Red responses represent less than three percent of the total number of patients who were in contact with the emergency primary health care services in Norway in 2007. Telephone to the emergency primary health care service or LEMC from patients or next of kin and direct attendance were the main contact forms. Only one third of the red responses came through the EMCC. On half of the red responses first action taken was call-out of primary care doctor on-call and ambulance. Patients older than 60 years had the highest rate of red responses.
Data from the Watchtowers are intended to be representative for the whole population and all emergency primary health care districts in Norway [7]. Differences between the emergency primary health care districts in the Watchtower project express variations between emergency primary health care districts in Norway in general.
The fact that more than three out of four patients had minor problems (category green) indicates that many or even a majority of these patients could probably have visited their rGP at daytime, not the emergency primary health care service. In the Netherlands the level of urgent problems was 4.6% for the GP cooperatives [9]. Definition of "urgency" is wider than the definition of "red response" in Norway. However, both the Dutch GP cooperatives and the Norwegian emergency primary health care services are mostly occupied with minor problems. This indicates that there should be a discussion towards more focus on higher priority grades, e.g. more focus on acute and urgent problems.
Evenings have the highest rate of red responses, but regression analyses showed no significant difference for the periods during the day, except for lower probability of calls through the EMCC in the evenings and nights. Emergencies occur 24 hours a day and preparedness cannot be reduced at any time.
In the Netherlands inhabitants can meet directly at hospitals in contrast to Norway where inhabitants first have to attend the primary health care system.
A study from the Netherlands showed more contacts to the ambulance services and direct attendance to accident and emergency departments in the evenings [10]. Another Dutch study showed that when patients called medical attention via accident and emergency departments there were no differences between out-of-hours and office hours [11]. Our regression analysis showed decreasing odds ratios for contacts through the EMCC during evenings and nights A good cooperation between the primary and the secondary health care system is essential to provide patients with good treatment at the appropriate care level.
Main contact form is telephone from patient, next of kin or contact from the EMCC. But there are interesting differences across the Watchtowers. WT7 (typical town district) have a higher proportion of direct attendance, due to casualty clinic with open access. Other districts representing more rural areas or a mix between rural areas and smaller towns have a higher proportion of telephone calls from patients and next of kin. It seems that inhabitants in rural areas tend to call the LEMC or the casualty clinic and inhabitants in city areas tend to call EMCC or meet directly at the casualty clinic. These findings are supported by earlier research [9, 12, 13]. In small single-municipal emergency primary health care districts, first action taken in the case of almost all red responses was a call-out for doctor and ambulance. Doctors in such districts have been characterised as more ready to act in cases of emergencies compared to doctors in emergency primary health care districts with a higher population [12, 14].
The total number of red responses in the ambulance services in 2004 was approximately 119 000 [15]. National estimates based on our research indicate 28 138 red response patients where the emergency primary health care services were the primary contact point (table 2). This strongly indicates that the secondary health care system with their EMCCs does not by far handle all red responses outside hospitals and that the emergency primary health care service make up an important part of the emergency health care system in Norway.
Differences in rates of red responses between the districts could have several explanations. As the oldest inhabitants have higher morbidity and age 60+ had the highest rate of red responses, different age distribution between the out-of-hours districts could be one possible explanation. However, there were no differences in age distribution between the districts. Different structural organisations of the emergency primary health care services can not effect the rate of red responses. But differences in access to rGPs on daytime can influence our data on rates of red responses. We have no data on GPs' accessibility in acute cases during office hours.
Different local triage pattern or traditions of patients are other plausible explanations. The Watchtowers are served by six different EMCCs and nine different LEMCs, and this may explain the differences, even using the same Norwegian Index system. Staff at the casualty clinics will probably not classify patients similarly based on direct attendance compared to telephone triage. Differences in triage, both by telephone and after direct attendance, will also probably exist between the different emergency primary health care districts. Studies on telephone triage demonstrate differences between staff even when using the same guidelines [16], and, not surprisingly, more when using different guidelines [17].
Differences in the number of red responses between the emergency primary health care districts are large. Based on the rate of 9 per 1 000 inhabitants, the largest (Oslo) out-of-hours district in Norway will approximately have 5 000 and the smallest approximately three red responses per year. Better web information about telephone numbers to the LEMCs could increase contact. Telephone numbers to the LEMCs were in half of the municipalities not easily accessible on the Internet [18]. Establishing a common number to the LEMCs in Norway is being discussed. A common phone number will probably increase contacts to the local out-of-hours services [19], underlining the continues need for professional personnel and use of a triage tool with good quality to sort the patients into the right levels of care, also within the local LEMCs and not only the more centralised EMCCs.