Referral, admission, and discharge patterns in a pediatric emergency department in Israel

The pediatric emergency department (PED) is an important component of the medical services provided by a hospital. The purpose of the study was to describe the patterns of referrals, admissions, and discharges in a PED to determine to what extent the PED is used solely as an emergency unit, as opposed to being used as a part of a set of primary care facilities. Data were recorded from 1200 patient charts, out of 19,000 visits to a PED in Israel in 1988. Variables such as age, sex, ethnicity, and distance between residence and hospital were checked. About half of the patients arrived during the morning shift. There was an inverse relationship between the distance from the patient's home to the hospital and the rate of visits to the PED. Fifty-eight percent of the total were self-referred; this rate increased to 84% during the night shift. Only one quarter of all children had additional laboratory or x-ray tests. Most of the diagnoses did not require emergency services. Eighty-one percent of the patients were discharged from the PED to their community physician. The rate of admissions was low (11%). This study shows that a large part of the PED work is actually primary care. Some of the demographic, cultural, and ethnic reasons for these patterns are reviewed.     

Telephone triage of cardiac emergency calls by dispatchers: a prospective study of 1386 emergency calls

OBJECTIVES: To evaluate the handling of potential cardiac emergency calls by dispatchers, to determine their final diagnosis and urgency, and to determine the value of the main complaint in predicting urgency and the ability of the dispatchers to recognise non-urgent conditions. DESIGN: Prospective data collection and recording of main complaint of emergency calls placed via the 06-11 alarm telephone number with follow up to hospital when the patients were transported and the general practitioner when they were not. SETTING: Dispatch centres of the emergency medical services in Amsterdam (urban area) and Enschede (rural area). PATIENTS: 1386 consecutive adult subjects of emergency calls placed by citizens about chest problems or unconsciousness not caused by injury. MAIN OUTCOME MEASURES: Frequency of characteristics of the calls, outcome in diagnosis, and assessment of urgency. RESULTS: 69 (5%) patients were dead when the ambulance arrived. Diagnosis was established in 1071 patients (77%). The disorders most often reported were cardiac, with acute ischaemia in 15% of all subjects. In 28% of cases and for each presenting complaint no organic explanation was found. Overall 39% of all emergency calls were urgent; the urgency rate was lowest for calls for people with abdominal discomfort. Dispatchers correctly identified 90% of the non-urgent calls, but 55% of the calls that they identified as urgent proved to be non-urgent. CONCLUSION: Currently, direct dialling for an ambulance without the intervention of a general practitioner imposes a high work load on emergency systems and hospitals because triage by dispatchers is not sufficiently accurate. It may be possible to increase the accuracy of triage by developing and testing decision algorithms.     

Most common dermatologic problems identified by internists, 1990-1994

BACKGROUND: Internists in all settings see many patients with skin conditions. Thus, their education in dermatology is important. Information on which areas of dermatology are most commonly seen in internal medicine practices is necessary for designing effective educational programs on skin disease. OBJECTIVE: To determine what types of dermatologic problems internists most commonly diagnose. METHODS: National Ambulatory Medical Care Survey data from 1990 to 1994 were analyzed for dermatologic diagnoses. Physicians specializing in internal medicine and all its subspecialties were compared with dermatologists and with other physicians. RESULTS: The most common skin disorders diagnosed by internists were dermatitis (15.8% of all diagnoses) and bacterial skin infections (14.0% of all diagnoses). Combined, bacterial, fungal, and viral infections included 28.3% of the most common dermatologic diagnoses made by internists. The top 10 most common diagnoses accounted for 57.9% of all skin-related diagnoses and the top 20 most common diagnoses accounted for 72.8%. Internists were more likely to see patients for bacterial skin infections, herpes infection, exanthem, urticaria, and insect bites while dermatologists more commonly saw patients for actinic and seborrheic keratoses, warts, benign and malignant skin tumors, and psoriasis. CONCLUSIONS: The most common dermatologic diseases diagnosed by internists differ considerably from those diagnosed by dermatologists. Because dermatologists do much of the dermatology teaching of internal medicine residents, it is important to recognize these differences to place emphasis on the proper areas of study. Some common or serious skin conditions not often diagnosed by internists such as psoriasis and melanoma also deserve attention in internal medicine training programs.     

