24-hour Coverage Research Articles

Bedtime Hypertension Treatment Increases Ambulatory Blood Pressure Control and Reduces Cardiovascular Risk in Resistant Hypertension

To the Editor: A cross-sectional 24-hour ambulatory blood pressure (BP) monitoring study1 reported 37.5% incidence of isolated office resistant hypertension (RH), there defined as clinic BP ≥140/90 mm Hg plus 24-hour BP mean 3 medications per day is true RH, regardless of BP values; exclusion of patients treated with ≥4 medications per day would decrease the reported prevalence to 24.6%; and, second, nocturnal hypertension and abnormal nondipper BP pattern are prevalent in RH1,2; current guidelines designate separate diagnostic thresholds for daytime and nighttime BP means; mean nighttime BP ≥120/70 …

Masters of radiology panel discussion: the commoditization of radiology.

Masters of Radiology Panel Discussion: The Commoditization of RadiologyHoward P. Forman1, David B. Larson2, Alan D. Kaye3, Ella A. Kazerooni4, Alexander Norbash5, John K. Crowe6, Marcia C. Javitt7 and Norman J. Beauchamp, Jr.8Audio Available | Share

Stroke telepresence

Telestroke permits time-sensitive acute stroke consultations to remote Emergency Departments (ED) regardless of distance.1 Time is the critical issue in acute stroke, where minutes matter. The odds of an excellent 3-month outcome decline with every minute before tissue plasminogen activator (tPA) is administered.2 In this issue of Neurology ®, Sairanen and colleagues3 describe how “hub” consultants provided telestroke coverage to remote Finnish “spoke” hospitals 80–500 miles away, to help decide whether to administer tPA. They showed that the 3-month functional outcomes and symptomatic intracranial bleeding rate in tPA-treated spoke patients were similar to those treated in person at the hub. More than half of spoke consultations resulted in the administration of IV tPA, a higher percentage than observed in other studies, where only about a quarter are treated.4 This may be due to “spot coverage.” The 29 consultants provided less than 24-hour coverage; during the regular day shift, tPA was administered by local neurologists so that the ED staff was experienced. It is likely, then, that experienced ED teams' consultations were more likely to result in tPA administration. The consultations took about 23 minutes and the median onset to treatment time was about 120 minutes, further evidence that telestroke consultations lead to early treatment.4 All patients remained in the spoke hospitals …

Benefits of once-daily therapies in the treatment of hypertension

In patients with hypertension, 24-hour blood pressure control is the major therapeutic goal. The number of daily doses is one characteristic of an antihypertensive agent that may affect the adequacy of 24-hour control. One measure of therapeutic coverage is the 24-hour trough-to-peak ratio, which determines the suitability of an agent for once-daily administration. The closer an agent is to a 100% trough-to-peak ratio, the more uniform the 24-hour coverage and therefore blood pressure control. High trough-to-peak ratio, long-acting antihypertensive medications lower blood pressure more gradually, which reduces the likelihood of adverse events attributable to abrupt drug action that occurs with shorter-acting agents. In hypertension, the natural diurnal variation of blood pressure may be altered, including elevated nighttime pressures. An optimal once-daily hypertension therapy would not only lower blood pressure but also normalize any blunted circadian variations in blood pressure. The benefits of once-daily agents with sustained therapeutic coverage may also be explained, in part, by increased patient adherence to simpler regimens as well as lower loss of blood pressure control during virtually inevitable intermittent noncompliance. Studies have demonstrated that once-daily antihypertensive agents have the highest adherence compared with twice-daily or multiple daily doses, including greater adherence to the prescribed timing of doses.

Impact of Admission Time on Mortality in an Indian Intensive Care Unit With Round-the-Clock Intensivist Coverage

Higher mortality in patients admitted during off hours has been attributed to inadequate staffing, but only a few studies have assessed the impact of 24-hour intensivist coverage on ICU mortality. We aimed to assess the impact of admission time on mortality for patients admitted to an ICU with 24-hour in-house intensivist coverage through a retrospective study analyzing data from all admissions to a medical ICU over 15 months. Patients were divided into 2 groups by time of ICU admission: regular hours (Monday-Saturday 9 am to 5 pm) and off hours (Monday-Saturday 5 pm to 9 am, Sunday). Patients were compared with regard to demographics, severity of illness, ICU course, and ICU outcome. Primary outcome measure was ICU mortality. Of 653 admissions, 391 (59.9%) were admitted during off hours. There was no significant difference in age, sex, severity of illness, need for organ support, and ICU stay. ICU mortality was 14.9% and 16.4% in regular and off hours, respectively ( P = .689). Relative risk of death for admission in after hours was 1.018 (95% CI, 0.952-1.088), with the odds ratio of dying being 1.119 (95% CI, 0.726-1.726). We concluded that full-time intensivist coverage ensures continuity of care. Hence, off-hour admissions may not be associated with any increased mortality.

