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Background: Emergency diagnostic and treatment units (EDTUs) may provide an alternative to hospitalization for patients with reversible diseases, such as asthma, who fail to adequately respond to emergency department therapy., Objective: To evaluate the medical and cost-effectiveness, patient satisfaction, and quality of life of patients receiving EDTU care for acute asthma compared with inpatient care., Methods: A prospective, randomized clinical trial performed at 2 urban public hospitals enrolled patients with acute asthma (age range, 18-55 years) not meeting discharge criteria after 3 hours of emergency department therapy. Patients were treated with inhaled adrenergic agonists and steroids in an EDTU for up to 9 hours after randomization or with routine therapy in a hospital ward. Patients were followed up for 8 weeks., Main Outcome Measures: Discharge rate from the EDTU, length of stay, relapse rates, days missed from work or school, days incapacitated during waking hours, symptom-free days and nights, nocturnal awakenings, direct medical costs, patients satisfaction, and patient quality of life., Results: The study consisted of 222 patients with asthma. Sixty-five patients (59%) treated in an EDTU were discharged home; the remainder were admitted to the hospital. There were no differences during the follow-up period in relapse rates (P = .74) or in any other morbidities between the EDTU and inpatient groups. There were significant differences in the length of stay, patient satisfaction, and quality of life favoring EDTU care. The mean (+/-SD) cost per patient in the EDTU group was $1202.79 +/- $1343.96, compared with $2247.32 +/- $1110.18 for the control group (P < .001)., Conclusions: Treatment of selected patients with asthma in an EDTU results in the safe discharge of most such patients. This study suggests that quality gains and cost-effective measures can be achieved by the use of such units.

Objective: To evaluate the predictive value of standard letters of recommendation (LORs) vs preprinted questionnaires (PPQs) for resident performance at one emergency medicine (EM) residency program., Methods: A retrospective association of LORs and PPQs with in-training residents performance ratings was done at one EM residency program. The residency application files of EM residents who completed the program were reviewed to locate files that had LORs and PPQs written by the same author. Seventeen resident files contained 32 LOR/PPQ pairs. These LORs and PPQs were submitted in a blinded fashion to 3 outside EM residency directors. Each LOR and PPQ was evaluated for the applicant's suitability for the specialty of EM, medical knowledge, procedural skills, interpersonal skills, motivation, and overall rank. The scores given by the outside reviewers were compared with resident performance ratings determined by 5 EM attending physicians who evaluated the residents along the same 6 dimensional ratings., Results: Statistically, no differences were found between the LORs and PPQs in predicting resident performance., Conclusions: PPQs may substitute for LORs in the evaluation of resident applicants.

In this multicenter prospective trial, we studied posterior (V7 to V9) and right ventricular (V4R to V6R) leads to assess their accuracy compared with standard 12-lead electrocardiograms (ECGs) for the diagnosis of acute myocardial infarction (AMI). Patients aged >34 years with suspected AMI received posterior and right ventricular leads immediately after the initial 12-lead ECG. ST elevation of 0.1 mV in 2 leads was blindly determined and inter-rater reliability estimated. AMI was diagnosed by World Health Organization criteria. The diagnostic value of nonstandard leads was determined when 12-lead ST elevation was absent and present and multivariate stepwise regression analysis was also performed. Of 533 study patients, 64.7% (345 of 533) had AMI and 24.8% received thrombolytic therapy. Posterior and right ventricular leads increased sensitivity for AMI by 8.4% (p = 0.03) but decreased specificity by 7.0% (p = 0.06). The likelihood ratios of a positive test for 12, 12 + posterior, and 12 + right ventricular ECGs were 6.4, 5.6, and 4.5, respectively. Increased AMI rates (positive predictive values) were found when ST elevation was present on 6 nonstandard leads (69.1%), on 12 leads only (88.4%), and on both 6 and 12 leads (96.8%; p <0.001). Treatment rates with thrombolytic therapy increased in parallel with this electrocardiographic gradient. Logistic regression analysis showed that 4 leads were independently predictive of AMI (p <0.001): leads I, II, V3, V5R; V9 approached statistical significance (p = 0.055). The standard ECG is not optimal for detecting ST-segment elevation in AMI, but its accuracy is only modestly improved by the addition of posterior and right ventricular leads.

