This article was downloaded by: [UQ Library] On: 13 March 2015, At: 06:14 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Hospital Topics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vhos20
Outpatient/Emergency: Monitoring Utilization of a Municipal Hospital Emergency Department Steven Jonas Senior Editor M.D. Sylvia Wassertheil-Smoller Ph.D. a
a b c
, Roberta Flesh M.D.
d e
, Ronald Brook
f b
&
b
Department of Social Medicine , Morrisania City Hospital
b
Department of Community Health , Albert Einstein College of Medicine , Bronx, New York, USA c
Department of Community Medicine, Health Sciences Center , State University of New York , Stony Brook, USA d
Downstate Medical Center , Brooklyn, New York, USA
e
Department of Health , New York City, USA
f
King Health Center Published online: 13 Jul 2010.
To cite this article: Steven Jonas Senior Editor M.D. , Roberta Flesh M.D. , Ronald Brook & Sylvia WassertheilSmoller Ph.D. (1976) Outpatient/Emergency: Monitoring Utilization of a Municipal Hospital Emergency Department, Hospital Topics, 54:1, 43-48, DOI: 10.1080/00185868.1976.9952378 To link to this article: http://dx.doi.org/10.1080/00185868.1976.9952378
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Monitoring Utilization of a Municipal Hospital Emergency Department Roberta Flesh, M.D. Formerly fourth-year medical student, Downstate Medical Center, Brooklyn, New York and Summer Research Student, New York City, Department of Health.
Ronald Brook Formerly Director of Research and Evaluation, King Health Center, and Assistant Professor, Department of Community Health, Albert Einstein College of Medicine, Bronx, New York.
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Sylvia Wassertheil-Smoller, Ph.D.
Steven Jonas, M.D., Senior Editor Formerly Director, Department of Social Medicine, Morrisania City Hospital, and Assistant Professor, Department of Community Health Albert Einstein College of Medicine, Bronx, New York. Presently Associate Professor, Department of Community Medicine, Health Sciences Center, State University of New York at Stony Brook. I. INTRODUCTION LITERATURE REVIEW mergency rooms, emergency departments and emergency services have come under increasing study in recent years. One area which has not received too much attention is the collection of emergency unit utilization and patient characteristic data on a continuing basis. It is possible that the availability of such data could help in the planning and operation of emergency and related services to make them more appropriate to patient needs. This paper reports an attempt to develop such an approach. There have been a number of studies reported, dealing with various aspects of emergency medical care. Among them are works dealing with general issues, I - ’ historical current problems10-12 emergency services in teaching hospitals13- l4 physician staffing , - Is quality,Ig utilizati~n,~. 20-26 and the relationship between neighborhood health centers and emergehcy ~ervices.’~-~~ A characteristic shared by all of the studies cited above was that they were carried out on a one-time basis. They were intended to reveal information about the emergency units studied at particular points in time. In an attempt to develop a system which could be used on a continous basis, Brenner and Weinerman proposed and tested a comprehensive ambulatory service data systern.l9 It required special forms, however.
E
JANUA R Y/F EBRUARY 1976
Associate Professor, Department of Community Health, Albert Einstein College of Medicine, Bronx, New York. Acknowledgement: We thank Raymond C. Lerner, Ph.D., formerly, Director, Bronx County Health Information Project, presently Associate Professor, Department of Comm unity Medicine, Health Sciences Center, State University of New York at Stony Brook, for assistance. The study herein reported had two aims. The first was to determine if existing forms could be used to generate data helpful in the planning and operation of hospital emergency services, which could be collected on an on-going basis. The second was to collect utilization and patient characteristic data at a discrete point in time for the adult emergency unit of the Morrisania City Hospital, (MCH), Bronx, New York, which might be useful in program planning at that institution. At the time this study was done, the only data regularly collected and published in the emergency unit at MCH were total visits by month, with comparisons to previous months, and number of visits by day by shift. 11. METHOD A. Setting This study was conducted at the Morrisania City Hospital, (MCH), a 331 bed hospital in the Westcentral Bronx, New York. There were approximately 400,OOO people in the hospital’s designated out-patient department service area. The area served by the hospital’s ambulances was slightly larger, including a piece of Manhattan. In 1970 (the year the study was carried out), there were 121,964 visits to the clinics, 133,855 visits to the adult and pediatric emergency units, and 11,308 inpatient admissions. Among the municipal hospitals, Morrisania had the 4th busiest emergency service, although it ranked 14th in bed capacity. 43
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At the time of this study, there were two emergency units at MCH, one for adults and one for children. The adult emergency unit, the subject of this study, also handled trauma in children. In 1970 there were 73,182 adult visits and 3,687 pediatric trauma visits. Physician staffing was provided by a combination of hospital house staff on rotation and physicians hired on a sessional basis. The latter included physicians in private practice, moonlighting housestaff and ECFMG-qualified physicians. Most nursing services were provided primarily by regularly assigned nurses on all shifts. The clerical staff was virtually all full-time in the emergency unit and supervision was provided on all shifts. The first step in admission to the emergency unit for all except obviously critically ill patients was registration. The following information was collected on a standard New York City Health and Hospital Corporation emergency unit form, used at all corporation hospital emergency units: name, address, age and date of birth, sex, marital status, ethnic group, religion, source of payment, employment status, and mode of arrival. B. Sampling Frame This study was carried out during a two-week period, from July 6th through July 19, 1970. Nine emergency unit shifts were chosen for analysis. The May 1970 Emergency statistics had shown that approximately 3,050 patient visits were being made every fourteen days, approximately 220 patient visits per day. The average number of patient visits per shift was: 8A.M. - 4 P.M. 100 patients 4 P.M. - 12 midnight 90 p a tien ts 12 midnight - 8 A.M. 30 patients It was considered to be adequate for future statistical analysis if three shifts from each time period were included in the sample, to produce an estimated sample size of 660. The days and shifts were chosen in an effort to get representation from all types of days and time periods. C. Data Categories Using the existing Health and Hospitals Corporation emergency unit record form the following information was collected for each patient: Address, age, sex, religion, marital status, ethnicgroup Mode of arrival Laboratory, x-ray, EKG. and other tests ordered Degree of urgency Physician ‘s diagnosis Pharmaceuticals prescribed Disposition It was expected that all of these data, with the exception of degree of urgency would be recorded on the patient’s emergency unit record by the clerks, nurses and physicians as the patients proceeded through the Emergency Unit. Each chart was checked for completeness by one of us (R.F.). A designation of degree of urgency was given to all patients after reviewing the charts and appraising the situation surrounding their arrival to the 44