Community rehabilitation for schizophrenia patients: Is it feasible in South Africa?

No abstract available.

52: The Impact of Teleradiology Preliminary Reports on Emergency Department Patient Care

The use of remote teleradiology provides emergency physicians with preliminary interpretation of radiographic studies in hospitals unable to provide 24-hour on-site board-certified radiologist coverage. Over 82% of community-based emergency departments are reported to use such resources to obtain timely radiologic interpretations. The following study was performed to assess the effectiveness of teleradiology by evaluating the incidence of major discrepancies between preliminary teleradiology reports and next day on-site radiology interpretations among varying study modalities.

Critical appraisal of once-weekly formulation of exenatide in the control of type 2 diabetes mellitus

Critical appraisal of once-weekly formulation of exenatide in the control of type 2 diabetes mellitus Jason Seewoodhary1, Leanne Griffin1, Stephen C Bain11Department of Diabetes and Endocrinology, Swansea School of Medicine, University of Wales, Swansea SA2 8PP, UKAbstract: Exenatide (also known as exendin-4) is a glucagon-like peptide-1 mimetic, which is indicated for the treatment of type 2 diabetes mellitus. The currently available formulation of this drug is a twice-daily exenatide (exenatide BID) injection that should be administered within 60 minutes of food. Once-weekly exenatide (exenatide QW) formulation is now being assessed in a clinical trial program. Exenatide QW has been shown to be the only noninsulin monotherapy to achieve glycosylated hemoglobin levels of <7% in >75% of treated patients. It has also demonstrated potential cardiovascular benefits by lowering total and low-density lipoprotein cholesterol concentrations, triglyceride levels, and both systolic and diastolic blood pressure. In addition, patients treated with exenatide QW achieved significant weight loss, which may also lead to significant cardiovascular risk reduction. Exenatide QW is associated with a lower incidence of gastrointestinal adverse effects compared with exenatide BID, and no patients treated with exenatide QW monotherapy experienced a confirmed hypoglycemic event. Exenatide QW results in 24-hour coverage with exenatide concentrations that are known to improve glycemic control and remain well tolerated in patients with type 2 diabetes mellitus. This review defines the state of play with exenatide QW by critically appraising its role in clinical practice.Keywords: GLP-1 mimetic, HbA1c, weight loss

Critical appraisal of once-weekly formulation of exenatide in the control of type 2 diabetes mellitus

Exenatide (also known as exendin-4) is a glucagon-like peptide-1 mimetic, which is indicated for the treatment of type 2 diabetes mellitus. The currently available formulation of this drug is a twice-daily exenatide (exenatide BID) injection that should be administered within 60 minutes of food. Once-weekly exenatide (exenatide QW) formulation is now being assessed in a clinical trial program. Exenatide QW has been shown to be the only noninsulin monotherapy to achieve glycosylated hemoglobin levels of <7% in >75% of treated patients. It has also demonstrated potential cardiovascular benefits by lowering total and low-density lipoprotein cholesterol concentrations, triglyceride levels, and both systolic and diastolic blood pressure. In addition, patients treated with exenatide QW achieved significant weight loss, which may also lead to significant cardiovascular risk reduction. Exenatide QW is associated with a lower incidence of gastrointestinal adverse effects compared with exenatide BID, and no patients treated with exenatide QW monotherapy experienced a confirmed hypoglycemic event. Exenatide QW results in 24-hour coverage with exenatide concentrations that are known to improve glycemic control and remain well tolerated in patients with type 2 diabetes mellitus. This review defines the state of play with exenatide QW by critically appraising its role in clinical practice.

