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PurposeThe purpose of this paper is to develop a conceptual understanding of organizational consciousness that expands the discussion of organizational analysis, and use a case study to apply it in the analysis of a merger between an academic health center and a regional medical center.Design/methodology/approachThe paper draws on the experiences and insights of scholars who have been exploring complex organizational issues in relationship with consciousness.FindingsOrganizational consciousness is the organization's capacity for reflection; a centering point for the organization to “think” and find the degree of unity across systems; and a link to the organization's identity and self‐referencing attributes. It operates at three stages: reflective, social, and collective consciousness.Research limitations/implicationsTranslating abstract concepts such as consciousness to an organizational model is complex and interpretive. For now, the idea of organizational consciousness remains mostly a theoretical concept. Empirical evidence is needed to support the theory.Practical implicationsFaced with complicated and compelling issues for patient care, health care organizations must look beyond the analysis of structure and function, and be vigilant in their decisions on where important issues sit on the ladder of competing priorities. Organizational consciousness keeps the organization's attention focused on purpose and unifies the collective will to succeed.Originality/valueIf the paper can come to understand how consciousness operates in organizations, and learn how to apply it in organizational decisions, the pay‐off could be big in terms of leading initiatives for change. The final goal is to use what is learned to improve organizational outcomes.

This article is addressed to long-term-care administrators and planners as well as purchasers of long-term care. Believing the current and future business environment will force continued adaptation in long-term-care organizations, the authors utilize nine categories to map pressures for change: cultural, technological, educational, political, legal, natural resource, demographic, sociologic, and economic. Long-term-care organizations, especially those that are not-for-profit, are becoming members of alliances as one way of addressing these pressures. This article describes and presents a case example of a composite alliance to demonstrate the advantages of membership in a strategic alliance. We also present examples of ways in which alliance members use strategic partnerships to improve their ability to manage these forces.

The operating environment in the health care industry is turbulent—organizations are expected to adapt or die. This paper addresses the structure of a strategic planning process for long-term-care organizations. Nursing homes, assisted living (personal care) facilities, continuing care retirement communities, adult day services centers, hospice programs and home-and community-based agencies face both opportunities and threats. The authors recommend an eight-step process for strategy making: plan to plan; external analysis; internal analysis; vision; matching current and future strategies; strategy choice; action and linkage to operations and budget. A case example illustrates the concepts. Long-term-care leaders are encouraged to plan for their future or face a future planned by competitors and regulators.

Objective: To characterize the impact of abdominal aortic aneurysm repair (AAAR) on spontaneous as well as lipopolysaccharide (LPS)-induced gene expression of pro- and anti-inflammatory cytokines. Design: Prospective, controlled in vivo / ex vivo study. Setting: University hospital. Patients and interventions: Whole blood from 14 consecutive patients undergoing AAAR withdrawn prior to surgery (T1), at the end of ischemia (T2), 90 min after declamping (T3) and on the first postoperative day (T4) was cultured in the absence or presence of LPS. Five patients undergoing elective inguinal hernia repair served as controls. Measurements and results: While tumor necrosis factor (TNF), Interleukin (IL)-1 and IL-10 plasma concentrations did not increase significantly, IL-6 was elevated at each time point, as compared with T1. Despite the spontaneous release of trace amounts of IL-6, the ability of cultured whole blood to mount a cytokine response in vitro to LPS was impaired for all cytokines studied at T2 (TNF –62 %, IL-1 –51 %, IL-6 –20 %, IL-10 –51 %). The stimulated IL-6 response was restored early after declamping (T3: + 56 %) and enhanced 1 day after operation (T4: + 144 %). In contrast, stimulated TNF and IL-1 responses remained depressed at T3 (TNF –48 %, IL-1 –64 %) and T4 (TNF –40 %, IL-1 –24 %). A biphasic pattern was observed for IL-10 with initial depression at T3 (-51 %) and restoration at T4 ( + 40 %). Among the different cytokines monitored, only impaired TNF responsiveness at early reperfusion (T3) correlated with the postoperative course, as reflected by APACHE II. Cytokine response to LPS was maintained or even increased during and after surgery in the whole blood from patients undergoing hernia repair. Conclusions: Despite consistent development of clinical signs of systemic inflammatory response syndrome (SIRS) and spontaneous release of IL-6 abdominal aortic aneurysm repair produces a state of impaired pro-inflammatory cytokine response upon a subsequent in vitro Gram-negative stimulus. This early impairment of TNF responsiveness seems to correlate with an unfavorable postoperative course.

