, 34 in total, are both single-municipal and inter-municipal, rural and city areas.

To secure a uniform use of the AMIS program a meeting between the leaders of the EMCCs was arranged. The AMIS forms contained information on date, time of day, time for alerts to the different pre-hospital recourses, who responded, response time, criteria code for the emergency cases and to where the patients were transported. AMIS forms and copies of ambulance records from all red responses were submitted to the project manager every second week. In the cases where doctors on-call or air ambulances had been involved, copies of medical records were requested by mail. Data registration period lasted from October 1st to December 31st 2007. Collection of medical records from different parts of the health care system was made until October 2008.

From the retrieved records we extracted the information needed to classify the severity of the medical problems based on The National Committee on Aeronautics Score System (NACA) [11]. NACA score were in the analyses dichotomised into not life-threatening (NACA value 0-3) and life-threatening or dead (NACA value 4-7). Data on municipalities were obtained from Statistics Norway. Municipal centrality is categorised with values from zero to three. This variable was then dichotomised into remote (value 0-1) and central municipalities (value 2-3).

The statistical analyses were performed using Statistical Package for the Social Sciences (SPSS version 15). Standard univariate statistics were used to characterise the sample. Data are presented as mean (SD). Skewed distributed data are presented as median with 25-75% percentiles. Differences between variables were analysed using Pearson's χ2 test. Fisher's exact test was computed when tables had cells with a frequency of less than five in 2 × 2 tables. P value < 0.05 was considered as statistically significant. Rate is presented as numbers of red responses per 1 000 inhabitants per three months. Logistic regression analyses were used to calculate the odds ratio (OR) for alerts sent to doctors on-call and doctors' responses to the alerts. Cases without an alert sent to a doctor are excluded from the regression analyses together with secondary air ambulance missions (transfer between hospitals). The dependent variable "doctor's response" was dichotomised into "call-out" or not, "await" or not and "consult" or not. Air ambulance on call-out (yes or no), the dichotomised versions of NACA score, municipal centrality (dichotomised), and the variable "populations in the primary care district" were used as independent variables in the analyses. "Populations in the primary care district" was divided into five categories, with value 1 including 0-25 000, value 2 including 25 001-50 000, value 3 including 50 001-75 000, value 4 including 75 001-100 000 and value 5 >100 000 inhabitant. Cases where a doctor was the caller to the EMCC are left out in some of the analyses, because there is no need to alert the doctor when the doctor already knows about the situation.

Approval of the study was given by the Privacy Ombudsman for Research, Regional Committees for Medical Research Ethics and Norwegian Directorate of Health.

Results

During the three months of inclusion 5 105 red responses with AMIS forms were recorded and included. In 4 551 (89%) of the forms we retrieved one or more extra records belonging to same case. Total rate (per 3 months) of red responses was 6.2 per 1 000 inhabitants.

Next of kin was the main caller to the EMCCs. Health care personnel, LEMCs and doctors made more than a third of the calls for ambulances (table 1). Ambulances were alerted in nearly all the red response cases and doctors on-call in nearly half of the cases. Doctors on-call responded with call-out in 42% of the cases in which they were alerted. Differences between the EMCC districts are pronounced with respect to alerting doctors on-call. EMCC Innlandet alerted doctors on-call in a fifth of the cases compared with three out of four of the cases in Stavanger and Haugesund, but there were no statistical significant differences in call-out as response when an alert was given (p = 0.056).
Table 1

Red responses distributed by caller, alert and responses

 

Total

Innlandet

Stavanger

Haugesund

 

n

%

n

%

n

%

n

%

Caller to the EMCCs

        

   Next of kin

1 705

34

899

34

520

35

286

31

   Bystander

857

17

411

16

263

18

183

20

   Health personnel

914

18

523

20

229

15

162

17

   Doctor

455

9

267

10

95

6

93

10

   LMCC

451

9

206

8

192

12

53

6

   Patient

349

7

144

6

117

8

88

10

   Police

221

4

115

4

57

4

49

5

   Fire department

87

2

58

2

23

2

6

1

Alerted

        

   Ambulance

4 896

96

2 549

97

1 457

95

890

96

   GP on call*

2 105

47

469

21

1 047

75

589

72

   Air ambulance#

377

8

118

5

201

15

58

7

   Anaesthetist (from hospital)