emergency room. In order to keep as much uniformity as possible in this categorization, only one of us made the determinations of degree of urgency, following the Weinerman definitions.2’ EMERGENT: Condition required immediate medical attention, time delay is harmful to the patient, disorder is acute and potentially threatening to life and function. URGENT: Condition requires medical attention within the period of a few hours, there is possible danger to the patient if medically unattended; disorder is acute but not necessarily severe. NON-URGENT: Condition does not require the resources of an emergency service; referral for routine medical care may or may not be needed; disorder is nonacute or minor in severity. 111. RESULTS* A. Demographic Data There were 678 patients in the sample-very close to the predicted number, 660. The distribution of demographic characteristics, (Table A)*, showed that more than 50% of the patients were between 15 and 34; females outnumbered males; almost half of them were married; 80% were Black or Puerto Rican; almost half were Catholic. B. Address, Mode of Arrival, and Time of Arrival by Shift Patient addresses were assigned to New York City Health Department Health Areas, from tables supplied by the Bronx County Health Information Project of the Albert Einstein College of Medicine. The rank order of frequency distribution of visits by the sample population per health area was determined, and divided, approximately, into quartiles, (Table I). 30% of patient visits came from 6.7% of health areas served, 54% of visits from 13.4% of health areas served and three quarters of all visits from one quarter of health areas served. The map in Figure I shows how these health areas cluster around the hospital. One half of the visits are provided by patients living within an approximately 0.5 mile radius of the hospital. The distribution of mode of arrival, (Table B) showed that most frequent were walking (20%), taxi (19%), and public transportation (16%), although if ambulances (14%), and police cars (5%) were lumped together, that form, which might be termed “municipal emergency transportation,” moved to second place. Time of arrival by shift showed that 47% of patients appeared during the 8 A.M. - 4 P.M. shift, followed by the 4 P.M. -midnight (35%) and Midnight - 8 A.M. shifts (16%). Note: *Few tables will be reproduced in this report, due to limitations of space. A complete set of tables is available from the senior author on request. Printed tables will be referred to by Roman Numerals; other, available tables by capital letters. I
HOSPITAL TOPICS
TABLE I
TABLE II
Patient Visits, by Census Tract, Number and Percent, MCH Census Tract, Ranked by Quartile”, for Patients with Known Addresses.
Distributions by Diagnosis, Degree of Urgenc and Disposition, Number and Percent
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HEALTH 4REA
PATIENTS Percent Number of Total
CENSUS TRACTS Percent Number of Total
Number
Yo*
Medical Surgical Ob-Gyn Psychiatric Other Not Available
287 196 74 17 103 1
42 29 11 3 15
Degree of Urgency Emergent Urgent Non-urgent Undetermined
37 254 359 28
5 38 53 4
270 265 13 68 14
40 39 2 10 2
26 22
4 3
Diagnostic Category
25 33.10 33.20 SUB TOTAL
QUARTILE I 71 11.6 59 9.6 57 9.3 (187) (30.5)
22.20 26 39 SUB TOTAL
QUARTILE 2 49 8.0 46 7.5 46 7.5 (141) (23.0)
22.10 34 38 15.20 23.20 24 SUB TOTAL
QUARTILE 3 36 5.9 32 5.2 23 3.8 19 3.1 19 3.1 18 2.9 (147) (24.0)
6
13.4
SUB TOTAL
QUARTILE 4 (139) (23.3)
33
73.2
DisDosition Treated and released MCH Clinic Referral Other Clinic Referral MCH Admission Transfer for admission Left ER without medical disposition Unavailable
45
100.0
*rounded
TOTAL
614
100.8**
3
3
6.7
6.7
*Specific census tracts not shown for Quartile 4 **Rounding errors
C. Utilization of Services About 40% of persons received at least one diagnostic test, (lab, X-ray, EKG or other), while more than 60% received at least one medication. X-ray was the most frequently utilized diagnostic procedure. D. Diagnosis, Degree of Urgency and Disposition Information useful to any emergency unit is the distribution of diagnostic categories which patients present, severity of illness and patient disposition. Patient diagnoses were grouped into five major categories: medical, surgical, ob-gyn, psychiatric and other, Table 11. (“Other” includes a category of “musculo-skeletal,” consisting of arthritis, backache, bursitis, fractures, and the like, which cannot be logically grouped in their entirety under either medical or surgical.) Degree of urgency was rated using the Weinerman definitions.21 The distribution of patients by degree of urgency is also shown in Table 11. About one-half the patient load consisted of persons with non-urgent problems. Disposition too is shown in Table 11. 80% of patients were either treated and released or referred to clinic for a subsequent appointment. Relatively few left before receiving a formal disposition. JANUARY/FEBRUARY 1976
-
E. Cross-Tabulations We were particularly interested in this study in producing information which could be of help or at least interest in designing and planning emergency services at MCH. Thus, we will report only a limited series of cross-tabulations. Of these, only cross tabulations demonstrating statistically significant differences are shown. The distribution of several utilization variables were measured against patient residence by quartile group of census tract of residence. There were no significant differences by residence quartile group for distributions of degree of urgency, time of arrival by shift, or diagnosis. Mode of arrival, however, was affected by patient residence by quartile groups, Table C. As is to be expected, the further away patients lived from the hospital, the more likely they were to arrive by taxi, municipal emergency transport or public transportation. The distribution of several variables were measured against patient diagnosis. For example, medical, gyn and “other” patients were more likely to appear on the 4 P.M. - Midnight shift, (Table D). Patients in all diagnostic categories except surgery were most likely to have non-urgent problems, (Table 111). Patients with surgical diagnoses were most likely to have urgent problems. In terms of disposition, patients with medical and “other” diagnoses were more likely to be treated and released, (Table E). Surgical and obstetrico-gynecological patients were more likely to be referred to clinic, while medical and obstetrico-gynecological patients were more likely to be hospitalized. 45
Finally, the distribution of degree of urgency by shift was determined, (Table F). Proportionately, and almost absolutely, patients in the emergent category were more likely to arrive between midnight and 8 A.M. While patients in the urgent category were more likely to come in on the 4 P.M. - mid-night shift.