A sudden awakening from a near coma after combined intake of gamma-hydroxybutyric acid (GHB) and ethanol

OBJECTIVE: The excess of pediatric emergencies going to hospitals has been the subject of many studies in Spain and, on some occasions, this problem has attributed to the inefficiency of pediatric primary care. Our main objective was to evaluate whether or not our community health center is an efficient filter for hospital emergencies. PATIENTS AND METHODS: We conducted a prospective one year long study of all pediatric emergency demands within our normal office hours (workdays, from 08:00 to 21:00 hours). RESULTS: The total number of emergencies amounted to 1,294, with an average of 5.78 per day. The largest inflow occurred in September and the lowest in August. Most of the emergencies were between 16:00 and 19:00 hours. Fifty percent of the patients were under 4 years of age. We made 86 different diagnoses according to the WONCA classification. Only 10 diagnoses came with a frequency superior to 3%, and 60% of the emergencies were related to one of these 10 diagnoses. Of all pediatric emergencies, 94.7% were completely resolved by us. Only 60 patients (4.6%) were sent-on to hospital emergency services. Among these patients, 40 required traumatological or surgical attention, 5 ophthalmological care, 3 otorhinolaryngological care, and only 12 exclusively needed pediatric attention. In 55.7% of the cases there was no reason to use the emergency channel. CONCLUSIONS: During our office hours, our community health center is an efficient filter for hospital pediatric emergencies.     

Streptococcal pharyngitis: impact of a high-sensitivity antigen test on physician outcome

The purpose of the present study was to determine whether the availability of results from a high-sensitivity, rapid test for group A streptococci (Strep A OIA; BioStar, Inc., Boulder, Colo.) improves physician outcome. The study population included 465 consecutive patients with symptoms of acute pharyngitis seen in two outpatient clinics in a large suburban medical center; one clinic, a walk-in clinic (WIC), primarily saw adult patients, and one clinic, a pediatric and adolescent medicine clinic (PED), primarily saw pediatric patients. We measured improvement in physician outcome by comparing physician intent for prescribing an antibiotic based on clinical impression with physician practice once the results of the Strep A OIA were known. Based upon intent, the physicians seeing WIC patients (WIC physicians) would have prescribed an appropriate antibiotic course for 42% of patients with cultures positive for group A beta-hemolytic streptococci (GABHS) and 61% of patients with cultures negative for GABHS. After receiving the results of the Strep A OIA, WIC physicians prescribed an appropriate antibiotic course for 81% of patients with positive cultures and 72% of patients with negative cultures. Based upon intent, the physicians seeing PED patients (PED physicians) would have prescribed an appropriate antibiotic course for 35% of patients with positive cultures and 77% of patients with negative cultures. After receiving the results of the Strep A OIA, PED physicians prescribed an appropriate antibiotic course for 90% of patients with positive cultures and 81% of patients with negative cultures. Based on a 14.5% prevalence of GABHS among WIC patients, Strep A OIA improved the overall WIC physician outcome from 58 to 74%. Based on a 31.5% prevalence of GABHS among PED patients, Strep A OIA improved the PED physician outcome from 64 to 84%. Had Strep A OIA alone guided therapeutic choice, physicians would have prescribed an appropriate antibiotic course for 95% of the patients at the time of the initial encounter. We conclude that the use of Strep A OIA improves physician outcome.     

Care-seeking patterns of inner-city families using an emergency room. A three-decade comparison