Background: Although accelerated diagnostic protocols are being increasingly used in emergency departments to diagnose acute cardiac ischemia, there have been no prospective evaluations of a chest pain diagnostic protocol with serial determinations of creatine kinase MB isoenzyme and mandatory exercise electrocardiography (ExECG)., Methods: Prospective cross-sectional study in which chest pain protocol results were compared with final (reference) diagnoses of acute cardiac ischemia (including acute myocardial infarction and unstable angina). Patients in need of hospital admission but at low probability (by a validated algorithm) for acute myocardial infarction were examined for exclusions: known coronary artery disease, cardiac complications, severe comorbidities, or inability to perform exercise testing. A 12-hour diagnostic protocol included serial measurements of creatine kinase MB, ECG, and clinical assessments followed by ExECG for those with negative initial serial testing. Reference diagnoses were established during hospitalization and diagnostic accuracy was assessed., Results: The study group of 317 patients was 54% male and 65% black, and had a mean age of 46.6 years; 9.5% had a final diagnosis of acute cardiac ischemia. For this diagnosis, the protocol had a sensitivity of 90.0% (95% confidence interval, 72.3%-97.4%); specificity, 50.5% (95% confidence interval, 44.6%-56.4%); positive predictive value, 16.0%; and negative predictive value, 98.0%. Creatine kinase MB, serial ECGs, and ExECG each made a contribution to improved sensitivity and accuracy, whereas clinical reassessments were less discriminating, as indicated by protocol's receiver operating characteristic curve., Conclusions: A chest pain diagnostic protocol achieved high sensitivity and improved specificity over the standard emergency department workup. There were no adverse advents associated with early ExECG.

The function and phenotypes of CD4+ lymphocytes in infants are different than in adults and are modulated by maturational changes and exposure to environmental antigens. Infants of non-human immunodeficiency virus (HIV)-infected mothers and uninfected infants of HIV-infected mothers, 0 to 6 months of age, were examined for CD4+ lymphocyte function by in vitro interleukin-2 (IL-2) production and for CD4+ phenotypes by three-color flow cytometry. A minority of these uninfected infants (28%) had functional responses similar to those of healthy adult women (IL-2 production in response to anti-CD3, alloantigen, and mitogen), while the remainder were capable of responding to alloantigen and mitogen but not to anti-CD3. We did demonstrate reduced phytohemagglutinin-stimulated IL-2 production in uninfected infants born to HIV-seropositive mothers compared to that in infants from seronegative mothers. The proportions of CD3+ CD4+, CD4+ HLA-DR- CD38+, and CD4+ CD45RA+ RO- (naive) lymphocytes were much higher in infants than in adults, and the proportions of CD4+ CD45RA- RO+ (memory) and CD4+ CD25+ (IL-2 receptor-bearing) lymphocytes were lower in infants than in adults. The proportions of activated (CD4+ HLA-DR+ CD38+) and memory (CD4+ CD45RA- RO+) lymphocytes were increased in uninfected infants of HIV-infected mothers compared to infants of uninfected mothers. Therefore, T-helper-cell function is immature in many infants, but the CD4+ lymphocytes of some HIV-exposed, uninfected infants have been stimulated by antigen at an early age.