Prevalence of Methicillin-Resistant Staphylococcus Aureus in Ambulances in Southern Maine

Objective. To determine whether methicillin-resistant Staphylococcus aureus (MRSA) could be found in ambulances in a predominantly rural state. Methods. Samples were obtained from specified areas in 51 ambulances in southern Maine. These samples were tested on mannitol salt agar containing 4 μg/mL oxacillin. Resulting colonies were gram-stained and tested for the presence of catalase and coagulase. Results. Of the 51 ambulances tested, 25 (49%%) had at least one area positive for MRSA contamination. Conclusions. A significant number of ambulances operating in southern Maine have MRSA contamination, and ambulances may represent an important reservoir for the transmission of potentially serious infections to patients and EMS personnel. There was no statistical difference between the service types (fire-based vs. non–fire-based) or annual call volume. There was, however, a statistically significant lower rate of contamination in services that provided paid, 24-hour coverage versus those that did not.

Reducing Obstetric Litigation Through Alterations in Practice Patterns

OBJECTIVE: To estimate the extent to which obstetric malpractice claims might be reduced by adherence to a limited number of specific practice patterns. METHODS: We examined all 189 closed perinatal claims between 2000 and 2005 from a single, large, professional liability insurer. Each case was subjected to three separate analyses: 1) whether the adverse outcome was caused by substandard care, 2) what changes in practice likely would have avoided the adverse outcome, regardless of standard-of-care considerations, and 3) to what extent did substandard documentation lead to payment in cases in which there was no objective evidence of substandard care. RESULTS: Seventy percent of claims involving obstetric practice (accounting for 79% of all costs) involved substandard care. Payments in 85% of cases involving non-vaginal birth after cesarean (VBAC) fetal monitoring, 16% of maternal injury cases, 80% of cases involving VBAC, and 54% of shoulder dystocia cases were avoidable had four specific practice and documentation patterns been followed. CONCLUSION: Most money currently paid in conjunction with obstetric malpractice cases is a result of actual substandard care resulting in preventable injury. Well more than half of hospital litigation costs might be avoided if physician practice included: 1) delivery in a facility with 24-hour in-house obstetric coverage; 2) adherence to published high-risk medication protocols; 3) a more conservative approach to VBAC; and 4) use of a comprehensive, standardized procedure note in cases of shoulder dystocia.

419: Work-Induced Memory Decline in Emergency Medicine Attending Physicians

Shift work is known to result in desynchronosis and cognitive decline. The 24-hour coverage of the emergency medicine (EM) specialty requires shift work, but any decline in cognitive performance could potentially jeopardize patient care. We employed a battery of validated neuropsychiatric tests to measure changes in cognition, executive function, and impulsiveness in emergency medicine attending physicians before and after day and overnight shifts. This study tested the hypothesis that the work-induced decline in cognition would differ between day and overnight shifts.

24-Hour Blood Pressure Control – A Predictor for Clinical Outcomes

Although many studies have addressed the relevance of assessing blood pressure (BP) control over a 24-hour period, it is still an area of dispute among clinicians. There is no clear agreement as to which 24-hour parameters are most important and no standardized definitions. Different types of 24-hour measurement have different implications for outcomes and, differ in their impact on the health economics of hypertension. For example, several groups have reported a connection between the systolic BP surge on rising and the incidence of cardiovascular complications in hypertensives. As BP surge on rising occurs toward the end of the dosing period, the use of an antihypertensive with extended duration of action and proven forgiveness to missed dose is more likely to attenuate the adverse outcomes associated with an early morning BP surge. Studies in this area provide quantitative estimates of the relationship between suboptimal 24-hour BP control and morbidity and mortality outcomes. Growing evidence demonstrates that there are improved outcomes in those patients whose BP values are lowered throughout a 24-hour period. However, 24-hour control is even more difficult to achieve than clinic BP control, and not all antihypertensive drugs are equally capable of reducing BP over the full 24-hour period. Some drugs claim beneficial effects on certain aspects of 24-hour control but may not control other aspects adequately; plus not all drugs have the same effects on target organ damage (over and above effects due to BP control). Whilst 24-hour measurements are not needed for routine clinical practice, choosing an antihypertensive that is proven to provide complete 24-hour coverage is likely to translate into improved outcomes. Mathematical modeling can be a useful tool in linking various measures of 24-hour BP control to longer-term outcomes and when evaluating antihypertensive strategies for reimbursement purposes. However, it is important to develop standardized and agreed modeling approaches that look at effects over the whole 24-hour period, including when doses are missed.

