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This chapter discusses the tragic case of Karen Ann Quinlan, a New Jersey resident. At the age of 22, she lies in a debilitated and allegedly moribund state at Saint Clare's Hospital in Denville, New Jersey. On the night of April 15, 1975, for reasons still unclear, Karen Quinlan ceased breathing for at least two 15 minute periods. She received some ineffectual mouth to-mouth resuscitation from friends. Three days later, Dr. Morse examined Karen at the request of the Newton admitting physician, Dr. McGee. He found her comatose with evidence of decortication, a condition relating to derangement of the cortex of the brain causing a physical posture in which the upper extremities are flexed and the lower extremities are extended. Dr. Morse, as well as the several other medical and neurological experts who testified in this case, believed with certainty that Karen Quinlan is not "brain dead".

BACKGROUND Hospitalists frequently consult medical subspecialists in the management of inpatients. Given the potential impact on health resource utilization, it is important to understand the working relationship between these groups. METHODS A cross-sectional survey of hospitalists, n = 655, and subspecialists across Ohio (nephrologists and endocrinologists), n = 293, was conducted to investigate perceptions and communication about reasons, timing, and impact of hospital consultations. RESULTS Survey response rate was 13.3%. Hospitalists were more likely to report subspecialty request to serve as admitting physician with subsequent consultation 63.2% versus 26.7%, p < .001. Hospitalists with a daily workload ≥15 patients per day were more likely to report that this impeded their ability to manage details of patient care versus hospitalists with

Background Patient blood management (PBM) programs seek to optimize the utilization of blood components. Since our institution's program started, the annual number of red blood cell (RBC) units transfused has decreased by 27% overall. Study Design and Methods We collected data for 6 months in 2007 (pre-PBM) compared with the same months in 2011 (post-PBM) to determine which changes in practice decreased RBC utilization. Indications for transfusion of nonsurgical patients were collected from the electronic medical records, while surgical indications were assigned to the admitting physician's specialty. Results Pre-PBM, we transfused 19,888 RBC units for a mean of 0.96 units per patient discharged, compared with 14,472 post-PBM, for a mean of 0.55 units per discharge. This represents a 43% reduction in RBC units transfused per patient discharged. While transfusion episodes decreased only slightly from 9519 to 9261, the success can be explained by the overall reduction in mean number of units per transfusion from 2 to 1.5 (p

The Emergency Department (ED) is an environment at risk for medical errors.Our aim was to determine the factors associated with the adverse events resulting from medical errors in the ED among patients who were admitted.This was a prospective observational study. For a 1-month period, we included all ED patients who were subsequently admitted to the medical ward. Detection of medical errors was made by the admitting physician and then validated by two experts who reviewed all available data and medical charts pertaining to the patient's hospital stay, including the first review from the ward physician. Related adverse events resulting from medical errors were then classified by type and severity. Adverse events were defined as medical errors that needed an intervention or caused harm to the patient. Univariate analysis examined relationships between characteristics of both patients and physicians and the risk of adverse events.From 197 analyzed patients, 130 errors were detected, of these, 34 were categorized as adverse events among 19 patients (10%). Seventy-six percent of these were categorized as proficiency errors. The only factors associated with a lower risk of adverse events were the transition of care involving a handoff within the ED (0% vs. 19%; p = 0.03) and the involvement of a resident (junior doctor) in addition to the senior physician (37% vs. 67%; p0.01).In our study, the involvement of more than one physician was associated with a lower risk of adverse events.

The transition out of the hospital is a vulnerable time for patients, relying heavily on communication and coordination of resources across care settings. Understanding the perspectives of inpatient and outpatient physicians regarding factors contributing to readmission and potential preventive strategies is crucial in designing appropriately targeted readmission prevention efforts. To examine and compare inpatient and outpatient physician opinions regarding reasons for readmission and interventions that might have prevented readmission. Cross-sectional multicenter study. We identified patients readmitted to general medicine services within 30 days of discharge at 12 US academic medical centers, and surveyed the primary care physician (PCP), discharging physician from the index admission, and admitting physician from the readmission regarding their endorsement of pre-specified factors contributing to the readmission and potential preventive strategies. We calculated kappa statistics to gauge agreement between physician dyads (PCP-discharging physician, PCP-admitting physician, and admitting-discharging physician). We evaluated 993 readmission events, which generated responses from 356 PCPs (36 % of readmissions), 675 discharging physicians (68 % of readmissions), and 737 admitting physicians (74 % of readmissions). The most commonly endorsed contributing factors by both PCPs and inpatient physicians related to patient understanding and ability to self-manage. The most commonly endorsed preventive strategies involved providing patients with enhanced post-discharge instructions and/or support. Although PCPs and inpatient physicians endorsed contributing factors and potential preventive strategies with similar frequencies, agreement among the three physicians on the specific factors and/or strategies that applied to individual readmission events was poor (maximum kappa 0.30). Differing opinions among physicians on factors contributing to individual readmissions highlights the importance of communication between inpatient and outpatient providers at discharge to share their different perspectives, and suggests that multi-faceted, broadly applied interventions may be more successful than those that rely on individual providers choosing specific services based on perceived risk factors.