Study Objective: Patient satisfaction is an essential outcome measure in the diagnosis and treatment of acute chest pain in the emergency department. We compared patient satisfaction with the diagnostic protocol of a chest pain observation unit (CPOU) and standard inpatient hospitalization., Methods: We prospectively studied patients who presented to the ED with chest pain and were found to have a low risk of acute myocardial infarction (AMI) but who still might have benefited from a diagnostic protocol to rule out AMI. Consenting patients (N = 104) were randomized to the CPOU (experimental) arm or the hospital inpatient (control) arm and assessed for satisfaction by means of an interview before hospital discharge., Results: The CPOU protocol scored higher on four summary ratings of overall patient satisfaction. Correlations between overall satisfaction, number, and type of problems with care, and patient characteristics demonstrated content validity and revealed strengths and improvements that might be made in CPOUs., Conclusion: Patients were more satisfied with rapid diagnosis in the CPOU than with inpatient stays for acute chest pain. Our findings add important information to the standard practice of weighing clinical and cost outcomes between two medical care alternatives.

Study Objective: To evaluate the applicability of a short-stay protocol for exclusion of acute ischemic heart disease without hospital admission and to analyze these results in the context of a conceptual model., Methods: An observational study of patients who presented with chest pain to the emergency department of an 886-bed inner-city municipal hospital and who needed hospital admission to rule out acute myocardial infarction (AMI). Patients were assessed by ED attending physicians to determine eligibility for an alternative, 12-hour protocol in an ED chest pain observation unit (CPOU) followed by immediate exercise testing. Outcome measures were proportion of patients eligible for the short-stay protocol, risk factor profile, and reasons for exclusion., Results: Of 500 patients screened, 446 had sufficient data points to determine protocol eligibility. Of these, 238 (53.3%; 95% confidence interval [CI], 48.7% to 57.9%) were found to have low probability for AMI. After study exclusion criteria were applied to the patient cohort, 63 patients (14.1%; 95% CI, 10.9% to 17.3%) were eligible for the protocol. The most common reasons for exclusion were history of coronary artery disease (46%) and inability to perform an interpretable exercise tolerance test (42%)., Conclusion: Although most admitted patients with chest pain (53%) were at low probability for AMI, only a minority (14%) were eligible for a short-stay protocol that required patients to be free of known coronary artery disease and able to perform an exercise tolerance test. Factors affecting the operations and efficiency of a CPOU include clinical characteristics of the target patient population, protocol tests used, and hospital occupancy and reimbursement patterns.

Objectives: The learning style preferences of public health students are investigated. Learning styles, as defined by Kolb, refer to the four distinct manners of processing information., Methods: Students' learning styles are analyzed for associations by gender, occupation, and public health program. The value of learning styles to predict students' preference for oral presentation versus written exams, performance on different types of exams, and course grade are studied., Results: Learning styles of the students sampled were neither predominantly of one learning style nor evenly distributed. Learning style preferences did not vary significantly according to gender, occupation, or public health program. Learning styles also did not predict the students' choice of oral presentation or written exam. Assimilators, however, scored significantly higher than the other three learning styles on the theoretical exam and in their course grade., Discussion: The authors suggest that public health instructors employ a variety of teaching methods and evaluative opportunities when class composition is initially assessed as having diverse learning styles. This "instructional pluralism' is necessary to facilitate learning, maximize participation, and permit multiple pathways for students to demonstrate educational performance.

This study explores provider adherence to national guidelines in treating Latino and African-American asthmatics. We hypothesized that there would be more variations in asthma treatment existing for minorities as a result of variation in physician's adherent to the guidelines. A 96-item survey was administered to 138 Latino and African-American asthmatics attending a hospital emergency department. Data were obtained on demography, severity, access, patient satisfaction, and patient's assessment of physician asthma management. Results were analyzed by ethnicity, gender, practice site of regular provider, and severity. Variation in physician practice was found in these variables. Asthma treatment received by Latino and African-American respondents was deficient compared to guidelines. Regression analyses showed that Latinos fared more poorly on the number of prednisone bursts taken, use of written crisis plans and dispensation of peak flow meters controlling for gender, practice site and severity. African-Americans expressed less dissatisfaction in obtaining services, while both groups expressed high degrees of satisfaction with their providers.

