Analyzing patterns-of-treatment data to provide feedback to physicians.

Physicians' practice patterns can be influenced through feedback programs. The purpose of this article is to define a methodology that provides the feedback information necessary to affect physicians' practice patterns, using data collected by a large multispecialty physician group and individualized feedback plans for primary care physicians.

Financial and operational impact of a transfer center.

A tertiary care hospital established a transfer center to manage the large number of transfer requests from other hospitals in its catchment region. Motivating factors included occurrence of economic transfers, medically inappropriate transfers, poor interfacility communication, and a bed shortage. An interdisciplinary task force was convened to design and implement the transfer center, requiring two months from conception to implementation. Non-recurring direct costs were $3000. At the time of implementation, written transfer agreements were promoted and signed with many transferring hospitals. A retrospective audit covering 28 weeks of operation indicates that 1141 inpatient days were avoided for an average of 21.5 days per back-transferred patient. (Back-transfer refers to the return of a patient to the original hospital.) An additional 140 admissions were possible as a result of these avoided days. Approximately $550,000 in variable costs were saved on an annualized basis. Moreover, substantial improvements in communications and interfacility cooperation were realized. No cases of inappropriate denials or delays in transfer were identified. We conclude that a transfer center can be a highly cost-effective mechanism to manage the large number of patients transferred to a tertiary care center.

Analyzing clinical case distributions to improve an emergency medicine clerkship.

Recommendations for a core curriculum for undergraduate emergency medicine education have been published. It is expected that a combination of bedside teaching and didactic sessions will cover all aspects of the curriculum, but this has not been demonstrated. This study describes a method of using the distribution of clinical cases to shape the mix of clinical and didactic learning in an emergency medicine clerkship. All senior students at the Albany Medical College participate in a four-week emergency medicine rotation. A brief log describing each clinical encounter is maintained by the students. Data from one year were sorted into 32 categories adapted from American College of Emergency Physicians guidelines and were tabulated. A criterion of 80% of students encountering at least one case in each category was chosen to ensure a reasonable level of exposure to a particular case or topic. One hundred twenty-three students were exposed to an average of 63.7 +/- 27.5 (SD) patients. Seven categories met the criterion, and the remaining 25 categories failed the criterion. Results indicate that exposure to certain categories of patients with appropriate monitoring can be reasonably ensured in our clinical setting. The didactic portion of the curriculum can be adjusted so that categories not meeting the clinical criterion will be emphasized, whereas those meeting the criterion will be de-emphasized. A method has been described that identifies gaps in the clinical exposure of students and permits appropriate identification of didactic sessions to create a clerkship more consistent with recommended guidelines.

Clinical practice guidelines: promise or illusion?

The uncertainties about appropriateness and rates of use are unfolding against the backdrop of rising costs and an explosion in new biomedical and technological information. Achieving consensus in this environment is increasingly difficult as payers demand proof of effectiveness, consumers want access to the newest technology, and physicians struggle to assimilate new information. The net result is a drive toward practice standards or guidelines.

Emergency health impact of a severe storm.

A severe, premature snow storm resulted in widespread loss of power, communications, and transportation in a populous region of the Northeast. Staff in hospital emergency departments centered in the path of the storm reported a large number of injuries and many unexpected health effects related to the storm. A retrospective survey of the five major hospital emergency departments serving the most heavily affected urban and suburban areas was undertaken to determine the emergency health impact of the storm and resulting operational problems. Expected findings included a decrease in emergency department visits the day of the storm, followed by a sharp increase the day after. Clean-up activities accounted for a large number of the injuries, most of which were preventable. Unexpected findings include a large number of carbon monoxide poisonings and disposition and staffing problems created by caring for many patients who lost access to customary home health care services. Emergency department staff are encouraged to engage in public education efforts that may reduce serious illness or injury related to severe weather and its aftermath. Moreover, traditional disaster plans may need to be supplemented in anticipation of the disposition and staffing problems created by a growing population of elderly patients who will be cut off from vital home health care services by severe weather.

Bacteriology of the marine environment: implications for clinical therapy.