OBJECTIVES: Since World War II, the urban hospital emergency room has been a major source of medical care for inner-city poor families, many of whom receive Medicaid. Given the expensive and episodic nature of emergency room care, there has been renewed interest in enrolling Medicaid recipients into managed care plans to increase access to care and to reduce medical costs. Thus, the primary care physician, in many managed care plans, is expected to give prior approval for emergency room care in nonurgent situations. The goals of managed care may create tension between its requirements and historical patterns of inner-city families seeking care in an emergency room. In 1964, Alpert developed a typology that categorized inner-city families' patterns of seeking medical care in a pediatric emergency department (PED) by describing the relation between regular source of medical care and reliance on this source before the PED visit. In 1976, using the same typology, Alpert and Scherzer updated care-seeking patterns in Boston after the introduction of neighborhood health centers (NHCs) and Medicaid. In 1993, the typology is a method that can be used to assess the impact of managed care on PED utilization by inner-city families. This article compares the 1993 pattern of seeking PED care with that measured in 1964 and 1976. METHODS: In 1964, 1976, and 1993 families were interviewed as they sought care in a PED. Families were asked if they had a regular source of care, defined as the place where families take their child most often for either well or sick visits. A judgment was made as to whether or not the PED visit was coordinated with their regular source of care. Coordinated care was defined as having a regular source of care and attempting to contact the source before the PED visit. Uncoordinated care occurred when the family had a regular source and did not attempt contact, or had no regular source. RESULTS: In 1964, 63% of families reported a regular source of care compared with 89% in 1976 and 95% in 1993. The hospital was reported as the regular source of care by 57% of the respondents in 1964, by 31% in 1976, and 43% in 1993. Community-based sources (physicians and NHCs) were identified as a regular source of care by 43% in 1964, 69% in 1976, and 57% in 1993. In 1964, 55% of the families engaged in an uncoordinated pattern of seeking care compared with 64% in 1976 and 72% in 1993. CONCLUSIONS: Efforts to provide access to care through Medicaid, NHCs, and hospital-based primary care resulted in a greater percentage of families reporting a regular source of care; however, a majority of families continue to exhibit an uncoordinated pattern of seeking care. More families in 1993 did not contact their regular source before seeking care in the PED when compared with 1964 and 1976. For managed care plans to increase access and reduce costs, a shift in PED utilization patterns remains necessary. The primary care system must have the capacity to accommodate these changes and considerable patient education must occur if urgent care is to be provided outside the PED.     

The incidence of pediatric rheumatic diseases: results from the Canadian Pediatric Rheumatology Association Disease Registry

OBJECTIVE: To determine the incidence of rheumatic diseases in children, and the frequency of musculoskeletal disorders seen by pediatric rheumatology specialists in Canada. METHODS: Applying standardized disease definitions and disease codes modified from ICD-9, members of the Canadian Pediatric Rheumatology Association from 13 centers in all 10 provinces of Canada registered all new patients seen between May 1, 1991 and April 30, 1993. Patient data included age, sex, ethnicity, date of birth, date of disease onset, date of diagnosis, and diagnostic codes (more than one diagnosis could be entered). To minimize the bias of right censoring, only data from patients with disease onset between May 1, 1991 and October 31, 1992 were used to estimate disease incidence. RESULTS: 3362 records totalling 3683 diagnoses (92 separate diagnoses) were registered. Median referral rate per year to a pediatric rheumatology center was 26 per 100,000 children at risk. The frequency of diseases seen was 23.3% for all forms of chronic arthritis, 6.5% for connective tissue diseases, and 6.1% for all forms of vasculitis. The minimum incidence rates per 100,000 children at risk per year calculated from the whole registry were: all forms of chronic arthritis 4.08 (95% CI: 3.62, 4.60), systemic lupus erythematosus 0.28 (0.18, 0.45), and dermatomyositis 0.15 (0.09, 0.29). Substantially higher figures were obtained if the figures were calculated excluding the 2 provinces (Alberta and Quebec) that had disproportionately low referral rates. CONCLUSION: Pediatric rheumatologists see children with a wide variety of diseases. It is important that pediatric rheumatology training reflects this and does not focus exclusively on the classical inflammatory arthropathies. The minimum incidence data show there are substantial numbers of children developing potentially lifelong chronic rheumatic diseases each year in Canada. These data should be helpful in planning the delivery of pediatric rheumatology services not only in Canada, but also in other developed countries.     