Young black males are disproportionately represented as patients in trauma units. Unemployment, low educational level, and family composition may predispose young black males to trauma unit admission. To test this hypothesis, 300 males between the ages of 18 and 40 admitted to the Cook County Hospital Trauma Unit were surveyed with respect to demographic data, family composition, educational level, and employment background. The majority of patients were black (87%) and unemployed (68%). The most common diagnoses were penetrating trauma (53.2%) and assault (33.5%). Highest unemployment and lowest educational levels were found among patients who were victims of penetrating trauma or assault. Sixty-six percent reported the presence of an adult male in the household while growing up, and 93% reported the consistent presence of their biological mother. There was a significant correlation between race, trauma mechanism, unemployment, low educational level, and family composition. Recognition and amelioration of the economic and educational inequities that may exist in this population might reduce the incidence of trauma significantly.

Objective: To determine whether acute myocardial infarction (AMI) patients who have negative ECGs on presentation have significantly lower complication rates than do those AMI patients who have positive ECGs on presentation., Methods: Retrospective, cohort analysis comparing rates of hospital complications (ventricular fibrillation or tachycardia, shock, atrial arrhythmia or bradyarrhythmia with systolic blood pressure < or = 90 mm Hg, pulmonary edema) or interventions among patients with a final hospital diagnosis of AMI and an initially negative vs positive ECG. A negative ECG was normal or had nonspecific ST-segment and/or T-wave abnormalities (upright, flattened T waves; an isolated inverted T wave; ST depression < 0.1 mV; tall T waves with J-point elevation) or minor nonischemic abnormalities. Sample size was adequate to detect a 30% between-group difference in complication rates [alpha = 0.05, 1 - beta (power) = 0.80]., Results: The 27 negative-ECG AMI patients differed from the 38 control patients in (mean +/- SD) age [57 +/- 12 vs 66 +/- 12 years, p < 0.01] but not in gender or history of AMI. The negative- and positive-ECG groups had similar rates of hospital complications [30% (95% CI: 13-47%) vs 42% (95% CI: 26-58%), p = 0.44] and intensive procedures [19% (95% CI: 4-34%) vs 29% (95% CI: 15-43%), p = 0.50], respectively. The negative-ECG patients with hospital complications had ECG evolution precede the event in 83% (95% CI: 69-97%) of cases; persistently negative-ECG patients had no complications [(95% CI: 0-33%), p = 0.06]., Conclusions: Negative- and positive-ECG AMI patients do not have moderate or large differences in the rates of in-hospital complications. Most negative-ECG patients who suffer complications evolve ECG changes prior to the event and such changes indicate the potential need for a higher level of care.

To analyze the paradox of acute myocardial infarction (AMI) with an initially normal electrocardiogram (ECG), we reviewed the records of 732 patients discharged with a final diagnosis of AMI over a 2-year period. Twenty-one patient were identified whose initial ECG was normal and who underwent coronary arteriography during the index hospitalization. According to the ECG evolution, three distinct groups were identified: Group 1: those who subsequently developed ST elevation or Q waves (n = 7), Group 2: those who developed ST depression or T-wave inversion (n = 8), and Group 3: those whose ECG remained normal ( n = 6). Peak creatine kinase (CK), timing of the first ECG change, life-threatening complications, and location of the infarct-related coronary lesion were recorded. Infarct-related coronary lesions were also classified into those in a major coronary trunk versus those in secondary branches. The incidence of AMI with a normal ECG was 3.7%. There was no difference in the frequency of coronary artery involvement in the groups studied: left anterior descending (33%), right coronary artery (38%), and circumflex (28%). All ECG changes developed within the first 48 h of hospitalization; 17 +/- 15 in Group 1, and 24 +/- 12 h in Group 2. All six patients who had a persistently normal ECG (Group 3) had lesions in branch vessels (p < 0.05 when compared with Group 1 plus Group 2). Patients who developed ST elevation or Q waves (Group 1) always had a major artery trunk involved (p < 0.05 when compared with Group 2 plus Group 3). Patients in Group 3 had less myocardial damage and fewer complications compared with the other two groups. Myocardial infarction with an initial normal ECG is uncommon and may result from involvement of any of the three coronary arteries. Electrocardiographic evolution usually occurs within the first 48 h of hospitalization. Patients whose ECGs remain normal appear to have culprit lesions in coronary branches, smaller infarctions, and fewer in-hospital complications.