92

2

89

3

0

0

0

0

   Fire department

210

4

122

5

47

3

32

3

   Police

314

6

160

6

89

6

65

7

Doctors' response

        

   Call out

829

42

176

47

434

41

219

40

   Await

750

37

96

26

471

44

183

33

   Confer

287

14

88

24

62

6

137

25

   No contact

94

5

11

3

69

6

14

2

   Occupied

35

2

3

~0

30

3

2

~0

   Total¤

1 995

100

374

100

1 066

100

555

100

¤Differences in numbers between alerted doctors and total numbers on responses are due to missing data in both variables

*Selected cases without doctors as caller

#Selected cases without secondary missions (transfer between hospitals)

† Selected cases where GPs were alerted

In 9% of the cases a doctors was the caller to the EMCC (table 1). Other health care personnel and LEMCs called for ambulances in 27% of the cases, and thus patients, next of kin and bystanders were the callers in less than 60% of the incidents. More than half (55%) of the calls from doctors to the EMCCs were during daytime, 33% in the evenings and 12% during the night. Patient's location when doctors were callers was in 42% of the cases private homes, 9% casualty clinics, 22% doctors' surgeries, 20% hospitals and nursing homes, and other locations in 7% of the cases. When the EMCCs alerted the doctors the distribution of alerts was 37% for both daytime and evenings, and 26% during nights. When doctors on-call were alerted, the location of the patient was a private home in 63% of the cases, 30% was public places, 4% nursing homes, and 3% other places. Doctors on-call were alerted median 0 minutes (0-2) after the ambulances, 57% at the same time and 86% within the first five minutes. Innlandet alerted 67% during the first 5 minutes after the ambulances had been alerted, Stavanger 95% and Haugesund 83% (p < 0.001). Doctors on-call were alerted after the arrival of ambulances to patients in 3% of the cases.

In cases when the air ambulance/anaesthetist was alerted (transfer between hospitals are excluded) the EMCCs also alerted doctors on-call in 72% of the cases and doctors on-call responded with a call-out in 62% of those cases. Innlandet alerted doctors on-call in 38% of the same cases as the air ambulances/anaesthetist, Haugesund 68% and Stavanger 78% (p < 0.000). The doctors on-call responded in 64% of the same cases as the air ambulance/anaesthetist in Innlandet, 72% in Haugesund and 53% in Stavanger (p < 0.04).

Primary care doctors' involvement in the treatment and the decision regarding the location to which the patients were transported are shown in table 2. In situations where doctors on-call were not alerted patients were transported directly to hospitals with ambulance twice as often compared to situations where doctors were alerted. 26% of all patients were transported to casualty clinics independently of whether the doctors on-call were alerted or not. When doctors responded with call-out, more than half of the patients were admitted to hospitals, and when "await" was the response more than 43% of the patients were taken to casualty clinics. When doctors called the EMCCs the majority of the patients were admitted to hospital by doctor's referral. In both the not life-threatening and the life-threatening cases a fourth of the patients was transported with ambulances directly to hospitals without any involvement of doctors. Doctors on-call were involved in 42% of all red response cases. Including daytime activity among rGPs the primary health care services were involved in 50% of the cases.
Table 2

Involvement of doctors and locations for transport of patients

Patients transported to

Casualty clinic

Hospital via casualty clinic

Admitted to hospital by doctors

Directly to hospital by ambulance

Patients stayed at scene

Dead patients

Follow up by others

Total*

 

n

%

n

%

n

%

n

%

n

%

n

%

n

%

n

%

Doctors were callers

22

5

30

7

356

80

16

4

20

4

3

~0

0

0

447

100

Doctors alerted§

                

   Yes

328

15

270

13

781

37

334

16

283

13

117

5

23

1

2 136

100

   No

403

14

250

9

934

34

837

31

239

9

50

2

18

1

2 731

100

   Total

731

15

520

11

1 715

35

1 171

24

522

11

167

3

41

1

4 867

100

Doctors' response when alerted

                