Rocuronium ist ein nicht-depolarisierendes Muskelrelaxans mit raschem Wirkungseintritt. Wahrend der rasche Wirkungseintritt von besonderer Bedeutung fur die Narkoseeinleitung des aspirationsgefahrdeten Patienten ist, konnen in elektiven Situationen auch langere Anschlagzeiten akzeptiert werden. Vor diesem Hintergrund untersuchten wir, ob unter Verzicht auf den raschen Wirkungseintritt im klinischen Alltag die Intubationsdosis von Rocuronium auf Werte unter der 2fachen ED95 reduziert werden kann. Methoden: Dazu wurden an insgesamt 90 Patienten der zeitliche Verlauf der neuromuskularen Blockade und die Intubationsbedingungen von 0,6 mg/kg Rocuronium (2×ED95) und 0,4 mg/kg Rocuronium (1,3×ED95) untersucht. Zuerst wurde mittels Elektromyographie die neuromuskulare Blockade nach beiden Rocuroniumdosierungen an jeweils 15 Patienten gemessen. Im zweiten Teil der Untersuchung wurden die Intubationsbedingungen 3 min nach Injektion des Muskelrelaxans beurteilt. Pro Gruppe wurden in diesem Teil der Untersuchung jeweils 30 Patienten eingeschlossen. Ergebnisse: Durch Dosisreduktion von 0,6 mg/kg Rocuronium auf 0,4 mg/kg verlangerte sich die Anschlagzeit von 148 (±32) s auf 220 (±30) s (p

Fragestellung: Die Untersuchung des Einflusses von Gamma-Hydroxy-Buttersaure (GHB) auf die spontane und durch Lipopolysaccharid (LPS) induzierte Freisetzung der Zytokine Tumor-Nekrose-Faktor alpha (TNF), Interleukin-1β (IL-1β), Interleukin-6 (IL-6) und Interleukin-10 (IL-10) bei aortokoronaren Bypassoperationen (ACB) unter Anwendung der extrakorporalen Zirkulation (EKZ) sowie die Charakterisierung des pharmakologischen Effekts von GHB in 2 Praparationen (GHB-Na und GHB-Ethanolamid) auf die Lipopolysaccharid (LPS)-induzierte Zytokinfreisetzung in vitro. Methodik: In einer prospektiven, randomisierten Doppelblindstudie wurden insgesamt 12 Patienten untersucht, die sich einer elektiven ACB unterzogen. Je 6 Patienten erhielten intraoperativ entweder NaCl 0,9% (Kontrollgruppe) oder GHB-Na (25 mg/kg/h nach einem initialen Bolus von 25 mg/kg). Zu insgesamt 3 Meszeitpunkten (A=praoperativ, B=20 min nach EKZ, C=24 h postoperativ) erfolgte die Blutentnahme zur Zytokindiagnostik. Die Plasmakonzentrationen (spontane Freisetzung) und die unter LPS-Stimulation beobachtete Freisetzung der verschiedenen Zytokine zu den einzelnen Meszeitpunkten wurden in einem Vollblutansatz ex vivo gemessen und mit der m-RNA-Expression in peripheren mononuklearen Zellen (PBMC) korreliert. Weiterhin erfolgte in einem in vitro-Ansatz die Analyse des pharmakologischen Einflusses von GHB selbst (GHB-Na und GHB-Ethanolamid) auf die LPS-induzierte Zytokinfreisetzung. Ergebnisse: Die Plasmakonzentrationen von IL-6 und IL-10 waren nach Ende der EKZ in beiden Gruppen (Kontrolle und GHB) im Vergleich zum praoperativen Ausgangswert signifikant erhoht, wahrend TNF und IL-1β nur vereinzelt nachweisbar waren. Am Ende der EKZ war zu diesem Meszeitpunkt die durch LPS stimulierbare Freisetzung aller untersuchten Zytokine ex vivo signifikant gegenuber dem praoperativen Ausgangswert vermindert. Trotz besser erhaltener Stimulierbarkeit der Zytokin-m-RNA war auch bei den mit GHB behandelten Patienten die Ausschuttung der Zytokine ex vivo signifikant gehemmt. Am ersten postoperativen Tag war die stimulierbare Zytokinantwort im statistischen Mittel wieder hergestellt, wobei deutliche interindividuelle Unterschiede auftraten. In vitro (pharmakologischer Dosierungen) bewirkte GHB-Na (2 mg/ml) eine signifikante, selektive Verminderung der Freisetzung von IL-1β, wahrend GHB-Ethanolamid keinerlei Veranderungen der Zytokinantwort bewirkte. Zusatzlich hemmte der kompetitive GHB-Rezeptorantagonist NCS-382 die monozytare IL-1β-Antwort fast vollstandig auf 2,5% des Ausgangswerts ohne NCS. Schlusfolgerung: Die Ergebnisse der Freisetzung verschiedener pro- und antiinflammatorischer Zytokine bei ACB zeigen einen biphasichen Verlauf. Initial kommt es ex vivo zu einer relativen Suppression mit partieller Toleranz gegenuber LPS-Stimulation, die am ersten postoperativen Tag weitgehend uberwunden ist. Ob die pharmakologischen Effekte von GHB-Na und NCS-382 auf die IL-1β-Freisetzung monozytarer Zellen uber spezifische GHB-Rezeptoren vermittelt sind, mus aufgrund der diskrepanten Ergebnisse offen bleiben. GHB-Na bewirkt in klinisch ublichen Dosierungen im Vergleich zur Kontrollgruppe keine statistisch nachweisbare Modulation der Zytokinfreisetzung.