Study Objective: To study the relationship between a trauma center per diem charges and medicare DRG reimbursement., Design: Retrospective comparison of charges ($630/day, $1500/ICU day) and hypothetical DRG reimbursement using medical records ICD-9 N and P codes and version 5.0 of grouper., Setting: An urban level I trauma center that participates in a trauma system that serves a population of 3 million people., Patient Population: Trauma patients > or = 16 years old (mean age of 32 years) admitted and discharged between 1/1/88 and 9/30/88. The group was 85% male, 75% black, with a blunt mechanism of injury in 64%. The mean ICU stay was 0.9 days, and the mean total length of stay was 5.0 days., Results: Total per diem charges were $8,652.159, and DRG reimbursement was $8,636,505, causing a net loss of $15,654, or 0.2% of charges. Mean charges and reimbursement did not differ for the entire group. The mean loss per patient was "8. Mean charges and reimbursement differed in penetrating trauma patients (mean loss = $138), as well as those with different lengths of stay. The correlation between charges and reimbursement was 0.42; for penetrating trauma patients, the correlation was 0.58 (p < .001)., Conclusion: If DRG reimbursement were provided for all admitted trauma patients, the amount would equal per diem rates. Trauma centers with similar patients and lengths of stay can use these per diem rates to estimate DRG reimbursement.

Study Hypothesis: Femoral artery injuries can be predicted by the mechanism of injury, wound location and tract, and physical findings following penetrating thigh trauma., Design: Retrospective case-control study., Participants: All 808 consecutive patients undergoing femoral arteriography for penetrating thigh trauma from September 1986 through December 1990 were eligible for inclusion in the study. All 50 patients in the eligible population with proven femoral artery injuries diagnosed by angiogram were the study subjects. Fifty patients with penetrating thigh trauma who had angiograms negative for injury and were systematically chosen from the eligible population served as controls., Interventions: Data included mechanism of injury; location of wound entrance, tract, exit, and retained missile; physical findings (including ankle-brachial index); and the presence of femur fractures. Physical findings were divided into hard findings (pulse abnormality, expanding hematoma, or pulsatile bleeding) or soft findings (neurologic deficit, hypotension without another source, or bruit/thrill)., Results: Of the 808 eligible patients, 50 (6.2%) had a femoral arterial injury on angiography, 20 (40%) of which were clinically occult injuries. A medial thigh tract made an arterial injury 58 times more likely (odds ratio [OR], 57.5; P < .001) and was present in 100% of cases and 64% of controls. An anteromedial thigh tract made an arterial injury 12 times more likely (OR, 11.5; P < .001) and was present in 92% of cases and 50% of controls. A wound with hard physical findings was 118 times more likely to have an arterial injury (OR, 118; P < .00001) and was found in 54% of cases and none of the controls. The presence of any physical finding made an arterial injury 36 times more likely (OR, 36; P < .00001) and was found in 60% of cases and 4% of controls. The presence of a femur fracture or a gunshot mechanism was not predictive of injury., Conclusion: Only patients with medial thigh wounds need to undergo angiography for the detection of femoral artery injuries. This approach would have reduced the angiography rate by 36% in this series. Had angiography been performed only on patients with any physical findings, a 70% reduction in the rate of angiography would have been achieved, although five occult arterial injuries per year would have been missed. Angiography should not be performed solely because of a gunshot mechanism or the presence of a femur fracture.

