Christine Kilgore

For a copy of the EMTALA technical advisory group's final report, visit www.magpub.com/emtala/EMTALA%20Final%20Report_final.pdf

As the technical advisory group examining the Emergency Medical Treatment and Labor Act wraps up its work, some of its 55 recommendations are already finding their way into federal regulators' approaches to emergency on-call policies and specialty hospitals' responsibilities.

Despite those advances, the panel cautioned that larger issues within EMTALA remain to be addressed.

The panel put its efforts to rest in April with a final report that its physician members hope will make on-call service more workable and improve the statute's effects in the trenches.

“One of our overarching goals was to encourage attending physician participation in the on-call system, to make it easier and more practical for physicians and hospitals to work together and fulfill their obligations,” said Dr. David M. Siegel, an emergency physician and lawyer who chaired the technical advisory group (TAG). “A lot of the clarifications and definitions we provided should have some impact if adopted.”

The advisory panel met seven times over 3 years to advise the Secretary of the Department of Health and Human Services on how to improve guidance and enforcement of EMTALA. The 19-member advisory group included Centers for Medicare and Medicaid Services (CMS) staff, the inspector general of HHS, various patient and hospital representatives, and physician representation.

CMS Considers On-Call Crisis

Several of the panel's recommendations to improve on-call systems already have been implemented or are under serious consideration.

The CMS changed its interpretive guidelines, for instance, to clarify that a treating physician has final say on whether an on-call physician should come to the emergency department, and that he or she may use a variety of methods, including telemedicine, to communicate.

CMS also has begun to make it clear that specialty hospitals are not exempt from EMTALA obligations. Furthermore, in a draft Inpatient Prospective Payment System regulation for fiscal year 2009, the agency is now proposing that hospitals be allowed to group together and form community call to meet their on-call responsibilities.

The TAG's other recommendations cover a broad swath of issues, from improvement in EMTALA enforcement to review of “triage out” practices and improvement in medical screening exams and care for psychiatric patients, said Dr. Siegel, senior vice president at Meridian Health in Neptune, N.J.

The panel “had a fairly circumscribed charge, in that they weren't being asked to tackle the big problems lurking behind EMTALA,” said Barbara Tomar, director of federal affairs for the American College of Emergency Physicians.

“They did a tremendous job in dealing with some incredibly technical and complex issues … in simplifying and clarifying language, and in refining what [EMTALA] means,” she added.

The panel did not let its limited charge—and the broader issues—go unnoticed. It included in its list of recommendations two “high-priority” items: HHS should amend EMTALA to include liability protection, and it should develop a funding mechanism for hospitals and physicians who provide care covered by the statute.

The panel also filed its report with a letter urging HHS to not only adopt the recommendations, but to give “serious consideration” to the larger, systemic issues that are fueling on-call problems across the country.

“No matter what we put together, the TAG recommendations will not solve the ongoing on-call crisis,” said panel member Dr. Mark Pearlmutter, chief of the Caritas Emergency Medical Group at St. Elizabeth's Medical Center, Boston.

Can Community Call Deliver?

Like other TAG recommendations, the request for CMS to clarify its position on “shared or community call” and permit formal arrangements is a recognition of local variations. It's also a reflection of how the emergency care environment has changed overall since 2003, when EMTALA regulations were revised to allow on-call physicians more flexibility.

The advisory panel's conclusion that participation in community call plans can “satisfy [hospitals'] on-call coverage obligations”—a notion that CMS is now seeking comment on—is “a new option on the table,” said Ms. Tomar.

“It's a recognition of the fact that you no longer have full contingents of on-call doctors waiting at every hospital … that if you can get a community to pull together doctors to serve different hospitals on different days and connect that with your EMS system, you've got a potential plan,” she said.

The panel received testimony from leaders of various regional call pilot projects around the country “that [the projects] really worked,” Dr. Pearlmutter said. “It was very clear this was something we needed to recommend.”

It may not always be possible to implement such plans successfully—at least one solid regional effort recently collapsed, Tomar noted. In that light, the panel clearly stated in its recommendation that hospitals must have backup plans, and that a community call arrangement does not negate a hospital's obligation under EMTALA to perform medical screening exams.

The TAG's final report also is sprinkled with high-priority recommendations aimed at making it clear that patients may not be transferred unnecessarily, and that hospitals must have—and review annually—plans for on-call coverage for services they regularly offer to the public. That includes specialty hospitals without dedicated emergency departments.

The 2006 Inpatient Prospective Payment System final rule adopted another related recommendation: Hospitals with specialized capabilities but no EDs are bound by the same responsibilities under EMTALA as specialty hospitals with dedicated EDs.

Inpatient Transfers Hotly Debated

The advisory group closed with heated debate, when questions were raised near the end of the panel's seventh and final meeting last September about whether EMTALA should apply to the transfer of inpatients who are never fully stabilized.

The panel was presented with several scenarios, such as a patient who comes in with chest pain and is admitted with a probable diagnosis of angina—but who is found with additional testing to have a dissecting thoracic aneurysm or other life-threatening surgical emergency that the admitting hospital is unable to address.

“We heard testimony about hospitals getting on the phone and trying to transfer that patient to a receiving facility that refused, citing they had no obligation to do so,” Dr. Pearlmutter recalled.

After several votes, the panel narrowly recommended that EMTALA be extended to cover inpatient transfers, but only if the patient has not been stabilized for the condition requiring admittance.

“Deciding what to recommend,” Dr. Pearlmutter said, “was a difficult, deliberate process.”

In the end, the contentious recommendation became one that CMS ran with. Like the community call recommendation, it made its way into the draft Inpatient Prospective Payment System regulation for fiscal year 2009.

In a series of recommendations on psychiatric issues in the emergency setting, the group again “spoke to the issue that EMTALA requirements have not recognized the need for local responses,” Ms. Tomar said.

The advisory panel said, for instance, that physicians and hospitals can use community protocols, services, and resources to help determine whether psychiatric emergency medical conditions exist, and how and where patients should be placed and cared for.

Proposed EMTALA Policy Changes

Other high-priority recommendations in the EMTALA TAG's final report include:

▸ HHS should improve the consistency of EMTALA interpretations and enforcement across CMS regions, establish intermediate sanctions for less serious violations, and establish an appeals process for hospitals and providers.

▸ While taking calls selectively may violate EMTALA, taking calls for patients with whom the physician has a preexisting relationship should not be considered “selective call.”

▸ An emergency medical condition does not need to be resolved to be considered stabilized for the purpose of discharge—as long as it is determined that the patient's care can be reasonably performed as an outpatient or later as an inpatient, and as long as the patient receives a plan for follow-up care.

▸ HHS should monitor and evaluate, however, the consequences of deferred care and of patients being “triaged out.”

▸ A psychiatric medical screening exam should attempt to determine whether an individual is suicidal, homicidal, or gravely disabled (poses a danger to oneself because of extremely poor judgment or inability to care for oneself)—though such a determination does not necessarily mean the patient has an emergency medical condition.

▸ Hospitals with specialized behavioral health capabilities should be required to accept the transfer of patients who are gravely disabled and have an emergency medical condition, if these hospitals have the necessary resources and capacity and the transferring hospital does not.

▸ The use of chemical or physical restraints may provide a temporary safe environment by minimizing risk during patient transport, but it does not in itself stabilize a psychiatric emergency medical condition. Unless the hospital or physician can demonstrate that a patient is stabilized regardless of the restraints, EMTALA still applies.

For a copy of the EMTALA technical advisory group's final report, visit www.magpub.com/emtala/EMTALA%20Final%20Report_final.pdf

As the technical advisory group examining the Emergency Medical Treatment and Labor Act wraps up its work, some of its 55 recommendations are already finding their way into federal regulators' approaches to emergency on-call policies and specialty hospitals' responsibilities.

Despite those advances, the panel cautioned that larger issues within EMTALA remain to be addressed.

The panel put its efforts to rest in April with a final report that its physician members hope will make on-call service more workable and improve the statute's effects in the trenches.

“One of our overarching goals was to encourage attending physician participation in the on-call system, to make it easier and more practical for physicians and hospitals to work together and fulfill their obligations,” said Dr. David M. Siegel, an emergency physician and lawyer who chaired the technical advisory group (TAG). “A lot of the clarifications and definitions we provided should have some impact if adopted.”

The advisory panel met seven times over 3 years to advise the Secretary of the Department of Health and Human Services on how to improve guidance and enforcement of EMTALA. The 19-member advisory group included Centers for Medicare and Medicaid Services (CMS) staff, the inspector general of HHS, various patient and hospital representatives, and physician representation.

CMS Considers On-Call Crisis

Several of the panel's recommendations to improve on-call systems already have been implemented or are under serious consideration.

The CMS changed its interpretive guidelines, for instance, to clarify that a treating physician has final say on whether an on-call physician should come to the emergency department, and that he or she may use a variety of methods, including telemedicine, to communicate.

CMS also has begun to make it clear that specialty hospitals are not exempt from EMTALA obligations. Furthermore, in a draft Inpatient Prospective Payment System regulation for fiscal year 2009, the agency is now proposing that hospitals be allowed to group together and form community call to meet their on-call responsibilities.

The TAG's other recommendations cover a broad swath of issues, from improvement in EMTALA enforcement to review of “triage out” practices and improvement in medical screening exams and care for psychiatric patients, said Dr. Siegel, senior vice president at Meridian Health in Neptune, N.J.

The panel “had a fairly circumscribed charge, in that they weren't being asked to tackle the big problems lurking behind EMTALA,” said Barbara Tomar, director of federal affairs for the American College of Emergency Physicians.

“They did a tremendous job in dealing with some incredibly technical and complex issues … in simplifying and clarifying language, and in refining what [EMTALA] means,” she added.

The panel did not let its limited charge—and the broader issues—go unnoticed. It included in its list of recommendations two “high-priority” items: HHS should amend EMTALA to include liability protection, and it should develop a funding mechanism for hospitals and physicians who provide care covered by the statute.

The panel also filed its report with a letter urging HHS to not only adopt the recommendations, but to give “serious consideration” to the larger, systemic issues that are fueling on-call problems across the country.

“No matter what we put together, the TAG recommendations will not solve the ongoing on-call crisis,” said panel member Dr. Mark Pearlmutter, chief of the Caritas Emergency Medical Group at St. Elizabeth's Medical Center, Boston.

Can Community Call Deliver?

Like other TAG recommendations, the request for CMS to clarify its position on “shared or community call” and permit formal arrangements is a recognition of local variations. It's also a reflection of how the emergency care environment has changed overall since 2003, when EMTALA regulations were revised to allow on-call physicians more flexibility.

The advisory panel's conclusion that participation in community call plans can “satisfy [hospitals'] on-call coverage obligations”—a notion that CMS is now seeking comment on—is “a new option on the table,” said Ms. Tomar.

“It's a recognition of the fact that you no longer have full contingents of on-call doctors waiting at every hospital … that if you can get a community to pull together doctors to serve different hospitals on different days and connect that with your EMS system, you've got a potential plan,” she said.

The panel received testimony from leaders of various regional call pilot projects around the country “that [the projects] really worked,” Dr. Pearlmutter said. “It was very clear this was something we needed to recommend.”

It may not always be possible to implement such plans successfully—at least one solid regional effort recently collapsed, Tomar noted. In that light, the panel clearly stated in its recommendation that hospitals must have backup plans, and that a community call arrangement does not negate a hospital's obligation under EMTALA to perform medical screening exams.

The TAG's final report also is sprinkled with high-priority recommendations aimed at making it clear that patients may not be transferred unnecessarily, and that hospitals must have—and review annually—plans for on-call coverage for services they regularly offer to the public. That includes specialty hospitals without dedicated emergency departments.