Purpose Many seriously ill patients with cancer do not discuss prognosis or advance directives (ADs), which may lead to inappropriate and/or unwanted aggressive care at the end of life. Ten years ago, patients with cancer said they would not like to discuss ADs with their oncologist but would be willing to discuss them with an admitting physician. We assessed whether this point of view still held. Patients and Methods Semi-structured interviews were conducted with 75 consecutively admitted patients with cancer in the cancer inpatient service. Results Of those enrolled, 41% (31 of 75) had an AD. Nearly all (87%, 65 of 75) thought it acceptable to discuss ADs with the admitting physician with whom they had no prior relationship, and 95% (62 of 65) thought that discussing AD issues was very or somewhat important. Only 7% (5 of 75) had discussed ADs with their oncologist, and only 23% (16 of 70) would like to discuss ADs with their oncologist. When specifically asked which physician they would choose, 48% (36 of 75) of patients would prefer their oncologist, and 35% (26 of 75) would prefer their primary care physician. Conclusion Fewer than half of seriously ill patients with cancer admitted to an oncology service have an AD. Only 23% (16 of 70) would like to discuss their ADs with their oncologist but nearly all supported a policy of discussing ADs with their admitting physician. However, fully 48% (36 of 75) actually preferred to discuss advance directives with their oncologist if AD discussion was necessary. We must educate patients on why communicating their ADs is beneficial and train primary care physicians, house staff, hospitalists, and oncologists to initiate these difficult discussions.

In cases of sudden, life-threatening illness where the chance of survival appears negligible to the admitting physician, this opinion is not always revealed during the initial meeting with the patient's relatives. Reasons as to why this withholding of the truth may be acceptable are explored through review of available evidence and personal reflection. Factors identified include: the importance of hope in families' coping mechanisms, and the instinct to preserve it; the fallibility of physicians' perception of poor prognosis in the early phase of illness; the need to avoid large swings in relatives' expectations that occur when patients appear to rally during initial resuscitation; and the adverse effect that an atmosphere of hopelessness can have on the provision of medical care. A strategy for the staged disclosure of information and the confirmation of hopelessness is then described, the aim being to find a compromise between providing a true opinion about a patient's prognosis, and regard for the opposing factors described.

Current emphasis on the number of deaths due to medical errors has pushed the patient safety issue to the forefront at many medical institutions. The Institute of Medicine's recommendation for improved coordination and collaboration between physicians, as well as the paucity of related literature, has led the authors to explore the nature of the handover between emergency department and admitting physicians. Research was conducted at two Ohio hospitals to document the phases and issues found in emergency department (ED) handovers. The phases for ED handovers were similar to those found in shift changes in other types of industries (e.g., paper mill, air traffic control) with minor variations in the order of the phases. Three areas were identified where potential errors could occur including the spoken communication between physicians, selection of diagnostic tests based on the specific admitting physician, and the use of surrogates by the admitting physician. Physicians identified the level of trust in ED resident physicians, incomplete handovers between ED physicians at their shift change, differences in exams and treatment plans based on admitting physician, and notification of possible admission prior to receiving results for exams as potential problem areas. The findings of this research illustrate the need for future research into physician communication. These studies have tremendous opportunity to enable the Institute of Medicine's goal of improving communication between physicians for better patient care and outcomes.

