Room For Care Research Articles

Nonemergent Emergency Room Utilization for an Inner-City Pediatric Population

To identify patient reasons for accessing an urban Pediatric Emergency Room (PER) for primary care and to explore attitudes and practice regarding alternative sources for their medical home. A total of 210 questionnaires, consisting of 24 questions each, were completed in a face-to-face interview performed by trained interviewers. Questions asked included sources of medical care, frequency of use, and factors that went into caregiver decisions for using different sources of care. Caregivers choose the PER because of the short amount of time it takes for their child to be seen and discharged by a physician. Nearly 60% ranked wait time to see a doctor more important than seeing the same doctor every time (37.6%). About one-third of caregivers routinely brought their children to the PER for illness that is not serious. Only 77% of caregivers claimed that their children have a regular doctor. Many caregivers cited that they are seen more by their regular doctor for shots (well visits) than for ill visits and are seen in the PER for illness. In this study, 56% of children did not see the same regular doctor as their siblings. Efficiency and speed of health care delivery is of prime importance to this primarily Medicaid urban population. If strategies are to be implemented to attract these patients to a medical home that will strengthen their ties to their regular doctor, then the needs prioritized by the caregiver must be taken into consideration.

Case 5—2002 selective bronchial blockade in patients with previous contralateral lung surgery

Case 1. A 58-year-old man was scheduled for right middle lobe lobectomy to remove a lung tumor. He previously had a cystectomy and an iliac conduit for bladder cancer and left pneumonectomy for lung cancer. After left pneumonectomy, respiratory function data showed forced vital capacity (FVC) was 3.14 L (82.8%) and forced expiratory volume at 1 second (FEV1.0) was 1.74 L (53.6%). Breathing room air, blood gas analysis showed pH 7.392; PaO2, 80.9 mmHg; PaCO2, 44.5 mmHg; SaO2, 96.3%; and base excess, 1.7 mEq/L. After placement of an epidural catheter at T5-6, anesthesia was induced with 3 mg/kg of thiopental followed by 0.15 mg/kg of vecuronium. To use the bronchial blocker of a Univent tube (Fuji Co Ltd, Tokyo, Japan) as an independent blocker, the authors detached it from a Univent tube. The bronchial blocker initially was introduced into the trachea, after which the patient was intubated with a standard 9.0-mm internal diameter tube. The bronchial blocker was used outside the endotracheal tube. After this, radial artery and right internal jugular vein catheters were placed. Arterial blood gases were continuously monitored by a Paratrend7 (Biomedical Sensors Ltd, High Wycombe, UK). Anesthesia was maintained with fentanyl, isoflurane and oxygen, and epidurally administered 1% lidocaine. Fig 1 shows the changes in PaO2 and PaCO2 during the operation. Guided by fiberoptic bronchoscopy, initially the blocker was advanced to the bronchus intermedius, and the middle and lower lobes were collapsed, but PaO2 rapidly decreased and PaCO2 continued to increase. The authors then ventilated the whole lung and tried to block the middle lobe. This was successful, allowing normocapnia to be maintained throughout the operation with PaO2 at 80 mmHg. Collapse of the middle lobe also provided adequate surgical exposure and facilitated surgical procedures. When the middle lobe bronchus was stapled, ventilation was transiently stopped, and the blocker was withdrawn. Middle lobe lobectomy was performed uneventfully. After the operation, the patient was extubated and transferred to the recovery room for postoperative care. Case 2. A 65-year-old woman was scheduled for basal segmentectomy (S7-10) of the right lung for lung cancer. She previously had a left lower lobectomy for lung cancer. After lobectomy, respiratory function data showed FVC was 2.47 L (103.4%) and FEV1.0 was 1.4 L (69.9%). Breathing room air, blood gas analysis showed pH 7.415; PaO2, 86.6 mmHg; PaCO2, 42.9 mmHg; SaO2, 96.9%; and base excess, 2.6 mEq/L. After placement of an epidural catheter at T5-6, anesthesia was induced with 3 mg/kg of thiopental followed by 0.15 mg/kg of vecuronium. Similar to case 1, a bronchial blocker detached from a Univent tube initially was introduced to the trachea, after which the patient was intubated with a standard 8.0-mm internal diameter tube and received a radial artery catheter. One-lung ventilation initially was tried, but oxygen saturation as measured by pulse oximetry (SpO2) rapidly decreased to 82%. One-lung ventilation was abandoned, and both lungs were ventilated until SpO2 returned to 100%; then, guided by fiberoptic bronchoscopy, the blocker was advanced into the bronchus intermedius and blocked the middle and lower lobes. Using this technique, SpO2 subsequently was maintained at 100% throughout the operation. Case 3. A 64-year-old man was scheduled for segmentectomy (S1) of the right lung to remove a tumor. He previously had a left upper lobectomy for lung cancer. After lobectomy, respiratory function data showed FVC was 2.82 L (87.3%) and FEV1.0 was 2.00 L (70.9%). Breathing room air, blood gas analysis showed pH 7.375; PaO2, 70.6 mmHg; PaCO2, 45.5 mmHg; SaO2, 93.0%; and base excess, 0.9 mEq/L. After placement of an epidural catheter at T7-8, anesthesia was induced with 1.5 mg/kg of propofol and 2 g/kg of fentanyl followed by 0.15 mg/kg of vecuronium. The trachea was intubated with an 8.0-mm internal diameter Univent tube. Anesthesia was maintained with propofol, 5 to 10 mg/kg/h, with intermittently administered 1.5% lidocaine epidural anesthesia. A radial artery catheter also was placed. Guided by fiberoptic bronchoscopy, a bronchial blocker was introduced into the right upper bronchus and blocked only the right upper lobe. Subsequently, normocapnia was maintained with sufficient oxygenation (SpO2, 100%) throughout the operation. *S. Hagihira, N. Maki, and M. Kawaguchi

