The association between residents' work-rounds styles and the process and outcome of medical care.

OBJECTIVE: To determine whether the manner in which residents conduct work rounds is associated with the adequacy of their care processes and the outcomes of their patients. METHODS: Two types of data were collected: time and motion data for residents (n = 12) during work rounds, and clinical and outcome data for the patients they cared for during the observation period (n = 211). Five residents were classified as data gatherers because they spent twice as much time gathering clinical data about their patients as they spent engaging in other activities. Three physicians blinded to the resident's identity rated the quality of the care process and assessed the frequency of undesirable events occurring during the stay and after discharge. RESULTS: A data-gathering style was associated with higher quality of care as judged by both process and outcomes. The data gatherers were more likely to comply with the "stability of medications before discharge" criterion (86% of the data gatherers' cases vs 73% of others', p = 0.07), and their patients were less likely to have unanticipated problems, in that fewer required calls from nurses (20% vs 37%, p < 0.01) and visits by on-call housestaff (33% vs 50%, p = 0.01). The data gatherers' patients were less likely to be readmitted within 30 days (14% vs 38%, p < 0.01). CONCLUSIONS: A data-gathering work-rounds style is associated with better process and outcome. Residency programs should provide formal instruction to trainees in the conduct of work rounds.

Pleural effusion: comparison of clinical judgment and Light's criteria in determining the cause.

Pleural fluid analysis is often the initial diagnostic test used to determine the cause of a pleural effusion. We prospectively studied 33 consecutive patients with pleural effusions to determine whether the fluid arose from a transudative or an exudative process. Clinical judgment by an internist before thoracentesis and both serum and pleural fluid protein and lactic dehydrogenase levels (commonly referred to as "Light's criteria") were compared to the patient's final diagnosis. The internist correctly classified 15 of 17 exudative processes and all 16 transudative processes; the presence of any one of Light's three criteria correctly classified 15 of 17 exudative processes, whereas the absence of all three criteria correctly classified 14 of 16 transudative processes. Clinical judgment and Light's criteria are comparable in their ability to predict whether an exudative or transudative process was responsible for the effusion. Both methods are associated with errors, though of different kinds; these errors occurred infrequently. Recognizing the limitations of these methods will permit the most accurate effusion categorization.

Preparation for barium enema: comparison of a commercial formula diet and low-residue, clear-liquid diets in inpatients.

The barium enema examination is the most frequently done initial diagnostic evaluation for disease of the lower gastrointestinal tract. Adequate preparation of the colon is essential because inadequate preparation necessitates repetition, with patient discomfort, decreased caloric intake, and increased cost. A formula diet (Ensure) has been reported as superior to the usual low-residue, clear-liquid diet for bowel preparation. We evaluated the feasibility of using this formula diet in a general medical inpatient population. We found no significant difference in the quality of preparation (72% and 76% optimal or adequate preparation, respectively) for our inpatient population. The formula diet has several theoretical advantages, including a greater number of calories, lower cost, and better patient acceptance.