The 2006 Inpatient Prospective Payment System final rule adopted another related recommendation: Hospitals with specialized capabilities but no EDs are bound by the same responsibilities under EMTALA as specialty hospitals with dedicated EDs.

Inpatient Transfers Hotly Debated

The advisory group closed with heated debate, when questions were raised near the end of the panel's seventh and final meeting last September about whether EMTALA should apply to the transfer of inpatients who are never fully stabilized.

The panel was presented with several scenarios, such as a patient who comes in with chest pain and is admitted with a probable diagnosis of angina—but who is found with additional testing to have a dissecting thoracic aneurysm or other life-threatening surgical emergency that the admitting hospital is unable to address.

“We heard testimony about hospitals getting on the phone and trying to transfer that patient to a receiving facility that refused, citing they had no obligation to do so,” Dr. Pearlmutter recalled.

After several votes, the panel narrowly recommended that EMTALA be extended to cover inpatient transfers, but only if the patient has not been stabilized for the condition requiring admittance.

“Deciding what to recommend,” Dr. Pearlmutter said, “was a difficult, deliberate process.”

In the end, the contentious recommendation became one that CMS ran with. Like the community call recommendation, it made its way into the draft Inpatient Prospective Payment System regulation for fiscal year 2009.

In a series of recommendations on psychiatric issues in the emergency setting, the group again “spoke to the issue that EMTALA requirements have not recognized the need for local responses,” Ms. Tomar said.

The advisory panel said, for instance, that physicians and hospitals can use community protocols, services, and resources to help determine whether psychiatric emergency medical conditions exist, and how and where patients should be placed and cared for.

Proposed EMTALA Policy Changes

Other high-priority recommendations in the EMTALA TAG's final report include:

▸ HHS should improve the consistency of EMTALA interpretations and enforcement across CMS regions, establish intermediate sanctions for less serious violations, and establish an appeals process for hospitals and providers.

▸ While taking calls selectively may violate EMTALA, taking calls for patients with whom the physician has a preexisting relationship should not be considered “selective call.”

▸ An emergency medical condition does not need to be resolved to be considered stabilized for the purpose of discharge—as long as it is determined that the patient's care can be reasonably performed as an outpatient or later as an inpatient, and as long as the patient receives a plan for follow-up care.

▸ HHS should monitor and evaluate, however, the consequences of deferred care and of patients being “triaged out.”

▸ A psychiatric medical screening exam should attempt to determine whether an individual is suicidal, homicidal, or gravely disabled (poses a danger to oneself because of extremely poor judgment or inability to care for oneself)—though such a determination does not necessarily mean the patient has an emergency medical condition.

▸ Hospitals with specialized behavioral health capabilities should be required to accept the transfer of patients who are gravely disabled and have an emergency medical condition, if these hospitals have the necessary resources and capacity and the transferring hospital does not.

▸ The use of chemical or physical restraints may provide a temporary safe environment by minimizing risk during patient transport, but it does not in itself stabilize a psychiatric emergency medical condition. Unless the hospital or physician can demonstrate that a patient is stabilized regardless of the restraints, EMTALA still applies.

For a copy of the EMTALA technical advisory group's final report, visit www.magpub.com/emtala/EMTALA%20Final%20Report_final.pdf

As the technical advisory group examining the Emergency Medical Treatment and Labor Act wraps up its work, some of its 55 recommendations are already finding their way into federal regulators' approaches to emergency on-call policies and specialty hospitals' responsibilities.

Despite those advances, the panel cautioned that larger issues within EMTALA remain to be addressed.

The panel put its efforts to rest in April with a final report that its physician members hope will make on-call service more workable and improve the statute's effects in the trenches.

“One of our overarching goals was to encourage attending physician participation in the on-call system, to make it easier and more practical for physicians and hospitals to work together and fulfill their obligations,” said Dr. David M. Siegel, an emergency physician and lawyer who chaired the technical advisory group (TAG). “A lot of the clarifications and definitions we provided should have some impact if adopted.”

The advisory panel met seven times over 3 years to advise the Secretary of the Department of Health and Human Services on how to improve guidance and enforcement of EMTALA. The 19-member advisory group included Centers for Medicare and Medicaid Services (CMS) staff, the inspector general of HHS, various patient and hospital representatives, and physician representation.

CMS Considers On-Call Crisis

Several of the panel's recommendations to improve on-call systems already have been implemented or are under serious consideration.

The CMS changed its interpretive guidelines, for instance, to clarify that a treating physician has final say on whether an on-call physician should come to the emergency department, and that he or she may use a variety of methods, including telemedicine, to communicate.

CMS also has begun to make it clear that specialty hospitals are not exempt from EMTALA obligations. Furthermore, in a draft Inpatient Prospective Payment System regulation for fiscal year 2009, the agency is now proposing that hospitals be allowed to group together and form community call to meet their on-call responsibilities.

The TAG's other recommendations cover a broad swath of issues, from improvement in EMTALA enforcement to review of “triage out” practices and improvement in medical screening exams and care for psychiatric patients, said Dr. Siegel, senior vice president at Meridian Health in Neptune, N.J.

The panel “had a fairly circumscribed charge, in that they weren't being asked to tackle the big problems lurking behind EMTALA,” said Barbara Tomar, director of federal affairs for the American College of Emergency Physicians.

“They did a tremendous job in dealing with some incredibly technical and complex issues … in simplifying and clarifying language, and in refining what [EMTALA] means,” she added.

The panel did not let its limited charge—and the broader issues—go unnoticed. It included in its list of recommendations two “high-priority” items: HHS should amend EMTALA to include liability protection, and it should develop a funding mechanism for hospitals and physicians who provide care covered by the statute.

The panel also filed its report with a letter urging HHS to not only adopt the recommendations, but to give “serious consideration” to the larger, systemic issues that are fueling on-call problems across the country.

“No matter what we put together, the TAG recommendations will not solve the ongoing on-call crisis,” said panel member Dr. Mark Pearlmutter, chief of the Caritas Emergency Medical Group at St. Elizabeth's Medical Center, Boston.

Can Community Call Deliver?

Like other TAG recommendations, the request for CMS to clarify its position on “shared or community call” and permit formal arrangements is a recognition of local variations. It's also a reflection of how the emergency care environment has changed overall since 2003, when EMTALA regulations were revised to allow on-call physicians more flexibility.

The advisory panel's conclusion that participation in community call plans can “satisfy [hospitals'] on-call coverage obligations”—a notion that CMS is now seeking comment on—is “a new option on the table,” said Ms. Tomar.

“It's a recognition of the fact that you no longer have full contingents of on-call doctors waiting at every hospital … that if you can get a community to pull together doctors to serve different hospitals on different days and connect that with your EMS system, you've got a potential plan,” she said.

The panel received testimony from leaders of various regional call pilot projects around the country “that [the projects] really worked,” Dr. Pearlmutter said. “It was very clear this was something we needed to recommend.”

It may not always be possible to implement such plans successfully—at least one solid regional effort recently collapsed, Tomar noted. In that light, the panel clearly stated in its recommendation that hospitals must have backup plans, and that a community call arrangement does not negate a hospital's obligation under EMTALA to perform medical screening exams.

The TAG's final report also is sprinkled with high-priority recommendations aimed at making it clear that patients may not be transferred unnecessarily, and that hospitals must have—and review annually—plans for on-call coverage for services they regularly offer to the public. That includes specialty hospitals without dedicated emergency departments.

The 2006 Inpatient Prospective Payment System final rule adopted another related recommendation: Hospitals with specialized capabilities but no EDs are bound by the same responsibilities under EMTALA as specialty hospitals with dedicated EDs.

Inpatient Transfers Hotly Debated

The advisory group closed with heated debate, when questions were raised near the end of the panel's seventh and final meeting last September about whether EMTALA should apply to the transfer of inpatients who are never fully stabilized.

The panel was presented with several scenarios, such as a patient who comes in with chest pain and is admitted with a probable diagnosis of angina—but who is found with additional testing to have a dissecting thoracic aneurysm or other life-threatening surgical emergency that the admitting hospital is unable to address.

“We heard testimony about hospitals getting on the phone and trying to transfer that patient to a receiving facility that refused, citing they had no obligation to do so,” Dr. Pearlmutter recalled.

After several votes, the panel narrowly recommended that EMTALA be extended to cover inpatient transfers, but only if the patient has not been stabilized for the condition requiring admittance.

“Deciding what to recommend,” Dr. Pearlmutter said, “was a difficult, deliberate process.”

In the end, the contentious recommendation became one that CMS ran with. Like the community call recommendation, it made its way into the draft Inpatient Prospective Payment System regulation for fiscal year 2009.

In a series of recommendations on psychiatric issues in the emergency setting, the group again “spoke to the issue that EMTALA requirements have not recognized the need for local responses,” Ms. Tomar said.

The advisory panel said, for instance, that physicians and hospitals can use community protocols, services, and resources to help determine whether psychiatric emergency medical conditions exist, and how and where patients should be placed and cared for.

Proposed EMTALA Policy Changes

Other high-priority recommendations in the EMTALA TAG's final report include:

▸ HHS should improve the consistency of EMTALA interpretations and enforcement across CMS regions, establish intermediate sanctions for less serious violations, and establish an appeals process for hospitals and providers.

▸ While taking calls selectively may violate EMTALA, taking calls for patients with whom the physician has a preexisting relationship should not be considered “selective call.”

▸ An emergency medical condition does not need to be resolved to be considered stabilized for the purpose of discharge—as long as it is determined that the patient's care can be reasonably performed as an outpatient or later as an inpatient, and as long as the patient receives a plan for follow-up care.

▸ HHS should monitor and evaluate, however, the consequences of deferred care and of patients being “triaged out.”

▸ A psychiatric medical screening exam should attempt to determine whether an individual is suicidal, homicidal, or gravely disabled (poses a danger to oneself because of extremely poor judgment or inability to care for oneself)—though such a determination does not necessarily mean the patient has an emergency medical condition.

▸ Hospitals with specialized behavioral health capabilities should be required to accept the transfer of patients who are gravely disabled and have an emergency medical condition, if these hospitals have the necessary resources and capacity and the transferring hospital does not.

▸ The use of chemical or physical restraints may provide a temporary safe environment by minimizing risk during patient transport, but it does not in itself stabilize a psychiatric emergency medical condition. Unless the hospital or physician can demonstrate that a patient is stabilized regardless of the restraints, EMTALA still applies.

The technical advisory group examining the Emergency Medical Treatment and Labor Act put its efforts to rest in April with a final report that its physician members hope will make on-call service more workable and improve the statute's effects in the trenches.

The report recommends “community call” plans that share resources to fulfill EMTALA responsibilities, and emphasizes the obligations of specialty hospitals in meeting the on-call crisis. The advisory panel met seven times over 3 years to advise the Secretary of the Department of Health and Human Services on how to improve guidance and enforcement of EMTALA. The 19-member advisory group included Centers for Medicare and Medicaid Services (CMS) staff, the inspector general of HHS, various patient and hospital representatives, and physician representation. Several of the panel's recommendations to improve on-call systems already have been implemented.

The CMS has begun to make it clear that specialty hospitals are not exempt from EMTALA obligations. Furthermore, in a draft Inpatient Prospective Payment System regulation for fiscal year 2009, the agency is now proposing that hospitals be allowed to group together and form community call to meet their on-call responsibilities.

The panel “had a fairly circumscribed charge, in that they weren't being asked to tackle the big problems lurking behind EMTALA,” said Barbara Tomar, director of federal affairs for the American College of Emergency Physicians. “They did a tremendous job in dealing with some incredibly technical and complex issues … in simplifying and clarifying language, and in refining what [EMTALA] means.”