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Nonwgent Urgent Emergent Indet. Total
162 98
22
s
287
5 6 66 34 34 119 61 4 8 8 2 3 2 100 196 IW
56 14 4
o
76 10 19 7 5 0
n o
71 100 17
64 62 16 16 3 3 0 2 0 1 9 100 103 100 59
41 0
359 53 254 37 5 37 4 2 8 678 Io(1
IV. DISCUSSION AND CONCLUSIONS A. Methodology This study has demonstrated that it is possible ta derive a great deal of useful information about patien ts and their emergency unit utilization patterns from existing record forms in the New York City Hospital system, The only item of information collected which was not asked for on the existing form is “degree of urgency.” There were fairly sizeable “indeterminate” groups for many variables, which did indicate that lack of chart completeness is a significant methodological problem, despite the presence of an investigator in the emergency unit during each studied shift. We concluded that lack of completeness was not due to the lack of investigator diligence but rather to emergency room congestion, extreme at times, lack of clerical understanding of the importance of complete records, patient uncooperativeness, hand writing problems, and physician variation in completing charts. We do feel that with appropriate staff motivation and instruction, however, these problems could be largely overcome. The sample size was not large, and the study period was limited to two weeks in the summer, when emergency unit visit volumes traditionally rise at MCH. Thus the study was a pilot, not intended to be definitive. We do feel that we have demonstrated the feasibility of collecting emergency room utilization data on an on-going basis, in part: a great deal of useful information was already being collected routinely and sampling could be done by sampling sessions rather than all charts. Several key problems do remain: lack of chart completeness, method for assigning urgency ratings, and methods for on line data-processing, However, significant advances have been made in dealing with all of these problems since we did our study.30, 3 1 The improvements in service which could be created by an on-line program of this sort for planning staffing patterns, and insuring better patient flow through the whole hospital ambulatory care system would be very important. 46
B. Results The personal demographic characteristics of patients seen by the MCH emergency unit is similar to that observed in a number of other studies of patients in “central-city’’ hospitals serving lowincome, minority neighborhood~.~’-~~ We did not compare our data with those from the census, but this could easily have been done, especially in a census year. We would guess, however, that men, older persons, whites and non-Catholics living in the service area, (one in which the sections immediately around the hospital were undergoing a classic inner-city white-Jewish to Black and Puerto Rican transformation), were under-represented in the emergency unit population. Patient address figures are interesting. The closeness to the hospital of the majority of the population served by the emergency unit indicates that MCH is really a neighborhood hospital, providing significant service to only a portion of the 400,000people in its broad designated service area. This conclusion can be drawn not only for the emergency unit itself, but also for the in-patient service. 10% of persons seen in the adult emergency unit were admitted to the hospital. In 1970, then, there were about 7300 adult admissions from the emergency unit at MCH. This was, in fact, about 75% of the total of 9,669 adult admissions to MCH that year. We do not have a cross-tabulation for residence vs. disposition, but there was no significant relationship between residence and degree of urgency, (that is, distribution of degree of urgency did not vary with quartile of residence), and there was a significant relationship between degree of urgency and disposition, (Table G), so that it was unlikely that there was any significant relationship between residence and disposition. Thus, the geographical distribution of emergency unit patients probably did reflect the geographical distribution of inpatients, and confirmed the neighborhood character of MCH. The finding in Table I11 that “medical” patients produced the highest proportion of emergent cases is consistent with the fact that the distribution of degree of urgency is similar to that found in other studies, and the fact that medical diagnoses were generally more common at MCH compared with surgical ones than they were at other institutions. The cross-tabulation shown in Table 111 is important for other reasons, helpful in planning. True emergencies at MCH were more likely to be medical than surgical, surgical cases were more likely to be urgent, (produced mostly by simple lacerations, a figure swollen in the MCH adult emergency unit by the presence of pediatric trauma cases), and gyn cases were most likely to be nonurgent. A view commonly held by staff in the MCH emergency unit was that, although there might have been slightly fewer patients on the 4 - 12 than there are on the 8 - 4,they were sicker, again an important consideration in planning the staffing, was confirmed by the distribution of degree of urgency by shift. HOSPITAL TOPICS
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Distribution on patient diagnosis by shift is also useful information. At the time this study was done, most physician staffing in the emergency unit was provided by paid sessional private practitioners and ECFMG physicians, almost all of whom had at least minor surgical skills. We were attempting to obtain additional physical help in the form of assignment of regular house staff, on rotation. There was, for example, a tentative offer, never actually made, of about 40 hours of surgical resident time per week. Using the figures obtained in this study, we knew that the most logical time-slot for this help, if it had indeed been given, was the 4 - 12 shift. Likewise, when money was made available to hire moon-lighting psychiatric residents, we knew that the 4 - 12 shift was the one on which to concentrate limited resources. The distribution of disposition by diagnostic category is instructive. The relatively-high fate of OPD referrals for surgical patients most likely reflected appointments for suture check and removal. Appropriate coordination between the emergency unit and the surgical clinic resulted in the establishment of a block of time in surgical clinic for the express purpose of suture removal. Ob-gyn patients were the most likely ones to be referred to clinic and to be admitted to hospital. The high rate of clinic referrals most likely reflected the lack of regular ob-gyn physician staffing in the emergency unit. The regular ob-gyn house staff was stretched far too thin to provide it, especially since the bulk of ob-gyn emergency unit visits occured during the 8 - 4 shift, when the obgyn residents were very busy in the clinics. The delay in obtaining ob-gyn clinic appointments for these patients was 3 - 4 weeks which in itself probably indicated two things: the ob-gyn clinics were already packed so that a "drop-in" clinic there was not feasible; patients recognized the crowding and came to the emergency unit, only to be referred to clinic in any case. A fairly clear case for additional ob-gyn staff for the hospital, to be assigned to the clinics and the emergency unit on rotation was made by this data. C. Medical Quality Control Little has been done in this area in emergency services. We did not get into it in this particular study. Nevertheless, quality of medical care measurement and control is of great importance. Data of the sort collected in this study could be used for medical quality control procedures with the addition of a few bits of information. FINAL THOUGHTS The necessity for rational planning of community hospital emergency services is apparent from our national experience as reported in the literature. The particular types of responses in terms of how emergency units are to be organized and staffed will certainly vary between the two major groups of community hospitals: teaching and non-teaching. We believe that we have demonstrated in this study that a great deal of information useful for planning and operations can
be gathered from existing emergency unit patient records, without further patient or provider interview. We have also demonstrated how specific data which was collected was and could be used in planning, staffing and operating the adult emergency department in the Morrisania City Hospital and in improving patient flow through the whole hospital ambulatory care system. Quality of medical care measurement and control in hospital emergency services is a matter of great importance. It is obvious that data of the sort collected in this study, with a few additions, could be processed in such a way as to provide useful information for quality control purposes. Hospital emergency services need a great deal of improvement. The major requirements for such improvement lie in changing provider, institutional and patient attitudes and in the provision of adequate resources. Given those prerequisites, however, data of the type collected in this study, gathered either on a periodic or an on-going basis is extremely important for proper program implementation.
