-1-mililipplill division of regional medical -,rograms A communication device October IS, 1968 designed to speed the exchange of newo4 HOSPITAL PRACTICE FEATURE: "The Program information and data on Is Regional, The Feedback Is Local" Regional Medical Programs The feature on Regional Medical Programs which appeared in the September 1968 issue of HOSPITAL PRACTICE is reproduced in this issue for those who would not otherwise have the opportunity to see it. In addition to its regular readers, this article was read and (D-tJtah) on the received favorable comment from Senator Frank Moss floor of the Senate and was reprinted in ttie ConZiessional Record of October 2, 1968 at his request. Reprinted by permission. Copyright (c) 1968 by the Hospital Practice Com-pany U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Bethesda, Maryland 20014 September 1968 Hospital Practice DEPARTMENTS 13 Letters to the Editor Impact on Hospital Practice rogram Is Regional, 'Me Feedback Is I L M 0 N C A S T L E University of Utah ARTICLES 28 To Vaccinate or Not? C. H IE N R Y K E M P E University of Colorado The threat of smallpox in th@ country is minimal; the hazards of vaccination are many. An approach is outlined that could greatly diminish the morbidity and mortality arising from vaccination complications. 34 When To Hospitalize in Polycythemia Vera L 0 U I S R. W A S S E R M A N The Mount Sinai Hospital, New 2ork Hospitalization may be needed to differentiate "true' from "relative' polycythemia and secondary erythrocytoses; it always is for treatment of advanced complications. 46 How Close Is Fetal Surgery? 13 E N J A M I N T. J A C K S 0 N Boston Uni-versity Medical Center It is already being performed in erythroblastosis fetalis, and animal studies have pro- vided surgical techniques to meet many of the anticipated difficulties. 56 Suicide Prevention: The Hospital's Role E D W I N S. S H N E I D M A N National Institute of Mental Health Alertness by physicians and other hospital personnel to premonitory signs in the suicidal individual offers a path to prevention of many suicides. FEATURE 64 Salivary Tissue Transplants Reactivate Endocrine Function After Hypophysectomy EDITORIAL 9 'The Risk of Doing Nothing' S Y D N E Y S. G E L L i s Tufts University, Boston September i968 Volume 3 Number 9 n@ and treatment of wrh@ia& Govemment Impact on Hospital Practice Commenting on the Billings episode, the supervisor wrote I R M P headquar- ters at the medical center: "We are very proud of her and of the wonder- ful work you are doing for the people The Program Is Regional, of our community.' Billings is about 380 miles from Salt Lake City, as &e cmw ffies, on The Feedback Is Local &e other side of the Rocky Mountains. No form of transportation could have brought this patient to the medical C. H I L M 0 N C A S T L E Univer8ity of Utah center in time to save him. In the per- son of the trained nurse, however, the medical center was at the bedside. If Late on a Saturday night just before survival to the Intermountain Re- the words 'medical center" are taken Christmas last year, a 65-year-old gional Medical Progr@s course in to mean the place where the latest man was admitted to the coronary coronary care, which the nurse had advances in medical knowledge, equip- care unit of a Billings, Mont., hospital. completed hardly a month before. ment, and skills are ready for applica- As the nurse attached electrocardio- Held at the University of Utah Medi- tion, then I can phrase the I R Meg graphic leads and inserted an intra- cal Center and three hospitals in Salt objective as that of putting every pa- cath to monitor venous pressure, the Lake City, the course had emphasized tient in a medical center. patient went into ventricular fibrma- what a nurse should do in cardiopul- 'ne I R M P, covering one of the tion. Ile nurse defibrulated him monary emergencies in the absence of largest and most sparsely populated quickly. A supervisor attributed his a physician. It had also covered recog- areas among the 54 regional medical programs spanning the U.S., includes the entire state of Utah and portions of Wyoming, Colorado, Idaho, Ne- vada, and Montana. @ area of 2.2 million persons has 129 hospitals, mostly under 50 beds in size, and ap- proximately 2,000 physicians in 100 connnunities in and around the 'Great AmerkanDesert."Tryingtohelpmed- kine flourish despite the handicaps of geography and population scatter has never impressed us as easy in any way. By W I mean the medical centers, medical @iations of the states and counties, and hospital @s. In Au- gust 1966, after months of preparation, the I R M P received a $456,000 first- year pl mg grant under the federal law aimed at combating heart disease, cancer, @ke, and related diseases. In its short lifetime, the I R M P has re- cruited a staff, set up lines of com- munkation, explained itself to lay and professional persons, identified urgent needs, and established pilot projects. Of the 13 pilot projects funded since April 1967, the course in coro- nary care attended by the nurse from Billings probably best illustrates the outlook and modus operandi of the I R M P. 