Alcohol and other drugs: an assessment of testing and clinical practices in U.S. trauma centers

INTRODUCTION

The American College of Surgeons' (ACS) Committee on Trauma recommends drug and alcohol screening as "essential" for level I and II or "desirable" for level III trauma centers.

METHODS

Trauma centers were surveyed concerning alcohol and other drug testing policies and clinical practices during fiscal year 1989.

RESULTS

Surveys were returned from 125 level I, 153 level II, and 38 other centers (n = 316; 47 states and the District of Columbia). Resources to measure blood alcohol concentrations (BAC) and perform urine drug screens were available in 99.4% and 96.8% of centers, respectively. In 63.7% of level I and level II and 47.4% of other centers, BACs were "routinely" obtained. The 63.7% testing rate for level I and level II centers was not significantly higher than a 55.2% rate for such centers documented in a survey conducted 5 years earlier. In 40.0% of level I and level II and 26.3% of other centers, drug screens were obtained routinely. The higher overall BAC testing policy compared with that for other drugs was significant (p < 0.001). Substance abuse counselors were employed at 59.3% of the trauma centers, a rate significantly higher than the 31.8% rate identified in a previous survey (p < 0.001).

CONCLUSION

Despite available resources and repeated ACS recommendations, measurements of BACs and drug screens are routine in only 63.7% of level I and 40.0% of level II trauma centers.

Time associated with components of clinical services rendered by nurse-midwives. Sample data from phase II of nurse-midwifery care to vulnerable populations in the United States

The purpose of this article is to present prospective data from phase II of "Nurse-Midwifery Care to Vulnerable Populations in the United States" about the components of clinical services provided to women and infants by CNMs, and the amount of time spent providing services in a variety of settings. Three hundred sixty nine CNMs collected data on 16,729 client visits. The results indicate that the amount of time taken by a CNM to conduct an ambulatory client visit is similar, regardless of site. There were slight differences in the length of time taken for major components of a visit between sites but, in general, there was a remarkable similarity. The amounts of time spent in intrapartum care and inpatient visits is also reviewed.

Some problems in applying evidence in clinical practice

There is a considerable gap between sound evidence concerning health care interventions and the services that patients actually receive as health care. Practitioners and the health care system must overcome a number of barriers to narrow the gap. Viewed simplistically, there are three steps from evidence to practice: getting the evidence straight; developing clinical practice guidelines that are faithful to both the evidence and the clinical and personal situations of patients; and applying these guidelines to the right patient at the right time in the right way. Special problems in getting the evidence straight stem from difficulties in finding sound evidence. Lack of agreement on evidence standards undermine the effectiveness of authoritative practice guidelines. Applying evidence and practice guidelines effectively and efficiently is often thwarted by mismatches between evidence and usual practice circumstances. Time pressures undermine interpretation and application of evidence at every step. Understanding these problems may permit development of more effective strategies to bridge the gap between evidence and practice.

Diffusion, dissemination, and implementation: who should do what?

The concepts of diffusion, dissemination, and implementation are distinguished as progressively more active steps in the process of flowing valid and reliable research information into clinical practice. Using a staged model of behavior change, diffusion is seen as a precursor for dissemination activities, which in turn "predispose" physicians to consider change in their practices. Local implementation activities capitalize on this by "enabling" and subsequently "reinforcing" the desired behavior change. Different skills are needed for each activity. Biomedical journals, with some improvements, are identified as diffusion agents. Collaboration between academics and medical organizations is best suited to the dissemination stage. Local agents, empowered by resources, are best equipped for implementation activities.

The doctor is in

The growing trend toward an overproduction of specialists and an underproduction of generalists (i.e., family physicians, general internists, and general pediatricians) in the United States has prompted many in medicine and academic medicine to endorse the goal that 50% of the United States's physician graduates should be generalists. The author discusses (1) the definition of the term generalist; (2) the number of generalists presently being produced (as estimated by three methods) and why the 50% goal is an informed and reasonable one; (3) changes needed in graduate medical education of the three main categories of generalist physicians; (4) changes needed in medical education; (5) changes needed in the practice environment; and (6) overall implementation strategies and the question of how much the federal government or some central authority should be involved. He concludes by reflecting that the 50% goal is worthwhile, although challenging, and that it is better to have a goal--even if it is not met--then to have no goal at all.