Introduction Guidelines from the Association of British Neurologists and National Health Service Quality Improvement Scotland suggest that neurologists should be involved in the early management of patients presenting to hospital with acute neurological illness. Aim We chose to evaluate whether regular neurology review in an acute medical receiving unit in a busy city hospital was feasible, and whether it would have an impact on patient care. Methods Over a 5-week period from Monday to Friday, all neurology patients admitted to an acute medical receiving unit were identified and all headaches and blackouts were reviewed. Results Fourteen (24%) were headache patients, 37 (63%) presumed seizure and 8 (13%) had another neurological illness. Diagnosis was made by the admitting physician in six headache patients (43%). The remaining eight headache patients were diagnosed by the visiting neurologist and two physician diagnoses were revised. The diagnosis made by the admitting physician was clarified by the visiting neurologist in 13 blackout patients (35%) and nine other diagnoses were revised (24%). Appropriate outpatient follow-up or transfer was arranged. Conclusion These results suggest that a daily neurology review service is useful in medical receiving units by clarifying diagnoses, directing tests and limiting inappropriate follow-up.

Objective. To determine, for acute general pediatric admissions, 1) the proportion of admissions that the admitting physician would identify as potentially avoidable; 2) services that might help reduce avoidable admissions; 3) potential savings in hospital days through eliminating avoidable admissions; 4) the role that social factors play in admission decisions; and 5) if admitting physician judgment provides a valuable complement to Utilization Review (UR) in identifying avoidable admissions. Methods. A questionnaire was used to determine the proportion of 600 acute general pediatric admissions considered potentially avoidable by the admitting physician and to identify services required to prevent such admissions. Savings through eliminating potentially avoidable admissions and social factors influencing admission decisions were examined. Physicians' and UR assessments of necessity of inpatient care were compared. Results. Admitting physicians judged 28% of admissions as potentially avoidable, citing alternative services for each avoidable admission. Eliminating all avoidable admissions would have reduced hospital days by 7.7%. Physicians identified 6% of admissions as social admissions, most commonly due to an overwhelmed family. UR identified 1% of potentially avoidable admissions as unnecessary. Conclusion. Incorporating admitting physician judgment may significantly improve current efforts to identify and reduce avoidable hospital use.

Musculoskeletal diseases are common and may result in significant morbidity and mortality especially in the context of the multisystem autoimmune rheumatic ­disorders. Patients with rheumatological disorders present acutely to emergency rooms, and the cause of the sudden deterioration may be due to complications of the underlying disorder, sepsis, or an iatrogenic effect resulting from an acute adverse event from therapy. Given the complexity of these patients, it is not surprising that outcome can be poor with in-hospital mortality rates of 40%. This introductory chapter is aimed at the admitting physician presented with an acutely ill patient with a rheumatological disorder who is deteriorating rapidly and needs admission to a critical care unit.

The critical care unit is a hospital resource that must successfully blend individual admitting physician prerogatives with more generally applicable policies. This article discusses some of the problems associated with assuming unit leadership responsibilities and suggests strategies to negotiate among the multiple and often conflicting positions adopted by primary (admitting) physicians, consultants, nursing supervisors, and hospital administrators.

Objective To examine process of care and outcome for patients admitted with acute myocardial infarction to hospitals in England and Wales in relation to type of consultant care and type of hospital. Design Observational study of 88 782 patients admitted with myocardial infarction during 2004-5, using records from the national audit of myocardial infarction project (MINAP) database. Outcome measures Use of reperfusion treatment and secondary prevention drugs, use of angiography, and 90 day mortality of patients admitted under the care of cardiologists and non-cardiologists in hospitals with and without facilities for coronary intervention. Findings 36% of patients were admitted under the care of a cardiologist and 20% to a hospital with coronary interventional facilities. Patients admitted under cardiologists had fewer comorbidities than other patients and were more likely to have reperfusion treatment (12 266/14 433 (85%) v 13 682/17 064 (80%)) and appropriate secondary prevention drugs. Overall, 27 431/79 374 (35%) of patients had angiography. Relatively more patients admitted to interventional hospitals (8167/14 661; 56%) than to other hospitals had angiography (19 264/64 713; 30%). The adjusted risk of death by 90 days for patients treated in interventional compared with non-interventional hospitals was 0.93 (95% confidence interval 0.82 to 1.06). The adjusted risk of death at 90 days for patients admitted under cardiologists compared with non-cardiologists was 0.86 (0.81 to 0.91). Conclusions Patients cared for by cardiologists had less comorbidity than other patients. They were more likely to receive proved treatments and angiography, and they had a lower adjusted 90 day mortality. Large differences existed in the use of angiography between interventional and non-interventional hospitals. These findings show wide variations in the management and outcome of patients with myocardial infarction in England and Wales.