Objective: Evaluation of a research training program for emergency medicine residents., Methods: A cross-sectional, descriptive analysis of knowledge and skill acquisition observed following the introduction of a resident research curriculum was performed at a university-affiliated emergency medicine residency program within a large-volume, inner-city hospital. The didactic program was based upon a published SAEM model research curriculum and included tutorials in computer applications for research. Seventeen first-year residents participated in the new curriculum and self-assessment evaluation. The rate of research proposal preparation after curriculum implementation for the 17 course participants was compared with that of 26 historical control subjects from the same residency program., Results: Resident attendance for the sessions, offered twice annually, averaged 82%. Significant self-perceived knowledge gains (p < 0.05) were found in the areas of study design and methods, journal selection, research planning, and two microcomputer application areas. There was a strong correlation between postcourse examination scores for many specific subject areas and attendance at the related sessions. Thirteen of the 17 participants (76%) completed an original (NIH PHS398-formatted) research proposal within four months following the training program, compared with only six of 26 residents (23%) not exposed to such a curriculum in previous years (p < 0.05)., Conclusion: Residents appeared satisfied with this level of training and made gains in their skills and knowledge of research activities. The rate of preparation of research proposals by course attendees surpassed that of former residents. This educational intervention may augment the standard practice of faculty mentorship of residents and fellows for research knowledge and skill acquisition.

Study Objective: Pulse oximetry has been reported to be falsely elevated in the presence of carbon monoxide (CO). However, the degree to which pulse oximetry overestimates measured oxyhemoglobin saturation (O2Hb) has not been investigated in patients with CO exposure. This study quantifies the effect of CO on pulse oximetry and O2Hb in a series of patients with elevated carboxyhemoglobin (COHb) levels., Methods: A prospective case series of 25 pulse oximetry measurements, with concurrent arterial blood gas sampling, were obtained on 16 adults with CO exposure., Results: COHb levels (mean, 16.1%; SD, 11.6%; range, 2.2% to 44%) did not significantly correlate with pulse oximetry saturation (mean, 97.7%; SD, 1.5%; range 96% to 100%) (r = .45; P = .1 [NS]). Compared with COHb, a pulse oximetry gap (mean, 17.5%; SD, 1.5%; range, 2.3% to 42%), defined as pulse oximetry saturation minus O2Hb, yielded a linear regression model: pulse oximetry gap = 1.82 + 0.94 x COHb (SEM = 0.07; F = 204; R2 = .90; P < .0001)., Conclusion: Oxygen saturation as measured by pulse oximetry failed to decrease to less than 96% despite COHb levels as high as 44%. Regression between the pulse oximetry gap and COHb suggests that pulse oximetry overestimates O2Hb by the amount of COHb present. Pulse oximetry is unreliable in estimating O2Hb saturation in CO-exposed patients and should be interpreted with caution when used to estimate oxygen saturation in smokers.

To evaluate the relationship of cocaine to intraventricular hemorrhage in preterm (< or = 37 weeks gestation) infants, the charts of infants admitted to an intensive care nursery over a 2-year period were reviewed. Data were extracted regarding intrauterine exposure to cocaine, head ultrasonography, and specific independent variables: gestational age, 5-minute Apgar score, and the presence of pneumothorax. These variables were classified into high-, moderate-, and low-risk groups for the development of intraventricular hemorrhage. Analysis was done using chi-square, Mantel-Haentzel tests, crude odds ratio with 95% tests, crude odds ratio with 95% confidence intervals, and stepwise multiple logistic regression analysis. Intraventricular hemorrhage developed in 24 (22%) cocaine-exposed infants versus 49 (20%) nonexposed infants. Thirteen (12%) infants exposed to cocaine developed grades I to II and 11 (10%) developed grades III to IV intraventricular hemorrhage. The figures in the nonexposed infants were 29 (12%) and 20 (8%), respectively. Intraventricular hemorrhage was more likely to occur in infants who belonged to the high-risk groups: gestational age < or = 30 weeks, 5-minute Apgar score < or = 5, and the presence of pneumothorax. Pneumothorax was the single most significant factor associated with intraventricular hemorrhage grades III to IV. Intrauterine exposure to cocaine does not seem to influence the prevalence or severity of intraventricular hemorrhage in the preterm infant.

