Barry W. Wolcott

Effective algorithm-based triage and self-care protocols: Quality medicine at lower costs

The triage phase of an algorithm-based medical care system was analyzed in three military patient environments. Combat medics triaged 4,799 patients using a physician-prepared triage manual which specified levels of initial health care based on the patients presenting complaints and a brief history. Evaluation indicated that 36% of those reporting for sick call were eligible for treatment by medically appropriate self-care protocols. Of the remaining 64%, all but 4% could receive initial evaluation by non-physician health care extenders. The study demonstrates that personnel receiving basic medical training and orientation to an algorithm-directed triage system can direct military patients to appropriate levels of health care.

An Efficient Strategy for Managing Acute Respiratory Illness in Adults

A safe, effective, and efficient clinical algorithm (management rule) for the care of adults with acute respiratory illness by nonphysician providers is presented. The algorithm was created from a data base collected on more than 5000 patients and prospectively evaluated on an additional 2637. It eliminates unhelpful diagnostic tests and minimizes physician involvement in patient care without compromising clinical standards, illness outcome, or patient satisfaction. Total direct medical care costs when the algorithm was used were approximately 40% of those costs generated by physicians managing similar patients, primarily because the algorithm directed an 80% reduction in a diagnostic test costs. The results suggest that significant savings can result when algorithms are used in the care of ambulatory patients with common illnesses.

The effect of chest radiographs on the management and clinical course of patients with acute cough.

The authors studied 2018 consecutive patients with a cough of less than 1 months duration, presenting for medical care with this problem for the first time. Chest films were taken of all of the last 1819 of these patients. After physicians had specified diagnoses and patient management plans for the last 1531 of these 1819 patients, 98 per cent of the 1531 were randomized either to a group whose chest films were then used in their care, or to a group whose chest films were not available to the physician. The results show that chest radiographs ordered by physicians resulted in potentially beneficial change in the care of only 3 per cent of patients. Only use of chest radiographs not ordered by physicians led to the appropriate addition of antibiotics to the care of patients with infiltrates, and probably to improved illness outcome. Criteria for efficient, effective use of chest radiographs in the management of patients with acute cough are needed.

Acute headaches; presenting symptoms and diagnostic rules to identify patients with tension and migraine headache

Abstract Headache is the ninth most common cause of physician visits, but data on acute headaches have not been collected in a standardized manner and have not been analyzed in a multivariate fashion. We report on 726 patients presenting with acute headaches, which were diagnosed as tension (38%), migraine (25%), no diagnosis (30%), and other (6%). The prevalence of 32 signs and symptoms is shown for each group. Four of these findings were significant predictors of tension headache, and 19 were significant predictors of migraine headache (p

The Effectiveness and Cost of Acute Respiratory Illness Medical Care Provided by Physicians and Algorithm-assisted Physicians' Assistants

The medical management of patients with acute respiratory illnesses was analyzed at two different clinics during a 14− to 21-month period. Patients received care from either physicians or physician-supervised physicians assistants (PA). The PAs used respiratory illness clinical algorithms to guide their choice of diagnostic tests and treatment. Illness outcome, patient satisfaction, and medical care cost data were obtained for all patients approximately two weeks after the index illness.Despite significant differences in patient population characteristics, illness outcomes were similar, regardless of the providers educational background. Medical care costs, however, were highest for the physicians patients. For all patients, diagnostic tests contributed about one-third of the total direct costs, mainly because of chest x-ray and throat culture use. Sixty to eighty per cent of medication costs were due to nonprescription drugs used principally for symptom relief.The data demonstrate that the medical care delivered by these physicians assistants was as effective and less costly than the care provided by physicians. Reducing chest x-ray and throat culture use would have a significant economic impact, without adversely affecting medical care effectiveness.

Stress reactions among participants in mass casualty simulations

Specific stress reactions have been observed in health care providers involved in disaster relief and mass casualty care. To determine whether similar stress reactions occurred in mass casualty simulations, we observed the participants in five large military mass casualty simulations. Using a framework of specific questions, descriptive data were obtained using direct observation and discussion with participants by faculty present to evaluate the exercise. Observations revealed that stress reactions occurred consistently during these mass casualty simulations, and these reactions resembled those seen in health care workers involved in actual mass casualty care. Application of this information to disaster medicine training for emergency physicians is discussed.

The time relationship of performance and audit feedback on conformance with emergency department process criteria

Adherence to physician-developed process criteria is critical to the medical and legal acceptance of algorithm-directed nonphysician care of acute non-life-threatening illnesses seen in the emergency department. It is generally assumed that adherence to prescribed medical process criteria results in acceptable patient outcomes. We evaluated changes in compliance with varying time delays in audit feedback and varying degrees of supervision. Our evaluation indicated that, under ideal circumstances of daily audit and supervisory feedback, a conformance rate of 80% was achieved. This is a 100% improvement over a group in which neither element was operative.