Ocular trauma modelling.

Non-ophthalmologists must know how to detect, diagnose, and initially manage acute eye and ocular adnexal injuries in order to minimize their morbidity. Such instruction can be provided medical students in part from dog eyes and lids injured so as to produce models of common forms of ocular trauma. We describe the generation of such models and the format of instruction employed at the Uniformed Services University of the Health Sciences.

Stress reactions among participants in mass casualty simulations.

Specific stress reactions have been observed in health care providers involved in disaster relief and mass casualty care. To determine whether similar stress reactions occurred in mass casualty simulations, we observed the participants in five large military mass casualty simulations. Using a framework of specific questions, descriptive data were obtained using direct observation and discussion with participants by faculty present to evaluate the exercise. Observations revealed that stress reactions occurred consistently during these mass casualty simulations, and these reactions resembled those seen in health care workers involved in actual mass casualty care. Application of this information to disaster medicine training for emergency physicians is discussed.

The effect of chest radiographs on the management and clinical course of patients with acute cough.

The authors studied 2018 consecutive patients with a cough of less than 1 month's duration, presenting for medical care with this problem for the first time. Chest films were taken of all of the last 1819 of these patients. After physicians had specified diagnoses and patient management plans for the last 1531 of these 1819 patients, 98 per cent of the 1531 were randomized either to a group whose chest films were then used in their care, or to a group whose chest films were not available to the physician. The results show that chest radiographs ordered by physicians resulted in potentially beneficial change in the care of only 3 per cent of patients. Only use of chest radiographs not ordered by physicians led to the appropriate addition of antibiotics to the care of patients with infiltrates, and probably to improved illness outcome. Criteria for efficient, effective use of chest radiographs in the management of patients with acute cough are needed.

An efficient strategy for managing acute respiratory illness in adults.

A safe, effective, and efficient clinical algorithm (management rule) for the care of adults with acute respiratory illness by nonphysician providers is presented. The algorithm was created from a data base collected on more than 5000 patients and prospectively evaluated on an additional 2637. It eliminates unhelpful diagnostic tests and minimizes physician involvement in patient care without compromising clinical standards, illness outcome, or patient satisfaction. Total direct medical care costs when the algorithm was used were approximately 40% of those costs generated by physicians managing similar patients, primarily because the algorithm directed an 80% reduction in a diagnostic test costs. The results suggest that significant savings can result when algorithms are used in the care of ambulatory patients with common illnesses.

The time relationship of performance and audit feedback on conformance with emergency department process criteria.

Adherence to physician-developed process criteria is critical to the medical and legal acceptance of algorithm-directed nonphysician care of acute non-life-threatening illnesses seen in the emergency department. It is generally assumed that adherence to prescribed medical process criteria results in acceptable patient outcomes. We evaluated changes in compliance with varying time delays in audit feedback and varying degrees of supervision. Our evaluation indicated that, under ideal circumstances of daily audit and supervisory feedback, a conformance rate of 80% was achieved. This is a 100% improvement over a group in which neither element was operative.

Effective algorithm-based triage and self-care protocols: quality medicine at lower costs.

The triage phase of an algorithm-based medical care system was analyzed in three military patient environments. Combat medics triaged 4,799 patients using a physician-prepared triage manual which specified levels of initial health care based on the patient's presenting complaints and a brief history. Evaluation indicated that 36% of those reporting for sick call were eligible for treatment by medically appropriate self-care protocols. Of the remaining 64%, all but 4% could receive initial evaluation by non-physician health care extenders. The study demonstrates that personnel receiving basic medical training and orientation to an algorithm-directed triage system can direct military patients to appropriate levels of health care.

Reproducibility of clinical data and decisions in the management of upper respiratory illnesses: a comparison of physicians and non-physician providers.

The ability of non-physician providers to collect the data required by an algorithm for upper respiratory illness management, and the appropriateness of resulting key management decisions, were studied by comparing non-physician data and management decisions on 426 patients with those of internists. The internists, blinded to Amosists' findings and plans, evaluated the same patients and indicated management without using the algorithm (AM-MD) study). To control for variability of internists' data collecting and illness management, 171 additional patients were evaluated and managed consecutively by two internists, each also kept unaware of the other's findings and plans (MD-MD study). Overall AM-MD agreement on history and physical findings (90 per cent and 81 per cent) and on the need for tests (84 per cent) and treatment (87 per cent) was as high as MD-MD aggrement (91 per cent, 80 per cent, 88 per cent, and 75 per cent, respectively). In both studies, there was significantly more agreement on history data than on physical findings, evaluation, and therapy.

The usefulness of x-ray examinations in the evaluation of patients with back pain.

Process and outcome data from 440 patients with back pain were analyzed. As a part of their care, 106 patients (24 percent) had back x-ray examinations. The non-x-rayed group of patients was used as a naturally occurring control group to determine what contribution back radiographs made to the cost, to the diagnoses and therapeutic decisions of providers, and to the outcome and satisfaction of patients. Although back x-rays contributed more to the cost of patient care than any other diagnostic study, their contribution to diagnosis was minimal, and had little effect on therapeutic decisions. Patients receiving back x-rays were more likely to have had prolonged symptoms at their first visit, and less likely to be symptom-free at four weeks, but were more likely to be satisfied with their care. The authors conclude that, for patients under 50, back x-ray examinations have negligible diagnostic value and their use could be reduced without decreasing the quality of medical care.

Basic decisions in Emergency Department cases: a logical approach.

In the emergency department teaching program at Brooke Army Medical Center, housestaff rotating through the emergency department are given an algorithm for use in making basic diagnostic decisions. Housestaff frequently believe that the result of their contact with a patient should be establishment of the correct pathophysiological etiology of the patient's chief complaint followed by definitive therapy and feel anything less is unacceptable. The algorithm, which had been in use for nine months at the time of this report, was formulated in an attempt to deal with the problems such views may create, such as inappropriate management of patients who obviously require admission, second-best care, and delays for patients requiring emergency department evaluation. The algorithm has been successful in changing housestaff attitudes and actions and will continue to be used.

The effectiveness and cost of acute respiratory illness medical care provided by physicians and algorithm-assisted physicians' assistants.

The medical management of patients with acute respiratory illnesses was analyzed at two different clinics during a 14- to 21-month period. Patients received care from either physicians or physician-supervised physician's assistants (PA). The PAs used respiratory illness clinical algorithms to guide their choice of diagnostic tests and treatment. Illness outcome, patient satisfaction, and medical care cost data were obtained for all patients approximately two weeks after the index illness. Despite significant differences in patient population characteristics, illness outcomes were similar, regardless of the provider's educational background. Medical care costs, however, were highest for the physician's patients. For all patients, diagnostic tests contributed about one-third of the total direct costs, mainly because of chest x-ray and throat culture use. Sixty to eighty per cent of medication costs were due to nonprescription drugs used principally for symptom relief. The data demonstrate that the medical care delivered by these physician's assistants was as effective and less costly than the care provided by physicians. Reducing chest x-ray and throat culture use would have a significant economic impact, without adversely affecting medical care effectiveness.