Management of patient-staff and intrastaff problems in psychiatric consultations.

Four possible types of management of patient-staff and/or intrastaff (PS/IS) problems in psychiatric consultations are distinguished and operationalized. The occurrence and correlates of these types of interventions were studied in a multisite investigation of 1112 consecutive consultations in five general hospitals. PS/IS problems (possibly, probably, or certainly) played a role in 28.1% of the consultations studied. The psychiatric consultants utilized a primarily patient-oriented approach in 56.7% of these 310 consultations, whereas in 42.3% they performed (covert or overt) staff-oriented case consultations. A staff-oriented approach may be contraindicated when the PS/IS problems are not very serious or too complex. In the literature staff resistance and hospital culture are frequently mentioned as obstacles to staff-oriented interventions. The present study showed, however, that it was often the consultants' own degree of security about the PS/IS problems that determined the way they handled these problems. Staff-oriented consultations took significantly more of the psychiatric consultants' time. The clinical and economic benefits of such interventions have still to be established. But the psychiatric consultant with a true biopsychosocial approach should always be cognizant of the possible occurrence of PS/IS problems and consider applying a staff-oriented intervention.

A proposal for standardization of psychiatric consultation-liaison data.

There is still a striking lack of homogeneity in the terminology and classifications used in the registration of psychiatric consultation-liaison (C-L) data. Nowadays, the need for standardization of C-L data is greater than ever. Each registration consists of two components: the items and their categories. The present authors distinguish three levels of C-L data: fundamental, epidemiologic, and clinical-educational. A comprehensive proposal for standardization of such items and categories is presented, both on the fundamental and on the epidemiologic level. Data on 2657 consultations carried out by the Netherlands Consortium for C-L Psychiatry (NCCP) and from a literature review of 48 C-L reports serve to illustrate and as a supply for a large database. Various characteristics of the general hospital and of the C-L service are considered to be fundamental, that is, should be presented in each C-L publication. The epidemiologic data are divided into eight groups: sociodemographics, referral characteristics, history, diagnoses, diagnostic recommendations, ward management, discharge and aftercare management, and termination data. Finally, definitions and decision rules are given.

The size of infarction as judged enzymatically in 1974 patients with acute myocardial infarction. Relation with symptomatology, infarct localization and type of infarction.

A common data base of six coronary care units containing personal and clinical data of 17462 patients was used to investigate the relation between clinical symptoms of patients with acute myocardial infarction and size of infarction. In 1974 of the 5110 patients, in whom a final diagnosis of infarction was made, size of infarction was determined according to serially measured levels of serum alpha-hydroxybutyrate dehydrogenase. The episode of infarction was the first in 1396 patients, was recurrent in 497, and undetermined in 81 patients. We calculated the size factor (defined as the mean size of infarction of patients with a particular symptom divided by the mean size of infarction of patients without that symptom) to evaluate the role of the size of infarction to manifestation of certain clinical symptoms. Bradycardia, shock and right-sided failure when noted on admission to the coronary care unit, had factors for size of infarction significantly greater than 1.0 (1.15, 1.79 and 1.30, respectively) in patients suffering an initial infarction, but not significantly different from 1.0 in patients with recurrent infarction. The occurrence of primary and secondary ventricular tachycardia and/or fibrillation, left heart failure (Killip class II-IV), symptomatic supraventricular tachycardia, high-degree atrioventricular blocks, ruptures and death in the coronary care unit was associated with factors significantly greater than 1.0 in those patients having both initial and recurrent infarctions. The size of infarction as judged enzymatically was significantly larger in patients with anterior than inferior and lateral infarction. The size of infarctions without Q waves was judged to be generally 35% smaller than infarctions producing Q waves. It is concluded that the size of infarction determines the occurrence of several symptoms and complications diagnosed at admission or during stay in the coronary care unit.

The performance of three visual coding procedures and three computer programs in classification of electrocardiograms according to the Minnesota Code.

A test library composed of the ECG's of 228 patients with clinically proven myocardial infarction and 294 subjects without clinical evidence of infarction was used to assess the performance of three visual coding procedures and three computer programs designed to classify ECGs according to the Minnesota Code. The results showed that visual coding performed by one experienced senior coder tended to be more consistent than visual coding relying on two less experienced coders and arbitration of disagreements by a supervisor. There was no significant difference in coding results when only one preprocessed complex was coded in comparison with the more elaborate coding of the whole source ECG using majority rule. The coding performance of the three computer programs was similar to that of the visual coding procedures. It is concluded that computer coding of ECGs according to the Minnesota Code is feasible. Combined optimal use of automated coding and visual verification of selected items may still further improve coding precision. However, when judged against an ECG independent standard, the accuracy of all coding procedures in discriminating infarcts from non-infarcts according to the Minnesota code criteria is rather limited. 'Soft' criteria give a reasonable sensitivity with low specificity whereas the use of 'hard' criteria with adequate specificity results in a substantial drop in sensitivity.