Abdominal pain in geriatric emergency patients: variables associated with adverse outcomes

OBJECTIVE: To determine the diagnoses and outcomes of geriatric patients with abdominal pain, and to identify variables associated with adverse outcomes. METHODS: Geriatric emergency patients (aged 65 years and older) with a complaint of abdominal pain were participants in this longitudinal case series. Eligible patients were followed by telephone contact and chart review, to determine outcomes and final diagnoses. RESULTS: Of 380 eligible patients, follow-up information was available for 375 (97%), for the two months following the ED visit. Final diagnoses included infection (19.2%), mechanical-obstructive disorders (15.7%), ulcers/hypersecretory states (7.7%), urinary tract disease (7.7%), malignancy (7.2%), and others. Although 5.3% of the patients died (related to presenting condition), most (61.3%) patients ultimately recovered. Surgical intervention was required for 22.1% of the patients. Variables associated with adverse outcomes (death, and need for surgical intervention) included hypotension, abnormalities on abdominal radiography, leukocytosis, abnormal bowel sounds, and advanced age. Most physical examination findings were not helpful in identifying patients with adverse outcomes. This study demonstrated a higher incidence of malignancy (7.2%) and a lower incidence of disease necessitating surgical intervention (22.1%) than previously reported. CONCLUSIONS: The majority of geriatric emergency patients with abdominal pain have significant disease necessitating hospital admission. Morbidity and mortality among these patients are high, and specific variables are strongly associated with death and the need for surgical intervention. Absence of these variables does not preclude significant disease. Physical examination findings cannot reliably predict or exclude significant disease. These patients should be strongly considered for hospital admission, particularly when fever, hypotension, leukocytosis, or abnormal bowel sounds are present.     

Pediatric rheumatology clinic populations in the United States: results of a 3 year survey. Pediatric Rheumatology Database Research Group

OBJECTIVE: To describe the patient population referred to pediatric rheumatology centers (PRC) across the US 1992-95; and to compare these results to data on regional PRC populations. METHODS: A Pediatric Rheumatology Disease Registry was established in 1992. Data on new patients seen at 25 PRC across the US were submitted to the registry for a 36 month period from 1992 through 1995. RESULTS: A total of 12,939 patients were submitted to the registry. Of these patients, 5245 (40.5%) had rheumatological diagnoses. Patients with juvenile rheumatoid arthritis were the largest group of the patient population (2071 patients-16% of total diagnoses). There were 1568 patients with other forms of childhood arthritis (12%), 1172 with collagen vascular diseases (9%), and 434 with vasculitis (3.3%). Over 50% of the patients had nonrheumatologic diagnoses, including 1577 with idiopathic pain syndromes (12%). Other diagnoses included infections, orthopedic conditions, and malignancies. Fourteen percent of the patients were not given a diagnosis at the time of the initial visit. CONCLUSION: PRC see a wide variety of patients. Although the majority do have rheumatologic conditions, over 50% of new patients have conditions not autoimmune in origin. Fourteen percent of the patients cannot be diagnosed at the time of their first clinic visit, requiring time to see the evolution of their symptoms before a definitive diagnosis can be assigned.     