This report presents a summary and analysis of the continuous quality improvement and organizational change and redesign initiatives undertaken by the unit and service boards organized under the auspices of the HORIZONS Project. Board initiatives were identified and summarized by staff through interviews with the chairpersons and representatives of the boards and review of records. Forty-nine projects from the three pilot units were identified. Each project was classified according to outcome--positive, negative, mixed, and unknown. Sixty percent of initiatives had positive outcomes, and only three initiatives (6%) were negative. Case characteristics were summarized according to board identification, problem, outcome indicators, data baseline, proposed and selected solutions, implementation strategy, monitoring plan, results, change issues, and lessons learned. The study concludes that the board initiatives embody the HORIZONS Projects approach to improving patient care and improving quality of working life for staff and doing so in a budget-neutral manner. The HORIZONS boards process has moved the organization toward more open, collaborative forms of decision making than hitherto practiced.

Many health care organizations are currently engaged in changing the design of their health care services delivery system. The issues of cost containment, quality, and access are prominent. This paper reports on the impact of the implementation of a new organization design at one university hospital. The organization change effort (named HORIZONS) was a five year project funded in part by the Robert Wood Johnson Foundation and the Pew Charitable Trusts. In a changing health care environment, the project was undertaken with three goals in mind: (1) to maintain and enhance quality of patient care; (2) to improve the quality of working life; and (3) to accomplish this in a budget neutral manner. Initiated as a program to strengthen hospital nursing, the project became a patient-focused redesign effort encompassing both clinical and administrative affairs. The core ideas of the project approach included systems thinking, interactive planning and idealized design. This evaluation reports on the project's progress after six years.

The first part of this two-part series described the initial impetus driving a university hospital's planned change project, the planning process itself, and the interventions that were identified to meet our goals. This article describes and discusses the interventions—the implementation of our version of Ackoff's circular organization and issues related to barriers, selected outcomes, the change process, evaluation, and the project's significance to nursing.

Innovation to improve the quality of structure and process in health care organization is reported in this case example of change in an academic medical center. Interactive planning and the circular organization de sign concept were the driving principles and methods. This report presents the needs for and initial obstruc tions to change, planning and project design work, a description of the change process, and illustrative ac complishments to date— two cases, one of conscious sedation policy and one of nuisance pages. Evaluative criteria for judging the progress and lessons of the project regarding key design characteristics also are included.

How do corporate executives handle internal people problems and encourage the continuing development of their human social system? One tool is the corporate ombudsman. Four organizations with active ombudsmen in four industrial fields (banking, utilities, transportation, and health-care) were studied as a continuation of research on corporate ombudsmen begun in the 1980s. The results are of interest to all organizations concerned with managing employee disputes and litigation and continuously improving productivity and quality.