It is of clinical and financial importance to identify those heart failure patients who are likely to improve rapidly. The authors evaluated, as predictors of short-term resolution, three clinical variables often used to predict long-term outcome. Consenting patients admitted to the emergency department with dyspnea were examined daily until resolution (symptom reversion to baseline absent worsening clinical signs or x-ray). The authors then compared hours to resolution of heart failure with serum B-type natriuretic peptide (BNP), ejection fraction (EF), and admitting physician prediction. They calculated negative and positive predictive values for EF, BNP, and physician opinion using quintile and published severity standards as cutoffs (for EF and BNP). Among 85 patients, BNP

Although they are effective in outpatient settings, computerized reminders have not been proved to increase preventive care in inpatient settings.We conducted a randomized, controlled trial to determine the effects of computerized reminders on the rates at which four preventive therapies were ordered for inpatients. During an 18-month study period, a computerized system processed on-line information for all 6371 patients admitted to a general-medicine service (for a total of 10,065 hospitalizations), generating preventive care reminders as appropriate. Physicians who were in the intervention group viewed these reminders when they were using a computerized order-entry system for inpatients.The reminder system identified 3416 patients (53.6 percent) as eligible for preventive measures that had not been ordered by the admitting physician. For patients with at least one indication, computerized reminders resulted in higher adjusted ordering rates for pneumococcal vaccination (35.8 percent of the patients in the intervention group vs. 0.8 percent of those in the control group, P0.001), influenza vaccination (51.4 percent vs. 1.0 percent, P0.001), prophylactic heparin (32.2 percent vs. 18.9 percent, P0.001), and prophylactic aspirin at discharge (36.4 percent vs. 27.6 percent, P0.001).A majority of hospitalized patients in this study were eligible for preventive measures, and computerized reminders significantly increased the rate of delivery of such therapies.