The Emergency Room Medical Group: improving hospital efficiency.

With national health care expenditures in the United States consuming 14 percent of the gross domestic product, the U.S. health care industry faces a turbulent environment. Adding to this situation, health care executives are having a difficult time developing strategies for dealing with patients who use the emergency room for primary care. Hospital executives may consider forming an Emergency Room Medical Group (ERMG). ERMGs are defined (as well as their alternative health care alliances), and each is illustrated in a model called the Physician Alliance Continuum.

Care and Responsibility in 'The Best Interest of the Child': Relational voices of ethical dilemmas in teaching

This paper discusses ethical dilemmas in early childhood education as identified by kindergarten and elementary school teachers ( n = 26). Ethical dilemmas are investigated in the theoretical framework of virtue epistemology. The moral stances of care and responsibility are identified as basic elements in teachers' professional morality. The empirical findings present conflicts between teachers and parents, collegial conflicts between teachers, and inter-institutional conflicts in the community. The method used in the study is a relational reading of teachers' narratives. Interpretative accounts are created to give room for both care and responsibility voices in teachers' written reports. The analysis of the data reveals that the ethical dilemmas in early childhood education are very relational and deal with competing interpretations of 'the best interest of the child'. Teachers have taken the moral stance of care by identifying the ethical conflict. However, the responsible professional action has been more difficult for them to accomplish. Most of the time, discussions have not produced the desired results. Ethical conflicts in teaching invite teachers to consider the moral relevance of each dilemma by taking the perspectives of the involved parties.

The moderating effects of race on return visits to the psychiatric emergency room.

Racial differences in variables that predict return to the psychiatric emergency room were examined. A random sample of 319 clients was obtained from the logs of a psychiatric emergency room of a state-operated, acute care psychiatric hospital. The dependent variable was a return visit to the psychiatric emergency room within 18 months of the index visit. Separate logistic regression equations were calculated for African Americans (N = 163) and Caucasians (N = 156) to estimate the moderating effects of race. Four variables predicted return to the emergency room for both African Americans and Caucasians: previous visits to the psychiatric emergency room, previous psychiatric hospitalizations, current receipt of outpatient treatment, and nonreceipt of aftercare following the index visit to the emergency room. Three unique predictors were found for African Americans: never having been married, not living in stable housing, and not being admitted at the index visit. Generally, repeat visitors from both racial groups tended to be chronic users of psychiatric services who may be using the psychiatric emergency room for routine psychiatric care. However, race was also an important moderator variable; several risk factors predicted a return visit only for African Americans.