The panel did not let its limited charge—and the broader issues—go unnoticed. It included in its list of recommendations two “high-priority” items: HHS should amend EMTALA to include liability protection, and it should develop a funding mechanism for hospitals and physicians who provide care covered by the statute.

Like other TAG recommendations, the request for CMS to clarify its position on “shared or community call” and permit formal arrangements is a recognition of local variations. It's also a reflection of how the emergency care environment has changed overall since 2003, when EMTALA regulations were revised to allow on-call physicians more flexibility.

The advisory panel's conclusion that participation in community call plans can “satisfy [hospitals'] on-call coverage obligations”—a notion that CMS is now seeking comment on—is “a new option on the table,” said Ms. Tomar.

“It's a recognition of the fact that you no longer have full contingents of on-call doctors waiting at every hospital … that if you can get a community to pull together doctors to serve different hospitals on different days and connect that with your EMS system, you've got a potential plan,” she said.

It may not always be possible to implement such plans successfully—at least one solid regional effort recently collapsed, Tomar noted. In that light, the panel clearly stated in its recommendation that hospitals must have backup plans, and that a community call arrangement does not negate a hospital's obligation under EMTALA to perform medical screening exams.

The 2006 Inpatient Prospective Payment System final rule adopted another related recommendation: Hospitals with specialized capabilities but no EDs are bound by the same responsibilities under EMTALA as specialty hospitals with dedicated EDs.

The advisory group closed with heated debate, when questions were raised about whether EMTALA should apply to the transfer of inpatients who are never fully stabilized. The panel was presented with several scenarios, such as a patient who comes in with chest pain and is admitted with a probable diagnosis of angina—but who is found with additional testing to have a dissecting thoracic aneurysm or other life-threatening surgical emergency that the admitting hospital is unable to address.

The panel narrowly recommended that EMTALA be extended to cover inpatient transfers, but only if the patient has not been stabilized for the condition requiring admittance. And in the end, the CMS ran with the contentious recommendation. Like the community call recommendation, it made its way into the draft Inpatient Prospective Payment System regulation for fiscal year 2009.

The technical advisory group examining the Emergency Medical Treatment and Labor Act put its efforts to rest in April with a final report that its physician members hope will make on-call service more workable and improve the statute's effects in the trenches.

The report recommends “community call” plans that share resources to fulfill EMTALA responsibilities, and emphasizes the obligations of specialty hospitals in meeting the on-call crisis. The advisory panel met seven times over 3 years to advise the Secretary of the Department of Health and Human Services on how to improve guidance and enforcement of EMTALA. The 19-member advisory group included Centers for Medicare and Medicaid Services (CMS) staff, the inspector general of HHS, various patient and hospital representatives, and physician representation. Several of the panel's recommendations to improve on-call systems already have been implemented.

The CMS has begun to make it clear that specialty hospitals are not exempt from EMTALA obligations. Furthermore, in a draft Inpatient Prospective Payment System regulation for fiscal year 2009, the agency is now proposing that hospitals be allowed to group together and form community call to meet their on-call responsibilities.

The panel “had a fairly circumscribed charge, in that they weren't being asked to tackle the big problems lurking behind EMTALA,” said Barbara Tomar, director of federal affairs for the American College of Emergency Physicians. “They did a tremendous job in dealing with some incredibly technical and complex issues … in simplifying and clarifying language, and in refining what [EMTALA] means.”

The panel did not let its limited charge—and the broader issues—go unnoticed. It included in its list of recommendations two “high-priority” items: HHS should amend EMTALA to include liability protection, and it should develop a funding mechanism for hospitals and physicians who provide care covered by the statute.

Like other TAG recommendations, the request for CMS to clarify its position on “shared or community call” and permit formal arrangements is a recognition of local variations. It's also a reflection of how the emergency care environment has changed overall since 2003, when EMTALA regulations were revised to allow on-call physicians more flexibility.

The advisory panel's conclusion that participation in community call plans can “satisfy [hospitals'] on-call coverage obligations”—a notion that CMS is now seeking comment on—is “a new option on the table,” said Ms. Tomar.

“It's a recognition of the fact that you no longer have full contingents of on-call doctors waiting at every hospital … that if you can get a community to pull together doctors to serve different hospitals on different days and connect that with your EMS system, you've got a potential plan,” she said.

It may not always be possible to implement such plans successfully—at least one solid regional effort recently collapsed, Tomar noted. In that light, the panel clearly stated in its recommendation that hospitals must have backup plans, and that a community call arrangement does not negate a hospital's obligation under EMTALA to perform medical screening exams.

The 2006 Inpatient Prospective Payment System final rule adopted another related recommendation: Hospitals with specialized capabilities but no EDs are bound by the same responsibilities under EMTALA as specialty hospitals with dedicated EDs.

The advisory group closed with heated debate, when questions were raised about whether EMTALA should apply to the transfer of inpatients who are never fully stabilized. The panel was presented with several scenarios, such as a patient who comes in with chest pain and is admitted with a probable diagnosis of angina—but who is found with additional testing to have a dissecting thoracic aneurysm or other life-threatening surgical emergency that the admitting hospital is unable to address.

The panel narrowly recommended that EMTALA be extended to cover inpatient transfers, but only if the patient has not been stabilized for the condition requiring admittance. And in the end, the CMS ran with the contentious recommendation. Like the community call recommendation, it made its way into the draft Inpatient Prospective Payment System regulation for fiscal year 2009.

The technical advisory group examining the Emergency Medical Treatment and Labor Act put its efforts to rest in April with a final report that its physician members hope will make on-call service more workable and improve the statute's effects in the trenches.

The report recommends “community call” plans that share resources to fulfill EMTALA responsibilities, and emphasizes the obligations of specialty hospitals in meeting the on-call crisis. The advisory panel met seven times over 3 years to advise the Secretary of the Department of Health and Human Services on how to improve guidance and enforcement of EMTALA. The 19-member advisory group included Centers for Medicare and Medicaid Services (CMS) staff, the inspector general of HHS, various patient and hospital representatives, and physician representation. Several of the panel's recommendations to improve on-call systems already have been implemented.

The CMS has begun to make it clear that specialty hospitals are not exempt from EMTALA obligations. Furthermore, in a draft Inpatient Prospective Payment System regulation for fiscal year 2009, the agency is now proposing that hospitals be allowed to group together and form community call to meet their on-call responsibilities.

The panel “had a fairly circumscribed charge, in that they weren't being asked to tackle the big problems lurking behind EMTALA,” said Barbara Tomar, director of federal affairs for the American College of Emergency Physicians. “They did a tremendous job in dealing with some incredibly technical and complex issues … in simplifying and clarifying language, and in refining what [EMTALA] means.”

The panel did not let its limited charge—and the broader issues—go unnoticed. It included in its list of recommendations two “high-priority” items: HHS should amend EMTALA to include liability protection, and it should develop a funding mechanism for hospitals and physicians who provide care covered by the statute.

Like other TAG recommendations, the request for CMS to clarify its position on “shared or community call” and permit formal arrangements is a recognition of local variations. It's also a reflection of how the emergency care environment has changed overall since 2003, when EMTALA regulations were revised to allow on-call physicians more flexibility.

The advisory panel's conclusion that participation in community call plans can “satisfy [hospitals'] on-call coverage obligations”—a notion that CMS is now seeking comment on—is “a new option on the table,” said Ms. Tomar.

“It's a recognition of the fact that you no longer have full contingents of on-call doctors waiting at every hospital … that if you can get a community to pull together doctors to serve different hospitals on different days and connect that with your EMS system, you've got a potential plan,” she said.

It may not always be possible to implement such plans successfully—at least one solid regional effort recently collapsed, Tomar noted. In that light, the panel clearly stated in its recommendation that hospitals must have backup plans, and that a community call arrangement does not negate a hospital's obligation under EMTALA to perform medical screening exams.

The 2006 Inpatient Prospective Payment System final rule adopted another related recommendation: Hospitals with specialized capabilities but no EDs are bound by the same responsibilities under EMTALA as specialty hospitals with dedicated EDs.

The advisory group closed with heated debate, when questions were raised about whether EMTALA should apply to the transfer of inpatients who are never fully stabilized. The panel was presented with several scenarios, such as a patient who comes in with chest pain and is admitted with a probable diagnosis of angina—but who is found with additional testing to have a dissecting thoracic aneurysm or other life-threatening surgical emergency that the admitting hospital is unable to address.

The panel narrowly recommended that EMTALA be extended to cover inpatient transfers, but only if the patient has not been stabilized for the condition requiring admittance. And in the end, the CMS ran with the contentious recommendation. Like the community call recommendation, it made its way into the draft Inpatient Prospective Payment System regulation for fiscal year 2009.

Palliative care for children and adolescents with chronic or advanced respiratory and critical illnesses is a significant part of a new clinical policy statement issued by the American Thoracic Society.

In issuing the 15-page policy on palliative care, the ATS joins a growing number of national bodies, including the American Academy of Pediatrics, that have addressed the importance of this care and the need for professional competence in providing it.

Today's model of palliative care refers to the relief of suffering during any stage of illness and not only the end stages, the ATS and others have emphasized.

The ATS statement lists and describes a number of overarching and timeless “values and principles” relating to palliative care for children and adults: the need for an individualized approach and a focus on the patient and his or her family, for instance, as well as the need to begin care when patients become symptomatic and the importance of a comprehensive and multidisciplinary approach.

The policy also provides practical information on managing dyspnea and pain, on the decision making process, and on issues such as withholding and withdrawing life support (Am. J. Respir. Crit. Care Med. 2008;177:912–27).

Studies of end-of-life care for children and adults with cystic fibrosis suggest that providers often do not discuss palliative care early enough or at all, the statement says.

“In children, cystic fibrosis is probably the paradigm case, and is a model in terms of its being family centered. The literature suggests, though, that communication about the goals of care in CF and how to best meet them could be improved,” said Dr. Paul N. Lanken, professor of medicine and medical ethics at the Hospital of the University of Pennsylvania, Philadelphia, and cochair of the task force that developed the policy.

“Children may be getting certain types of curative care up to the very end, even though the goals of care have turned to 100% palliative,” he said in an interview.

Parents of children with any chronic progressive disease should, the statement says, be “sensitively informed about the likely trajectory” of the child's disease, so that they can adequately plan for the child's goals of care and palliative support needs.

Children become mature enough to actively participate in decision making at all different ages, so their role should be assessed on an individual basis. With adolescents, however, shared decision making with their parents “should be promoted,” the policy says. The ATS policy statement also warns that pain in young children often results “as much from diagnostic and therapeutic procedures as from the disease itself” and calls for adequate treatment of pain during initial procedures.

It encourages physicians to access certain up-to-date, resource-rich Web sites, such as that of the Center to Advance Palliative Care (www.capc.org

Palliative care for children and adolescents with chronic or advanced respiratory and critical illnesses is a significant part of a new clinical policy statement issued by the American Thoracic Society.

In issuing the 15-page policy on palliative care, the ATS joins a growing number of national bodies, including the American Academy of Pediatrics, that have addressed the importance of this care and the need for professional competence in providing it.

Today's model of palliative care refers to the relief of suffering during any stage of illness and not only the end stages, the ATS and others have emphasized.

The ATS statement lists and describes a number of overarching and timeless “values and principles” relating to palliative care for children and adults: the need for an individualized approach and a focus on the patient and his or her family, for instance, as well as the need to begin care when patients become symptomatic and the importance of a comprehensive and multidisciplinary approach.

