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Family member presence (FMP) during resuscitation attempts and invasive procedures is a concept with variable support and significant controversy. The concept of FMP is not entirely new and has been present in some institutions for decades. Family members generally support the concept of remaining at the bedside during resuscitation attempts, as do most nurses and many emergency physicians. Other clinical providers, including surgeons, pediatricians, and some emergency physicians, are divided on the value of such practices. Opinions on this topic are directly affected by previous experience with FMP, institutional beliefs, and educational exposure.

The Universal Billing Code of 1992 (UB-92) is a standard database used by hospitals to generate itemized charges for patient visits. This study examined the use of UB-92 information to monitor emergency department performance improvement projects. UB-92 data were used to determine whether urine tests had been ordered for emergency department patients. A population of patients at low risk for requiring a urine culture was defined as discharged female patients between 16 and 60 years of age undergoing a urinalysis as part of their emergency department treatment during a 10-month period. Based on UB-92 data, only a total of 2,138 patients were identified who met the study's low-risk criteria. Recommendations for the optimum use of these tests were presented to the emergency physicians as part of departmental performance improvement activities. Additional logistical problems associated with the procedure for ordering this test were identified and corrected as part of this project. After an additional 5-month period, a second analysis of the entire 15 months of UB-92 data was performed. Prior to physician notification, 41.6% of low-risk patients underwent both a urinalysis and a urine culture and sensitivity in the emergency department. In the 5-month follow-up period, the percentage of patients undergoing both tests decreased 18% to only 23%.

Objective: To describe the use of a noninvasive bi-level positive airway pressure (PAP) support system for ED patients with acute congestive heart failure (CHF). Methods: Retrospective case series analysis of ED patients presenting with acute CHF in imminent need of endotracheal intubation (ETI) managed with a bi-level PAP system. The bi-level PAP system was applied at the discretion of the treating emergency physician. Management of the bi-level PAP system, including setting of inspiratory PAP (IPAP) and expiratory PAP (EPAP), weaning, adjunct pharmacologic therapy, and failure of bi-level PAP support, was determined by the treating physician. Results: Only two (9%) of 22 patient presentations necessitated ETI. The mean duration of bi-level PAP therapy was 7.9 hours. The mean maximum IPAP and EPAP settings were 10.8 and 5.8 cm H2O, respectively. Mean intensive care unit length of stay (LOS) was 2.4 days, with a median LOS of only 1 day. There were three deaths in the series; none were attributed to the bi-level PAP system. No technical difficulty with the bi-level PAP system was noted. Conclusion: Noninvasive pressure support ventilation with a bi-level PAP support system may avert ETI in acute CHF patients. This device can be effectively used by ED personnel.

Opinions remain polarized on allowing family member presence during pediatric resuscitations (FMP). Reluctance to adopt FMP may stem from preconceived notions on this practice. This study evaluates the effect of prior experience with FMP and on its acceptance by emergency department personnel (EDP).EDP from three different EDs were surveyed concerning FMP. Study facilities included an urban teaching community ED with routine FMP (R-ED), a suburban community ED with occasional FMP (O-ED) and an urban university pediatric ED with virtually no FMP (N-ED) during pediatric resuscitations. Survey information included hospital of practice, position in ED, years in practice, opinions on FMP and personal experience with FMP for five clinical scenarios: laceration repair (LAC), intravenous access (IV), lumbar puncture (LP), endotracheal intubation (ETI), cardiopulmonary resuscitation (CPR), and critical resuscitation (CR). Statistical analysis was through chi square and regression analysis.Eighty-five emergency department personnel participated in the survey, 57 (67%) nurses, 22 (25%) physicians, 4 technicians (5%), and 2 nurses aids (2%). There was a significant correlation between a favorable opinion concerning family member presence during LP, ETI, CPR and CR and the type of Emergency Department in which the individual practiced (P0.002). Regression analysis demonstrated a similar relation between personal experience with LAC, IV, ETI, CR, and CPR and a favorable opinion on FMP during that activity (P0.03).Opinions on FMP are strongly influenced by experience with this practice. Emergency department personnel with prior exposure to family member presence during resuscitations favor this activity. Biases by EDP lacking experience with FMP may limit its introduction into unfamiliar institutions.

Emergency department (ED) practices are traditionally profiled in terms of their patient encounters. Such evaluations reflect a preponderance of outpatient visits while crediting income from admitted patients to traditional hospital-based services. This study evaluates the contribution of ED admissions to inpatient hospital revenue. The study was set at an urban tertiary care community hospital with university affiliation. Information referable to ED patients was collected from the hospital's Universal Billing Code (UB-92)-based patient information warehouse. Data fields referable to hospital charges, insurance type, and disposition were used for analysis of a 1-year period from September 1, 1998 to August 31, 1999. Statistical analysis was through chi square and ANOVA. During the study period 33,174 patients were treated in the ED with 6,671 (20%) admitted to inpatient services. Total hospital charges for all ED patients during this time were $107 million dollars with $9.1 million (8.5%) generated from discharged patients and $98.0 million (91.5%) from admitted ED patients (P.001). Mean charges for individual discharged patients were $344.10 whereas for individual admitted patients mean charges were $14,692.28. (P.001) Medicaid and self pay represented 55.4% of the insurance coverage for discharged ED patients whereas these same insurance classes accounted for only 16.3% of admitted patients. (P.001) Medicare visits accounted for 12.7% of discharged ED patients but 60.7% of admitted patients (P.001). Total hospital gross revenue for inpatient services for the study period was $288 million of which 34% was contributed from admitted ED patients. ED services represent a major source of inpatient hospital revenue. The recognition of the ED's potential in this area may be lost if income from patients admitted through the ED is credited to traditional hospital-based services.

We were surprised to read the poor results described in the article by Sharon et al. [(1)][1]comparing bilevel positive airway pressure (BiPAP) ventilation with intravenous isosorbide-dinitrate in patients with severe pulmonary edema. These findings are in marked contrast to our own research and

SUMMARY In the field of medicine and surgery new techniques or new methods of drug therapy must always be added with caution and after carefully controlled experiments. Ordinarily, the patient is the only person to be considered regarding safety and morbidity inherent in a given method or procedure. However, in the case of hyperbaric oxygenation, either as therapy or as an adjunct to surgery, far greater problems are encountered. Everyone involved including the medical and paramedical personnel as well as all individuals and property in the surrounding area can be jeopardized with an improperly constructed or operated hyperbaric facility. Caution must be the by-word for anyone working in this new clinical field. It is incumbent upon all who enter this field to do so forearmed with as much basic knowledge of the dangers and pitfalls as possible. It is possible that, following a decade of serious research this concept may fail to alter appreciably, or influence, medicine and surgery so that it will represent only a passing phase in medical history. On the other hand, the application of OHP into the sophisticated area of present medicine and surgery may reap rich rewards for civilization in general.