On 6 December 1805 HMS Isis, a 50 gun man-of-war, was stationed in home waters off Spithead when the ship's surgeon, Benjamin Lara, noted the addition to the sick-list of Able Seaman John Cummings. Cummings, a 29-year-old American, presented with 'excessive pain in the stomach and intestines, incapacity of retaining anything in the stomach and pain on walking or standing erect'. On questioning, he admitted to 'having swallowed on the preceding day 19 or 20 clasp knives and one clasp knife case, the latter of which was soon rejected, but the former retained'.1 Lara's journal ends before the completion of Cummings' clinical episode and the subsequent journal is lost. The end of the story, however, can be found in the library of the Royal Society of Medicine. Benjamin Lara, the surgeon, subsequently described the case in a letter dated 27 March 1809 and addressed to Dr Curry, a physician at Guy's Hospital. After Curry's death, this letter and other papers pertaining to the case, including the patient's own description of his story, were discovered by Alexander Marcet. Dr Alexander John Gaspard Marcet MD FRS (1770–1822) (Figure 1), likewise a Guy's man and a friend of the late Dr Curry, was a founding member and first secretary of the Medical and Chirurgical Society of London which subsequently became the Royal Society of Medicine. Marcet presented the case of John Cummings to the Society and this lecture and copies of both accounts are preserved in the Society's Transactions.2 Figure 1 Alexander John Gaspard Marcet, MD FRS (1770–1822). Painting by Sir Henry Raeburn, RA, which hangs in the dining room of The Royal Society of Medicine. (Reproduced by kind permission of The Royal Society of Medicine, London) In Cummings' own account of his illness, he revealed that this was not the first time he had swallowed knives. While stationed in France in 1799 he had watched a mountebank pretending to swallow knives in a circus near Havre de-Grace. He later bragged that he could do this in reality, and his shipmates wagered he could not. He swallowed four knives with no obvious ill effect, although only three of the four were seen again. Some six years later he was stationed in Boston, USA. His current shipmates did not believe his story and under the influence of grog (rum and water) he began again. After swallowing fourteen knives, he was admitted to Charleston Hospital with abdominal pain. After a few days the knives had all passed safely through and his symptoms resolved, just in time for him to sail back with his ship to France. His next ship was the Betty of Philadelphia. Early in the voyage back from France to the USA she was stopped by the Royal Navy and he was impressed into service aboard HMS Isis. On 4 December 1805, drunk once again, he swallowed his final twenty knives and two days later he reported to Benjamin Lara. He was given castor oil and 'glysters' (enemas) of thick water-gruel, and opium for the pain. When the symptoms continued, a dose of 30 or 40 drops of sulphuric acid daily was tried in an attempt to dissolve the iron. Finally he was given 'murinated tincture of iron', but this made his pain worse. After remaining on the sick list for three months he 'felt the knives drop into his bowel and felt much relieved' and was discharged back to light duties. In June 1806, Cummings vomited one side of a knife handle; in November and again the following February he passed more pieces. Although Lara was transferred off HMS Isis in November 1806 his successor, Mr Peter Kelly, kept him informed of the patient's progress. Cummings continued to pass pieces of iron and knife handles; each ejection was accompanied by considerable pain and in one instance the vomiting of two pounds of blood. He was finally discharged from the ship, as unfit, in June 1807. After leaving HMS Isis, Cummings travelled immediately to London and presented himself to Guy's Hospital for treatment. His admitting physician, Dr Babbington, did not believe his story and discharged him after a few days. He was readmitted in August, however, his condition much deteriorated. Examining the patient with Sir Astley Cooper, Babbington 'after minute discussion' asked for the opinion of the surgeon Mr Lucas. Lucas performed a rectal examination and felt one of the knives in the rectum. Although he was again discharged on 28 October 1807, Cummings was readmitted in September 1808, this time under the care of Dr Curry. He was given more acid, mucilage and opium but slowly deteriorated, suffering bouts of pain and indigestion and having difficulty eating. He finally died in March 1809 'in a state of extreme emaciation'. The necropsy was conducted by Mr Travers, surgeon and anatomy demonstrator at Guy's, supervised by Mr Lucas. The abdominal cavity was noted to have a 'black ferruginous' tinge from the iron knives. A knife blade and a knife back-spring were found in the intestines. The spring had chronically eroded through into the peritoneum, transfixing the colon near the left kidney but without causing peritonitis. The blade was wedged across the rectum, its end embedded in the pelvic wall. Thirty to forty fragments of wood, metal and horn were found when the stomach was opened. The case was presented to the Medical and Chirurgical Society of London by Alexander Marcet on 19 March 1822, just a few months before his own death. He displayed the pieces taken from Cummings' stomach to the audience in a glass case (Figure 2). Figure 2 Fragments of knives found in the stomach of John Cummings. Displayed to the members of the Medical and Chirurgical Society of London on 19 March 1822. The items on the bottom row were expelled whilst he was on board HMS Isis. The spring that transfixed ...

Aim To evaluate the role of a regular neurology review in acute medical receiving. Over 5 weeks, patients admitted to acute medical receiving were reviewed by a neurologist. Presenting complaint, medical diagnosis, and neurological diagnosis were documented. Other neurological illnesses leading to admission were also identified, but not reviewed. Results 51 patients were reviewed (14 headaches, 37 blackouts). Eight patients with other neurological symptoms were also identified. 31 males were seen, of whom five were headaches (16%). Of the 20 females, nine were headache (45%). A diagnosis was made by the admitting physician in 6 headache patients (43%). The remaining eight headache patients were diagnosed by the visiting neurologist and two of the physicians’ diagnoses were revised. The diagnosis made by the admitting physician in 13 blackout patients was unclear (35%). Diagnosis was made by the visiting neurologist in these patients and diagnoses were revised in nine other patients (24%). Five headache patients were followed up in neurology outpatient. Migraineurs were initiated on appropriate prophylaxis with GP follow. Five first seizures were referred to 1st fit clinic, while the SAH and subdural patients were transferred directly to neurosurgery. Conclusions These results suggest that a daily neurology review service is useful in medical receiving units by clarifying diagnoses, directing tests, and limiting inappropriate follow-up.

bacteria sensitive to ciprofloxacin. The admitting physician has been told about the spasms and when ordering the antibiotic, also orders atropine, 0.4 mg qd per o$, as long as needed. The nurse taking care of Ms. Dell isn't familiar with the Latin word os and, assuming it to be an abbreviation, looks it up in the medical abbrevi? ations section in Tabeas Cyclo? pedic Medical Dictionary. There she finds O.S., defined as "left eye." She gives the patient four atropine eye drops from the floor stock, in the left eye. On rounds that morning, the attending physi? cian is very concerned that Ms. Dell has one dilated pupil (atro? pine causes pupil dilation) and orders a series of neurologic tests. The nursing superviso*; in arrang? ing for transport for the tests, checks the patient's chart. She knows that eye drops wouldn't relieve bladder spasms and figures out that the physician's order was misinterpreted. Oral atropine tablets are ordered for the patient, and the patient isn't harmed.