The policy also provides practical information on managing dyspnea and pain, on the decision making process, and on issues such as withholding and withdrawing life support (Am. J. Respir. Crit. Care Med. 2008;177:912–27).

Studies of end-of-life care for children and adults with cystic fibrosis suggest that providers often do not discuss palliative care early enough or at all, the statement says.

“In children, cystic fibrosis is probably the paradigm case, and is a model in terms of its being family centered. The literature suggests, though, that communication about the goals of care in CF and how to best meet them could be improved,” said Dr. Paul N. Lanken, professor of medicine and medical ethics at the Hospital of the University of Pennsylvania, Philadelphia, and cochair of the task force that developed the policy.

“Children may be getting certain types of curative care up to the very end, even though the goals of care have turned to 100% palliative,” he said in an interview.

Parents of children with any chronic progressive disease should, the statement says, be “sensitively informed about the likely trajectory” of the child's disease, so that they can adequately plan for the child's goals of care and palliative support needs.

Children become mature enough to actively participate in decision making at all different ages, so their role should be assessed on an individual basis. With adolescents, however, shared decision making with their parents “should be promoted,” the policy says. The ATS policy statement also warns that pain in young children often results “as much from diagnostic and therapeutic procedures as from the disease itself” and calls for adequate treatment of pain during initial procedures.

It encourages physicians to access certain up-to-date, resource-rich Web sites, such as that of the Center to Advance Palliative Care (www.capc.org

Palliative care for children and adolescents with chronic or advanced respiratory and critical illnesses is a significant part of a new clinical policy statement issued by the American Thoracic Society.

In issuing the 15-page policy on palliative care, the ATS joins a growing number of national bodies, including the American Academy of Pediatrics, that have addressed the importance of this care and the need for professional competence in providing it.

Today's model of palliative care refers to the relief of suffering during any stage of illness and not only the end stages, the ATS and others have emphasized.

The ATS statement lists and describes a number of overarching and timeless “values and principles” relating to palliative care for children and adults: the need for an individualized approach and a focus on the patient and his or her family, for instance, as well as the need to begin care when patients become symptomatic and the importance of a comprehensive and multidisciplinary approach.

The policy also provides practical information on managing dyspnea and pain, on the decision making process, and on issues such as withholding and withdrawing life support (Am. J. Respir. Crit. Care Med. 2008;177:912–27).

Studies of end-of-life care for children and adults with cystic fibrosis suggest that providers often do not discuss palliative care early enough or at all, the statement says.

“In children, cystic fibrosis is probably the paradigm case, and is a model in terms of its being family centered. The literature suggests, though, that communication about the goals of care in CF and how to best meet them could be improved,” said Dr. Paul N. Lanken, professor of medicine and medical ethics at the Hospital of the University of Pennsylvania, Philadelphia, and cochair of the task force that developed the policy.

“Children may be getting certain types of curative care up to the very end, even though the goals of care have turned to 100% palliative,” he said in an interview.

Parents of children with any chronic progressive disease should, the statement says, be “sensitively informed about the likely trajectory” of the child's disease, so that they can adequately plan for the child's goals of care and palliative support needs.

Children become mature enough to actively participate in decision making at all different ages, so their role should be assessed on an individual basis. With adolescents, however, shared decision making with their parents “should be promoted,” the policy says. The ATS policy statement also warns that pain in young children often results “as much from diagnostic and therapeutic procedures as from the disease itself” and calls for adequate treatment of pain during initial procedures.

It encourages physicians to access certain up-to-date, resource-rich Web sites, such as that of the Center to Advance Palliative Care (www.capc.org

WASHINGTON — Cardiopulmonary resuscitation is often poorly performed by paramedics, physicians, and other well-trained hospital staff, and several problems—mainly frequent pauses and slow compression rates, shallow compression depths, and hyperventilation—are significantly reducing survival from cardiac arrest, emergency medicine leaders said.

“We can triple survival to hospital discharge by [addressing these problems] and doing good basic life support,” said Dr. Ahamed H. Idris, director of emergency medicine research at Southwestern Medical Center, Dallas, during a panel discussion on resuscitation at the annual meeting of the Society of Academic Emergency Medicine.

Research presented earlier at the meeting by Dr. Henry Wang of the University of Pittsburgh was emblematic of the growing body of data. His study of out-of-hospital cardiac arrests treated by paramedics documented frequent and prolonged interruptions in chest compressions due to endotracheal intubation (ETI) efforts.

Of 129 cases of cardiac arrest, they identified ETI-associated chest compression interruptions in 64 cases. The median duration of all ETI-associated interruptions was 78 seconds, Dr. Wang reported, and 35% of the interruptions exceeded 120 seconds.

Published reports of in-hospital cardiac arrest care have similarly documented widely variable and suboptimal chest compression rates, among other problems.

“We need to better monitor the quality of CPR” in and out of our hospitals, said Dr. Benjamin Abella, clinical research director of the Center for Resuscitative Science at the University of Pennsylvania Health System, Philadelphia, during the panel discussion.

Among the most recent studies published on cardiac arrest care is one published in January 2008 showing that delayed defibrillation is common and is associated with lower rates of survival.

Investigators identified 6,789 patients who had cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia at approximately 370 hospitals participating in the National Registry of Cardiopulmonary Resuscitation. They found that delayed defibrillation (more than a minute) was associated with a significantly lower probability of surviving to hospital discharge (22% vs. 39%) than was defibrillation that was not delayed (N. Engl. J. Med. 2008;358:9-17).

Dr. Abella said studies at his institution have shown that the chance of successful shock plummets with every 5, 10, or 15 seconds of additional pausing.

“If we can get the shock out in less than 10 seconds vs. 20 or 30 seconds, it makes a huge difference in terms of shock efficacy,” he said.

“We now know … that pauses [in CPR] are lethal,” Dr. Abella said in an interview, citing the landmark study published in 2000 that compared standard CPR (then cycles of 15 compressions and two breaths) with chest compression alone. The study utilized a dispatcher-assisted CPR program in Seattle, in which individuals who called 911 could be instructed in CPR. Investigators found that about 15% of the patients whose rescuers were instructed only in chest compression survived, compared with about 10% of those whose rescuers were instructed in rescue breathing and compression (Crit. Care Med. 2000;28:N190-2).

The study had significant limitations, but “at the time, this was shocking,” he said, “We all thought that breaths should be important.”

With respect to compression depth, animal studies have also shown that a coronary perfusion pressure of approximately 15 mm is necessary for resuscitation. In one study, that pressure (and a good survival rate) was achieved with compressions that were 2 inches deep, but not with compressions of 1.5 inches. In fact, all of the animals that received 2-inch-deep compressions survived, while very few of the animals that received 1.5-inch compressions survived.

Hyperventilation during CPR is also a problem. Changes to the American Heart Association's CPR guidelines published in 2005—namely, the change in the recommended ratio of compressions to breaths from 15:2 to 30:2—were intended to address this point.

With regard to the optimal rate of chest compression during CPR for cardiac arrest, new data come partly from prospective observational studies that Dr. Abella and his associates have performed of in-hospital cardiac arrests. The studies have revealed an inconsistent quality of CPR that often does not meet published guideline recommendations.

One of the studies, which covered 67 patients, documented chest compression rates of less than 90/min in 28% of recorded 30-second segments of CPR. Current guidelines recommend a rate of 100 compressions/min. The study also documented a shallow compression depth of less than 38 mm for 37% of compressions, as well as high ventilation rates, with more than 20 breaths/min given during 61% of CPR segments (JAMA 2005;293:305-10).

Another of the studies similarly showed compression rates of less than 80/min in 37% of CPR segments, and rates of less than 70/min in 22% of segments. Such suboptimal rates were associated with poor return of spontaneous circulation, Dr. Abella explained (Circulation 2005;111:428-34).

The most important message from his own research, Dr. Idris said, is not that there is a specific ideal compression rate, but that the more chest compressions per minute a patient receives, the better the outcome. “If a patient receives 80-100 compressions/min, the survival rate more than triples, compared to 20 chest compressions/min,” he explained.

Dr. Abella and his colleagues at the University of Pennsylvania, Philadelphia, have recently increased their rates of survival to hospital discharge for cardiac arrest patients by using defibrillators that monitor CPR, recording and providing feedback on the depth and rate of compressions. They also have initiated a “debriefing” program in which leaders routinely meet with rescue teams to review CPR data immediately after care is given.

EMS programs in Seattle and other locations, in the meantime, have begun telling their paramedics “to start compressions immediately and not intubate—to bag only—for the first 10 minutes,” Dr. Idris said.

With 80-100 compressions/min, the survival rate more than triples, compared with 20 compressions/min. DR. IDRIS

Some EMS programs have begun telling paramedics to start compressions immediately and not intubate—to bag only—for the first 10 minutes. ©Nancy Louie/iStockphoto, Inc.

WASHINGTON — Cardiopulmonary resuscitation is often poorly performed by paramedics, physicians, and other well-trained hospital staff, and several problems—mainly frequent pauses and slow compression rates, shallow compression depths, and hyperventilation—are significantly reducing survival from cardiac arrest, emergency medicine leaders said.

“We can triple survival to hospital discharge by [addressing these problems] and doing good basic life support,” said Dr. Ahamed H. Idris, director of emergency medicine research at Southwestern Medical Center, Dallas, during a panel discussion on resuscitation at the annual meeting of the Society of Academic Emergency Medicine.

Research presented earlier at the meeting by Dr. Henry Wang of the University of Pittsburgh was emblematic of the growing body of data. His study of out-of-hospital cardiac arrests treated by paramedics documented frequent and prolonged interruptions in chest compressions due to endotracheal intubation (ETI) efforts.

Of 129 cases of cardiac arrest, they identified ETI-associated chest compression interruptions in 64 cases. The median duration of all ETI-associated interruptions was 78 seconds, Dr. Wang reported, and 35% of the interruptions exceeded 120 seconds.

Published reports of in-hospital cardiac arrest care have similarly documented widely variable and suboptimal chest compression rates, among other problems.

“We need to better monitor the quality of CPR” in and out of our hospitals, said Dr. Benjamin Abella, clinical research director of the Center for Resuscitative Science at the University of Pennsylvania Health System, Philadelphia, during the panel discussion.

Among the most recent studies published on cardiac arrest care is one published in January 2008 showing that delayed defibrillation is common and is associated with lower rates of survival.

Investigators identified 6,789 patients who had cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia at approximately 370 hospitals participating in the National Registry of Cardiopulmonary Resuscitation. They found that delayed defibrillation (more than a minute) was associated with a significantly lower probability of surviving to hospital discharge (22% vs. 39%) than was defibrillation that was not delayed (N. Engl. J. Med. 2008;358:9-17).

Dr. Abella said studies at his institution have shown that the chance of successful shock plummets with every 5, 10, or 15 seconds of additional pausing.

“If we can get the shock out in less than 10 seconds vs. 20 or 30 seconds, it makes a huge difference in terms of shock efficacy,” he said.

“We now know … that pauses [in CPR] are lethal,” Dr. Abella said in an interview, citing the landmark study published in 2000 that compared standard CPR (then cycles of 15 compressions and two breaths) with chest compression alone. The study utilized a dispatcher-assisted CPR program in Seattle, in which individuals who called 911 could be instructed in CPR. Investigators found that about 15% of the patients whose rescuers were instructed only in chest compression survived, compared with about 10% of those whose rescuers were instructed in rescue breathing and compression (Crit. Care Med. 2000;28:N190-2).

The study had significant limitations, but “at the time, this was shocking,” he said, “We all thought that breaths should be important.”