Background: The purpose of this study was to test the contribution of aminophylline in improving peak expiratory flow rate (PEFR) during emergency department treatment of acute asthma when metaproterenol sulfate and steroid therapy are also provided., Methods: In a prospective, randomized, double-blind, and placebo-controlled trial at a municipal hospital emergency department, 44 patients with acute asthma, aged 18 to 45 years, with theophylline levels below 28 mumol/L, who had failed to achieve a PEFR of 40% predicted after one nebulized metaproterenol treatment, were recruited. An aminophylline or placebo loading dose and maintenance infusion were administered. All patients received hourly nebulized metaproterenol and initial methylprednisolone sodium succinate. The PEFR was measured hourly for 5 hours. Two-factor repeated-measures analysis of variance of improvement in PEFR ([final-initial PEFR]/predicted PEFR) was assessed., Results: There was no difference in improvement of PEFR at any hour between the treatment and placebo groups. After 5 hours, the difference in improvement ratio was 0.40 (aminophylline) vs 0.36 (placebo) (P = .30; n = 22 in each group). The treatment group suffered more tremor, nausea or vomiting, and palpitations (P < .05)., Conclusion: In the emergency department setting, aminophylline contributes no significant improvement in PEFR when beta 2-agonists and corticosteroids are being provided, while causing more side effects.

Study Objective: To demonstrate that a complete and rapid clinical history can be obtained using a self-administered, bilingual questionnaire., Design: A post-test experimental design was used to evaluate time spent obtaining the history and information completeness for the two groups., Setting: Urban county emergency department., Participants: All patients were non-English-speaking Hispanic women who presented with gynecologic complaints., Methods: Fifty-five patients completed a history questionnaire in Spanish on a form that displayed their responses in English on the carbon copy. In the control group, a history was obtained using a bilingual interpreter., Results: Average completion time was significantly less (t = 14.38; P < .0001) for the experimental group (chi 2 = 5.67 minutes; SD, 1.89) than for controls (chi 2 = 14.58 minutes; SD, 4.19). There was no statistical difference in review criteria for documentation between groups., Conclusion: Using a bilingual questionnaire to obtain a clinical history results in more rapid patient evaluation without affecting the quality of information obtained.

Study Objectives: To assess sensitivity, specificity, and odds ratios of ECG findings on leads V4R, V8, and V9 for acute myocardial infarction., Design: Prospective, two-stage cohort study., Setting: A 660-bed university-affiliated community hospital., Type of Participants: One hundred forty-nine admitted patients with suspected myocardial infarction or unstable angina., Interventions: Standard 12-lead ECG followed immediately by V4R, V8, and V9., Measurements: Initial ECG findings of ST-segment displacement, Q waves, T-wave inversion, and eligibility for thrombolytic therapy., Results: Major abnormalities (ST-segment deviation, T-wave inversion, Q waves) were found on the extra three leads in 28.9% (43 of 149) of patients. Sensitivity of ST-segment elevation for acute myocardial infarction on 12 versus 15 leads increased from 47.1% to 58.8%, respectively, with no decrease in specificity. McNemar's pair-matched analysis for ST-segment elevation on myocardial infarction subgroup showed an association of ST elevation with the 15-lead ECG (P < .05). An eightfold increase in the odds of detecting ST elevation was found (90% confidence interval, 1.42 to 14.58); 22% of patients negative for ST elevation on 12 leads were positive on 15 leads. Analysis of ECG criteria for thrombolytic therapy presenting uniquely on extra leads showed an increased sensitivity from 35.3% to 44.1% on 12 versus 15 leads, respectively; there was a sixfold increase in the odds of meeting ECG thrombolytic therapy criteria (90% confidence interval, 0.34 to 11.66); 13.5% of patients not meeting criteria on 12 leads did so on 15 leads., Conclusion: The 15-lead ECG provides increased sensitivity and odds of detecting ST-segment elevation in acute myocardial infarction patients with no loss of specificity; its use may expand the selection of thrombolytic therapy candidates and provide a fuller ECG description of the extent of myocardial injury and necrosis.