ContextAcute myocardial infarction (AMI) is a common condition that is treated by physicians with varying levels of clinical experience, but whether the level of experience affects outcome remains uncertain.ObjectiveTo evaluate the relationship between the average annual volume of cases treated by admitting physicians and mortality after AMI.Design, Setting, and PatientsRetrospective cohort study using linked administrative databases containing patient admission information for 98 194 patients treated by 5374 physicians between April 1, 1992, and March 31, 1998, in Ontario, Canada.Main Outcome MeasuresMortality risk rates for 30 days and 1 year post-AMI, adjusted by physician volume and patient, physician, and hospital characteristics.ResultsThe 30-day mortality rate was 13.5% and the 1-year mortality rate was 21.8%. A strong inverse relationship between the average annual volume of AMI cases treated by the admitting physician and mortality after an AMI was observed. The 30-day risk-adjusted mortality rate was 15.3% for physicians who treated 5 or fewer AMI cases per year (lowest quartile) compared with 11.8% for physicians who treated more than 24 AMI cases annually (highest quartile; P

1. McDowell KM, 2. Chatburn RL, 3. Myers TR, 4. O'Riordan MA, 5. Kercsmar CM (1998) Arch Pediatr Adolesc Med. 152:977–984. [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] #### Purpose of the Study The purpose of this study was to show that the use of an “Assessment-driven protocol” for those children admitted to the hospital for status asthmaticus will result in improved health care outcomes at reduced costs. ##### Study Population Children 1 to 18 years of age were admitted to a ward where an asthma care algorithm (ACA) was used. Control subjects were admitted to different wards and were managed according to orders of the admitting physician. There were no ACA forms or protocols followed in the control group. The study was nonrandomized. Patients were in either the control or protocol group based on bed availability at the time of admission. ##### Methods The algorithm was established after an extensive review of the literature and reflects the state of the art for … [1]: {openurl}?query=rft.jtitle%253DArchives%2Bof%2BPediatrics%2Band%2BAdolescent%2BMedicine%26rft.stitle%253DArch%2BPediatr%2BAdolesc%2BMed%26rft.issn%253D0002-922X%26rft.aulast%253DMcDowell%26rft.auinit1%253DK.%2BM.%26rft.volume%253D152%26rft.issue%253D10%26rft.spage%253D977%26rft.epage%253D984%26rft.atitle%253DA%2BCost-Saving%2BAlgorithm%2Bfor%2BChildren%2BHospitalized%2Bfor%2BStatus%2BAsthmaticus%26rft_id%253Dinfo%253Adoi%252F10.1001%252Farchpedi.152.10.977%26rft_id%253Dinfo%253Apmid%252F9790607%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1001/archpedi.152.10.977&link_type=DOI [3]: /lookup/external-ref?access_num=9790607&link_type=MED&atom=%2Fpediatrics%2F104%2FSupplement_2%2F379.1.atom [4]: /lookup/external-ref?access_num=000076295000006&link_type=ISI

Sir, In their informative article, Constantine and Thenabadu1 identify reasons for delay in initiating thrombolysis, including failure to diagnose acute myocardial infarction at the time of admission. This resulted from a lack of specific electrocardiogram (ECG) changes or a failure to recognise them. This concurs with previously published observations regarding diagnostic difficulty when the admitting physician is faced with a patient with prolonged …

IN order to attract admitting physicians, hospitals must provide or otherwise arrange for specific services that these physicians demand for their patients. These services include not only the traditional hospital amenities such as room, board, medical supplies, and nursing care but also the talents of other hospital-based physicians (HBPs) who do not themselves admit or manage the care of patients but who instead perform ancillary medical tasks at the request of the admitting physician or of the hospital. The four principal HBP specialties are anesthesiology, radiology, pathology, and emergency medicine. In this market characterization, the hospital sells services to the admitting physicians, who serve as the patient's agents.1 The admitting physicians are hospital customers in the important sense of deciding which hospital to patronize. The hospital is the buyer (also in the "choice of supplier" sense) of all of the separate inputs that jointly define hospital services.2 Like many buyers in most industries, hospitals often arrange