With respect to compression depth, animal studies have also shown that a coronary perfusion pressure of approximately 15 mm is necessary for resuscitation. In one study, that pressure (and a good survival rate) was achieved with compressions that were 2 inches deep, but not with compressions of 1.5 inches. In fact, all of the animals that received 2-inch-deep compressions survived, while very few of the animals that received 1.5-inch compressions survived.

Hyperventilation during CPR is also a problem. Changes to the American Heart Association's CPR guidelines published in 2005—namely, the change in the recommended ratio of compressions to breaths from 15:2 to 30:2—were intended to address this point.

With regard to the optimal rate of chest compression during CPR for cardiac arrest, new data come partly from prospective observational studies that Dr. Abella and his associates have performed of in-hospital cardiac arrests. The studies have revealed an inconsistent quality of CPR that often does not meet published guideline recommendations.

One of the studies, which covered 67 patients, documented chest compression rates of less than 90/min in 28% of recorded 30-second segments of CPR. Current guidelines recommend a rate of 100 compressions/min. The study also documented a shallow compression depth of less than 38 mm for 37% of compressions, as well as high ventilation rates, with more than 20 breaths/min given during 61% of CPR segments (JAMA 2005;293:305-10).

Another of the studies similarly showed compression rates of less than 80/min in 37% of CPR segments, and rates of less than 70/min in 22% of segments. Such suboptimal rates were associated with poor return of spontaneous circulation, Dr. Abella explained (Circulation 2005;111:428-34).

The most important message from his own research, Dr. Idris said, is not that there is a specific ideal compression rate, but that the more chest compressions per minute a patient receives, the better the outcome. “If a patient receives 80-100 compressions/min, the survival rate more than triples, compared to 20 chest compressions/min,” he explained.

Dr. Abella and his colleagues at the University of Pennsylvania, Philadelphia, have recently increased their rates of survival to hospital discharge for cardiac arrest patients by using defibrillators that monitor CPR, recording and providing feedback on the depth and rate of compressions. They also have initiated a “debriefing” program in which leaders routinely meet with rescue teams to review CPR data immediately after care is given.

EMS programs in Seattle and other locations, in the meantime, have begun telling their paramedics “to start compressions immediately and not intubate—to bag only—for the first 10 minutes,” Dr. Idris said.

With 80-100 compressions/min, the survival rate more than triples, compared with 20 compressions/min. DR. IDRIS

Some EMS programs have begun telling paramedics to start compressions immediately and not intubate—to bag only—for the first 10 minutes. ©Nancy Louie/iStockphoto, Inc.

WASHINGTON — Cardiopulmonary resuscitation is often poorly performed by paramedics, physicians, and other well-trained hospital staff, and several problems—mainly frequent pauses and slow compression rates, shallow compression depths, and hyperventilation—are significantly reducing survival from cardiac arrest, emergency medicine leaders said.

“We can triple survival to hospital discharge by [addressing these problems] and doing good basic life support,” said Dr. Ahamed H. Idris, director of emergency medicine research at Southwestern Medical Center, Dallas, during a panel discussion on resuscitation at the annual meeting of the Society of Academic Emergency Medicine.

Research presented earlier at the meeting by Dr. Henry Wang of the University of Pittsburgh was emblematic of the growing body of data. His study of out-of-hospital cardiac arrests treated by paramedics documented frequent and prolonged interruptions in chest compressions due to endotracheal intubation (ETI) efforts.

Of 129 cases of cardiac arrest, they identified ETI-associated chest compression interruptions in 64 cases. The median duration of all ETI-associated interruptions was 78 seconds, Dr. Wang reported, and 35% of the interruptions exceeded 120 seconds.

Published reports of in-hospital cardiac arrest care have similarly documented widely variable and suboptimal chest compression rates, among other problems.

“We need to better monitor the quality of CPR” in and out of our hospitals, said Dr. Benjamin Abella, clinical research director of the Center for Resuscitative Science at the University of Pennsylvania Health System, Philadelphia, during the panel discussion.

Among the most recent studies published on cardiac arrest care is one published in January 2008 showing that delayed defibrillation is common and is associated with lower rates of survival.

Investigators identified 6,789 patients who had cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia at approximately 370 hospitals participating in the National Registry of Cardiopulmonary Resuscitation. They found that delayed defibrillation (more than a minute) was associated with a significantly lower probability of surviving to hospital discharge (22% vs. 39%) than was defibrillation that was not delayed (N. Engl. J. Med. 2008;358:9-17).

Dr. Abella said studies at his institution have shown that the chance of successful shock plummets with every 5, 10, or 15 seconds of additional pausing.

“If we can get the shock out in less than 10 seconds vs. 20 or 30 seconds, it makes a huge difference in terms of shock efficacy,” he said.

“We now know … that pauses [in CPR] are lethal,” Dr. Abella said in an interview, citing the landmark study published in 2000 that compared standard CPR (then cycles of 15 compressions and two breaths) with chest compression alone. The study utilized a dispatcher-assisted CPR program in Seattle, in which individuals who called 911 could be instructed in CPR. Investigators found that about 15% of the patients whose rescuers were instructed only in chest compression survived, compared with about 10% of those whose rescuers were instructed in rescue breathing and compression (Crit. Care Med. 2000;28:N190-2).

The study had significant limitations, but “at the time, this was shocking,” he said, “We all thought that breaths should be important.”

With respect to compression depth, animal studies have also shown that a coronary perfusion pressure of approximately 15 mm is necessary for resuscitation. In one study, that pressure (and a good survival rate) was achieved with compressions that were 2 inches deep, but not with compressions of 1.5 inches. In fact, all of the animals that received 2-inch-deep compressions survived, while very few of the animals that received 1.5-inch compressions survived.

Hyperventilation during CPR is also a problem. Changes to the American Heart Association's CPR guidelines published in 2005—namely, the change in the recommended ratio of compressions to breaths from 15:2 to 30:2—were intended to address this point.

With regard to the optimal rate of chest compression during CPR for cardiac arrest, new data come partly from prospective observational studies that Dr. Abella and his associates have performed of in-hospital cardiac arrests. The studies have revealed an inconsistent quality of CPR that often does not meet published guideline recommendations.

One of the studies, which covered 67 patients, documented chest compression rates of less than 90/min in 28% of recorded 30-second segments of CPR. Current guidelines recommend a rate of 100 compressions/min. The study also documented a shallow compression depth of less than 38 mm for 37% of compressions, as well as high ventilation rates, with more than 20 breaths/min given during 61% of CPR segments (JAMA 2005;293:305-10).

Another of the studies similarly showed compression rates of less than 80/min in 37% of CPR segments, and rates of less than 70/min in 22% of segments. Such suboptimal rates were associated with poor return of spontaneous circulation, Dr. Abella explained (Circulation 2005;111:428-34).

The most important message from his own research, Dr. Idris said, is not that there is a specific ideal compression rate, but that the more chest compressions per minute a patient receives, the better the outcome. “If a patient receives 80-100 compressions/min, the survival rate more than triples, compared to 20 chest compressions/min,” he explained.

Dr. Abella and his colleagues at the University of Pennsylvania, Philadelphia, have recently increased their rates of survival to hospital discharge for cardiac arrest patients by using defibrillators that monitor CPR, recording and providing feedback on the depth and rate of compressions. They also have initiated a “debriefing” program in which leaders routinely meet with rescue teams to review CPR data immediately after care is given.

EMS programs in Seattle and other locations, in the meantime, have begun telling their paramedics “to start compressions immediately and not intubate—to bag only—for the first 10 minutes,” Dr. Idris said.

With 80-100 compressions/min, the survival rate more than triples, compared with 20 compressions/min. DR. IDRIS

Some EMS programs have begun telling paramedics to start compressions immediately and not intubate—to bag only—for the first 10 minutes. ©Nancy Louie/iStockphoto, Inc.

WASHINGTON – Five years after the establishment of across-specialty rules to limit resident work hours, the issue of trainee schedules in teaching hospitals is again under the microscope as a continuing threat to patient safety–and this time an Institute of Medicine committee has been forewarned that specific “workable” solutions are needed.

The schedules in teaching hospitals “belie virtually all the tenets of providing good health care. How can we profess to provide the best possible quality of care when we know we have staff members who are operating at levels of sleep deprivation so severe that they are similar to someone driving under the influence of alcohol?” Dr. Carolyn Clancy, director of the federal Agency for Health Care Research and Quality, asked at a meeting sponsored by the Institute of Medicine.

“If we don't give members of Congress some workable solutions, they'll come up with their own,” she told members of the IOM's Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules.

The committee, which held the first of four workshops in December, was formed at the request of Rep. John D. Dingell (D-Mich.) and colleagues on the House Committee on Energy and Commerce as part of an investigation into preventable medical errors. The IOM will publish a report including strategies and actions for implementing safe work schedules in February 2009.

The issue of resident works hours received relatively little attention in the IOM's landmark 1999 report on medical errors, experts said at the workshop, despite several decades of research on the effects of sleep deprivation on human performance and research more specifically showing an impaired ability of interns to read EKGs after long shifts.

Since then–and especially within the past several years–various studies have demonstrated the effects of sleep deprivation in medical residents and have shown that reductions in work hours can reduce errors, physicians told the committee.

A prospective, national survey of more than 2,700 interns, for instance, showed that residents were seven times more likely to report a harmful fatigue-related error when they worked five or more 24-hour shifts in a month than when they worked no 24-hour shifts. They were four times more likely to report a fatal error.

And in a randomized controlled trial, residents had twice as many EEG-documented attention failures at night when working the traditional schedule of 24- to 30-hour shifts than when working an “intervention” schedule of a 16-hour maximum. Both studies were led by researchers at Harvard University.

Dr. Christopher P. Landrigan, who directs the Sleep and Patient Safety Program at Brigham and Women's Hospital, Boston, said the Harvard research has also shown that residents working 24- to 30-hour shifts make five times as many serious diagnostic errors as do those scheduled to work 16 hours or less. They're also twice as likely to crash their cars, and they suffer 61% more needlestick injuries, he told the IOM committee.

Limits instituted by the American Council on Graduate Medical Education in 2003 mark shifts of 24–30 hours as acceptable. The council's “common duty hour standards” call for a 24-hour limit on continuous duty, with an additional 6 hours allowed for continuity and the transfer of care, as well as an 80-hour weekly limit averaged over 4 weeks. Programs can request an increase of up to 8 hours a week and can apply for further exemptions. Residents must also have a minimum rest period of 10 hours between duty periods, 1 in 7 days free from patient care responsibilities, and in-house call no more than every third night, averaged over a 4-week period, the standards say.

The American Council on Graduate Medical Education says it has issued citations to individual programs for duty hour violations and has done resident surveys that demonstrate a compliance rate of 94%. Others argue, however, that enforcement is inadequate and that an independent body is needed to ensure compliance with the rules. Culture and tradition are so entrenched, they say, that too little has changed and that residents routinely underreport hours for fear of retaliation.

“I'm a resident who said one thing on a survey and did another thing in real life,” Dr. Sunny Ramchandani, past chair of the AMA Residents and Fellows Section, told the IOM committee. “I'd have a 30-hour shift, work at least 34 hours, and report 16.”

Part of the problem is that residents' workloads tend to remain the same even when shifts are shortened. Surveys of faculty and program directors taken by the American College of Physicians indicate that, even under the current rules, there is often less time for both formal and informal education, less time for ambulatory training, less time at the bedside, and a loss of continuity in care.

“Changing duty hours means changing everything,” from work flow and coverage strategies to transfer-of-care techniques and the “very fundamentals of how patients are treated” and what residents are responsible for, said Dr. Ethan Fried, director of graduate medical education at St. Luke's-Roosevelt Hospital Center in New York.