V.
JANUARY/FEBRUARY 1976
Is' PUARTILE
PPUAR~ILE 3RoPUARTILE 4'"QUARTILE
47
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REFERENCES 1. “Roles and Resources of Federal Agencies in Support of Comprehensive Emergency Medical Services.” National Academy of Sciences/National Research Council. Washington, D.C. 1972. 2. Gibson, G., Bugbee, G., Anderson, O.W. “Emergency Medical Services in the Chicago Area.” Center for Health Administration Studies, University of Chicago, 1970. 3. Gibson, G. “Emergency Services: Status of Urban Services-I.” Hospitals, J.A.H.A. Vol. 45, December 1, 1971, p. 49. 4. Shortliffe, E.C., et al. “The Emergency Room and the Changing Pattern of Medical Care.” New England Journal of Medicine, 258, 20, 1958. 5. Lee, S.S. et al. “How New Patterns of Medical Care Affect the Emergency Unit.” The Modern Hospital 94: 97, May, 1960. 6. Weinerman, E.R. and Edwards, H.R. “Yale Studies in Ambulatory Medical Care. I. Changing Patterns in Hospital Emergency Service.” Hospitals, J.A.H.A. 38: 55:62, Nov. 16,1964. 7. Guide Issue. Hospitals. J.A.H.A. August lst, Part 2, each year. 8. “Physician Visits.” Vital and Health Statistics. Series 10, No. 75 National Center for Health Statistics, Rockville, Maryland 1972. 9. Piore, N., el al. “A Statistical Profile of Hospital Outpatient Service in the United States: Present Scope and Potential Role” Association for the Aid of Crippled Children, N.Y. 1972. 10. Kunian, L. “Role of the Emergency Unit in a Community Hospital.” New England Journal of Medicine 283, 1367, 1970. 11. “The Crisis in Emergency Care.” Medical World News. In four parts. December 4, 1970, Jan. 1, Jan. 29, March 5, 1971. 12. Taubenhaus, L.J. “Emergency Services.” Hospitals, J.A.H.A., Vol.46, p.81, April 1, 1972. 13. Walt, A.1. & Krome, R.L. “Of Wicked Ste mothers, Ugly Sisters, and Academic Cinderellas.” T i e Journal of Trauma, 11, 554, 1971. 14. Stephenson, H.E. “The Teaching of Emergency Medical Care in Medical Schools in the U.S.and Canada.” Bulletin of the American College of Surgeons. 56, 9,1971. 15. Webb, S.B. & Lawrence, R.W. “Physician Staffing and Reimbursement Trends.“ Hospitals, J.A.H.A. 46, 69 October 1, 1972. 16. Gersonde, R.J., ef al. “Two Approaches to Providing Physician Coverage in the E.R.” Hospital Topics 49, 50, February, 1971. 17. Mills, J.D. “Emergency Department Management.” Southern Medical Bulletin. Dec. 1971, p. 18. 18 Hannas, R.R. “Emergency Medicine - A Survey.” Southern Medical Bulletin, Dec. 1971, p. 11. 19. Brook, R.H. & Stevenson, R.L. “Effectiveness of Patient Care in an Emergency Room.” New England Journal of Medicine. 283, 904, 1970. 20. Bergman, A.B. & Haggerty, RJ. “The Emergency Clinic.” American Journal of Diseases of Children. 104, 36, 1962. 21. Weinerman, E.R., et al. “Yale Studies in Ambulatory Medical Care V. Determinants of Use of Hospital Emergency Services.” American Journal of Public Health. 56, 1037,1966. 22. Perkoff, G.T. & Anderson, M. “Relationshi between Demographic Characteristics, Patient’s Chief $omplaint, and Medical Care Destination in an Emergency Room.” Medical Care. 8, 309, 1970. 23. Jacobs, A.R., et al. “Emergency Department Utilization in an Urban Community.” Journal of the American Medical Association. 216, 307. 1971. 24. Berman, 1.1. & Luck, E. “Patients’ Ethnic Backgrounds affect Utilization.” Hospitals, J.A.H.A., Vol. 45, July 16, 1971, p. 65. 25. Weinerman, ER., et a/. “Yale Studies in Ambulatory Medical Care. 11. Effects of Medical ‘Triage’ in Hospital Emergency Service.” Public Health Reports. 80, 389,1965. 26. Torrens, P.R. & Yedvab, D.G. “Variations Among Emergency Room Populations: A Comparison of Four Hospitals in New York City.” Medical Core. 8, 60,1970. 27. Hochheiser, L.I., et aL “Effect of the Neighborhood Health Center on the Use of Pediatric Emergency Departments in Rochester. N.Y.” New England Journal of Medicine. 285, 148,1971. 28. Moore, G.T., d a/. “Effect of a Neighborhood Health Center on Hospital Emergency Roam Use.” Medical Care. 10, 240,1972.
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29. Brenner, M.H. & Weinerman, E.R. “An Ambulatory Service Data System.” American Journal ofPublic Health. 59, 1154,1969. 30. “Report of the Conference on Ambulatory Medical Care Records.” Medical Care. Vol. 11, No. 2, March - April, 1973, Supplement. 31. Herr, C.E.A., v d Patdkas, E.O. “Keeping Track of Ambulatory Care. Hospitals, J.A.H.A., Vol. 49, March 1, 1975, p. 89.