Performance evaluation measures for multimembership classifiers are presented and applied in a retrospective study on the diagnostic performance of the MEDAS (Medical Emergency Decision Assistance System) system. Admission and discharge diagnoses for 122 patients with one or more of 26 distinct disorders in five major disorder categories were gathered. The average number of disorders per patient was 2 with 36 (29.5 percent) patients having 3 or more disorders simultaneously. The features (symptoms, signs, and laboratory data) available at admission were entered into a multimembership Bayesian pattern recognition algorithm which permits for diagnosis of multiple disorders. When the top five computer-ranked diagnoses were considered, all of the correct diagnoses for 86.1 percent of the patients were displayed by the fifth position. In 71.6 percent of these cases, no false diagnosis preceded any correct diagnosis. In ten cases a discharge diagnosis which was suggested by the available findings was omitted by the admitting physician. In six of these ten cases, the overlooked diagnoses appeared at the computer ranked list above all false diagnoses. Considering the urgency of diagnosis in the Emergency Department, the high uncertainty involved due to the limited availability of data, and the high frequency with which multiple disorders coexist, this limited study encourages our confidence in the MEDAS knowledge base and algorithm as a useful diagnostic support tool.

A method was developed to increase community-hospital pharmacist consultation on patient drug use in order to detect drug-related problems upon patient admission to the hospital. A medication history was takenon criteria-selected patients admitted to two hospitals in distant, but similar, geographically small and isolated areas. Tho total number of patients selected was 392. Information about prior drug use was obtained from participating community pharmacists and their patient prescription records and medication profiles. It was found by pharmacist-acquired drug histories that one of five criteria-selected patients had a preexisting drug-related problem that the admitting physician acknowledged probably contributed to the admission and necessitated professional and patient communication. These problems included: adverse response to prescribed therapy, misuse of medication or noncompliance, effect of diet on therapy, patient treatment by more than one prescriber, and therapeutic ineffectiveness or inappropriateness of prescribed therapy. Drug histories were not obtainable in 25.6% of the patients.

The special organizational and institutional structure of the hospital industry has implications for cost differences between forprofit and nonprofit hospitals. These implications are developed and tested on a panel of data on California hospitals for which as estimate of the cost of admitting physician services could be made. Forprofit hospitals in general are significantly less costly than nonprofits after accounting for differences in case mix, but the interpretation of this result is complicated by the possibility of systematic overtreatment of certain case types by independent, or nonchain forprofits. The paper argues that the more appropriate comparison is between nonprofits and chain forprofits. The latter type of hospital has a distribution of cases which is similar to that of nonprofits but is less costly than both nonprofit and nonchain forprofit hospitals.

The purpose of this study was to increase the documentation of allergy and body weight information on pharmacy medication profile cards for pediatric patients. The intent was to facilitate pharmacist evaluation of medication dosages ordered for these patients. A plastic allergy/weight imprinting card was supplied to each nursing unit and was used to imprint all admitting physician's order sheets. Allergy and weight information was to be filled in by the physician and/or nurse before routing a copy of these orders to the satellite pharmacy. Inservice education was presented and follow-up phone calls were made. During an 18-day control period, baseline data on documentation of allergies and weight were collected. During an 18-day study period, the allergy/weight card was used and follow-up phone calls were made. During an 18-day post-study period, the card and phone calls were removed. Percent of profiles having allergies and weight were, respectively: control period, 33 percent and 28 percent; study period, 80 percent and 76 percent; post-study period, 47 percent and 46 percent. Imprinting “allergy/weight” with space for filling in this information can result in an increased number of pharmacy patient profiles having these data so that medications can be checked prior to dispensing the first dosages of medication.

admitting physician. The packet of powder obtained by the university police was submitted to the Charity Hospital Clinical Pharmacology-Toxicology laboratory for analysis. The identification of 4-bromo-2,5-dimethoxyphenethylamine as a street drug is described. NMR, UV, and mass spectral data used in the identification of the compound are presented.

A total of 241 veterans who applied for admission to a Veterans Administration hospital underwent automated multiphasic health testing and services (AMHTS). The authors compare test findings with the admitting physician's decision as to whether or not a patient should be worked up by the psychiatry service for admission. The findings indicate that an AMHTS system may be able to assist the admitting physician in making this decision: Discriminant function analysis from the patient's history questionnaire simulated the physician's decision fairly well.