Academic health centers (AHCs) and health maintenance organizations (HMOs) often hold each other at arm's length because of fundamental organizational differences. AHCs view HMOs as too intrusive in the clinical management of patients and too concerned with the financial bottom line. HMOs view AHCs as organizationally fragmented and expensive in providing health care services. AHCs must expand their primary care networks and reassess their mission and public accountability in training a more balanced physician workforce. HMOs are growing rapidly and need well-trained generalist physicians to support that growth. This paper uses an organizational systems model in examining AHCs and HMOs to identify common needs, mutual interests, areas for potential collaboration, and bridging strategies. These include health care systems development, professional education, information management systems, and health services research. As the financing and delivery of health care continue to change and to become more integrated, both organizations have much to gain from collaboration.

In our view TQM and CQI represent important innovations in the continuing effort to develop higher performance organizations. Never before has the need been so great to improve quality while at the same time constraining, or reducing, costs. An increasing number of health care organizations can document their experiences that as quality goes up, costs can come down. The contribution of these new approaches is in some sense the wedding of many long established methodologies--the scientific method, statistical quality control, planning, joint problem solving, participative management, and empowerment of the work force. While this recognition could lend support to those who label this new model a fad, that perception denies the linkage of TQM/CQI to the greater stream of innovations pushing us toward ever-greater organizational excellence. Can we not take the philosophy and methods that are potentially useful and try them experimentally? Let our empirical tests tell us of their contribution. We believe the concepts and procedures of TQM/CQI will help us to be better in years to come, even though we highly respect our starting point.

In a clinical trial, the influence of repeated intermittent prone position on pulmonary gas exchange was investigated in 6 patients with severe ARDS. Despite various intra- and interindividual differences, oxygenation index (calculated by the paO2:FiO2 ratio) was improved significantly by change from supine to prone position in the first two days of treatment, whereas paCO2 remained unchanged. Later on, a significant improvement of oxygenation could not be verified. In patients with proven or presumed densities of dorsal lung regions, body position changes from supine to prone position in the early phase of treatment may improve arterial oxygenation and may be regarded as a therapeutic principle in conventional ARDS treatment.

Increasingly, businesses are reporting successful implementation of self-directed work teams. In health care, team-based structures in both clinical and nonclinical areas are now rapidly emerging. This paper describes the linkage between the literature of sociotechnical systems theory and current applications of self-directed work teams, and outlines the organizational processes used to design and implement them. Several examples of self-directed work teams in industry and health care systems are provided. As much of the existing literature on self-directed work teams is from industry, there is a need for case reports and further research on their current applications in health care systems.

This paper discusses the use of the Kast and Rosenzweig systems and contingency model for teaching and practice in organizational analysis and planning, management policy, and organizational development. The need for an organizational model for graduate students and field-based managers and executives is identified. The model is presented beginning with the Kast and Rosenzweig work, with integration of research by Daft, Schein, Trist, Deal and Kennedy, Ackoff, Delbecq, and Mintzberg. The teaching and practice uses of the model in four areas are presented, including organizational analysis and planning, management policy making, and organizational development. In each area case examples of the use of the model in teaching and practice are presented. Needs for future research and implications for the use of the model are discussed.

This paper identifies organizational barriers to quality improvement in medical and health care or ganizations. Quality is now recognized as one of the most challenging issues of the 1990s. The push for quality improvement rests on the significant assump tion that large and small medical and health care organizations will engage in quality assessment and assurance. Both researchers and practitioners must consider the organizational barriers the quality movement will encounter, particularly those major impediments to be overcome in the next 5-10 years. This paper organizes the analysis of organizational barriers to quality assessment and assurance accord ing to a five-part systems model of the organization. The barriers are categorized as technical, structural, psychosocial, managerial, and goals and values. Fol lowing a mapping of the barriers, education, training, and research and development needs to support qual ity improvement are identified.

This paper reports on the design, presentation, and evaluation of a graduate university course in quality assurance and utilization review. The authors cite the need for expanded course offerings in this field and present descriptions of the course design and student participants, including program location, objectives, learning themes and content, instructor team, stu dents, and course process. Student feedback is re ported including comments on course strengths and needs, teaching methods, and learning evaluation. Additional work requirements are cited.

This article reports on the progress of a fellowship program for physicians in quality assurance and uti lization review (QA/UR). The article begins with a description of the initial program concept and pre sents the "program-in-action" including: academic coursework, site rotations, learning experiences of the fellow/resident, funding, outcomes to date, strengths and weaknesses analysis, current require ments, and future research and development needs. By presenting design and operations this 2-year progress report is intended to assist other developing programs as QA/UR education increases nationally.