“Practice of Supervision,” New Film Series, Shows How To Plan, Organize and Control
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HOSPITAL TOPICS
Hospital Topics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vhos20
Outpatient/Emergency: Monitoring Utilization of a Municipal Hospital Emergency Department Steven Jonas Senior Editor M.D. Sylvia Wassertheil-Smoller Ph.D. a
a b c
, Roberta Flesh M.D.
d e
, Ronald Brook
f b
&
b
Department of Social Medicine , Morrisania City Hospital
b
Department of Community Health , Albert Einstein College of Medicine , Bronx, New York, USA c
Department of Community Medicine, Health Sciences Center , State University of New York , Stony Brook, USA d
Downstate Medical Center , Brooklyn, New York, USA
e
Department of Health , New York City, USA
f
King Health Center Published online: 13 Jul 2010.
To cite this article: Steven Jonas Senior Editor M.D. , Roberta Flesh M.D. , Ronald Brook & Sylvia WassertheilSmoller Ph.D. (1976) Outpatient/Emergency: Monitoring Utilization of a Municipal Hospital Emergency Department, Hospital Topics, 54:1, 43-48, DOI: 10.1080/00185868.1976.9952378 To link to this article: http://dx.doi.org/10.1080/00185868.1976.9952378
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Monitoring Utilization of a Municipal Hospital Emergency Department Roberta Flesh, M.D. Formerly fourth-year medical student, Downstate Medical Center, Brooklyn, New York and Summer Research Student, New York City, Department of Health.
Ronald Brook Formerly Director of Research and Evaluation, King Health Center, and Assistant Professor, Department of Community Health, Albert Einstein College of Medicine, Bronx, New York.
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Sylvia Wassertheil-Smoller, Ph.D.
Steven Jonas, M.D., Senior Editor Formerly Director, Department of Social Medicine, Morrisania City Hospital, and Assistant Professor, Department of Community Health Albert Einstein College of Medicine, Bronx, New York. Presently Associate Professor, Department of Community Medicine, Health Sciences Center, State University of New York at Stony Brook. I. INTRODUCTION LITERATURE REVIEW mergency rooms, emergency departments and emergency services have come under increasing study in recent years. One area which has not received too much attention is the collection of emergency unit utilization and patient characteristic data on a continuing basis. It is possible that the availability of such data could help in the planning and operation of emergency and related services to make them more appropriate to patient needs. This paper reports an attempt to develop such an approach. There have been a number of studies reported, dealing with various aspects of emergency medical care. Among them are works dealing with general issues, I - ’ historical current problems10-12 emergency services in teaching hospitals13- l4 physician staffing , - Is quality,Ig utilizati~n,~. 20-26 and the relationship between neighborhood health centers and emergehcy ~ervices.’~-~~ A characteristic shared by all of the studies cited above was that they were carried out on a one-time basis. They were intended to reveal information about the emergency units studied at particular points in time. In an attempt to develop a system which could be used on a continous basis, Brenner and Weinerman proposed and tested a comprehensive ambulatory service data systern.l9 It required special forms, however.
E
JANUA R Y/F EBRUARY 1976
Associate Professor, Department of Community Health, Albert Einstein College of Medicine, Bronx, New York. Acknowledgement: We thank Raymond C. Lerner, Ph.D., formerly, Director, Bronx County Health Information Project, presently Associate Professor, Department of Comm unity Medicine, Health Sciences Center, State University of New York at Stony Brook, for assistance. The study herein reported had two aims. The first was to determine if existing forms could be used to generate data helpful in the planning and operation of hospital emergency services, which could be collected on an on-going basis. The second was to collect utilization and patient characteristic data at a discrete point in time for the adult emergency unit of the Morrisania City Hospital, (MCH), Bronx, New York, which might be useful in program planning at that institution. At the time this study was done, the only data regularly collected and published in the emergency unit at MCH were total visits by month, with comparisons to previous months, and number of visits by day by shift. 11. METHOD A. Setting This study was conducted at the Morrisania City Hospital, (MCH), a 331 bed hospital in the Westcentral Bronx, New York. There were approximately 400,OOO people in the hospital’s designated out-patient department service area. The area served by the hospital’s ambulances was slightly larger, including a piece of Manhattan. In 1970 (the year the study was carried out), there were 121,964 visits to the clinics, 133,855 visits to the adult and pediatric emergency units, and 11,308 inpatient admissions. Among the municipal hospitals, Morrisania had the 4th busiest emergency service, although it ranked 14th in bed capacity. 43
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At the time of this study, there were two emergency units at MCH, one for adults and one for children. The adult emergency unit, the subject of this study, also handled trauma in children. In 1970 there were 73,182 adult visits and 3,687 pediatric trauma visits. Physician staffing was provided by a combination of hospital house staff on rotation and physicians hired on a sessional basis. The latter included physicians in private practice, moonlighting housestaff and ECFMG-qualified physicians. Most nursing services were provided primarily by regularly assigned nurses on all shifts. The clerical staff was virtually all full-time in the emergency unit and supervision was provided on all shifts. The first step in admission to the emergency unit for all except obviously critically ill patients was registration. The following information was collected on a standard New York City Health and Hospital Corporation emergency unit form, used at all corporation hospital emergency units: name, address, age and date of birth, sex, marital status, ethnic group, religion, source of payment, employment status, and mode of arrival. B. Sampling Frame This study was carried out during a two-week period, from July 6th through July 19, 1970. Nine emergency unit shifts were chosen for analysis. The May 1970 Emergency statistics had shown that approximately 3,050 patient visits were being made every fourteen days, approximately 220 patient visits per day. The average number of patient visits per shift was: 8A.M. - 4 P.M. 100 patients 4 P.M. - 12 midnight 90 p a tien ts 12 midnight - 8 A.M. 30 patients It was considered to be adequate for future statistical analysis if three shifts from each time period were included in the sample, to produce an estimated sample size of 660. The days and shifts were chosen in an effort to get representation from all types of days and time periods. C. Data Categories Using the existing Health and Hospitals Corporation emergency unit record form the following information was collected for each patient: Address, age, sex, religion, marital status, ethnicgroup Mode of arrival Laboratory, x-ray, EKG. and other tests ordered Degree of urgency Physician ‘s diagnosis Pharmaceuticals prescribed Disposition It was expected that all of these data, with the exception of degree of urgency would be recorded on the patient’s emergency unit record by the clerks, nurses and physicians as the patients proceeded through the Emergency Unit. Each chart was checked for completeness by one of us (R.F.). A designation of degree of urgency was given to all patients after reviewing the charts and appraising the situation surrounding their arrival to the 44