Hospitals in New York state have been dealing with work hour limits and supervision requirements since 1988, several years after the death of Libby Zion in a teaching hospital spurred the state to take action.

Changes made at Dr. Fried's hospital mean that a patient may now be admitted by one team of residents, treated by another, and discharged by yet another. “And it's up to educators to help residents integrate these experiences,” he said. “I [still] don't know whether I can.”

In Europe, the IOM committee was reminded, physicians and other health care workers are prohibited from working more than 13 hours straight or more than 48–56 hours per week. And for decades, physicians in New Zealand have worked with 16-hour shift limits and 72-hour weekly limits.

Different methods of graduate medical education financing and other health system differences make comparisons difficult, however. Here in the United States, Dr. Fried said, “with duty hour restrictions coming at the same time as patient volumes have increased, as acuity (of illness) in teaching hospitals has increased, and even as our treatments have become higher-stakes treatments, we have the perfect storm.”

WASHINGTON – Five years after the establishment of across-specialty rules to limit resident work hours, the issue of trainee schedules in teaching hospitals is again under the microscope as a continuing threat to patient safety–and this time an Institute of Medicine committee has been forewarned that specific “workable” solutions are needed.

The schedules in teaching hospitals “belie virtually all the tenets of providing good health care. How can we profess to provide the best possible quality of care when we know we have staff members who are operating at levels of sleep deprivation so severe that they are similar to someone driving under the influence of alcohol?” Dr. Carolyn Clancy, director of the federal Agency for Health Care Research and Quality, asked at a meeting sponsored by the Institute of Medicine.

“If we don't give members of Congress some workable solutions, they'll come up with their own,” she told members of the IOM's Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules.

The committee, which held the first of four workshops in December, was formed at the request of Rep. John D. Dingell (D-Mich.) and colleagues on the House Committee on Energy and Commerce as part of an investigation into preventable medical errors. The IOM will publish a report including strategies and actions for implementing safe work schedules in February 2009.

The issue of resident works hours received relatively little attention in the IOM's landmark 1999 report on medical errors, experts said at the workshop, despite several decades of research on the effects of sleep deprivation on human performance and research more specifically showing an impaired ability of interns to read EKGs after long shifts.

Since then–and especially within the past several years–various studies have demonstrated the effects of sleep deprivation in medical residents and have shown that reductions in work hours can reduce errors, physicians told the committee.

A prospective, national survey of more than 2,700 interns, for instance, showed that residents were seven times more likely to report a harmful fatigue-related error when they worked five or more 24-hour shifts in a month than when they worked no 24-hour shifts. They were four times more likely to report a fatal error.

And in a randomized controlled trial, residents had twice as many EEG-documented attention failures at night when working the traditional schedule of 24- to 30-hour shifts than when working an “intervention” schedule of a 16-hour maximum. Both studies were led by researchers at Harvard University.

Dr. Christopher P. Landrigan, who directs the Sleep and Patient Safety Program at Brigham and Women's Hospital, Boston, said the Harvard research has also shown that residents working 24- to 30-hour shifts make five times as many serious diagnostic errors as do those scheduled to work 16 hours or less. They're also twice as likely to crash their cars, and they suffer 61% more needlestick injuries, he told the IOM committee.

Limits instituted by the American Council on Graduate Medical Education in 2003 mark shifts of 24–30 hours as acceptable. The council's “common duty hour standards” call for a 24-hour limit on continuous duty, with an additional 6 hours allowed for continuity and the transfer of care, as well as an 80-hour weekly limit averaged over 4 weeks. Programs can request an increase of up to 8 hours a week and can apply for further exemptions. Residents must also have a minimum rest period of 10 hours between duty periods, 1 in 7 days free from patient care responsibilities, and in-house call no more than every third night, averaged over a 4-week period, the standards say.

The American Council on Graduate Medical Education says it has issued citations to individual programs for duty hour violations and has done resident surveys that demonstrate a compliance rate of 94%. Others argue, however, that enforcement is inadequate and that an independent body is needed to ensure compliance with the rules. Culture and tradition are so entrenched, they say, that too little has changed and that residents routinely underreport hours for fear of retaliation.

“I'm a resident who said one thing on a survey and did another thing in real life,” Dr. Sunny Ramchandani, past chair of the AMA Residents and Fellows Section, told the IOM committee. “I'd have a 30-hour shift, work at least 34 hours, and report 16.”

Part of the problem is that residents' workloads tend to remain the same even when shifts are shortened. Surveys of faculty and program directors taken by the American College of Physicians indicate that, even under the current rules, there is often less time for both formal and informal education, less time for ambulatory training, less time at the bedside, and a loss of continuity in care.

“Changing duty hours means changing everything,” from work flow and coverage strategies to transfer-of-care techniques and the “very fundamentals of how patients are treated” and what residents are responsible for, said Dr. Ethan Fried, director of graduate medical education at St. Luke's-Roosevelt Hospital Center in New York.

Hospitals in New York state have been dealing with work hour limits and supervision requirements since 1988, several years after the death of Libby Zion in a teaching hospital spurred the state to take action.

Changes made at Dr. Fried's hospital mean that a patient may now be admitted by one team of residents, treated by another, and discharged by yet another. “And it's up to educators to help residents integrate these experiences,” he said. “I [still] don't know whether I can.”

In Europe, the IOM committee was reminded, physicians and other health care workers are prohibited from working more than 13 hours straight or more than 48–56 hours per week. And for decades, physicians in New Zealand have worked with 16-hour shift limits and 72-hour weekly limits.

Different methods of graduate medical education financing and other health system differences make comparisons difficult, however. Here in the United States, Dr. Fried said, “with duty hour restrictions coming at the same time as patient volumes have increased, as acuity (of illness) in teaching hospitals has increased, and even as our treatments have become higher-stakes treatments, we have the perfect storm.”

WASHINGTON – Five years after the establishment of across-specialty rules to limit resident work hours, the issue of trainee schedules in teaching hospitals is again under the microscope as a continuing threat to patient safety–and this time an Institute of Medicine committee has been forewarned that specific “workable” solutions are needed.

The schedules in teaching hospitals “belie virtually all the tenets of providing good health care. How can we profess to provide the best possible quality of care when we know we have staff members who are operating at levels of sleep deprivation so severe that they are similar to someone driving under the influence of alcohol?” Dr. Carolyn Clancy, director of the federal Agency for Health Care Research and Quality, asked at a meeting sponsored by the Institute of Medicine.

“If we don't give members of Congress some workable solutions, they'll come up with their own,” she told members of the IOM's Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules.

The committee, which held the first of four workshops in December, was formed at the request of Rep. John D. Dingell (D-Mich.) and colleagues on the House Committee on Energy and Commerce as part of an investigation into preventable medical errors. The IOM will publish a report including strategies and actions for implementing safe work schedules in February 2009.

The issue of resident works hours received relatively little attention in the IOM's landmark 1999 report on medical errors, experts said at the workshop, despite several decades of research on the effects of sleep deprivation on human performance and research more specifically showing an impaired ability of interns to read EKGs after long shifts.

Since then–and especially within the past several years–various studies have demonstrated the effects of sleep deprivation in medical residents and have shown that reductions in work hours can reduce errors, physicians told the committee.

A prospective, national survey of more than 2,700 interns, for instance, showed that residents were seven times more likely to report a harmful fatigue-related error when they worked five or more 24-hour shifts in a month than when they worked no 24-hour shifts. They were four times more likely to report a fatal error.

And in a randomized controlled trial, residents had twice as many EEG-documented attention failures at night when working the traditional schedule of 24- to 30-hour shifts than when working an “intervention” schedule of a 16-hour maximum. Both studies were led by researchers at Harvard University.

Dr. Christopher P. Landrigan, who directs the Sleep and Patient Safety Program at Brigham and Women's Hospital, Boston, said the Harvard research has also shown that residents working 24- to 30-hour shifts make five times as many serious diagnostic errors as do those scheduled to work 16 hours or less. They're also twice as likely to crash their cars, and they suffer 61% more needlestick injuries, he told the IOM committee.

Limits instituted by the American Council on Graduate Medical Education in 2003 mark shifts of 24–30 hours as acceptable. The council's “common duty hour standards” call for a 24-hour limit on continuous duty, with an additional 6 hours allowed for continuity and the transfer of care, as well as an 80-hour weekly limit averaged over 4 weeks. Programs can request an increase of up to 8 hours a week and can apply for further exemptions. Residents must also have a minimum rest period of 10 hours between duty periods, 1 in 7 days free from patient care responsibilities, and in-house call no more than every third night, averaged over a 4-week period, the standards say.

The American Council on Graduate Medical Education says it has issued citations to individual programs for duty hour violations and has done resident surveys that demonstrate a compliance rate of 94%. Others argue, however, that enforcement is inadequate and that an independent body is needed to ensure compliance with the rules. Culture and tradition are so entrenched, they say, that too little has changed and that residents routinely underreport hours for fear of retaliation.

“I'm a resident who said one thing on a survey and did another thing in real life,” Dr. Sunny Ramchandani, past chair of the AMA Residents and Fellows Section, told the IOM committee. “I'd have a 30-hour shift, work at least 34 hours, and report 16.”

Part of the problem is that residents' workloads tend to remain the same even when shifts are shortened. Surveys of faculty and program directors taken by the American College of Physicians indicate that, even under the current rules, there is often less time for both formal and informal education, less time for ambulatory training, less time at the bedside, and a loss of continuity in care.

“Changing duty hours means changing everything,” from work flow and coverage strategies to transfer-of-care techniques and the “very fundamentals of how patients are treated” and what residents are responsible for, said Dr. Ethan Fried, director of graduate medical education at St. Luke's-Roosevelt Hospital Center in New York.

Hospitals in New York state have been dealing with work hour limits and supervision requirements since 1988, several years after the death of Libby Zion in a teaching hospital spurred the state to take action.

Changes made at Dr. Fried's hospital mean that a patient may now be admitted by one team of residents, treated by another, and discharged by yet another. “And it's up to educators to help residents integrate these experiences,” he said. “I [still] don't know whether I can.”

In Europe, the IOM committee was reminded, physicians and other health care workers are prohibited from working more than 13 hours straight or more than 48–56 hours per week. And for decades, physicians in New Zealand have worked with 16-hour shift limits and 72-hour weekly limits.

Different methods of graduate medical education financing and other health system differences make comparisons difficult, however. Here in the United States, Dr. Fried said, “with duty hour restrictions coming at the same time as patient volumes have increased, as acuity (of illness) in teaching hospitals has increased, and even as our treatments have become higher-stakes treatments, we have the perfect storm.”

WASHINGTON — Five years after the establishment of across-specialty rules to limit resident work hours, the issue of trainee schedules in teaching hospitals is again under the microscope as a continuing threat to patient safety—and this time an Institute of Medicine committee has been forewarned that specific “workable” solutions are needed.

The schedules in teaching hospitals “belie virtually all the tenets of providing good health care. How can we profess to provide the best possible quality of care when we know we have staff members who are operating at levels of sleep deprivation so severe that they are similar to someone driving under the influence of alcohol?” Dr. Carolyn Clancy, director of the federal Agency for Health Care Research and Quality, asked at a meeting sponsored by the Institute of Medicine.

“If we don't give members of Congress some workable solutions, they'll come up with their own,” she told members of the IOM's Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules.

The committee, which held the first of four workshops in December, was formed at the request of Rep. John D. Dingell (D-Mich.) and colleagues on the House Committee on Energy and Commerce as part of an investigation into preventable medical errors. The IOM will publish a report including strategies and actions for implementing safe work schedules in February 2009.