Risk Factors for Attempted Suicide During Adolescence

It is unknown whether adolescents can provide the information necessary to identify their risk for attempted suicide. The present study was designed to determine whether data collected directly from adolescents can be used to develop a simple model for differentiating suicidal from nonsuicidal adolescents. Patients aged 13 to 19 years hospitalized for medical complications of serious suicide attempts (n = 56) or for acute illnesses unrelated to injuries or ingestions (n = 248) completed self-administered questionnaires pertaining to psychosocial function, recent stress, alcohol and drug use, and health care use. Compared with ill adolescents, suicidal adolescents had poorer mental health, impulse control, family relationships, and school performance; higher 3-month stress scores and alcohol-use scores; and more use of 7 of 12 drugs (P less than .05). Compared with ill adolescents, suicidal adolescents were more likely to report previous suicide attempts (39% vs 10%, P less than .001) and previous mental health care (27% vs 8%, P less than .001) but were less likely to identify a primary care site (61% vs 87%, P less than .001). In a logistic regression model based on previous suicide attempts, previous mental health care, poor school performance, marijuana use, and dependence on the emergency room for primary care, 84% of the suicidal and 55% of the ill adolescents were correctly identified. If validated prospectively, these five self-administered questions may constitute a helpful screen for the rapid identification of suicidal adolescents.

An index of severity for acute pediatric illness.

A study population of 1,106 patients presenting to a pediatric emergency room for care of acute non-traumatic illness were prospectively assessed to determine what clinical manifestations and/or functional status indicators predicted the severity of their illnesses. From these data, a "Severity Index" was developed using a 0-1-2 point score for the five most significant predictors to give a maximum score of 10 points. The predictor variables include respiratory effort, skin color, activity, temperature, and ability to play. The index has a predictive accuracy for non-severe illness of 98.7 per cent with only 1.3 per cent false negative predictions. In predicting major illness, a false positive prediction rate of 15.8 per cent was obtained. The index appears valid both across and within diagnostic categories.

Patient identification with the I SPY health program (children and youth project).

By use of an interview questionnaire survey done in the home, the Comprehensive Children and Youth Program, I SPY, at the Beth Israel Medical Center, was able to find out something about patient identification with the program, medical care patterns utilized by the interviewed population, and health perceptions within this surveyed group. Some of the findings were as follows: 70 per cent of those interviewed identified the I SPY program as the source of medical care. Better than 90 per cent of those who identified with the I SPY program knew the doctor by name. Sixty-five per cent of those interviewed identified I SPY as the only source of health care. The remaining one third used other sources, including private physicians, other clinics, and neighborhood centers. Sixty-eight per cent of the sample used Beth Israel Hospital emergency room for medical care when the I SPY program was closed. Sixty-four per cent of those interviewed went to the doctor for regular visits. Eighty per cent of those interviewed knew their child's immunization status. The majority used and expressed a preference for the appointment system. However, the need to accommodate the unplanned for sudden illness was evident.

A Recovery Room

T HIS IS THE EXPERIENC. E of one hospital in planning for and establishing a recovery room for the immediate care of postoperative patients. The rather., wellknown advantages of a recovery room for surgical patients are the saving in nursing time, i.e., the supervision of more than one postsurgical patient by one nurse, and the immediate administration of transfusions, intravenous, and other special therapy as needed. Duke Hospital, opened as a unit of the Duke University School of Medicine in July 1930, was built to care for 6oo patients. The administration could, scarcely foresee that 1946 would bring an annual total of over 1.70,400 days of hospital care, 129,504 outpatient visits, and 9,185 operations. These increases were due in part to the greatly accelerated rate of admissions and discharges. The rapid turnover of patients brought problems for each department but in no place were they felt more acutely than in the nursing service. One problem which concerned surgeons, anesthetists, and nurses was adequate postoperative care. Until February 1947, the -usual procedure was to return postoperative patients to their respective units at once. There were two exceptions-patients in surgical shock and patients with plastic surgery. Patients in these categories were kept in a small anesthesia room in order that the surgeon and anesthetists might observe them more readily and the nursing stafl' administer immediate and constant postoperative care. Patients who have had plastic surgery need not only the usual close observation which all patients require after a general anesthetic, but in addition protection against damage to their grafts and wounds. A staff nurse had been assigned to care for those patients. Under this plan it was difficult in either the anesthesia room or on the ward for a nurse to care for more than one postoperative patient. Our daily average of twentynine operations required more immediate postoperative nursing care than an already overburdened nursing service could provide.