Paramedic judgment of the need for trauma team activation for pediatric patients

OBJECTIVE: To determine the value of paramedic judgment in determining the need for trauma team activation (TA) for pediatric blunt trauma patients. METHODS: A prospective, observational study was conducted at the ED of Children's Hospital Medical Center of Akron between July 12, 1996, and February 28, 1997, in cooperation with Akron Fire Department emergency medical technician-paramedics (EMT-Ps). The ED provides on-line and off-line medical control for pediatric transports. Patients with minor or no identifiable injuries are released at the scene with the instructions to see a physician. The remainder are transported to the ED. The decision for TTA is based on ED trauma protocols as well as emergency physician judgment of injury severity in combination with the judgment of the treating paramedic. During the study, EMT-Ps were asked (before physician input) whether, based solely on their judgment, a patient needed TTA. Patients 0-14 years old who were involved in motor vehicle crashes, bike crashes, or falls from a height of >10 feet were included in the study. TTA was defined as necessary if the patient was admitted to the intensive care unit (ICU) or operating room (OR) for nonorthopedic surgical procedures. Out-of-hospital, ED, and hospital records were reviewed. Coroners' records as well as medical records of all trauma admissions during the study period were reviewed to ensure that the patients released at the scene were not mistriaged. RESULTS: One hundred ninety-two patients met study criteria. Eighty-five patients (44%) were transported to the ED, of whom 12 had TTA. EMT-Ps requested TTA for 10 of these patients, and 2 patients had TTA per ED trauma protocol. Two of the patients who were judged by EMT-Ps to need TTA were admitted to the ICU/OR, and neither of the patients identified by ED trauma protocol to require TTA were admitted to the ICU/OR. Two initially stable patients who did not have TTA deteriorated after arrival to the ED. Both were admitted to the ICU. The sensitivity and specificity of paramedic judgment of the need for TTA for pediatric blunt trauma patients were 50% (95% CI 9.2-90.8) and 87.7% (95% CI 78.0-93.6), respectively. The positive and negative predictive values were 16.7% (95% CI 2.9-49.1) and 97.3% (95% CI 89.6-99.5). None of the patients released at the scene was mistriaged based on the review of the coroners' and trauma admission records. CONCLUSION: Results of this investigation indicate that a small percentage of pediatric blunt trauma patients require TTA. EMT-P judgment alone of the need for TTA for pediatric blunt trauma patients is not sufficiently sensitive to be of clinical use. The low sensitivity is explained by the deterioration in the clinical condition of 2 initially stable patients. The paramedic disposition decisions from the scene were always accurate. Nontransport by emergency medical services (EMS) may be acceptable in some uninjured pediatric trauma patients. Injured pediatric trauma patients who appear to be stable may deteriorate shortly after injury. However, if a pediatric patient appears injured, transport from the scene and examination by a trauma specialist are needed. Finally, the role of paramedic judgment must be further defined by larger studies with urban, rural, and suburban EMS systems before it can be used as a sole predictor of TTA.     

After-hours telephone coverage: the application of an area-wide telephone triage and advice system for pediatric practices

BACKGROUND: After-hours telephone calls are a stressful and frustrating aspect of pediatric practice. At the request of private practice pediatricians in Denver, a metropolitan area-wide system was created to manage after-hours pediatric telephone calls and after-hours patient care. This system, the After-Hours Program (AHP), uses specially trained pediatric nurses with standardized protocols to provide after-hours telephone triage and advice for the patients of 92 Denver pediatricians, representing 56 practices. OBJECTIVES: This report describes the AHP, presents data from 4 years' experience with the program, and describes results of our evaluation of the following aspects of the program: subscribing physician satisfaction, parent satisfaction, the accuracy and appropriateness of telephone triage, and program costs. METHODS: After-Hours Program records (including quality assurance data) for all 4 years of operation were retrospectively reviewed, tabulated, and analyzed. The results of two subscribing physician surveys and one parent caller satisfaction survey are presented. A retrospective review of after-hours patient care encounter forms assessed the necessity for after-hours visits triaged by the AHP. An analysis of the total cost of this program to 10 randomly selected subscribing physicians was conducted using current AHP data and a survey of the 10 physicians. RESULTS: In 4 years, 107,938 calls have been successfully managed without an adverse clinical outcome. Minor errors in using protocols occurred in one call out of 1450 after-hours calls. After-hours phoen calls necessitated an after-hours patient visit 20% of the time and generated one after-hours hospital admission out of every 88 calls. Just over half of the patients were managed with home care advice only, and 28% were given home care advice after-hours and seen the next day in the primary physician's office. Of all patients directed by the telephone triage nurses to be seen after hours, 78% were determined to have a condition necessitating after-hours care. Data are presented regarding call volumes by time of day, day of week, patient age, and patient's initial complaint. The 6 most common complaints accounted for more than one half of the calls, and 38 complaints accounted for more than 95% of all after-hours calls. Utilization by subscribing physicians is described. Satisfaction among subscribing pediatricians was 100%, and among parents was 96% to 99% on a variety of issues. The total cost to participating Denver pediatricians (which includes revenues "given up" as a result of not seeing patients after hours) ranged from 1% to 12% of their annual net income, depending on a variety of factors. CONCLUSIONS: Large-scale after-hours telephone coverage systems can be effective and well-received by patients, parents, and primary physicians. Data presented in this report can assist in planning the training of personnel who provide after-hours telephone advice and triage. Controversies associated with this type of program are discussed. Suggestions are made regarding the direction of future programs and research.     