emergency room. In order to keep as much uniformity as possible in this categorization, only one of us made the determinations of degree of urgency, following the Weinerman definitions.2’ EMERGENT: Condition required immediate medical attention, time delay is harmful to the patient, disorder is acute and potentially threatening to life and function. URGENT: Condition requires medical attention within the period of a few hours, there is possible danger to the patient if medically unattended; disorder is acute but not necessarily severe. NON-URGENT: Condition does not require the resources of an emergency service; referral for routine medical care may or may not be needed; disorder is nonacute or minor in severity. 111. RESULTS* A. Demographic Data There were 678 patients in the sample-very close to the predicted number, 660. The distribution of demographic characteristics, (Table A)*, showed that more than 50% of the patients were between 15 and 34; females outnumbered males; almost half of them were married; 80% were Black or Puerto Rican; almost half were Catholic. B. Address, Mode of Arrival, and Time of Arrival by Shift Patient addresses were assigned to New York City Health Department Health Areas, from tables supplied by the Bronx County Health Information Project of the Albert Einstein College of Medicine. The rank order of frequency distribution of visits by the sample population per health area was determined, and divided, approximately, into quartiles, (Table I). 30% of patient visits came from 6.7% of health areas served, 54% of visits from 13.4% of health areas served and three quarters of all visits from one quarter of health areas served. The map in Figure I shows how these health areas cluster around the hospital. One half of the visits are provided by patients living within an approximately 0.5 mile radius of the hospital. The distribution of mode of arrival, (Table B) showed that most frequent were walking (20%), taxi (19%), and public transportation (16%), although if ambulances (14%), and police cars (5%) were lumped together, that form, which might be termed “municipal emergency transportation,” moved to second place. Time of arrival by shift showed that 47% of patients appeared during the 8 A.M. - 4 P.M. shift, followed by the 4 P.M. -midnight (35%) and Midnight - 8 A.M. shifts (16%). Note: *Few tables will be reproduced in this report, due to limitations of space. A complete set of tables is available from the senior author on request. Printed tables will be referred to by Roman Numerals; other, available tables by capital letters. I
HOSPITAL TOPICS
TABLE I
TABLE II
Patient Visits, by Census Tract, Number and Percent, MCH Census Tract, Ranked by Quartile”, for Patients with Known Addresses.
Distributions by Diagnosis, Degree of Urgenc and Disposition, Number and Percent
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HEALTH 4REA
PATIENTS Percent Number of Total
CENSUS TRACTS Percent Number of Total
Number
Yo*
Medical Surgical Ob-Gyn Psychiatric Other Not Available
287 196 74 17 103 1
42 29 11 3 15
Degree of Urgency Emergent Urgent Non-urgent Undetermined
37 254 359 28
5 38 53 4
270 265 13 68 14
40 39 2 10 2
26 22
4 3
Diagnostic Category
25 33.10 33.20 SUB TOTAL
QUARTILE I 71 11.6 59 9.6 57 9.3 (187) (30.5)
22.20 26 39 SUB TOTAL
QUARTILE 2 49 8.0 46 7.5 46 7.5 (141) (23.0)
22.10 34 38 15.20 23.20 24 SUB TOTAL
QUARTILE 3 36 5.9 32 5.2 23 3.8 19 3.1 19 3.1 18 2.9 (147) (24.0)
6
13.4
SUB TOTAL
QUARTILE 4 (139) (23.3)
33
73.2
DisDosition Treated and released MCH Clinic Referral Other Clinic Referral MCH Admission Transfer for admission Left ER without medical disposition Unavailable
45
100.0
*rounded
TOTAL
614
100.8**
3
3
6.7
6.7
*Specific census tracts not shown for Quartile 4 **Rounding errors
C. Utilization of Services About 40% of persons received at least one diagnostic test, (lab, X-ray, EKG or other), while more than 60% received at least one medication. X-ray was the most frequently utilized diagnostic procedure. D. Diagnosis, Degree of Urgency and Disposition Information useful to any emergency unit is the distribution of diagnostic categories which patients present, severity of illness and patient disposition. Patient diagnoses were grouped into five major categories: medical, surgical, ob-gyn, psychiatric and other, Table 11. (“Other” includes a category of “musculo-skeletal,” consisting of arthritis, backache, bursitis, fractures, and the like, which cannot be logically grouped in their entirety under either medical or surgical.) Degree of urgency was rated using the Weinerman definitions.21 The distribution of patients by degree of urgency is also shown in Table 11. About one-half the patient load consisted of persons with non-urgent problems. Disposition too is shown in Table 11. 80% of patients were either treated and released or referred to clinic for a subsequent appointment. Relatively few left before receiving a formal disposition. JANUARY/FEBRUARY 1976
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E. Cross-Tabulations We were particularly interested in this study in producing information which could be of help or at least interest in designing and planning emergency services at MCH. Thus, we will report only a limited series of cross-tabulations. Of these, only cross tabulations demonstrating statistically significant differences are shown. The distribution of several utilization variables were measured against patient residence by quartile group of census tract of residence. There were no significant differences by residence quartile group for distributions of degree of urgency, time of arrival by shift, or diagnosis. Mode of arrival, however, was affected by patient residence by quartile groups, Table C. As is to be expected, the further away patients lived from the hospital, the more likely they were to arrive by taxi, municipal emergency transport or public transportation. The distribution of several variables were measured against patient diagnosis. For example, medical, gyn and “other” patients were more likely to appear on the 4 P.M. - Midnight shift, (Table D). Patients in all diagnostic categories except surgery were most likely to have non-urgent problems, (Table 111). Patients with surgical diagnoses were most likely to have urgent problems. In terms of disposition, patients with medical and “other” diagnoses were more likely to be treated and released, (Table E). Surgical and obstetrico-gynecological patients were more likely to be referred to clinic, while medical and obstetrico-gynecological patients were more likely to be hospitalized. 45
Finally, the distribution of degree of urgency by shift was determined, (Table F). Proportionately, and almost absolutely, patients in the emergent category were more likely to arrive between midnight and 8 A.M. While patients in the urgent category were more likely to come in on the 4 P.M. - mid-night shift.