The issue of resident works hours received relatively little attention in the IOM's landmark 1999 report on medical errors, experts said at the workshop, despite several decades of research on the effects of sleep deprivation on human performance and research more specifically showing an impaired ability of interns to read EKGs after long shifts.

Since then—and especially within the past several years—various studies have demonstrated the effects of sleep deprivation in medical residents and have shown that reductions in work hours can reduce errors, physicians told the committee.

A prospective, national survey of more than 2,700 interns, for instance, showed that residents were seven times more likely to report a harmful fatigue-related error when they worked five or more 24-hour shifts in a month than when they worked no 24-hour shifts. They were four times more likely to report a fatal error.

In a randomized trial, residents had twice as many EEG-documented attention failures at night when working the traditional schedule of 24- to 30-hour shifts than when working an “intervention” schedule of a 16-hour maximum. Both studies were led by researchers at Harvard University.

Dr. Christopher P. Landrigan, who directs the Sleep and Patient Safety Program at Brigham and Women's Hospital, Boston, said the Harvard research has also shown that residents working 24- to 30-hour shifts make five times as many serious diagnostic errors as do those scheduled to work 16 hours or less. They're also twice as likely to crash their cars, and they suffer 61% more needlestick injuries, he told the IOM committee.

Limits instituted by the American Council on Graduate Medical Education in 2003 mark shifts of 24–30 hours as acceptable. The council's “common duty hour standards” call for a 24-hour limit on continuous duty, with an additional 6 hours allowed for continuity and the transfer of care, as well as an 80-hour weekly limit averaged over 4 weeks. Programs can request an increase of up to 8 hours a week and can apply for further exemptions.

Residents must also have a minimum rest period of 10 hours between duty periods, 1 in 7 days free from patient care responsibilities, and in-house call no more than every third night, averaged over a 4-week period, the standards say.

The American Council on Graduate Medical Education says it has issued citations to individual programs for duty hour violations and has done resident surveys that demonstrate a compliance rate of 94%.

Others argue that enforcement is inadequate and that an independent body is needed to ensure compliance. Culture and tradition are so entrenched, they say, that too little has changed and that residents routinely underreport hours for fear of retaliation.

“I'm a resident who said one thing on a survey and did another thing in real life,” Dr. Sunny Ramchandani, past chair of the AMA Residents and Fellows Section, told the IOM committee. “I'd have a 30-hour shift, work at least 34 hours, and report 16.”

Residents' workloads tend to remain the same even when shifts are shortened. Surveys of faculty and program directors taken by the American College of Physicians indicate that, even under the current rules, there is often less time for both formal and informal education.

“Changing duty hours means changing everything,” from work flow and coverage strategies to transfer-of-care techniques and the “very fundamentals of how patients are treated” and what residents are responsible for, said Dr. Ethan Fried, director of graduate medical education at St. Luke's-Roosevelt Hospital Center in New York.

Hospitals in New York state have been dealing with work hour limits and supervision requirements since 1988, several years after the death of Libby Zion in a teaching hospital spurred the state to take action.

Changes made at Dr. Fried's hospital mean that a patient may be admitted by one team of residents, treated by another, and discharged by yet another. “It's up to educators to help residents integrate these experiences,” he said. “I don't know whether I can.”

WASHINGTON — Five years after the establishment of across-specialty rules to limit resident work hours, the issue of trainee schedules in teaching hospitals is again under the microscope as a continuing threat to patient safety—and this time an Institute of Medicine committee has been forewarned that specific “workable” solutions are needed.

The schedules in teaching hospitals “belie virtually all the tenets of providing good health care. How can we profess to provide the best possible quality of care when we know we have staff members who are operating at levels of sleep deprivation so severe that they are similar to someone driving under the influence of alcohol?” Dr. Carolyn Clancy, director of the federal Agency for Health Care Research and Quality, asked at a meeting sponsored by the Institute of Medicine.

“If we don't give members of Congress some workable solutions, they'll come up with their own,” she told members of the IOM's Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules.

The committee, which held the first of four workshops in December, was formed at the request of Rep. John D. Dingell (D-Mich.) and colleagues on the House Committee on Energy and Commerce as part of an investigation into preventable medical errors. The IOM will publish a report including strategies and actions for implementing safe work schedules in February 2009.

The issue of resident works hours received relatively little attention in the IOM's landmark 1999 report on medical errors, experts said at the workshop, despite several decades of research on the effects of sleep deprivation on human performance and research more specifically showing an impaired ability of interns to read EKGs after long shifts.

Since then—and especially within the past several years—various studies have demonstrated the effects of sleep deprivation in medical residents and have shown that reductions in work hours can reduce errors, physicians told the committee.

A prospective, national survey of more than 2,700 interns, for instance, showed that residents were seven times more likely to report a harmful fatigue-related error when they worked five or more 24-hour shifts in a month than when they worked no 24-hour shifts. They were four times more likely to report a fatal error.

In a randomized trial, residents had twice as many EEG-documented attention failures at night when working the traditional schedule of 24- to 30-hour shifts than when working an “intervention” schedule of a 16-hour maximum. Both studies were led by researchers at Harvard University.

Dr. Christopher P. Landrigan, who directs the Sleep and Patient Safety Program at Brigham and Women's Hospital, Boston, said the Harvard research has also shown that residents working 24- to 30-hour shifts make five times as many serious diagnostic errors as do those scheduled to work 16 hours or less. They're also twice as likely to crash their cars, and they suffer 61% more needlestick injuries, he told the IOM committee.

Limits instituted by the American Council on Graduate Medical Education in 2003 mark shifts of 24–30 hours as acceptable. The council's “common duty hour standards” call for a 24-hour limit on continuous duty, with an additional 6 hours allowed for continuity and the transfer of care, as well as an 80-hour weekly limit averaged over 4 weeks. Programs can request an increase of up to 8 hours a week and can apply for further exemptions.

Residents must also have a minimum rest period of 10 hours between duty periods, 1 in 7 days free from patient care responsibilities, and in-house call no more than every third night, averaged over a 4-week period, the standards say.

The American Council on Graduate Medical Education says it has issued citations to individual programs for duty hour violations and has done resident surveys that demonstrate a compliance rate of 94%.

Others argue that enforcement is inadequate and that an independent body is needed to ensure compliance. Culture and tradition are so entrenched, they say, that too little has changed and that residents routinely underreport hours for fear of retaliation.

“I'm a resident who said one thing on a survey and did another thing in real life,” Dr. Sunny Ramchandani, past chair of the AMA Residents and Fellows Section, told the IOM committee. “I'd have a 30-hour shift, work at least 34 hours, and report 16.”

Residents' workloads tend to remain the same even when shifts are shortened. Surveys of faculty and program directors taken by the American College of Physicians indicate that, even under the current rules, there is often less time for both formal and informal education.

“Changing duty hours means changing everything,” from work flow and coverage strategies to transfer-of-care techniques and the “very fundamentals of how patients are treated” and what residents are responsible for, said Dr. Ethan Fried, director of graduate medical education at St. Luke's-Roosevelt Hospital Center in New York.

Hospitals in New York state have been dealing with work hour limits and supervision requirements since 1988, several years after the death of Libby Zion in a teaching hospital spurred the state to take action.

Changes made at Dr. Fried's hospital mean that a patient may be admitted by one team of residents, treated by another, and discharged by yet another. “It's up to educators to help residents integrate these experiences,” he said. “I don't know whether I can.”

WASHINGTON — Five years after the establishment of across-specialty rules to limit resident work hours, the issue of trainee schedules in teaching hospitals is again under the microscope as a continuing threat to patient safety—and this time an Institute of Medicine committee has been forewarned that specific “workable” solutions are needed.

The schedules in teaching hospitals “belie virtually all the tenets of providing good health care. How can we profess to provide the best possible quality of care when we know we have staff members who are operating at levels of sleep deprivation so severe that they are similar to someone driving under the influence of alcohol?” Dr. Carolyn Clancy, director of the federal Agency for Health Care Research and Quality, asked at a meeting sponsored by the Institute of Medicine.

“If we don't give members of Congress some workable solutions, they'll come up with their own,” she told members of the IOM's Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules.

The committee, which held the first of four workshops in December, was formed at the request of Rep. John D. Dingell (D-Mich.) and colleagues on the House Committee on Energy and Commerce as part of an investigation into preventable medical errors. The IOM will publish a report including strategies and actions for implementing safe work schedules in February 2009.

The issue of resident works hours received relatively little attention in the IOM's landmark 1999 report on medical errors, experts said at the workshop, despite several decades of research on the effects of sleep deprivation on human performance and research more specifically showing an impaired ability of interns to read EKGs after long shifts.

Since then—and especially within the past several years—various studies have demonstrated the effects of sleep deprivation in medical residents and have shown that reductions in work hours can reduce errors, physicians told the committee.

A prospective, national survey of more than 2,700 interns, for instance, showed that residents were seven times more likely to report a harmful fatigue-related error when they worked five or more 24-hour shifts in a month than when they worked no 24-hour shifts. They were four times more likely to report a fatal error.

In a randomized trial, residents had twice as many EEG-documented attention failures at night when working the traditional schedule of 24- to 30-hour shifts than when working an “intervention” schedule of a 16-hour maximum. Both studies were led by researchers at Harvard University.

Dr. Christopher P. Landrigan, who directs the Sleep and Patient Safety Program at Brigham and Women's Hospital, Boston, said the Harvard research has also shown that residents working 24- to 30-hour shifts make five times as many serious diagnostic errors as do those scheduled to work 16 hours or less. They're also twice as likely to crash their cars, and they suffer 61% more needlestick injuries, he told the IOM committee.

Limits instituted by the American Council on Graduate Medical Education in 2003 mark shifts of 24–30 hours as acceptable. The council's “common duty hour standards” call for a 24-hour limit on continuous duty, with an additional 6 hours allowed for continuity and the transfer of care, as well as an 80-hour weekly limit averaged over 4 weeks. Programs can request an increase of up to 8 hours a week and can apply for further exemptions.

Residents must also have a minimum rest period of 10 hours between duty periods, 1 in 7 days free from patient care responsibilities, and in-house call no more than every third night, averaged over a 4-week period, the standards say.

The American Council on Graduate Medical Education says it has issued citations to individual programs for duty hour violations and has done resident surveys that demonstrate a compliance rate of 94%.

Others argue that enforcement is inadequate and that an independent body is needed to ensure compliance. Culture and tradition are so entrenched, they say, that too little has changed and that residents routinely underreport hours for fear of retaliation.

“I'm a resident who said one thing on a survey and did another thing in real life,” Dr. Sunny Ramchandani, past chair of the AMA Residents and Fellows Section, told the IOM committee. “I'd have a 30-hour shift, work at least 34 hours, and report 16.”

Residents' workloads tend to remain the same even when shifts are shortened. Surveys of faculty and program directors taken by the American College of Physicians indicate that, even under the current rules, there is often less time for both formal and informal education.

“Changing duty hours means changing everything,” from work flow and coverage strategies to transfer-of-care techniques and the “very fundamentals of how patients are treated” and what residents are responsible for, said Dr. Ethan Fried, director of graduate medical education at St. Luke's-Roosevelt Hospital Center in New York.

Hospitals in New York state have been dealing with work hour limits and supervision requirements since 1988, several years after the death of Libby Zion in a teaching hospital spurred the state to take action.

Changes made at Dr. Fried's hospital mean that a patient may be admitted by one team of residents, treated by another, and discharged by yet another. “It's up to educators to help residents integrate these experiences,” he said. “I don't know whether I can.”