Reducing Obstetric Litigation Through Alterations in Practice Patterns

To estimate the extent to which obstetric malpractice claims might be reduced by adherence to a limited number of specific practice patterns. We examined all 189 closed perinatal claims between 2000 and 2005 from a single, large, professional liability insurer. Each case was subjected to three separate analyses: 1) whether the adverse outcome was caused by substandard care, 2) what changes in practice likely would have avoided the adverse outcome, regardless of standard-of-care considerations, and 3) to what extent did substandard documentation lead to payment in cases in which there was no objective evidence of substandard care. Seventy percent of claims involving obstetric practice (accounting for 79% of all costs) involved substandard care. Payments in 85% of cases involving non-vaginal birth after cesarean (VBAC) fetal monitoring, 16% of maternal injury cases, 80% of cases involving VBAC, and 54% of shoulder dystocia cases were avoidable had four specific practice and documentation patterns been followed. Most money currently paid in conjunction with obstetric malpractice cases is a result of actual substandard care resulting in preventable injury. Well more than half of hospital litigation costs might be avoided if physician practice included: 1) delivery in a facility with 24-hour in-house obstetric coverage; 2) adherence to published high-risk medication protocols; 3) a more conservative approach to VBAC; and 4) use of a comprehensive, standardized procedure note in cases of shoulder dystocia. III.

Implementing after-hours pharmacy coverage for critical access hospitals in northeast Minnesota

A project that used health information technology (IT) to provide after-hours pharmacy coverage to critical access hospitals in northeast Minnesota is described. SISU Medical Systems was established to address the health care IT needs of the Wilderness Health Care Coalition hospitals. Administrators and nursing and pharmacy leaders at several Wilderness Coalition hospitals were interested in obtaining after-hours pharmacy services to optimize patient safety. Eight of the Wilderness Coalition critical access hospitals obtained the technology necessary to allow pharmacy staff at St. Luke's Hospital (the hub hospital) in Duluth, Minnesota, to electronically enter orders into the rural hospitals' patient electronic medical records. The system placed the orders into the patients' medication profiles on automated dispensing machines located at seven of the eight rural hospitals. The pharmacy computer system allowed for medication order processing, drug interaction checking, medication dispensing via automated dispensing cabinets at the rural hospital sites, and formulary and inventory management. Medications that were not available in a rural hospital's automated dispensing cabinet were obtained from the locked pharmacy by the nurse supervisor. Round-the-clock pharmacy coverage was almost achieved. Participating rural hospitals received 24-hour coverage from the hub hospital during weekends and holidays, but no after-hours (4 a.m.-7 a.m.) coverage was provided on weekdays. The staff at the rural hospitals determined from their experiences that new orders were less likely to be written during these hours. Using Internet-based health IT, pharmacists from a metropolitan (hub) hospital with round-the-clock pharmacist coverage participated in the care of patients at a number of small, rural hospitals and helped ensure that those patients received safe and effective medication therapy. The coverage provided by pharmacists at the hub hospital improved nursing satisfaction with the overall quality of pharmacy services provided by both the hub hospital and the local onsite pharmacists.

Stroke Center Designation Can be Achieved by Small Hospitals

In January 2005, the Massachusetts Department of Public Health announced the designation of approved hospitals as Primary Stroke Services (PSS), based on verifiable demonstration of care pathways for acute ischemic stroke. We investigated the effect of hospital characteristics on participation in the PSS program.In 2003, the Massachusetts Department of Public Health surveyed 72 Massachusetts hospitals on their readiness for PSS designation. Survey results and PSS participation rates were compared among hospitals categorized by bed size (<150 vs. > or =150 beds), rural location, and major teaching hospital status. In answer to 2003 survey questions, smaller hospitals (n = 35) were less likely than larger hospitals to have acute stroke teams (P = 0.01), 24-hour rapid computed tomography scanning and interpretation (P = 0.0006), 24-hour neurosurgery coverage (P = 0.001), and a stroke registry (P = 0.007). Smaller hospitals were less likely to be interested in PSS application in 2003 (P = 0.008), and less likely to be designated PSS when ambulance rerouting to PSS hospitals began in July 2005 (P < 0.0001). Despite this, by December 2005 the majority of Massachusetts hospitals (66/71, 92%) had achieved PSS designation. Smaller hospitals were more likely to use telemedicine to access acute stroke teams (P = 0.003).Many smaller hospitals are able to acquire the resources needed for provision of acute stroke care, despite initial limitations. Innovative strategies, such as telemedicine consultation and transfer agreements, may successfully allow smaller hospitals to satisfy Brain Attack Coalition criteria for primary stroke centers.