Diabetic nephropathy and isolated hyporeninemic hypoaldosteronism

OBJECTIVE: The objective of the Florida Trauma Triage Study was to assess the performance of state-adopted field triage criteria. The study addressed three specific age groups: pediatric (age < 15 years), adult (age 15-54 years), and geriatric (age 55+ years). Since 1990, Florida has used a uniform set of eight triage criteria, known as the trauma scorecard, for triaging adult trauma patients to state-approved trauma centers. However, only five of the criteria are recommended for use with pediatric patients. This article presents the findings regarding the performance of the scorecard when applied to a pediatric population. DESIGN: We used state trauma registry data linked to state hospital discharge data in a retrospective analysis of trauma patients transported by prehospital providers to any acute care hospital within nine selected Florida counties between July 1, 1991, and December 31, 1991. We used cross-table and logistic regression analysis to determine the ability of triage criteria to correctly identify patients who were retrospectively defined as major trauma. We applied the field criteria to physiologic and anatomy/mechanism of injury data contained in the trauma registry to "score" the patient as major or minor trauma. To make our retrospective determination of major or minor trauma we used the protocols developed by an expert medical panel as described by E. J. MacKenzie et al. (1990). MAIN OUTCOME MEASURES: We calculated sensitivity, specificity, and the corresponding over- and undertriage rates by comparing patient classifications (major or minor trauma) produced by the triage criteria and the retrospective algorithm. We used logistic regression to identify which triage criteria were statistically significant in predicting major trauma. RESULTS: Pediatric cases accounted for 9.2% of the total study population, 6.0% of all hospitalized cases, and 6.8% of all trauma deaths. Of the 1505 pediatric cases available for analysis, the triage criteria classified 269 cases as expected major trauma and 1236 cases as expected minor trauma. The retrospective algorithm classified 78 cases as expected major trauma and 1427 cases as expected minor trauma. The resulting specificity is 84.8% (15.2% overtriage), and the sensitivity is 66.7% (33.3% undertriage). Logistic regression indicated that, of the eight state-adopted field triage criteria, only the Glasgow coma score, ejection from vehicle, and penetrating injuries have a statistically significant impact on predicting major trauma in pediatric patients. CONCLUSIONS: Although the state-adopted trauma scorecard, applied to a pediatric population, produced acceptable overtriage, it did not produce acceptable undertriage. However, our undertriage rate is comparable to the results of other published studies on pediatric trauma. As a result of the Florida Trauma Triage Study, a new pediatric triage instrument was developed. It is currently being field-tested.     

Comparison of continuity clinic experience by practice setting and postgraduate level

OBJECTIVE: To compare continuity clinic experiences by practice setting and postgraduate level. DESIGN: Mailed questionnaire. SETTING: Baylor College of Medicine pediatric residents selected 1 of 3 continuity practice settings, including community-based private offices (n = 35) and university-based clinics in a private (n = 71) and a public (n = 12) hospital. SUBJECTS: One hundred eighteen pediatric residents, May 1993. OUTCOME MEASURES: Patient volume, continuity of care, type of patient visit, and faculty supervision. RESULTS: The response rate was 77% (91/118). Pediatric residents in community-based private offices reported seeing more patients per session than those in the university-based private and public clinics (88%, 10%, and 0% residents in the respective practice settings reported > or = 4 patients per session), but were less likely to see patients repeatedly (6%, 68%, and 40% residents in the respective practice settings had seen more than half their patients > 2 times). Residents in private offices provided a smaller percentage of well child care (16%, 61%, and 90% residents in the respective practice settings reported > 50% patients were well) and more acute care (68%, 15% and 0% residents in the respective practice settings reported > 25% patients were acutely ill). Residents in private offices reported a higher percentage of time spent observing only (33%, 0%, and 0% residents in the respective practice settings observed > 25% of the time) and less time managing patients independently (93%, 59%, and 40% residents, respectively, managed < or = 25% of the time). No significant differences among postgraduate levels were found for these variables. CONCLUSIONS: Patient volume, continuity of care, type of patient visit, and faculty supervision were significantly different among continuity practice settings. Postgraduate level of training did not affect significantly these measures of continuity clinic experience. These differences need to be considered in curriculum development.     