Strategies for improving and expanding the application of health status measures in clinical settings. A researcher-developer viewpoint

Health status instruments may be useful in clinical settings to screen for functional problems, monitor disease progression or therapeutic response, improve doctor-patient communications, assess quality of care, or provide case-mix adjustment for comparing other outcomes between patient groups. However, conceptual, practical, and attitudinal barriers have prevented their wider implementation. Aside from providing more data on how these measures influence the process and outcomes of clinical care, several strategies may help to improve and expand their application. Wider application would be promoted by training health care providers about the methods of health status assessment, their validity, and the available instruments; comparing newer functional measures and older scales with which clinicians are familiar (to make scores more meaningful); providing better data for the selection of instruments; and improving the responsiveness of these questionnaires to clinical changes. If health status measures are used in direct patient care, it is important to determine whether the goal is to screen for functional problems or to monitor patient changes over time. These different purposes may influence the selection of instruments, the types of patients targeted (e.g., based on age or diagnosis), and the frequency of patient assessment. Health status measures must be easily incorporated into the office routine, requiring that they be brief, easy to interpret, and not require complex training or scoring algorithms. In this setting, it may be helpful to provide clinicians not only with functional status scores, but with interpretations and recommendations about management or community resources to consider. The costs of health status measurement and data analysis will probably be borne by third-party payers, who must be persuaded of their utility. When health status measures are used for quality assurance, average scores for groups of patients should be adjusted for disease severity, comorbid conditions, demographic characteristics, socioeconomic status, and baseline health status. Furthermore, the sickest or most vulnerable members of a clinical population may be least able to provide valid health status information because of dementia, frailty, blindness, illiteracy, or inability to speak English. These patients may be of particular interest, and are likely to alter average health status scores for a population, so methods to assure complete ascertainment must be considered.

Benefits and obstacles for development of health status assessment measures in clinical settings

Health status measures offer scientific, humanistic, and economic benefits for clinical medicine. The main problem is the many intellectual and pragmatic obstacles that block successful development of these measures. The inventory of such problems includes the following: definition of health; medical components of health status; who makes the choice about what to include and emphasize; attributes to be rated by patients or clinicians; indexes to be created from those attributes (including mega-variable indexes, global indexes, and oligo-category indexes); different measurements of the same entity; and clinimetric problems in nonclinimetric models. Several solutions to these multiple, complex difficulties can be offered: 1) ensure that a specific purpose, focus, and setting are clearly identified for every health status index; 2) recognize that an off-the-shelf index with high statistical scores for so-called reliability and validity may not be pertinent for a given current situation in which it is to be used; 3) avoid indexes involving combinations of excessive numbers of variables; 4) let patients choose the most significant foci and components of the indexes; 5) seek greater communication and understanding among multidisciplinary collaborators, who may have many differences in the ethos and goals with which they approach the construction of health status indexes; and 6) recognize that the construction of suitable health status indexes is an outstanding challenge in basic scientific inquiry, and, in this spirit, support major alterations in the current ideology for conceptualization and funding of what is basic science in clinical medicine.

Influence of clinical knowledge, organizational context, and practice style on transfusion decision making. Implications for practice change strategies

Evidence shows that blood products, like other health care resources, are often used inappropriately, but the reasons for this have not been well studied. We conducted a face-to-face survey of 122 general surgeons, orthopedic surgeons, and anesthesiologists in three hospitals to evaluate the influence of several clinical and nonclinical factors on transfusion decision making. We found widespread deficiencies in physicians' knowledge of transfusion risks and indications. Each transfusion risk was estimated correctly by fewer than half of the physicians surveyed, and only 31% responded correctly to a set of four questions regarding transfusion indications. Attending physicians routinely had lower knowledge scores than did residents, yet they exhibited more confidence in their knowledge. Residents' transfusion decisions, however, were strongly influenced by the desires of their attending physicians, resulting in their ordering potentially inappropriate transfusions. Of the residents surveyed, 61% indicated that they ordered transfusions that they judged unnecessary at least once a month because a more senior physician suggested that they do so. These findings provide insights for the development of strategies to improve transfusion practices, which would address the dual concerns of quality of care and cost containment.

Course organizers in general practice

In August/September 1984 a survey of the 267 course organizers in post in England and Wales was carried out. Eighty-two per cent replied to a questionnaire asking for details about their work and personal status. All 16 regions in England and Wales completed a questionnaire about levels of staffing and remuneration of those involved in general practice postgraduate education. The results show that there are considerable variations between regions in the role and responsibilities of course organizers, in their training, and in the facilities that are provided for them. The majority of course organizers reported a workload greater than the number of sessions for which they were remunerated. The effects of these factors on recruitment, tenure of post, and job satisfaction are discussed. Recommendations are made for improving the situation, including the removal of course organizer pay from the scale of trainers' pay, so that there can be flexibility in the number of sessions which can be held, improvement in training and certain facilities, and the implementation of national and local job descriptions.