Letter

Back to table of contents Previous article Next article LetterFull AccessLetterColin Hemmings M.B.B.S., M.R.C.Psych.Lisa Underwood B.Sc.Nick Bouras Ph.D., F.R.C.Psych.Colin Hemmings M.B.B.S., M.R.C.Psych.Search for more papers by this authorLisa Underwood B.Sc.Search for more papers by this authorNick Bouras Ph.D., F.R.C.Psych.Search for more papers by this authorPublished Online:1 Aug 2008https://doi.org/10.1176/ps.2008.59.8.936AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail ACT for People With Intellectual Disabilities and Mental Health ProblemsTo the Editor: There is no consensus on whether assertive community treatment (ACT) for people with intellectual disabilities who also have mental health problems should be identical to ACT for people with mental illnesses. Two studies have evaluated ACT for people with intellectual disabilities and coexisting mental health problems ( 1 , 2 ). However, they used versions that were significantly different from each other and from the original ACT model ( 3 ). To evaluate the suitability of this model for this population, characteristics of ACT that are necessary for people with intellectual disabilities need to be identified. We therefore report the results of a study that explored the opinions of specialist health staff. The participants were 21 staff from four sites in the United Kingdom that deliver ACT-type services to people with intellectual disabilities. Participants included psychiatrists, psychologists, intellectual disability nurses, support workers, and occupational therapists. In-depth structured interviews were carried out in 2006 by two experienced clinicians. Participants were asked to express their opinion about each of 26 statements about ACT derived from the Dartmouth Assertive Treatment Scale ( 4 ). After complete description of the study, written informed consent was obtained from all participants. Ethical approval was obtained from Guy's Research Ethics Committee. In general, participants' opinions were similar, although some disagreement was noted. Participants believed that ACT for people with intellectual disabilities should include most of the structural and human resource features of the original model, including a shared caseload, regular team meetings, a practicing team leader, continuity of staff, and a vocational specialist on staff. They also thought that there should be more than one psychiatrist and more than two nurses per 100 service users. In regard to organizational boundaries, they believed that there should be explicit admission criteria, but having a low intake rate, 24-hour coverage, and a rule about not closing any cases were seen as unnecessary, unrealistic, or inappropriate for this population. Participants indicated that hospital admissions and discharge planning should involve personnel from the ACT service, but it was not agreed whether these personnel should take responsibility for such planning.There was disagreement about whether the ACT service should have full responsibility for treatment services, particularly housing support, employment, and rehabilitation. Participants agreed that the nature of the ACT service should be similar to that of the original model, including community delivery of services, involvement of service users' support networks, and a stagewise treatment model for those who misuse substances. There was disagreement on whether a no-dropout policy or high levels of service time and contacts were realistic or necessary. Participants did not support direct service provision by service users and family caregivers but agreed that their involvement in service development, support roles, and provision of feedback was essential. [Three tables that provide more details about participants' responses are available as an online supplement to this letter at ps.psychiatryonline.org.]The main limitation of this study was that participants did not share the same level of understanding about the original ACT model. In addition, they were typically serving persons with a wider range of mental health problems than those for whom ACT was originally intended. A focus on patients with more severe mental health problems—for example, by restricting future research on ACT among persons with intellectual disabilities to those who also have psychotic disorders—would better complement research on ACT among persons with mental illnesses.We thus hope that the findings reported here are useful for generating further discussion about ACT for persons with intellectual disabilities. It remains difficult to adequately determine whether service users with intellectual disabilities and mental health problems might benefit from ACT because of ongoing problems with the definition and implementation of the model for this service user group as well the lack of specialist professionals working with people with intellectual disabilities and mental health problems who have close knowledge and experience of ACT. Hence studies such as this one will be similarly limited. In our opinion, therefore, it may be more fruitful at present to explore the effectiveness of broader models of specialist community-based services for people with intellectual disabilities and coexisting mental health problems.Acknowledgments and disclosuresThe authors acknowledge the contributions of Stephen Higgins, M.Sc., Geraldine Holt, F.R.C.Psych., Dimitrios Paschos, M.R.C. Psych., Elias Tsakanikos, Ph.D., and Steve Wright, M.Sc.The authors report no competing in interests.Dr. Hemmings, Ms. Underwood, and Professor Bouras are affiliated with the Estia Centre, Institute of Psychiatry, King's College London.