This article presents the first data on the charac teristics of applicants to the physician fellowship pro gram in quality assurance (QA) and utilization review (UR). Data presented about applicants include demo graphic characteristics, board and national certifi cations, specialties, license type, practice experience, and QA and UR experience. These data were obtained from individual applications for admission to the pro gram. They are used here to create a database for the program to generate future information on this new specialty group. Characteristics of current applica tions selected begin to define the members of the profession.

We have assessed the effect of the choice of i.v. induction agent on intubation conditions, 60 s after administration of rocuronium 0.6 mg kg-1. We studied 60 adult patients, allocated randomly to one of two groups. Anaesthesia was induced with alfentanil 10 micrograms kg-1 followed by thiopental 5 mg kg-1 (AT-R group; n = 30) or etomidate 0.3 mg kg-1 (AE-R group; n = 30). Both groups received rocuronium 0.6 mg kg-1. Laryngoscopy was started 60 s later and intubation conditions were evaluated according to a standard score, which considered ease of laryngoscopy, condition of the vocal cords and reaction to intubation. In the AT-R group, overall intubation conditions were scored as excellent in 20 patients, good in nine and fair in the remaining patient. In the AE-R group, overall intubating conditions were excellent in 24 and good in six patients. The difference between the two groups was not significant. Of the three components of the intubation score assessed, response to intubation stimulus was significantly less pronounced in group AE-R compared with group AT-R (P < 0.05): group AE-R, no reaction in 24 patients, slight diaphragmatic movement in five and mild coughing in one patient; group AT-R, no reaction in 13, slight diaphragmatic movement in 14, mild coughing in two and severe coughing in one patient. We conclude that etomidate as part of an induction regimen containing alfentanil and rocuronium attenuated the reaction to intubation to a greater extent than thiopental.

Publisher Summary The current system of delivery is dysfunctional. Similar concerns for redesign exist in education, transportation, and international affairs. This chapter provides integrated systems-oriented approach to the redesign of organizations. The synthesized procedure for design/redesign is applicable to all health care organizations. The roots of this procedural synthesis are in teaching and learning, organization change and development, and evaluation and assessment. This system approach is based on five assumptions: redesign is a socio-technical systems task, future building is both intended/rational and emergent/intuitive, redesign procedures are “rough guidance” not a mechanical blueprint, procedural adaptation is required for each unique setting, and models will continue to evolve. Redesign implies and/or requires the addition of new resources or the redistribution of existing ones. Each redesign effort must identify the resource requirements in terms of the factors: production process, personnel, facility, equipment and supplies, and finances. To successfully implement the new design, production process needs such as training must be identified, as well as staff requirements, space, equipment, and an overall budget.

Eine schwer verlaufende Praeklampsie und ihre Komplika tionen sind die haufigsten Grunde fur eine Intensivbehandlung wahrend oder unmittelbar nach Beendigung der Schwangerschaft. Unter Praeklampsie versteht man eine proteinurische Hypertonie, die sich in der Spatschwangerschaft entwickelt und postpartal innerhalb weniger Tage wieder zuruckbildet (Tabelle 75-1). Da meist geichzeitig auch Odeme vorliegen, wird das Krankheitsbild insbesondere im deutschsprachigen Raum auch als EPH-Gestose bezeichnet (»edema«/Odem, Proteinurie, Hypertension)

Publisher Summary Managers of health organizations have been confronted by two classes of problems: Inadequate understanding and definition of the cost containment problem; and lack of management experience and skills that are needed to affect the many facets of health organizations contributing to the cost-containment problem. To improve cost control within the organizations, health care managers should adopt a broader, systems-based approach. Systems thinking and an organizational model can help define the cost-containment problem more broadly and, subsequently, can help design and manage specific cost-containment strategies. Currently, AMCs are facing significant pressures to adapt in what is increasingly defined as a “hostile organizational environment.” The key to successful interventions to contain costs lies in careful consideration of both the direct and the interactive impact on all systems of the health care organization. This chapter provides a case example of an academic medical center's (AMC) effort to curtail costs. The health care cost problem is, in effect, a design–redesign problem, not a single difficulty with, for example, a reimbursement system. It is not just the containment of hospital costs that is a strategic necessity, but health and medical care costs at all individual patient, provider, and organizational levels.

