Sulfur polymer solidification/stabilization of elemental mercury waste.

Elemental mercury, contaminated with radionuclides, presents a waste disposal problem throughout the Department of Energy complex. In this paper we describe a new process to immobilize elemental mercury wastes, including those contaminated with radionuclides, in a form that is non-dispersible, will meet EPA leaching criteria, and has low mercury vapor pressure. In this stabilization and solidification process, elemental mercury is combined with an excess of powdered sulfur polymer cement (SPC) and sulfide additives in a mixing vessel and heated to approximately 40 degrees C for several hours, until all of the mercury is converted into mercuric sulfide (HgS). Additional SPC is then added and the temperature of the mixture raised to 135 degrees C, resulting in a molten liquid which is poured into a mold where it cools and solidifies. The final treated waste was characterized by powder X-ray diffraction and found to be a mixture of the hexagonal and orthorhombic forms of mercuric sulfide. The Toxicity Characteristic Leaching Procedure was used to assess mercury releases, which for the optimized process averaged 25.8 microg/l, with some samples being well below the new EPA Universal Treatment Standard of 25 microg/l. Longer term leach tests were also conducted, indicating that the leaching process was dominated by diffusion. Values for the effective diffusion coefficient averaged 7.6x10(-18) cm2/s. Concentrations of mercury vapor from treated waste in equilibrium static headspace tests averaged 0.6 mg/m3.

Health care fraud and abuse.

In recent years, health care fraud and abuse have become major issues, in part because of the rising cost of health care, industry consolidation, the emergence of private "whistle-blowers," and a change in the concept of fraud to include an emerging concern about quality of care. The 3 types of conduct that are generally prohibited by health care fraud laws are false claims, kickbacks, and self-referrals. False claims are subject to several criminal, civil, and administrative prohibitions, notably the federal civil False Claims Act. Kickbacks, or inducements with the intent to influence the purchase or sale of health care-related goods or services, are prohibited under the federal Anti-Kickback statute as well as by state laws. Finally, self-referrals-the referral of patients to an entity with which the referring physician has a financial relationship-are outlawed by the Ethics in Patient Referral Act as well as numerous state statutes. Consequences of violations of these laws can include, in addition to imprisonment and fines, civil monetary penalties, loss of licensure, loss of staff privileges, and exclusion from participation in federal health care programs. Federal criminal and civil statutes are enforced by the US Department of Justice; administrative actions are pursued by the Department of Health and Human Services' Office of Inspector General; and all state actions are pursued by the individual states. In addition, private whistle-blowers may, acting in the name of the United States, file suit against an entity under the False Claims Act. Enforcement of health care fraud and abuse laws has become increasingly commonplace and now affects many mainstream providers. This trend is likely to continue.

Utilization strategies for intensive care units.

Critical care resources in the United States are being rationed, that is, not all critical care expected to be beneficial is being provided to all patients who desire it. Although the extent of rationing is uncertain, it is an everyday occurrence in some hospitals and is likely to occur at least some of the time in many hospitals. Substantial evidence suggests that current rationing practices are highly subjective and perhaps inequitable. Critical care is widely believed to be beneficial to many patients, despite a striking dearth of supportive data. Since this type of care is being inequitably denied to some patients, hospitals should either adopt formal rationing guidelines or, alternatively, they should take clear steps to avoid rationing by altering the supply of or the demand for critical care. Reasonable arguments are presented in support of both approaches, as are suggestions for their implementation.

KIE: Considerable evidence supports the contention that U.S. hospitals ration critical care resources in an informal, often irrational and unfair manner. The value, efficacy, and cost of intensive care units are discussed and two options are proposed to tackle the problem of rationing. Hospitals should either establish formal, specific, and equitable rationing guidelines or, alternatively, develop plans to avoid rationing by increasing the supply of resources or by decreasing the demand for them. It is suggested that demand be decreased by more aggressive discharge or by a system of graded care rather than by denying admission. Arguments in favor of and against rationing are presented. It is concluded that, whichever option is chosen, plans should be developed openly, approved by appropriate supervisory bodies, and brought to the attention of hospital staff and patients.

The therapeutic efficacy of critical care units. Identifying subgroups of patients who benefit.

The majority of patients are admitted to critical care units for observation and to facilitate intervention if deterioration occurs or complications develop. We attempted to determine if a reduction in mortality in a subgroup of these patients admitted directly to the critical care units could be identified. A new method using the scientific principles of a randomized trial applied to the case-control design was employed. All 1905 patients admitted to the medical service over a three-month period were prospectively evaluated for illness severity and stability. Patients who would not have been eligible for a randomized clinical trial were excluded. Based on the prospective evaluations, four prognostically distinct subgroups of patients were formed. An odds ratio for each of the prognostic groups was calculated, a ratio of greater than 1 indicating a protective effect of direct critical care admission. Only one subgroup of patients, the unstable moderately ill, had an odds ratio greater than 1 (13.3). These results, in association with the results of our previous study, suggest that at the time of admission to the hospital, direct admission to the critical care unit reduced mortality among the unstable moderately ill subgroup of patients.