   Call out

75

9

41

5

455

56

7

1

128

16

98

12

6

1

810

100

   Await

157

21

162

22

142

19

205

28

55

8

10

1

9

1

740

100

   Consult

32

11

25

9

128

45

23

8

72

25

2

1

2

1

284

100

   No contact

20

22

11

12

16

18

30

33

12

13

1

1

1

1

91

100

   Occupied

8

23

11

31

7

20

8

23

1

3

0

0

0

0

35

100

Total*

292

15

250

13

748

38

273

14

268

14

111

5

18

1

1 960

100

* Differences in numbers between alerted doctors and doctors response are due to missing data

§Doctors as callers are excluded

The frequency of alert and responses from the doctors on-call by central and remote municipalities are shown in table 3. Alert to doctors on-call was highest in central municipalities in all EMCC areas, although not statistically significant in Stavanger area. However, the number of responses with call-out is higher in remote compared to central municipalities, with smallest difference appearing in Haugesund.
Table 3

Alerts and responses by rural and central municipalities

    

Response if alerted§

 

Doctors alerted*

Call-out

Await

Consulted

Otherβ

Municipal centrality

n

%

P-

value

n

%

P-

value

n

%

P-

value

n

%

P-

value

n

%

P-

value

Innlandet (n = 461)

               

   Remote

387

19

 

147

49

 

70

23

 

72

24

 

13

4

 

   Central

74

28

0.00

19

32

0.02

25

42

0.00

15

25

0.74

1

1

0.36

Stavanger (n = 1058)

               

   Remote

71

70

 

39

57

 

12

18

 

10

15

 

7

10

 

   Central

987

76

0.22

381

40

0.00

439

46

0.00

50

5

0.00

89

9

0.81

Haugesund (n = 586)

               

   Remote

529

68

 

193

40

 

168

35

 

109

22

 

16

3

 

   Central

57

84

0.01

20

36

0.63

12

22

0.10

23

42

0.00

0

0

0.18

Total

               

   Remote

987

33

 

379

45

 

250

29

 

191

22

 

36

4

 

   Central

1 118

68

0.00

420

39

0.02

476

45

0.00

88

8

0.00

90

8

0.00

*Doctors as callers were excluded from analyses

§Differences between numbers for alerted doctors and total numbers for responses are due to missing data

β"Occupied" and "No contact" were merged to "Other"

The distribution of doctors as caller, alerted doctors and doctors' response between life and not life-threatening situations is shown in table 4. When doctors were the callers the majority of the cases were not life-threatening situations. Stavanger EMCC had the highest percentage of alerted doctors in both life-threatening and not life-threatening situations. Innlandet EMCC had the largest difference in alerts between life and not life-threatening conditions. Overall, differences in call-outs between life-threatening and not life-threatening conditions are pronounced when doctors are alerted. In not life-threatening conditions the response "await" was most frequent. In life-threatening conditions doctors on-call in Innlandet responded considerably more often with call-outs when compared to Stavanger and Haugesund. Doctors in the Stavanger area had the highest percentage of "await" as response.
Table 4

Alerts and responses for not life-threatening (NACA 0-3) and life-threatening situations (including death) (NACA 4-7)

   

Innlandet

Stavanger

Haugesund

 

Total

Not life-threatening

Life-threatening

Not life-threatening

Life-threatening

Not life-threatening

Life-threatening

 

n

%

n

%

n

%

n

%

n

%

n

%

n

%

Doctors were callers

403

100

152

61

96

39

48

65

26

35

51

63

30

37

Doctors on call alerted§

              

   Yes

1 881

47

277

18

146

26

676

77

255

78

366

73

161

69

   No

2 162

53

1 271

82

411

74

200

23

71

22

135

27

73

31

   Total

4 042

100

1 548

100

557

100

876

100

326

100

501

100

234

100

Doctors' response when alerted

              

   Call out

778

43

85

38

81

64

265

40

143

56

122

36

87

54

   Await

639

36

71

32

20

16

321

47

83

32

126

37

36

22

   Consult

287

16

57

25

26

20

39

6

12

5

83

24

34

22

   No contact

70

4

9

4

0

0

37

5

14

5

10

3

2

1

   Occupied

26

1

2

1

0

0

17

2

5

2

1

~0

1

1

   Total*

1 800

100

224

100

127

100

679

100

257

100

342

100

160

100

*Differences in numbers between alerted doctors and total numbers on responses are due to missing data

§Doctors as caller are excluded

Overall, 70% of all alerts sent to doctors on-call were for not life-threatening conditions, and 61% of all call-outs among the doctors on-call occurred in not life-threatening situations. In total, EMCCs alerted doctors on-call in half of the life-threatening situations, compared to 45% in not life-threatening situations (p < 0.004). Doctors on-call responded with call-outs in 56% of the life-threatening situations compared to 38% in not life-threatening situations (p < 0.000).