Die Bedeutung einer adaquaten intensivmedizinischen Antibiotikatherapie in Verbindung mit sinnvollen und konsequent durchgefuhrten hygienischen Masnahmen geht aus folgenden Fakten klar hervor: Patienten auf Intensivstationen haben im Krankenhaus das hochste Infektionsrisiko [13]. Multiorganversagen ist die Haupttodesursache von Intensivpatienten und wird uberwiegend durch septische Komplikationen ausgelost oder unterhalten [48]. In den USA erkranken jahrlich etwa 400.000 Patienten an einer Sepsis, etwa die Halfte davon (200.000) erleiden einen septischen Schock, der bei ca. 50% der Patienten todlich verlauft [61]. 10–30% der Mortalitat auf Intensivstationen werden nosokomialen Pneumonien zugeschrieben [69].

Publisher Summary Academics and practicing managers and executives continually search for methodologies and concepts that will help them develop their organizations, including the planning and policymaking work that contributes to efficiency and effectiveness. This chapter discusses the use of the Kast and Rosenzweig systems and contingency model for teaching and practice in organizational analysis and planning, management policy, and organizational development. The need for an organizational model for graduate students and field-based managers and executives is identified. The teaching and practice uses of the model in four areas are organizational analysis, organizational planning, management policymaking, and organizational development. The use of the model indicates its contribution to growing systems thinking managers and students in a wide variety of courses and field projects. Other faculty and consultants may choose other models to work with, but some model must be selected to help to surface assumptions and guide analysis, planning, policy, and development.

Publisher Summary Two procedural processes to ensure medical quality are at the whole organization level, track 1, as a strategic means to quality improvement; and at the project level, track 2, for an operational path to quality improvement work at the team level. It is suggested that successful efforts follow this double-track effort already and that further identification and elaboration of the pathways will speed diffusion of quality improvement efforts. Total quality management has clearly excited the private-sector industrial world. Planning is a preventive approach that eliminates quality problems at the process creation stage. Building on an organization perspective regarding teams and systems thinking, the chapter describes a double-track procedure for the application of continuous quality improvement programs. A review of existing procedural presentations indicated that common elements are present in many of the models. An integrationist effort resulted in the double-track model that offers both a strategic-level process and a set of steps for guiding the work of project-level teams. The strategic process, track 1, consists of five steps that enable the organization's leaders to make strategic decisions to support quality. Track 2, the project-level procedure, offers 10 steps to guide the groups' individual problem-solving work. Organizations seeking to improve quality must first begin to perceive the task in two-level terms. The need for a double-track approach is then a sensible follow up.

Background and objective: This prospective, randomized, double-blinded study was designed to compare the effects of remifentanil or fentanyl on anaesthetic induction characteristics of propofol, thiopental or etomidate.Methods: Seventy-two patients were enrolled in six groups of 12 individuals each. In three groups, fentanyl was given as a bolus dose of 1.5 μg kg−1, whereas the others received a remifentanil infusion at 0.5 μg kg−1 min−1. Five minutes later, propofol, thiopental or etomidate were titrated to a state of unresponsiveness. Assessment included the amounts of drug necessary for induction, haemodynamics and the times to apnoea, loss of eyelash reflex, and the release of a water-filled syringe held in the patient's hand.Results: Induction times to loss of the eyelash reflex were significantly shorter in the remifentanil than in the fentanyl groups: with propofol 50.7 ± 13.6 s (mean ± SD) versus 74.9 ± 27.0 s (P < 0.01), with thiopental 42.9 ± 16.8 s versus 77.2 ± 27.8 s (P < 0.01) and with etomidate 54.7 ± 17.6 s versus 72.3 ± 24.0 s (P < 0.05). The times to respiratory arrest or for the syringe to fall were significantly shorter with remifentanil than with fentanyl for propofol and for thiopental, but not for etomidate. In terms of dosages per kg body weight necessary to achieve unresponsiveness, less propofol (−29%, P < 0.05), thiopental (−25%, P < 0.05) or etomidate (−32%, P < 0.01) was necessary with remifentanil than with fentanyl. Haemodynamic responses to tracheal intubation were controlled more effectively with remifentanil. However, within the remifentanil groups, mean arterial pressure significantly decreased during induction: −26% with propofol,−18% with thiopental and −14% with etomidate (all P < 0.01).Conclusions: During anaesthetic induction, a remifentanil infusion of 0.5 μg kg−1 min−1 over 5 min is a suitable alternative to a 1.5 μg kg−1 bolus dose of fentanyl: induction times are shorter with reduced amounts of propofol, thiopental or etomidate.