'Mis project was based on the philosophy that effective postgraduate o 'Core Faculty' 0 Cardiopulmonary Resuscitation Programs Nurses Training education is problem oriented. And our other efforts for physicians, too, Heart dise-we p-gra- @e fed back to -my part,, of 1-te-@n region (outlined). are aimed at helping the practitioner Twenty-three community @tals now @ 'core facuw phy who have at- solve problems he meets in his daily @d cour8e8 in acute @ry care, cour8m for nurse$ have @ held at four centers. work and at domg so with an under- Hompital Practice Septetnber 1968 @ding of how people learn and what and the personnel to staff it. In plan- ity and thus minimize reliance o@, is attractive to the learner. ning discussions, it became clear to us extraregional resources. Before I R V In 1966, to gain a general impres- that a postgraduate medical education was operational, Ogden had s& sion of the Utah practitioners percep- effort centered on cc u's had a ready- nurses outside the state for training. tion of his needs and to begin a dia- made audience among physicians as Tle two physicians from Ogden logue between the practicing and aca- well as hospital administrators and and 23 from 11 other communities demic communities on what to do -to nurses. We recognized that the uni- made up the first group of 25 to be improve patient care, a survey was versity faculty could carry only part trained as core faculty members. Prior made in the state by the American of the burden. 'Me solution: IMe phy. Ito the first training session, core fac- Medical Association, the U@ State skians who need to learn must also , ulty members and IRMP representa- Medical Association, and the@'Univer- become teachers. tives had discussions on what the phy- sity of Utah College of Medicine. One of our first moves was to iden- sicians' commitment meant, what our We found that Utah physicians are tify the community hospitals with commitment meant, and what prob- similar to other American physicians cc u's in which the physicians and lems each party might confront. As in education and specialty distribu- nurses were willing to undertake train- core faculty members, we explained, tion. Iley work 53 hours a week on ing that would enable them to become they would be on the medical school the average. Half of 456 physicians supervisors or teachers for the units. clinical faculty in cardiology. They -responding to the survey (907 were These physicians would be expected were told that the I RM P would pay polled) indicated they felt they saw to carry the knowledge gained at a them a nominal stipend or consulta- too many patients. 'Me survey yielded medical center back to other physi- tion fee for time spent in teaching estimates that from 20% to 50% of cians and to hospital personnel in their coronary care. For supervising the what they do in practice could be done communities. 'Me physicians were Icare given in the c r- u's and while by an assistant under their supervi- designated "core faculty members" of training they would receive no fee. sion. Physicians spent relatively little the iRm P. We found that training 'Me -core faculty is expected to at- time in planned continuing education in acute cardiac care appealed to prac- tend a series of three three-day courses and mostly just read journals. Tley titioners in several ways. Some wanted within one year. Ile three-day span had no system for feedback in their to improve their reputations for ex- was picked as long enough to convey educational efforts and no reliable way pertise, some wanted identification a solid block of instruction and con- of telling how well they took care of with the university, some wanted to be venient for the practicing physician. patients. Interestingly enough, the able to specialize more in cardiology, 'ne series of courses eventually will survey found that physicians spent al- and some just wanted to learn some- tie together to provide the knowledge most as much time on third-party- thing new and become better doctors. and skills required for expert coronary payer forms as on continuing studies. Let me talk of our start in terms of cm as well as for effective teaching. There was marked variation in the, a single community. Ogden, Utah, 35 educational needs perceived by physi- miles from Salt Lake City, has a popu- i 'ne inaugural course, held in cians in various specialties, and there lation of 150,000 within about a January, focused primarily on ar- was no correlation between the most half-houf's automobile drive. Both rhythmias and electrical pacing, but frequent problems they encountered in hospitals in Ogden - Dee Memorial also covered elements of data gather- their offices and their list of priority and St. Benedict?s - have excellent ing and teaching. 