By regression analyses clear associations were found between EMCC areas and whether the doctors on-call were alerted or not. There is also a statistical significant association between alerts in not life-threatening situations and alerts to primary care doctors in remote municipalities (table 5).
Table 5

Odds ratio (95% CI) for primary care doctors being alerted

 

Doctors alerted †

Dispatch centrals and area

 

   Haugesund

1

   Stavanger

8.58 (6.98-10.6)

   Innlandet

0.91 (0.66-1.24)

Not life-threatening condition (NACA) ¤

1.28 (1.08-1.52)

Remote municipalities ¤

2.59 (2.00-3.35)

No use of radio among doctors on-call ¤

0.76 (0.62-0.95)

Population in the primary care districts

1.30 (1.22-1.39)

† Selected cases; Doctors as caller to the EMCCs are excluded

¤ Dichotomised variables, reference value = 1

Low severity score on NACA were associated with a higher possibility of call-out as response among the primary care doctors. There was a positive statistically significant association between call-out and remote municipalities in the total area, but when each district was analysed this association was significant only for Stavanger. For the total area the air ambulance on call-out was associated with a statistically significant decrease in odds ratio for primary care doctors being on call-out to the same patients, but the results were not statistically significant for the Stavanger area. Increasing population in the primary care districts is associated with more call-outs as the response among the primary care doctors in all three areas (table 6).
Table 6

Odds ratios for (95% CI) type of response when primary care doctors were alerted for total area and in the three EMCC districts

Doctors responses*

Call-out

Await

Confer

Total area

   

   Not life-threatening condition (NACA) ¤

2.11 (1.69-2.62)

0.53 (0.42-0.67)

1.02 (0.76-1.39)

   Air ambulances on call-out ¤

0.64 (0.46-0.89)

1.22 (0.86-1.74)

4.02 (1.93-8.41)

   Population in the primary care districts

1.41 (1.30-1.53)

0.74 (0.75-1.31)

1.01 (0.90-1.13)

   Remote municipalities ¤

2.10 (1.58-2.79)

0.99 (0.68-0.80)

0.36 (0.24-0.53)

Area of Innlandet

   

   Not life-threatening condition (NACA) ¤

2.62 (1.60-4.29)

0.45 (0.25-0.80)

0.97 (0.57-1.66)

   Air ambulances on call-out ¤

0.31 (0.13-0.73)

1.36 (0.54-3.44)

10.6 (1.42-78.9)

   Population in the primary care districts

1.21 (1.01-1.46)

1.02 (0.84-1.25)

0.83 (0.68-1.00)

   Remote municipalities ¤

0.66 (0.32-1.35)

2.35 (1.21-4.54)

0.81 (0.40-1.61)

Area of Stavanger

   

   Not life-threatening condition (NACA) ¤

1.80 (1.30-2.47)

0.63 (0.45-0.87)

0.86 (0.43-1.70)

   Air ambulances on call-out¤

0.94 (0.60-1.46)

1.17 (0.75-1.85)

2.52 (0.74-8.62)

   Population in the primary care districts

1.71 (1.49-1.95)

0.58 (0.50-0.69)

1.06 (0.85-1.33)

   Remote municipalities¤

3.70 (1.79-7.67)

0.51 (0.21-1.25)

0.37 (0.13-1.08)

Area of Haugesund

   

   Not life-threatening condition (NACA) ¤

1.99 (1.32-3.00)

0.58 (0.37-0.90)

0.99 (0.61-1.60)

   Air ambulances on call-out¤

0.45 (0.21-0.98)

1.73 (0.68-4.40)

2.08 (0.69-6.30)

   Population in the primary care districts

1.30 (1.07-1.57)

