Background Due to demographic changes, hospital emergency departments in many countries are overcrowded. Internationally, several primary healthcare models have been introduced as alternatives to hospitalisation. In Norway, municipal acute wards (MAWs) have been implemented as primary care wards that provide observation and medical treatment for 24 h. The intention is to replace hospitalisation for patients who require acute admission but not specialist healthcare services. The aim of this study was to explore primary care physicians’ (PCPs’) perspectives on admission to a MAW as an alternative to hospitalisation. Methods The study had a qualitative design, including interviews with 21 PCPs in a county in southeastern Norway. Data were analysed with a thematic approach. Results The PCPs described uncertainty when referring patients to the MAW because of the fewer diagnostic opportunities there than in the hospital. Admission of patients to the MAW was assumed to be unsafe for both PCPs, MAW nurses and physicians. The PCPs assumed that medical competence was lower at the MAW than in the hospital, which led to scepticism about whether their tentative diagnoses would be reconsidered if needed and whether a deterioration of the patients’ condition would be detected. When referring patients to a MAW, the PCPs experienced disagreements with MAW personnel about the suitability of the patient. The PCPs emphasised the importance of patients’ and relatives’ participation in decisions about the level of treatment. Nevertheless, such participation was not always possible, especially when patients’ wishes conflicted with what PCPs considered professionally sound. Conclusions The PCPs reported concerns regarding the use of MAWs as an alternative to hospitalisation. These concerns were related to fewer diagnostic opportunities, lower medical expertise throughout the day, uncertainty about the selection of patients and challenges with user participation. Consequently, these concerns had an impact on how the PCPs utilised MAW services.
Recent clinical practice guidelines recommend analgosedation in intensive care unit patients, where the patients' pain first is relieved, followed by sedatives only on indication. The aims of the present study was to examine sedation practice today, to evaluate the degree to which there is a difference in sedation practice between units, and to investigate the associations between nurses' demographic characteristics and their perception of sedation practice. A cross sectional survey was conducted to the nurses in three intensive care units in Norway. The results indicated that light sedation was implemented in the three intensive care unit studied. Continuous infusion of propofol and dexmedetomidine were used most frequently, and continuous infusion of midazolam was used occasionally. However, the sedation practices varied significantly between the units. Subjective scoring systems, physician's prescriptions, and prescription follow-up were reported to be most frequently used as guidelines and directives, and Richmond Agitation–Sedation Scale was reported to be the most frequently used sedation assessment tool.
Background In Norway, municipal acute wards (MAWs) have been implemented in primary healthcare since 2012. The MAWs were intended to offer decentralised acute medical care 24/7 for patients who otherwise would be admitted to hospital. The aim of this study was to assess whether the MAW represents the alternative to hospitalisation as intended, through 1) describing the characteristics of patients intended as candidates for MAWs by primary care physicians, 2) exploring the need for extended diagnostics prior to admission in MAWs, and 3) exploring factors associated with patients being transferred from the MAWs to hospital. Methods The study was based on register data from five MAWs in Norway in the period 2014–2020. Results In total, 16 786 admissions were included. The median age of the patients was 78 years, 60% were women, and the median length of stay was three days. Receiving oral medication (OR 1.23, 95% CI 1.09–1.40), and the MAW being located nearby the hospital (OR 2.29, 95% CI 1.92–2.72) were factors associated with patients admitted to MAW after extended diagnostics. Patients needing advanced treatment, such as oxygen therapy (OR 2.13, 95% CI 1.81–2.51), intravenous medication (OR 1.60, 95% CI 1.45–1.81), intravenous fluid therapy (OR 1.32, 95% CI 1.19–1.47) and MAWs with long travel distance from the MAW to the hospital (OR 1.46, 95% CI 1.22–1.74) had an increased odds for being transferred to hospital. Conclusions Our findings indicate that MAWs do not represent the alternative to hospitalisation as intended. The results show that patients receiving extended diagnostics before admission to MAW got basic treatment, while patients in need of advanced medical treatment were transferred to hospital from a MAW. This indicates that there is still a potential to develop MAWs in order to fulfil the intended health service level.
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