'ne 25 physicians needs. We learned from the survey c c u's. In trying to find prospective were busy from morning through eve- that what a physician wants to know core faculty members, we ran into re- ning in seminars, lectures, and labora- and what he needs to know are not luctance. As one physician expressed tory demonstrations conducted by five necessarily the same. For example, he it, "It sounds like a good idea, but I'm nationally known cardiologists and may want to be able to read cardio- not sure I want to be in a program members of the University of Utah grams expertly, but an audit of clini- supported by the federal government. faculty. One result of the course was cal records may show he has a greater Let me think about it." that physicians from the region were need to learn how to utilize digitalis. We explained the nature of the fed- drawn together and came to know the In the past few years, intensive eral RM P law, especially the corn- facilities and expertise available in coronary care units (c c u's) have been niitment to local initiative. Finally, we other communities that might benefit established in nearly two dozen hos- found two physicians able and willing a patient with a particular cardiac pitals in the IRMP area. Physicians to join the core faculty. Both had spe- problem. 'ney also became familiar have expressed a desire to learn how cial training in cardiology but wanted with the resources of the medical cen- to use this facility properly,where it more, and both were willing to help ter - its library, faculty, laboratories. exists locally or how to obtain a unit hospitals in the medical service area 'ne objective of the courses is not linked to Ogden hospitals (an area ex- todictate to the physician how a c c u tending as far as Idaho). Important should be run but to give him a back- Dr. Castle is coordinator of the Int@n- to i Rm P effectiveness was the willing- ground and assistance that he can ap- tain Regional Medical Program and pro- ness of these physicians to help other ply in his local community. After he fessor of postgraduate medical educati-, hospitals set up c c u's. Our hope was returns to his community, the I R MP associate professor of medicine, and asso- that the Ogden hospitals and core fac- maintains contact, providing informa- cWe dean of the Univers" of Utah Col- ulty members would be able, in time, tion, guides to practice, help in solving I loge of Medicine, Sak Lake City. to add to the I Rif Ps training capac- problems of care and teaching, and Hospital Practice Se@ber 1968 observations and suggestions about the medical center. A by-product of ,,iedical, nursing, and administrative 23 R M P'S Now Operational physician and nurse training is a activities on which he seeks assistance. greater demand for expert mainte- We make, sure the physician receives Among the 54 Regional Medical n ance of cc u equipment. Eventually, guides published by the American Programs a total of 23, including we expec.t to identify the aspects of Heart Association and American Col- the Intermountain, had gone oper- coronary care that a licensed practical lege of Cardiology on coronary care. ational as this article went to nurse can take over from the profes- To help the physician in teaching press. Eleven more had applica- sional registered nurse (who already his c c u nurses and in evaluating tions to become operational under does many tasks that two years. ago their performance, we give him a review in Washington, and Puerto. performed only by a physician). "Coronary Care Curriculum Guide.' Rico had just received a new I an- were ning grant. Delegation of tasks to personnel with In addition, w'e receive data from each Ile 23 operating R m P"a are as less formal training can be done, but cc u on the management of their pa- follows- Albany (N. Y.), for- only if training in coronary care has tients. We are establishing a form to nia, Central New York, been thorough and quality of care is be used by all c c u's that will help the Intermountain, Iowa, closely controlled. With the help of a physician review the activities he su- Maine, Me his, et lit cardiologist panel we are analyzing pervises. The form also will help us Washington (D. C.), many of the- cc u functions