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Nonwgent Urgent Emergent Indet. Total
162 98
22
s
287
5 6 66 34 34 119 61 4 8 8 2 3 2 100 196 IW
56 14 4
o
76 10 19 7 5 0
n o
71 100 17
64 62 16 16 3 3 0 2 0 1 9 100 103 100 59
41 0
359 53 254 37 5 37 4 2 8 678 Io(1
IV. DISCUSSION AND CONCLUSIONS A. Methodology This study has demonstrated that it is possible ta derive a great deal of useful information about patien ts and their emergency unit utilization patterns from existing record forms in the New York City Hospital system, The only item of information collected which was not asked for on the existing form is “degree of urgency.” There were fairly sizeable “indeterminate” groups for many variables, which did indicate that lack of chart completeness is a significant methodological problem, despite the presence of an investigator in the emergency unit during each studied shift. We concluded that lack of completeness was not due to the lack of investigator diligence but rather to emergency room congestion, extreme at times, lack of clerical understanding of the importance of complete records, patient uncooperativeness, hand writing problems, and physician variation in completing charts. We do feel that with appropriate staff motivation and instruction, however, these problems could be largely overcome. The sample size was not large, and the study period was limited to two weeks in the summer, when emergency unit visit volumes traditionally rise at MCH. Thus the study was a pilot, not intended to be definitive. We do feel that we have demonstrated the feasibility of collecting emergency room utilization data on an on-going basis, in part: a great deal of useful information was already being collected routinely and sampling could be done by sampling sessions rather than all charts. Several key problems do remain: lack of chart completeness, method for assigning urgency ratings, and methods for on line data-processing, However, significant advances have been made in dealing with all of these problems since we did our study.30, 3 1 The improvements in service which could be created by an on-line program of this sort for planning staffing patterns, and insuring better patient flow through the whole hospital ambulatory care system would be very important. 46
B. Results The personal demographic characteristics of patients seen by the MCH emergency unit is similar to that observed in a number of other studies of patients in “central-city’’ hospitals serving lowincome, minority neighborhood~.~’-~~ We did not compare our data with those from the census, but this could easily have been done, especially in a census year. We would guess, however, that men, older persons, whites and non-Catholics living in the service area, (one in which the sections immediately around the hospital were undergoing a classic inner-city white-Jewish to Black and Puerto Rican transformation), were under-represented in the emergency unit population. Patient address figures are interesting. The closeness to the hospital of the majority of the population served by the emergency unit indicates that MCH is really a neighborhood hospital, providing significant service to only a portion of the 400,000people in its broad designated service area. This conclusion can be drawn not only for the emergency unit itself, but also for the in-patient service. 10% of persons seen in the adult emergency unit were admitted to the hospital. In 1970, then, there were about 7300 adult admissions from the emergency unit at MCH. This was, in fact, about 75% of the total of 9,669 adult admissions to MCH that year. We do not have a cross-tabulation for residence vs. disposition, but there was no significant relationship between residence and degree of urgency, (that is, distribution of degree of urgency did not vary with quartile of residence), and there was a significant relationship between degree of urgency and disposition, (Table G), so that it was unlikely that there was any significant relationship between residence and disposition. Thus, the geographical distribution of emergency unit patients probably did reflect the geographical distribution of inpatients, and confirmed the neighborhood character of MCH. The finding in Table I11 that “medical” patients produced the highest proportion of emergent cases is consistent with the fact that the distribution of degree of urgency is similar to that found in other studies, and the fact that medical diagnoses were generally more common at MCH compared with surgical ones than they were at other institutions. The cross-tabulation shown in Table 111 is important for other reasons, helpful in planning. True emergencies at MCH were more likely to be medical than surgical, surgical cases were more likely to be urgent, (produced mostly by simple lacerations, a figure swollen in the MCH adult emergency unit by the presence of pediatric trauma cases), and gyn cases were most likely to be nonurgent. A view commonly held by staff in the MCH emergency unit was that, although there might have been slightly fewer patients on the 4 - 12 than there are on the 8 - 4,they were sicker, again an important consideration in planning the staffing, was confirmed by the distribution of degree of urgency by shift. HOSPITAL TOPICS
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Distribution on patient diagnosis by shift is also useful information. At the time this study was done, most physician staffing in the emergency unit was provided by paid sessional private practitioners and ECFMG physicians, almost all of whom had at least minor surgical skills. We were attempting to obtain additional physical help in the form of assignment of regular house staff, on rotation. There was, for example, a tentative offer, never actually made, of about 40 hours of surgical resident time per week. Using the figures obtained in this study, we knew that the most logical time-slot for this help, if it had indeed been given, was the 4 - 12 shift. Likewise, when money was made available to hire moon-lighting psychiatric residents, we knew that the 4 - 12 shift was the one on which to concentrate limited resources. The distribution of disposition by diagnostic category is instructive. The relatively-high fate of OPD referrals for surgical patients most likely reflected appointments for suture check and removal. Appropriate coordination between the emergency unit and the surgical clinic resulted in the establishment of a block of time in surgical clinic for the express purpose of suture removal. Ob-gyn patients were the most likely ones to be referred to clinic and to be admitted to hospital. The high rate of clinic referrals most likely reflected the lack of regular ob-gyn physician staffing in the emergency unit. The regular ob-gyn house staff was stretched far too thin to provide it, especially since the bulk of ob-gyn emergency unit visits occured during the 8 - 4 shift, when the obgyn residents were very busy in the clinics. The delay in obtaining ob-gyn clinic appointments for these patients was 3 - 4 weeks which in itself probably indicated two things: the ob-gyn clinics were already packed so that a "drop-in" clinic there was not feasible; patients recognized the crowding and came to the emergency unit, only to be referred to clinic in any case. A fairly clear case for additional ob-gyn staff for the hospital, to be assigned to the clinics and the emergency unit on rotation was made by this data. C. Medical Quality Control Little has been done in this area in emergency services. We did not get into it in this particular study. Nevertheless, quality of medical care measurement and control is of great importance. Data of the sort collected in this study could be used for medical quality control procedures with the addition of a few bits of information. FINAL THOUGHTS The necessity for rational planning of community hospital emergency services is apparent from our national experience as reported in the literature. The particular types of responses in terms of how emergency units are to be organized and staffed will certainly vary between the two major groups of community hospitals: teaching and non-teaching. We believe that we have demonstrated in this study that a great deal of information useful for planning and operations can
be gathered from existing emergency unit patient records, without further patient or provider interview. We have also demonstrated how specific data which was collected was and could be used in planning, staffing and operating the adult emergency department in the Morrisania City Hospital and in improving patient flow through the whole hospital ambulatory care system. Quality of medical care measurement and control in hospital emergency services is a matter of great importance. It is obvious that data of the sort collected in this study, with a few additions, could be processed in such a way as to provide useful information for quality control purposes. Hospital emergency services need a great deal of improvement. The major requirements for such improvement lie in changing provider, institutional and patient attitudes and in the provision of adequate resources. Given those prerequisites, however, data of the type collected in this study, gathered either on a periodic or an on-going basis is extremely important for proper program implementation.