0.94 (0.78-1.14)

0.76 (0.61-0.94)

   Remote municipalities¤

0.97 (0.52-1.82)

0.53 (0.26-1.09)

2.45 (1.31-4.56)

* Selected cases; doctors not alerted in the primary care system are excluded

¤ Dichotomised variables, reference value = 1

Discussion

Primary care doctors in the health care services, including rGPs during daytime and primary care doctors on-call out-of-hours, took active part in 50% of all red responses. Primary care doctors on-call were alerted in nearly half of the red response cases managed by the three EMCCs. The doctors on-call responded with call-outs or consulted the ambulance personnel in a majority of the alerted cases, and they responded with call-outs in more than 55% of the life-threatening situations in all three areas. There were significant differences in the proportion of alerted doctors between the EMCCs. If alerted, however, the response pattern was similar.

The strengths of our study include its completeness, representativity, and number of variables included. In the course of a three month period we were able to prospectively collect a complete material of more than 5 000 red responses based on a population of 816 000 inhabitants, close to 20% of the Norwegian population. The three EMCCs and their actions may not be representative for all EMCCs in Norway. Taken together, however, the three EMCCs have the same frequency of alerted doctors as was found in a national survey [9]. The minor differences between the three EMCC areas with respect to doctors' responses strengthen the representativeness of the 85 municipalities and 35 out-of-hours districts. In nearly 90% of all cases we retrieved records from car and air ambulances, casualty clinics and rGPs. Together with the complete set of AMIS forms this yields a comprehensive material for analysis of the objectives of the study. Severity score (NACA) on patients was assessed retrospectively based on medical records and may therefore have lower accuracy. It is also a limitation of the study that we lack access to the patients' medical records after hospitalisation. Analyse of the medical usefulness of having the primary care doctor at site was thus not possible.

The pronounced differences between the EMCCs with respect to alerting primary care doctors on-call indicate that the opportunity to have a doctor on scene as part of the initial examination and treatment varies among the inhabitants in different geographical areas. The government wants to have a decentralised pattern of settlement in Norway and obtaining equality in health care is a stated political goal [12]. By not alerting the doctors on-call an EMCC violates the regulation for pre-hospital emergency [3] and the inhabitants are not offered an equal level of medical competency. The large majority of the patients are not in need of immediate treatment based on protocols, like cardiopulmonary resuscitation, and most patients are elderly with more complex medical symptoms and comorbidities [13]. Ambulance personnel's formal education is two years in upper secondary school and two years in apprenticeship [3]. However, a large group of ambulance personnel does not fulfil that educational level [14]. As patients in most cases of the emergency situations have complex medical problems [14, 15] there is need of competence based on higher education and experience when examining the patients. Compared to ambulance personnel the doctors are superior when it comes to clinical judgement and deciding treatment and level of care when the patients have a serious illness. The professions provide supplementary contributions [15] and the professions should more frequently appear together on site. More doctors on site could possibly contribute to a reduction of transports to both casualty clinics and hospitals, thus decreasing hospitalisations and use of the ambulances. Direct transports to hospitals by the ambulance services were doubled when doctors on-call were not alerted, compared to whit if they were (table 2). This difference indicates the important gatekeeper function by the emergency primary healthcare services. Every patient treated by the primary care services will reduced costs because the patient is treated at a lower and less costly level of care. Still, differences in medical usefulness between patients transported directly to hospitals without a doctor's involvement and those admitted to hospitals by a doctor on-call is unknown. This should be addressed in further studies based on e.g. days spent in hospital before discharge.

For one third of all red response patients a professional medical judgement of the patient was made before the EMCCs were contacted. One third of the calls come from the primary health care system in the municipalities. Patients with serious illness can visit their rGP on daytime, and they may contact the casualty clinic or LEMC all hours. In addition home care nurses meet patients who are in need of immediate medical attention during their work. A study from Norway on incidences of emergency contacts (red responses) to the out-of-hours services found nearly the same volume of red responses as our study did [16].

The ambulance personnel transmit ECGs to hospitals and use doctors at the hospitals actively for consultations e.g. with regards to heart conditions and in order to decide what treatment to provide and where the patients should be transported [17]. This could be one reason for the small differences in the percentage of patients admitted to hospital by a doctor, regardless of whether the primary care doctors on-call were alerted or not.