To test whether the facilities and services offered by rural hospitals can put them at risk of closure or protect against it, this study compares U.S. rural community hospitals that closed during the period 1980-1987, with a matched set of hospitals that remained open. Utilizing epidemiologic matched case-control methods and controlling for type of ownership, we found that (1) physical therapy, respiratory therapy, intensive care unit, computed tomography scanner, hospital auxiliary, and diagnostic radioisotope were negatively correlated with closure (i.e., had a protective effect); (2) the facilities and services correlated with risk of closure differed significantly between the pre-PPS (1980-1983) and post-PPS (1984-1987) periods; and (3) the presence of a skilled nursing or other long-term care unit was a significant risk factor during the period 1984-1987. Implications of these findings for hospital survival strategies and rural health care delivery under PPS are discussed.

The use of sociodemographic data in planning ambulatory health services is discussed and illustrated. Five global indices are identified as important for establishing contours of need within local community areas: social class, population heterogeneity, resident mobility, family organization, and general stress factors. Knowledge of sociodemographic distributions within a given community can serve as an adjunct for rational decision making in planning and placement of ambulatory health care services. It can also establish a means for evaluating whether extant health services reach their intended targets via comparisons to the social demography of patients receiving care in private practices or public clinics. Such analyses are germane to ambulatory health care practitioners in both the public and private sector.

This is a case study in techniques for combining qualitative and quantitative data in local community service needs assessments. Problems in available administrative statistics when applied to local communities are illustrated and discussed. Supplementation of epidemiologic estimates and utilization statistics with ethnographic, historical, and sample survey data is shown.

Current environmental conditions such as limited financial resources, cost containment, rising consumer expectation, and perhaps more stringent regulation of available public monies to support social services signal declining opportunities for survival of autonomous, freestanding community agencies and the development of newer collaborative forms of organization. In order to preserve maximum input of need information among their professional and community environments, community agencies will require improved procedures for processing multisource assessments. A methodology is presented for weighting and pooling of multisource need information geared for use by planners and decisionmakers of performance oriented multi-agency health care systems.

The issue of rural hospital closings in the United States in recent years has become of increasing concern to health care policy analysts. Rural communities face unique health needs, necessitating access to local health care. Much has been written about the social, economic, legislative, and technological changes that have increased the stress on rural hospitals in the 1980s. However, quantifiable models have been lacking with which to examine in detail factors associated with rural hospitals and to correlate such factors with individual hospitals' risks of closing. In this study, we identify variables correlated with rural community hospital closures in the period 1980-87. Using epidemiologic case-control methods, 161 closed rural hospitals were matched 1 to 3 with a control group of 483 rural hospitals which remained open during the same period. A series of hospital performance indicators and demographic, economic, and social community variables were entered into a multiple logistic regression model. Four variables were found to be positively correlated with risk of closure. They are for-profit ownership; nongovernment, not-for-profit ownership; presence of a skilled nursing or other longterm care unit; and the number of other hospitals in the county. Variables negatively correlated with risk of closure were accreditation by the Joint Commission on the Accreditation of Healthcare Organizations, the number of facilities and services, and membership in a multihospital system. Policy and research implications at the Federal, State, and local levels are discussed.