to see compare the performances of units so Missou 'I, Moun St which aspects of care can be delegated. that we can identify successful and Me o, , 0 n,, unsuccessful patterns of care and ad- Roches Y.), ar*- As IRMP-trained physicians and just our training objectives. lina, Te ee h nurses at hospitals in Ogden, Poca- Washin -Alas, tello, Reno, and other communities in- Because record keeping is so im- York, in. struct more physicians and nurses, the portant to quality control and train- demand for cc u's will grow. In a ing, as well as to research, additional sense, we complete a circle that began details of our approach may be of in- how to collect data more effectively. with the need to staff existing ccu's, terest. The clinical data sheet we are Looking far down the line, I can visu- with well-trained persons. 'ne avail- developing will provide a uniform alize the transmission of data from a ability of training will spur outlying system for recording events in the pa- cc u by data-phone directly from sen- hospitals to have cc u's. In my opin- tient's illn ss and treat e@nt h@roti6- sors on the patient so that the attend- ion, most general hospitals need such logically and in detail. This chronol- ing cardiologist may query the corn- a unit. This should no longer be a ogy is expected to permit an expert puter's memory on experience of one question for debate. A basic rationale cardiologist to review the case and therapeutic maneuver versus another of the federal law is to provide equal ask searching questions about what in thousands of stored case records. access in every Te . to the highest In four hospitals we are now using the quality o r-@dless of the pa- the physician or nurse did or could f care e have done before or after an event. computer to collect data and establish tient's place of residence, and this re- The sheets should help identify asso- ranges of hemodynamic parameters quires ubiquity of cc u's. But even if ciations between treatment patterns in. patients with heart and lung dis- the law did not exist, no physician and patient responses. In short, the eases as well as in normal people. responsible for a cardiac patient today data will become our teacher. Our nurses' training program be- should lack'affiliation with a hospital The responsibility to furnish data gan before the physician training ef- having a cc u. on the sheet becomes a stimulus to fort. By early 1968, over 100 nurses The I R MP ideal is to have almost maintaining, quality of care. For ex- had been through a three-week cur- every patient within an hour of a c c u. ample, since the practitioner must re- riculum that gives them a foundation Practically, we aim at having 90% of cord parameters that are siznificant in acute cardiac care. After a three- the population in our region within 50 when an event occurs, he ca'n-not for- month interval, they return to the miles of a unit. To accomplish this, get these aspects of care. The record medical center for another week of the region needs to add 20 more c c u's also is important as a feedback for instruction and review of practical to the 20 it now has. We also are in- I R M P teaching functions. At first the problems encountered in patient care vestigating the use of helicopters and data sheets will be collated manually, and in teaching.their peers. During other mobile units to reduce transpor- but their design permits their adapta- the three-month interval they receive tation time. The mobile unit might tion to computer analysis. "homework" and tests by correspond- have drugs, intravenous fluids, devices Coronary care units provide an ex- ence. For instance, they. are sent car- for closed chest compression, an oscil- cellent opportunity for research, and diograms to analyze for arrhyt@mias loscope to display rhythm, a defibrilla- indeed there is no better way to grasp (and the I R M P checks the answers). tor, and equipment for cutdowns and clinical cardiology than through re- We emphasize this ability because passing catheters. search at the bedside. Two core fac- nurses encounter problems in rhythm ulty members are currentlycollecting every day. While they are in training Another ideal is to link all descriptions about patients' responses at the center, their expenses are re- physicians in postgraduate educa- to various drugs and procedures em- imbursed by the I R M P, and their. sala- tional activities. We have a two-way ployed in shock. From this effort they, ries are maintained by their hospitals. radio network covering 40 hospitals and we, will learn more effective Besides physicians and nurses, elec- and the medical center, plus a system means of treatment. We will also learn tronics technicians receive training