V.
JANUARY/FEBRUARY 1976
Is' PUARTILE
PPUAR~ILE 3RoPUARTILE 4'"QUARTILE
47
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REFERENCES 1. “Roles and Resources of Federal Agencies in Support of Comprehensive Emergency Medical Services.” National Academy of Sciences/National Research Council. Washington, D.C. 1972. 2. Gibson, G., Bugbee, G., Anderson, O.W. “Emergency Medical Services in the Chicago Area.” Center for Health Administration Studies, University of Chicago, 1970. 3. Gibson, G. “Emergency Services: Status of Urban Services-I.” Hospitals, J.A.H.A. Vol. 45, December 1, 1971, p. 49. 4. Shortliffe, E.C., et al. “The Emergency Room and the Changing Pattern of Medical Care.” New England Journal of Medicine, 258, 20, 1958. 5. Lee, S.S. et al. “How New Patterns of Medical Care Affect the Emergency Unit.” The Modern Hospital 94: 97, May, 1960. 6. Weinerman, E.R. and Edwards, H.R. “Yale Studies in Ambulatory Medical Care. I. Changing Patterns in Hospital Emergency Service.” Hospitals, J.A.H.A. 38: 55:62, Nov. 16,1964. 7. Guide Issue. Hospitals. J.A.H.A. August lst, Part 2, each year. 8. “Physician Visits.” Vital and Health Statistics. Series 10, No. 75 National Center for Health Statistics, Rockville, Maryland 1972. 9. Piore, N., el al. “A Statistical Profile of Hospital Outpatient Service in the United States: Present Scope and Potential Role” Association for the Aid of Crippled Children, N.Y. 1972. 10. Kunian, L. “Role of the Emergency Unit in a Community Hospital.” New England Journal of Medicine 283, 1367, 1970. 11. “The Crisis in Emergency Care.” Medical World News. In four parts. December 4, 1970, Jan. 1, Jan. 29, March 5, 1971. 12. Taubenhaus, L.J. “Emergency Services.” Hospitals, J.A.H.A., Vol.46, p.81, April 1, 1972. 13. Walt, A.1. & Krome, R.L. “Of Wicked Ste mothers, Ugly Sisters, and Academic Cinderellas.” T i e Journal of Trauma, 11, 554, 1971. 14. Stephenson, H.E. “The Teaching of Emergency Medical Care in Medical Schools in the U.S.and Canada.” Bulletin of the American College of Surgeons. 56, 9,1971. 15. Webb, S.B. & Lawrence, R.W. “Physician Staffing and Reimbursement Trends.“ Hospitals, J.A.H.A. 46, 69 October 1, 1972. 16. Gersonde, R.J., ef al. “Two Approaches to Providing Physician Coverage in the E.R.” Hospital Topics 49, 50, February, 1971. 17. Mills, J.D. “Emergency Department Management.” Southern Medical Bulletin. Dec. 1971, p. 18. 18 Hannas, R.R. “Emergency Medicine - A Survey.” Southern Medical Bulletin, Dec. 1971, p. 11. 19. Brook, R.H. & Stevenson, R.L. “Effectiveness of Patient Care in an Emergency Room.” New England Journal of Medicine. 283, 904, 1970. 20. Bergman, A.B. & Haggerty, RJ. “The Emergency Clinic.” American Journal of Diseases of Children. 104, 36, 1962. 21. Weinerman, E.R., et al. “Yale Studies in Ambulatory Medical Care V. Determinants of Use of Hospital Emergency Services.” American Journal of Public Health. 56, 1037,1966. 22. Perkoff, G.T. & Anderson, M. “Relationshi between Demographic Characteristics, Patient’s Chief $omplaint, and Medical Care Destination in an Emergency Room.” Medical Care. 8, 309, 1970. 23. Jacobs, A.R., et al. “Emergency Department Utilization in an Urban Community.” Journal of the American Medical Association. 216, 307. 1971. 24. Berman, 1.1. & Luck, E. “Patients’ Ethnic Backgrounds affect Utilization.” Hospitals, J.A.H.A., Vol. 45, July 16, 1971, p. 65. 25. Weinerman, ER., et a/. “Yale Studies in Ambulatory Medical Care. 11. Effects of Medical ‘Triage’ in Hospital Emergency Service.” Public Health Reports. 80, 389,1965. 26. Torrens, P.R. & Yedvab, D.G. “Variations Among Emergency Room Populations: A Comparison of Four Hospitals in New York City.” Medical Core. 8, 60,1970. 27. Hochheiser, L.I., et aL “Effect of the Neighborhood Health Center on the Use of Pediatric Emergency Departments in Rochester. N.Y.” New England Journal of Medicine. 285, 148,1971. 28. Moore, G.T., d a/. “Effect of a Neighborhood Health Center on Hospital Emergency Roam Use.” Medical Care. 10, 240,1972.
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29. Brenner, M.H. & Weinerman, E.R. “An Ambulatory Service Data System.” American Journal ofPublic Health. 59, 1154,1969. 30. “Report of the Conference on Ambulatory Medical Care Records.” Medical Care. Vol. 11, No. 2, March - April, 1973, Supplement. 31. Herr, C.E.A., v d Patdkas, E.O. “Keeping Track of Ambulatory Care. Hospitals, J.A.H.A., Vol. 49, March 1, 1975, p. 89.
“Practice of Supervision,” New Film Series, Shows How To Plan, Organize and Control
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HOSPITAL TOPICS