Prospective assessment of triage in an urban emergency department

BACKGROUND: This study examined the effectiveness of a triage system based on patient complaints, medical history, vital signs, and triage nurse impression. Measurements included recognizing patients needing admission, in correlating with disposition, and its effectiveness in all age groups. METHODS: Data were collected prospectively on all patients coming to a general emergency department (ED) of an urban teaching hospital from October 1, 1992, through November 30, 1992. Data included assigned triage acuity, disposition waiting time to physician examination, and disposition, as well as return to the ED within 2 weeks. The patients were divided into age groups: 0 to 16 years, 17 years to 25 years, 25 years to 50 years, 50 years to 65 years, and >65 years of age. RESULTS: There were five patients (n = 4,993, 0.4%) who were triaged nonemergently and subsequently admitted. The sensitivity and specificity of an assigned triage 3 acuity assignment in correlating with lack of admission were 99% and 56%, respectively. Mean waiting time to physician examination was 61 +/- 14 minutes for triage 1, 129 +/- 19 for triage 2, and 182 +/- 22 for triage 3. Mean time to admission from sign-in was 246 +/- 10 minutes for triage 1 and 372 +/- 16 minutes for triage 2. CONCLUSIONS: This triage system accurately correlated with disposition and determined waiting time to examination.     

The role of clinical autopsy in monitoring the quality of the clinical diagnosis in an emergency department

OBJECTIVE: A total of 61 autopsies performed in patients died in emergency department of a university hospital were retrospectively analysed and the findings were compared with clinical diagnoses. METHODS: Sensitivity and specificity of the clinical diagnoses and the correction of medical procedures were measured. The influence of age and sex of patients was analyzed using Fisher's exact test and chi-square-test. RESULTS: The most common causes of death were cardiovascular diseases (52.46%). Autopsy showed unexpected major findings in 44.26% of cases. Major discrepancies between the autopsy reports and the clinical diagnoses, were present in 26.22% of all cases. Absolute concordance between clinical and autopsy diagnoses was obtained in 44.26% of cases. The major sensitivity of clinical diagnosis was found in cerebrovascular disorders (100%), upper digestive hemorrhage (100%), and acute myocardial infarction (82.35%). The lowest sensitivity was found in malignant tumors (16.66%), hemorrhagic pancreatitis (0%) and bowel infarction (0%). The patient cares were correct in 68.85% of cases. No statistically significant differences were observed in relation to age and sex. CONCLUSIONS: We concluded that autopsy is a useful method for evaluate diagnostic procedures and quality of medical cares in emergency departments.     

Selection of an intact casein or casein hydrolysate diet by rats submitted to protein deprivation and bowel resection

OBJECTIVES: As part of their training, pediatric residents provide primary care services to young children, including youngsters who may have elevated blood lead levels. We set out to (1) determine the percentage of pediatric residents who screen children for elevated blood lead levels according to the guidelines of the Centers for Disease Control and Prevention and the American Academy of Pediatrics; (2) assess the likelihood of lead screening by residents based on demographic and practice-setting characteristics; and (3) compare the attitudes of residents who report that they are universal screeners, selective screeners, or nonscreeners. DESIGN: Confidential, cross-sectional survey of a nationally representative sample of pediatric residents conducted as part of the American Academy of Pediatrics 28th Periodic Survey of Fellows. SUBJECTS: One hundred forty-three responding pediatric residents (51% response rate). RESULTS: Seventy-five percent of pediatric residents reported screening all patients aged 9 to 36 months for elevated blood lead levels, 21% reported screening some, and 4% reported screening none. Pediatric residents who cared for patients in urban settings were more likely to report screening patients for elevated blood lead levels than were pediatric residents who cared for patients in suburban or rural settings (100% vs 73%; P < .001) and pediatric residents in the Northeast were more likely to report screening universally than were residents in the rest of the country (93% vs 63%; P < .001). Overall, pediatric residents who reported screening patients universally were more likely to believe that the benefits of screening outweigh the costs than were residents who reported screening patients selectively (67% vs 17%; P < .001). CONCLUSIONS: Most pediatric residents reported that they screened patients for elevated blood lead levels, either universally or selectively. Nevertheless, the screening practices of pediatric resident and their opinions concerning the relative benefits and costs of lead screening largely reflect the areas of the country and the practice settings in which they had their primary care experiences.