When alerted, the doctors on-call in the remote areas responded more often with call-outs than doctors in more central municipalities. The regression analyses support the findings for the total catchment area, but there are differences between the three EMCC areas. The findings are similar to earlier studies [57]. Again, the levels of professional medical knowledge offered to the inhabitants vary due to different patterns of response among doctors on-call in different geographical areas.

Primary care doctors on-call were more often on call-out to patients with high NACA scores. This was most explicit in the EMCCs Innlandet. Innlandet had the lowest percentage of alerted doctors on-call, but the highest percentage of call-outs in life-threatening situations. Thus, there seems to be some pre-selection of the red response cases before doctors are alerted, which could give the doctors on-call an experience of higher accuracy on severity. In one remote municipality in Norway the doctors on-call defined 39% percent of all red response alerts as yellow (urgent, not acute) immediately after the situation was described via radio [12]. In our study 71% was classified as not life-threatening conditions and this could be one reason for "await" being the response in 37% of the cases. Other studies also describe overtriage in dispatch [18, 19].

The association between specific EMCC districts and the probability of alerting doctors on-call is strong. The regression analyses also reflect that 71% of all red response cases were classified as not life-threatening. When doctors on-call were alerted and responded with call-out the large majority was done in not life-threatening situations. There is an association between alert and not life-threatening situations, and for the same reason the association between call-out and not life-threatening situations is strong in all three areas.

Conclusions

Primary care doctors on-call and the primary health care system with rGPs on daytime took part in clinical judgement and treatment in half of all red response cases, and for one third of these a clinical judgement was made before an EMCC was contacted. The inhabitants in the catchment area were offered different levels of professional medical judgement and treatment. The EMCCs are not consistent with regards to alerting doctors on-call in red responses. There are differences between the EMCCs areas in terms of frequency of alerted primary care doctors on-call, but the type of response was more similar among the doctors.

Declarations

Acknowledgements

This study could not have been carried out without help from the three EMCCs and support from Lars Solhaug, Dag Frode Kjernlie, Sissel Grønlien and Jan Nystuen from the area of Innlandet. Unni Eskeland and Olav Østebø from the area of Stavanger and Leif Landa, Kari Hauge Nilsen and Trond Kibsgaard in the area of Haugesund. We want to thank Pål Renland for valuable help in data coding, Tone Morken for help in statistical challenges, Thomas Knarvik and Lars Myrmel for good discussions about dispatch centres, and all the doctors on-call and personnel at casualty clinics and air ambulance crews who submitted copies of medical records

Authors’ Affiliations

(1)
Department of Research, Norwegian Air Ambulance Foundation
(2)
National Centre for Emergency Primary Health Care
(3)
Section for General Practice, Department of Public Health and Primary Health Care, University of Bergen

