Factors influencing physicians' assessment of urgency for inpatient surgery.

OBJECTIVES: To assess to what extent patient, disease and referral characteristics influenced physicians' assessment of urgency of inpatient surgery. METHODS: In total, 452 patients, mean age 50 years, were examined in surgical or gynaecological outpatient clinics in one hospital and referred for inpatient surgery. Data were collected by the examining physician, and the patients were either given a maximal waiting time or the waiting time was not specified. A stepwise logistic regression, with urgency for surgery within four weeks or less as the dependent variable, was used. The results are presented as adjusted odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Of 452 patients, 181 (40%) were deemed urgent (four weeks or less). In multivariate logistic regression analysis, suspected or verified malignant disease (OR 3.45, 95% CI 2.11 to 5.64), risk of serious deterioration (OR 4.53, 95% CI 2.17 to 9.46), being on sick leave from work (OR 3.97, 95% CI 1.82 to 8.64) and being assessed by a physician undergoing specialist training (OR 1.99, 95% CI 1.24 to 3.21) were significant predictors of being assessed as needing inpatient surgery urgently. CONCLUSIONS: Physicians' judgements, in an informal way, internalize many of the public's concerns for fairness, such as the severity of a condition, the potential for improvement and aversion to inequalities in health. More research is needed to understand the difference in urgency ratings between junior and more experienced physicians.

Endoscopic treatment and restrictive surgical policy in the management of peptic ulcer bleeding. Five years' experience in a central hospital.

BACKGROUND: Despite improved surgical and endoscopic technics, acute bleeding from peptic ulcer is still a serious condition, and management remains controversial. The aim of the study was to evaluate a management policy of aggressive endoscopic and restrictive surgical treatment for acute peptic ulcer bleeding. METHODS: We retrospectively investigated the course of all 341 hospital admissions during 1986 to 1990 caused by bleeding peptic ulceration from the first bleeding episode until 30 days after discharge. RESULTS: Total mortality, in-hospital 30 days' mortality, and operative mortality were 6.3%, 4.4%, and 23.5%, respectively. Risk factors associated with mortality were age and number of concomitant diseases, malignant disease, rebleeding episodes, and surgical complications. No patients without associated illness died. In 73 cases (21%) patients were treated endoscopically one or more times, and altogether 17 patients (5%) were operated on. Rebleeding occurred in 67 cases (23%), and only 23 of these were treated endoscopically at admission. Twenty-six (51%) of the rebleeding patients were treated endoscopically and 13 rebleeding patients were operated on. Two-thirds of patients presenting with arterial bleeding were managed endoscopically. No complications occurred in endoscopically treated patients, whereas there were complications in 8 of 17 operated patients. Operated patients needed significantly more intensive care unit observation time and had longer hospital stay than patients treated endoscopically. CONCLUSIONS: Endoscopic treatment is a safe procedure with a low mortality, and, if successful, the need for emergency surgery is substantially reduced. In the relatively few patients requiring surgery after unsuccessful endoscopy, the mortality remains high.

[Content, function and structure of standardized hospital waiting lists in Norway]. / Innhold, funksjon og oppbygging ved standardiserte sykehusventelister i Norge.

Standardization of hospital waiting lists will improve the quality of information on waiting lists, allowing comparison between different hospitals and different counties, and a nationwide aggregation. Waiting lists must include all elective referrals, and will accordingly allow future planning and surveillance of the complete elective hospital activity. A current indication for evaluation/treatment in hospital is a prerequisite for waiting list registration. The registers must be continuously validated by erasing old referrals. Referrals are categorized in relation to hospital departments, sections and levels of care. Subgroups comprise medical specialties and diagnostic groups.

[Grouping and calculated measurements of standardized waiting lists in Norway. Definitions and interpretations of waiting lists]. / Gruppering og opptellingsmåter ved standardiserte ventelister i Norge. Definisjoner og tolkning av ventetider.

Waiting list parameters calculated for defined dates and time periods allow studies to determine balance between new and completed referrals. The authors discuss various sub-groupings of the waiting lists. The main waiting time parameter is mean waiting time for the various levels of care in the case of the different medical specialties and diagnostic groups. Waiting time is defined as the difference between date of first admission to hospital and the date when the patient was referred. It is possible to calculate total waiting time for patients undergoing out-patient evaluation before in-patient or day-care treatment. Aggregated waiting times should exclude control admissions and admissions postponed at the wish of the patient.

[Reports of waiting list data from hospitals to the central registry--a database for reducing hospital waiting lists. Minimum dataset of waiting list parameters]. / Rapportering av ventelistedata fra sykehus til sentralregisteret--database for reduksjon av sykehuskø. Minste felles datasett med ventelisteparametre.

The governmental regulations concerning registration of waiting lists and priority of patients, laid down in July 1990, introduce a "waiting time guarantee" which ensures a waiting time not exceeding six months for patients suffering from diseases having severe impacts on health. Hospitals that are unable to treat these patients within six months are requested to refer them to other hospitals before the deadline. All hospitals have to make monthly reports of waiting list parameters to a Central Waiting List Register, enabling both a nationwide waiting list survey and comparisons between different hospitals and different counties. An online communication facility to the central register enables searches for and reporting of vacant treatment capacity.