at of acquiring, producing, and distribut- Hospital Practice SePtember 196@ ing films, slides, and television and the quality of care his patients receive to obtain them, and how the I R MP sound tapes for medical education. and for providing direction in develop- might help. Suppose, for example, Eighteen hospitals already have con- ing educational programs and diag- that the committee, on the basis of ference rooms for teaching, 10 have nostic'and treatment facilities. Sys- local data on the incidence of myo- audio playback equipment, and four tematic data collection and reporting cardial infarction, determines that the have TV tape playback capability. through the regional tumor re-istry local hospital needs a cc u. It might Nine hospitals have audited medical are expected to help us understand pat- launch a fund drive, simultaneously records systems integrated with edu- terns of disease within the region and lining up support for planning and cational programs. The IRMP pro- how local environmental factors influ- training from the I R M P. vides consultants on patient care prob- ence'them. Collection of data in re- Our message to communities, hos- lems in various diseases, laboratory mote communities may stimulate clin- pitals, and physicians boils down to services, and medical education proj- ical research on the types of patients this: "Come to grips with your own ects, and offers a cadre of teaching confronting the local practitioner problems. We will help identify them faculty for community hospital edu- rather than the highly selected.pa- and find solutions." Toward this end cation programs, a dial-access system tients seen by spOtialists in a large the I R MP is making up health care for information on specific clinical medical center. T%e registry is a fur- profiles for each community in Utah, subjects, and library loan services. ther application of our belief that clini- showing available manpower and hos- The use of these resources depends cal research in communities will cata- pital facilities, socioeconomic charac- on practitioner interest and need. The lyze postgraduate education. teristics, and financial resources. We problem-oriented approach has been are still in the early stages of our shown to be very effective in the coro- Besides linking physicians and work, but I believe our coronary care nary care effort. This approach is hospital colleagues, the IRMP is en- projects have already shown how re- being applied to the cancer and stroke couraging development of community gional medical programs can improve targets framed by the basic federal committees of professional and lay the distribution and quality of care. legislation under which IRMP oper- persons to assess community needs, They are thus helping to realize- ates. As these efforts reach the level of voice criticism, and express expecta- without compulsion or outside dicta- the coronary care effort, there will be ti,,,. So far, only three such groups tion - the goal of the federal law: "To a need to coordinate activities within have been formed, in Butte, Pocatello, encourage and assist the physicians a hospital, among hospitals, and be- and Reno. We are watching their evo- and medical institutions of the nation tween hospitals and the university. lution to see the kinds of roles they to make available to their patients the This role will be filled by a medical will play. We believe that such com- benefits of medical-scientific advances education coordinator (MEC) in the mittees could make surveys of what in the fields of heart, stroke, and community who is selected by the physical facilities and services the cancer." medical profession in the community connnunity needs, what is being done and the I R MP. The I R MP now has six m E c's, and two of them are in Ogden. One of the Ogden physicians who helped identify core faculty pros- pects and work out communications with the university is a full-time M E C. Other physicians serve part time. The hospitals served by the M E C'S will become - through heart, cancer, and stroke projects - controlled educa- tfonal environments in which medical students can be observedeand evalu- ated as they are introduced to the problems of medical practice in the community. With proper supervision and assistance, many community hos- pitals can provide learning experi- ences comparable to, and in some ways better than, those in university teaching hospitals. Cross-fertilization of projects in heart disease, cancer, and stroke is evolving. We expect that a computer- ized tumor registry with a system for patient follow-up and physician edu-, cation will be a model for a coronary registry. The cancer prototype is a tool for helping the physician evaluate