Pediatric Emergency Care in Europe

To examine determinants of quality of care provided by pediatric emergency departments (PEDs) in tertiary European centers. Analysis of questionnaires was sent to directors of PEDs. Questionnaires were sent through the pediatric research group of the European Society for Emergency Medicine. Three major descriptive categories were included in a 28-point questionnaire: institution's pediatric inpatient capabilities, scope of services, and medical staff education and structure. Sixty-five questionnaires were completed in full. Fifty-three tertiary medical centers from 14 countries were included in the study. In 86.8% of these institutions, the PED is separated from the adult emergency department; 91% have a pediatric intensive care unit, and 72% have an in-patient pediatric trauma service. Eighty-eight percent of the PEDs have incorporated triage protocols. Social service was not available in 17% of the departments. Sedation for painful procedures is provided by the staff in 77% of the PEDs. Only 24% of the PED medical directors have been formally trained in pediatric emergency medicine. In 17% of the departments, there is a 24-hour 7-day residents' coverage with no attending pediatrician or pediatric emergency medicine-trained physician. According to this pilot study, the basic services provided by tertiary PEDs in Europe appear to be appropriate. Physicians training level and staffing may not be adequate to achieve optimal patient outcome.

Time of delivery and neonatal morbidity and mortality

The objective of the study was to examine the association between time of delivery and neonatal outcomes in term deliveries. We conducted a retrospective cohort study of all term pregnancies delivered at an academic institution with 24-hour in-house obstetric and anesthesia coverage. Time of delivery was categorized as day (7 am to 6 pm), evening (6 pm to 12 midnight), and late night (12 midnight to 7 am). Outcomes included 5-minute Apgar less than 7, umbilical artery pH less than 7.0, base excess less than -12, admission to the neonatal intensive care unit (NICU), and neonatal death. We excluded patients delivered via cesarean delivery not in labor. We had greater than 80% power to detect a 25% difference in Apgar score, base excess, and admission to the NICU and 80% power to detect a 50% difference in umbilical artery pH less than 7.0. Among the 34,424 deliveries meeting inclusion criteria, 15,664 were during the day, 8495 were during the evening, and 10,265 were during the night. In univariate comparisons, there were no statistically significant differences in neonatal outcomes. For example, the rate of pH less than 7.0 was 0.7% during the day, 1.0% in the evening, and 0.6% at night (P = .12). Admissions to the NICU were 3.6% during the day, 3.7% in the evening, and 3.5% at night (P = .81). When we controlled for obstetric history, demographic factors, and labor characteristics, there were still no differences in rates of either neonatal morbidity or mortality by time of delivery. At our institution, we could not demonstrate any significant differences in neonatal morbidity or mortality by time of day among neonates delivered at term. These data can be used to counsel patients and families concerned about differences in time of delivery and potential impact on their infant's health. Future research should include time of delivery in relation to maternal and neonatal outcomes in various types of inpatient settings.

Impact of an On-duty Pulmonologist on the Activity of a Respiratory Medicine Department

To evaluate the impact on health care and clinical management of 24-hour coverage by an on-site pulmonologist in a respiratory medicine department. In February 2004, a new respiratory medicine 24-hour duty service was started in our hospital. The activity of the on-duty pulmonologist during the following 12 months was systematically and prospectively recorded. The results were put into perspective by comparing the number of monthly admissions and the mean length of stay during the study period with those of the previous 12-month period. During the study period, the on-duty pulmonologist received a mean (SD) of 9.02 (5.27) emergency calls every day, performed 202 diagnostic or therapeutic interventions, and discharged 342 patients. During this period, 1305 patients were admitted to the department (mean length of stay, 8.1 days), whereas in the previous 12 months, with no on-site pulmonologist, 1680 patients were admitted (mean length of stay, 9.0 days). This represents a 22.3% reduction in the annual number of admissions and a reduction in the mean stay by almost 1 day (0.9 days). The provision of an on-duty pulmonologist was efficient because it facilitated patient turnaround.