References

  1. Traumesystemet i Norge. (Trauma care system in Norway) (in Norwegian). [http://www.helse-sorost.no/stream_file.asp?iEntityId=1567]
  2. Lov om helsetjenesten i kommunene. (Act relating to the municipal health services). (in English), [http://www.ub.uio.no/cgi-bin/ujur/ulov/sok.cgi?type=LOV]
  3. Forskrift om krav til akuttmedisinske tjenester utenfor sykehus. (Regulation on pre-hospital emergency medicine services) (in Norwegian). [http://www.lovdata.no/cgi-wift/wiftldles?doc=/usr/www/lovdata/for/sf/ho/ho-20050318-0252.html&emne=krav+til+akuttmedisinske+tjenester&&]
  4. Norwegian Medical Association: Norsk indeks for medisinsk nødhjelp (Norwegian Index of Emergency Medical Assistance). 2005, Stavanger: The Laerdal Foundation for Acute Medicine, 2.1Google Scholar
  5. Zakariassen E, Hunskaar S: GPs' use of defibrillators and the national radio network in emergency primary healthcare in Norway. Scand J Prim Health Care. 2008, 26: 123-128. 10.1080/02813430801990302.View ArticlePubMedPubMed CentralGoogle Scholar
  6. Vaardal B, Lossius HM, Steen PA, et al: Have the implementation of a new specialised emergency medical service influenced the pattern of general practitioners involvement in pre-hospital medical emergencies? A study of geographic variations in alerting, dispatch, and response. Emerg Med J. 2005, 22: 216-221. 10.1136/emj.2004.015255.View ArticlePubMedPubMed CentralGoogle Scholar
  7. Zakariassen E, Sandvik H, Hunskaar S: Norwegian regular general practitioners' experiences with out-of-hours emergency situations and procedures. Emerg Med J. 2008, 25: 528-533. 10.1136/emj.2007.054338.View ArticlePubMedGoogle Scholar
  8. Wisborg T, Brattebo G: Confidence and experience in emergency medicine procedures. Norwegian general practitioners. Scand J Prim Health Care. 2001, 19: 99-100. 10.1080/028134301750235312.View ArticlePubMedGoogle Scholar
  9. Blinkenberg J, Jensen Å, Press K: Lege/ambulansealarm i helseradionettet, -en studie av bruk, tilgjengelighet og respons (Alarm to doctors and ambulances on radio, a study in use, accessibility and responses) (in Norwegian). 2008, Bergen: National Centre for Emergency Primary Health Care, Unifob Health, [http://www.unifobhelse.no/publications.aspx?ci=2391]Google Scholar
  10. Førland O, Zakariassen E, Hunskår S: Samhandling mellom ambulansearbeider og legevaktlege (Cooperation between ambulance personnel and regular general practitioners) (in Norwegian), summary in English. Tidsskr Nor Legeforen. 2009, 129: 1109-1111. 10.4045/tidsskr.08.0501.View ArticleGoogle Scholar
  11. The National Committee on Aeronautics (NACA). [http://www.economy-point.org/n/naca-score.html]
  12. Helse- og omsorgsdepartementet: Nasjonal helseplan (2007-2010). (National Health Plan for Norway (2007-2010). Ministry of Health and Care Services). (in Norwegian), summary in English, [http://www.regjeringen.no/en/ministries/hod/Whats-new/News/2007/National-Health-Plan.html?id=449316]
  13. Zakariassen E, Burman RA, Hunskaar S: The epidemiology of medical emergencies outside hospitals in Norway - a prospective population based study. BMC Scand J Trauma Resusc Emerg Med. 2010, 18: 9-10.1186/1757-7241-18-9.View ArticleGoogle Scholar
  14. National Census Norway. Statistics Norway. [http://www.ssb.no/en/]
  15. Rørtveit S, Hunskår S: Akuttmedisinske hendingar i ein utkantskommune (Medical emergencies in a rural community) (in Norwegian), summary in English. Tidsskr Nor Laegeforen. 2009, 129: 738-42. 10.4045/tidsskr.08.0019.View ArticlePubMedGoogle Scholar
  16. Hansen EH, Zakariassen E, Hunskaar S: Sentinel monitoring of out-of-hours services in Norway in 2007: an observational study. BMC Health Serv Res. 2009, 9: 123-10.1186/1472-6963-9-123.View ArticlePubMedPubMed CentralGoogle Scholar
  17. Aune E, Steen-Hansen JE, Hjelmesæth J, Otterstad JE: Prehospital diagnostikk og behandling av akutt hjerteinfarkt i Vestfold. (Prehospital diagnosis and treatment of acute myocardial infarction in Vestfold) (in Norwegian), summary in English. Tidsskr Nor Laegeforen. 2004, 124: 3058-3060.PubMedGoogle Scholar
  18. Sporer KA, Johnson NJ, Yed CC, Yougblood GM: Can emergency medical dispatch codes predict prehospital intervention for common 9-1-1 call types?. Prehosp Emerg Care. 2008, 12: 470-478. 10.1080/10903120802290877.View ArticlePubMedGoogle Scholar
  19. Sporer KA, Yougblood GM, Rordriguez RM: The ability of emergency medical dispatch codes of medical complains to predict ALS prehospital interventions. Prehosp Emerg Care. 2007, 11: 192-198. 10.1080/10903120701205984.View ArticlePubMedGoogle Scholar
  20. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-227X/10/5/prepub

Copyright

© Zakariassen and Hunskaar; licensee BioMed Central Ltd. 2010

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Advertisement