Ocean water and tissue samples were obtained from a variety of sources with phylogenetic and geographic diversity. Purified bacterial colonies were isolated and identification procedures were performed. A total of 67 isolates were recovered. Thirty-eight isolates belonged to the genus Vibrio and included six species. Twenty-four non-fermentative bacteria and four Gram-positive isolates were recovered. Antibiotic susceptibility testing showed that while the non-fermentative marine bacteria generally were susceptible to the antibiotics tested, marine Vibrio species were relatively resistant to a wide variety of antimicrobials. Antibiotics effective against all species included imipenem, trimethoprim/sulfamethoxazole, and chloramphenicol. Further recommendations for treatment are based on sensitivity in culture. Some isolates failed to grow in the medium used for susceptibility testing. Because commercial test kits may not yield accurate identifications of bacteria, the acquisition of antimicrobial susceptibility data gains added importance.

Efficacy of gastric emptying: gastric lavage versus emesis induced with ipecac.

A prospective study was done to compare the efficacy of gastric emptying achieved by gastric lavage (GL) with that of ipecac-induced emesis (IE) in victims of drug overdose. Thiamine was used as a marker of recovery in gastric samples, as measured by ion exchange/ion pair high-performance liquid chromatography. There were 51 patients in the IE group and 37 in the GL group. GL produced a higher mean per cent recovery of thiamine than did IE (90% +/- 34% compared with 50% +/- 35%). There was a significant difference between the two groups (P less than .001). Recovery of thiamine was more than 70% in 28% of the IE patients, and exceeded 70% in 75% of GL patients. When gastric emptying is desired for management of the adult overdose victim, the use of GL maximizes the chance of recovering unabsorbed liquid drugs from the stomach.

Pre-hospital tracheal intubation versus esophageal gastric tube airway use: a prospective study.

A prospective study compared the respiratory effectiveness of the endotracheal tube (ET) with that of the esophageal gastric tube airway (EGTA) for victims of nontraumatic cardiac arrest in the pre-hospital setting. Arterial blood gases were obtained within 3 minutes of hospital arrival, and survival (defined as discharge from the hospital) was determined. During EGTA ventilation, mean pH was 7.12 +/- 0.2, mean P02 was 77 +/- 92 mm Hg, and mean PC02 was 78.2 +/- 42.9 mm Hg; the survival rate was 4.5%. During ET ventilation, mean pH was 7.34 +/- 0.2, mean P02 was 265 +/- 151 mm Hg, mean PC02 was 35 +/- 20.5 mm Hg; the survival rate was 7%. The authors conclude that endotracheal intubation remains the procedure of choice for airway management in the victim of cardiopulmonary arrest.

The Reel Splint: experience with a new traction splint apparatus in the prehospital setting.

A new lower extremity splint apparatus was applied by paramedics to 50 patients in the prehospital setting to manage a total of 60 injuries. The Reel Splint was designed to provide stabilization with or without traction to a variety of angulated lower extremity fractures/dislocations. In 37 instances (74%), the splint was judged by the rescuers to be superior to the standard Thomas splint. In this series the splint was used successfully for extrication , to immobilize deformed limbs, and to provide traction for the restoration and maintenance of peripheral circulation, with frequent pain relief. No deleterious functional complexities or manufacturing defects were identified. The Reel Splint is a uniquely useful alternative to currently available splints.

Inadequate oxygenation and ventilation using the esophageal gastric tube airway in the prehospital setting.

In a prospective study to evaluate the respiratory effectiveness of the esophageal gastric tube airway (EGTA) in the prehospital setting, we analyzed arterial blood samples from 43 victims of out-of-hospital cardiopulmonary arrest managed with the EGTA. Five minutes after emergency department endotracheal intubation, arterial blood gas analysis was repeated for comparison. During EGTA ventilation, the mean arterial PO2 measured 83.6 +/- 110.4 mm Hg; endotracheal intubation increased the mean PO2 to 189 +/- 167.5 mm Hg. During EGTA ventilation, the mean arterial PCO2 measured 77.1 +/- 34 mm Hg; endotracheal intubation decreased the mean PCO2 to 57.8 +/- 34.4 mm Hg. We conclude that endotracheal intubation remains the procedure of choice for airway management in the victim of cardiopulmonary arrest.