Excerpt During the 14-year lifetime of this hospital, 40 patients were admitted with untreated pernicious anemia. Only once did the referring or admitting physician send the patient to his ward wit...

A valid informed consent must be obtainedby the admitting physician for routine hospital services, diagnostic procedures, and medical treatment. The matter of consent for children for radionuclide studies is considered comparable to that for routine roentgenographic procedures and thus is covered by the general consent form signed by the parent upon admission to the hospital. A second consent must be obtained for the therapeutic use of radionuclides and for the use of radionuclides for research in children. Therapeutic research, implying the probability of immediate or delayed benefit to the child studied, requires a separate consent. Parental consent may not be valid for nontherapeutic research, i.e., research where there is little probability of benefit to the child studied. Recommendations for preparation of children for nuclear imaging are given in this review. Dosage tables for radiopharmaceuticals used in routine imaging studies, and potassium perchlorate and Lugol's solution dosage schedules are offered. Pediatric dosimetry is discussed elsewhere in this seminar. A sedation technique for younger children, including dosage schedule, is described. Children cannot be treated as small adults. They present special problems that relate to their age and stage of development. This review attempts to place these unique requirements in perspective and to help the reader become aware of them.

To the Editor.— Among the tools on which we physicians rely is the hospital computer, from which we retrieve both laboratory results and, at many hospitals, the relevant range of normal values. Our trust in these values is not always merited. Report of a Case. — A 99-year-old previously healthy man presented to the emergency department with a complaint of weakness of 2 days' duration. A chest roentgenogram suggested pneumonia. The complete blood cell count revealed a white blood cell count of 19.4×10 9 /L. Though the accustomed normal range is 4.5 × 10 9 /L to 10.8 × 10 9 /L and at this hospital elevated values are flagged with an "H," this count was not so flagged. A glance at the normal range revealed the upper limit of normal to be 30 × 10 9 /L! The patient's admitting physician remarked that the computer must have had an

To the Editor.— Regarding "Two Consultations," Dr Cowan's 1 point regarding relative charges for "cognitive" vs procedural charges is well taken. However, he misses the even more pertinent point that an elderly man with gastrointestinal tract bleeding was hospitalized for five weeks, received multiple transfusions, and supposedly was examined twice—by the admitting physician and a gastroenterologist—without a rectal examination. How does five weeks of hospitalization compare in price with the cost of a rectal examination?

In Reply .—The purpose of our study was to determine if physicians could predict the etiology of failure to thrive. A corollary objective was to suggest that if the prediction was accurate it could be useful in maximizing the patient's therapeutic environment and also save money. We selected patients with admitting diagnoses of failure to thrive indicating that the admitting physician had already somewhat narrowed the diagnostic possibilities. Dr Oelberg makes the excellent point that many physicians do not recognize failure to thrive. His data indicated that many children's cases are being missed or "underdiagnosed" even prior to the point of being categorized. We agree also that the term "failure to thrive" needs a more rigid definition and that it be clearly differentiated from other vague diagnoses such as "growth failure." We suggest that when the diagnosis of failure to thrive is made it should be followed by two terms

The water in the swimming pool was too shallow for a man of twenty to dive into. Perhaps Mr. A. should have known this, but he didn't. He dove, hit the concrete floor of the pool with his head, felt a sudden "crunching" sensation in his neck. He remained conscious, however, and was able to swim to the edge of the pool where he needed help in climbing out. He was immediately aware of having a headache, pain in his neck, and weakness and pain in both his arms. Friends at the scene suspected the seriousness of his injury and called an ambulance to take him to the emergency department of a nearby hospital. There the admitting physician's diagnosis of fractures of the third, fourth, and fifth cervical vertebrae was confirmed by x-ray. Within a few hours after the accident, Mr. A. was taken to the operating room for the insertion of Crutchfield tongs in his skull in preparation for the application of skeletal traction to reduce the fractures of the vertebrae and facilitate nursing care. We first met Mr. A. in the neurosurgical unit following his operation. He remained with us until he was able to be up and about, although still wearing a support for his neck. During this time, we learned that a patient who has sustained a fracture or other serious injury of the cervical vertebrae has multiple problems and requires knowledgeable and gentle nursing care. His nurse must be wise, patient, resourceful, and skillful, for she will encounter many challenges.