Rapid and correct diagnosis of myocardial infarction: standardized case history and clinical examination provide important information for correct referral to monitored beds.

The value of thorough examination of the case history as a diagnostic tool on hospitalization of patients with suspected myocardial infarction was investigated in three independent prospective studies. Use of a limited number of pain-related elements (= 'criteria'), that had already been obtained in the emergency room, could improve the decision on whether or not to admit patients to the coronary-care unit. As an example, in one of the studies, use of such criteria would have reduced the number of 'unnecessary' coronary-care-unit admissions from 298 to 162, a 46% reduction (P less than 0.001). In the same patient sample, use of the criteria could have reduced the number of patients with definite acute myocardial infarction, admitted to the general wards, from 47 to 22, a 53% reduction (P less than 0.01). These favourable results were confirmed in the two independent, smaller-scale studies.

[Testing of a computer program model for the diagnosis of suspected acute coronary disease]. / Uttesting av en EDB-basert modell for diagnostisering av mulig akutt koronarsykdom.

A computerized diagnostic system to be used in patients with acute chest pain was recently developed in our department, and was tested prospectively in 213 consecutive patients with acute chest pain. In our study, the computer system almost invariably improved the decision as to whether or not admission to the coronary care unit was necessary. Thus, compared with decisions made by the emergency room physicians the computer system would have reduced by approximately 75% the number of patients with acute myocardial infarction who are incorrectly referred to the general ward. The system would also have reduced by the same figure the number of cases wrongly placed in the coronary care unit. Thus, in patients admitted with acute chest pain, the use of our computerized system would have improved both diagnostic accuracy and correct referral of patients from the emergency room.

Dose adjusted heparin treatment of deep venous thrombosis: a comparison of unfractionated and low molecular weight heparin.

Two studies have been done to establish recommendations for dosage and dose adjustment in the treatment of deep vein thrombosis (DVT) with low molecular weight heparin (LMWH). In the first, 56 patients were randomized in a double blind study to be treated either with unfractionated heparin (UFH) or LMWH s.c. every 12 h. Initial doses were given according to age and sex, disregarding bodyweight, and the dose was then adjusted when the peak plasma heparin concentration fell outside the desired range of 0.5-0.8 anti-FXa U/ml. There were fewer dose adjustments in the LMWH group. The correlation between injected dose (U/kg bodyweight) and the heparin concentration was higher in the LMWH group (r = 0.59) than in the UFH group (r = 0.38). The results suggest that, in order to obtain the desired heparin concentration, the initial dose of LMWH should be about 100 U/kg bodyweight every 12 h. In the second, open study, this dosage plan was followed in 15 patients. The peak heparin concentration on Day 2 ranged from 0.40 to 0.75 anti-FXa U/ml and adjustment was only required in 3 patients. Day to day variation in peak heparin activity in the individual patient varied little (CV 11-22%), and there was no accumulation. The results indicate that plasma heparin concentration is more predictable using LMWH than UFH, and they point to definite advantages in the use of LMWH in a bodyweight adjusted dosage.

Subcutaneous heparin treatment of deep venous thrombosis: a comparison of unfractionated and low molecular weight heparin.

In a double-blind study, patients with phlebographically proven deep venous thrombosis (DVT) were treated with subcutaneous injections twice a day of either unfractionated heparin (UH; n = 27) or low molecular weight heparin (LH; n = 29) for 7 days, and the dose was adjusted until therapeutic range was reached, according to a chromogenic substrate anti-Xa assay. Forty-eight percent of the LH group did not need dose adjustment as compared to 24% of the UH group. During the course of heparin administration, deviation from initial heparin activity was frequent in both groups, but mean activity did not indicate a cumulative effect in either group. There was 1 incidence of pulmonary embolism (LH) and only 1 minor bleeding episode (UH). Half of the patients in both groups were phlebographically improved. We conclude that subcutaneous heparin treatment with UH or LH appears safe and convenient.

The antithrombotic effect of heparin in deep venous thrombosis: relation to four heparin assays.

In a prospective study, 280 patients with phlebographically proven deep venous thrombosis received intravenous heparin infusion; 224 of the patients were subjected to control phlebography after 5-8 days of treatment. Females above 70 years showed least phlebographic improvement despite similar heparin dosage and heparin activity. Heparin activity in daily drawn blood samples was determined by four different assays. Chromogenic substrate (CS) assay (Coatest heparin), activated partial thromboplastin time (Cephotest), and thrombin time with recalcified plasma (CaTT) showed weak but significant correlations with thrombus resolution judged by phlebography (p = 0.004, 0.003 and 0.018, respectively). A linear prediction equation showed that the phlebographic result was about equally influenced by the mean dose and by the result of any of the three heparin assays. Thrombin time with citrated plasma showed no correlation. CS assay and CaTT showed significantly lower mean heparin activity in patients with (n = 13) than without clinically diagnosed pulmonary embolism (p = 0.012 and 0.001, respectively).