WASHINGTON — Five years after the establishment of across-specialty rules to limit resident work hours, the issue of trainee schedules in teaching hospitals is again under the microscope as a continuing threat to patient safety—and this time an Institute of Medicine committee has been forewarned that specific "workable" solutions are needed.

The schedules in teaching hospitals "belie virtually all the tenets of providing good health care. How can we profess to provide the best possible quality of care when we know we have staff members who are operating at levels of sleep deprivation so severe that they are similar to someone driving under the influence of alcohol?" Dr. Carolyn Clancy, director of the federal Agency for Health Care Research and Quality, asked at a meeting sponsored by the Institute of Medicine.

"If we don't give the members of Congress some workable solutions, they will come up with their own," she told members of the IOM's Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules.

The committee, which held the first of four workshops in December, was formed at the request of Rep. John D. Dingell (D-Mich.) and colleagues on the House Committee on Energy and Commerce as part of an investigation into preventable medical errors. The IOM will publish a report including strategies and actions for implementing safe work schedules in February 2009.

The issue of resident work hours received relatively little attention in the IOM's landmark 1999 report on medical errors, experts said at the workshop, despite several decades of research on the effects of sleep deprivation on human performance and research more specifically showing an impaired ability of interns to read EKGs after long shifts.

Since then—and especially within the past several years—various studies have demonstrated the effects of sleep deprivation in medical residents and have shown that reductions in work hours can reduce errors, physicians told the committee.

A prospective, national survey of more than 2,700 interns, for instance, showed that residents were seven times more likely to report a harmful fatigue-related error when they worked five or more 24-hour shifts in a month than when they worked no 24-hour shifts. They were four times more likely to report a fatal error.

And in a randomized controlled trial, residents had twice as many EEG-documented attention failures at night when working the traditional schedule of 24- to 30-hour shifts than when working an "intervention" schedule of a 16-hour maximum. Both studies were led by researchers at Harvard University.

Dr. Christopher P. Landrigan, who directs the Sleep and Patient Safety Program at Brigham and Women's Hospital, Boston, said the Harvard research has also shown that residents working 24- to 30-hour shifts make five times as many serious diagnostic errors as do those scheduled to work 16 hours or less. They're also twice as likely to crash their cars, and they suffer 61% more needlestick injuries, he told the IOM committee.

Limits instituted by the American Council on Graduate Medical Education in 2003 mark shifts of 24–30 hours as acceptable. The council's "common duty hour standards" call for a 24-hour limit on continuous duty, with an additional 6 hours allowed for continuity and the transfer of care, as well as an 80-hour weekly limit averaged over 4 weeks. Programs can request an increase of up to 8 hours a week and can apply for further exemptions.

Residents must also have a minimum rest period of 10 hours between duty periods, 1 in 7 days free from patient care responsibilities, and in-house call no more than every third night, averaged over a 4-week period, the standards say.

The American Council on Graduate Medical Education says that it has issued citations to individual programs for duty hour violations and has done resident surveys that demonstrate a compliance rate of 94%.

Others argue, however, that enforcement is inadequate and that an independent body is needed to ensure compliance with the rules. Culture and tradition are so entrenched, they say, that too little has changed and that residents routinely underreport hours for fear of retaliation.

"I'm a resident who said one thing on a survey and did another thing in real life," Dr. Sunny Ramchandani, past chair of the AMA Residents and Fellows Section, told the IOM committee. "I'd have a 30-hour shift, work at least 34 hours, and report 16."

Part of the problem is that residents' workloads tend to remain the same even when shifts are shortened. Surveys of faculty and program directors taken by the American College of Physicians indicate that, even under the current rules, there is often less time for both formal and informal education, less time for ambulatory training, less time at the bedside, and a loss of continuity in care.

"Changing duty hours means changing everything," from work flow and coverage strategies to transfer-of-care techniques and the "very fundamentals of how patients are treated" and what residents are responsible for, said Dr. Ethan Fried, director of graduate medical education at St. Luke's-Roosevelt Hospital Center in New York.

Hospitals in New York state have been dealing with work hour limits and supervision requirements since 1988, several years after the death of Libby Zion in a teaching hospital spurred the state to act.

Changes made at Dr. Fried's hospital mean that a patient may now be admitted by one team of residents, treated by another, and discharged by yet another. "And it's up to educators to help residents integrate these experiences," he said. "I [still] don't know whether I can."

In Europe, the IOM committee was reminded, physicians and other health care workers are prohibited from working more than 13 hours straight or more than 48–56 hours per week. And for decades, physicians in New Zealand have worked with 16-hour shift limits and 72-hour weekly limits.

Different methods of graduate medical education financing and other health system differences make comparisons difficult, however. Here in the United States, Dr. Fried said, "with duty hour restrictions coming at the same time as patient volumes have increased, as acuity (of illness) in teaching hospitals has increased, and even as our treatments have become higher-stakes treatments, we have the perfect storm."

WASHINGTON — Five years after the establishment of across-specialty rules to limit resident work hours, the issue of trainee schedules in teaching hospitals is again under the microscope as a continuing threat to patient safety—and this time an Institute of Medicine committee has been forewarned that specific "workable" solutions are needed.

The schedules in teaching hospitals "belie virtually all the tenets of providing good health care. How can we profess to provide the best possible quality of care when we know we have staff members who are operating at levels of sleep deprivation so severe that they are similar to someone driving under the influence of alcohol?" Dr. Carolyn Clancy, director of the federal Agency for Health Care Research and Quality, asked at a meeting sponsored by the Institute of Medicine.

"If we don't give the members of Congress some workable solutions, they will come up with their own," she told members of the IOM's Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules.

The committee, which held the first of four workshops in December, was formed at the request of Rep. John D. Dingell (D-Mich.) and colleagues on the House Committee on Energy and Commerce as part of an investigation into preventable medical errors. The IOM will publish a report including strategies and actions for implementing safe work schedules in February 2009.

The issue of resident work hours received relatively little attention in the IOM's landmark 1999 report on medical errors, experts said at the workshop, despite several decades of research on the effects of sleep deprivation on human performance and research more specifically showing an impaired ability of interns to read EKGs after long shifts.

Since then—and especially within the past several years—various studies have demonstrated the effects of sleep deprivation in medical residents and have shown that reductions in work hours can reduce errors, physicians told the committee.

A prospective, national survey of more than 2,700 interns, for instance, showed that residents were seven times more likely to report a harmful fatigue-related error when they worked five or more 24-hour shifts in a month than when they worked no 24-hour shifts. They were four times more likely to report a fatal error.

And in a randomized controlled trial, residents had twice as many EEG-documented attention failures at night when working the traditional schedule of 24- to 30-hour shifts than when working an "intervention" schedule of a 16-hour maximum. Both studies were led by researchers at Harvard University.

Dr. Christopher P. Landrigan, who directs the Sleep and Patient Safety Program at Brigham and Women's Hospital, Boston, said the Harvard research has also shown that residents working 24- to 30-hour shifts make five times as many serious diagnostic errors as do those scheduled to work 16 hours or less. They're also twice as likely to crash their cars, and they suffer 61% more needlestick injuries, he told the IOM committee.

Limits instituted by the American Council on Graduate Medical Education in 2003 mark shifts of 24–30 hours as acceptable. The council's "common duty hour standards" call for a 24-hour limit on continuous duty, with an additional 6 hours allowed for continuity and the transfer of care, as well as an 80-hour weekly limit averaged over 4 weeks. Programs can request an increase of up to 8 hours a week and can apply for further exemptions.

Residents must also have a minimum rest period of 10 hours between duty periods, 1 in 7 days free from patient care responsibilities, and in-house call no more than every third night, averaged over a 4-week period, the standards say.

The American Council on Graduate Medical Education says that it has issued citations to individual programs for duty hour violations and has done resident surveys that demonstrate a compliance rate of 94%.

Others argue, however, that enforcement is inadequate and that an independent body is needed to ensure compliance with the rules. Culture and tradition are so entrenched, they say, that too little has changed and that residents routinely underreport hours for fear of retaliation.

"I'm a resident who said one thing on a survey and did another thing in real life," Dr. Sunny Ramchandani, past chair of the AMA Residents and Fellows Section, told the IOM committee. "I'd have a 30-hour shift, work at least 34 hours, and report 16."

Part of the problem is that residents' workloads tend to remain the same even when shifts are shortened. Surveys of faculty and program directors taken by the American College of Physicians indicate that, even under the current rules, there is often less time for both formal and informal education, less time for ambulatory training, less time at the bedside, and a loss of continuity in care.

"Changing duty hours means changing everything," from work flow and coverage strategies to transfer-of-care techniques and the "very fundamentals of how patients are treated" and what residents are responsible for, said Dr. Ethan Fried, director of graduate medical education at St. Luke's-Roosevelt Hospital Center in New York.

Hospitals in New York state have been dealing with work hour limits and supervision requirements since 1988, several years after the death of Libby Zion in a teaching hospital spurred the state to act.

Changes made at Dr. Fried's hospital mean that a patient may now be admitted by one team of residents, treated by another, and discharged by yet another. "And it's up to educators to help residents integrate these experiences," he said. "I [still] don't know whether I can."

In Europe, the IOM committee was reminded, physicians and other health care workers are prohibited from working more than 13 hours straight or more than 48–56 hours per week. And for decades, physicians in New Zealand have worked with 16-hour shift limits and 72-hour weekly limits.

Different methods of graduate medical education financing and other health system differences make comparisons difficult, however. Here in the United States, Dr. Fried said, "with duty hour restrictions coming at the same time as patient volumes have increased, as acuity (of illness) in teaching hospitals has increased, and even as our treatments have become higher-stakes treatments, we have the perfect storm."

WASHINGTON — Five years after the establishment of across-specialty rules to limit resident work hours, the issue of trainee schedules in teaching hospitals is again under the microscope as a continuing threat to patient safety—and this time an Institute of Medicine committee has been forewarned that specific "workable" solutions are needed.

The schedules in teaching hospitals "belie virtually all the tenets of providing good health care. How can we profess to provide the best possible quality of care when we know we have staff members who are operating at levels of sleep deprivation so severe that they are similar to someone driving under the influence of alcohol?" Dr. Carolyn Clancy, director of the federal Agency for Health Care Research and Quality, asked at a meeting sponsored by the Institute of Medicine.

"If we don't give the members of Congress some workable solutions, they will come up with their own," she told members of the IOM's Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules.

The committee, which held the first of four workshops in December, was formed at the request of Rep. John D. Dingell (D-Mich.) and colleagues on the House Committee on Energy and Commerce as part of an investigation into preventable medical errors. The IOM will publish a report including strategies and actions for implementing safe work schedules in February 2009.

The issue of resident work hours received relatively little attention in the IOM's landmark 1999 report on medical errors, experts said at the workshop, despite several decades of research on the effects of sleep deprivation on human performance and research more specifically showing an impaired ability of interns to read EKGs after long shifts.

Since then—and especially within the past several years—various studies have demonstrated the effects of sleep deprivation in medical residents and have shown that reductions in work hours can reduce errors, physicians told the committee.

A prospective, national survey of more than 2,700 interns, for instance, showed that residents were seven times more likely to report a harmful fatigue-related error when they worked five or more 24-hour shifts in a month than when they worked no 24-hour shifts. They were four times more likely to report a fatal error.

And in a randomized controlled trial, residents had twice as many EEG-documented attention failures at night when working the traditional schedule of 24- to 30-hour shifts than when working an "intervention" schedule of a 16-hour maximum. Both studies were led by researchers at Harvard University.

Dr. Christopher P. Landrigan, who directs the Sleep and Patient Safety Program at Brigham and Women's Hospital, Boston, said the Harvard research has also shown that residents working 24- to 30-hour shifts make five times as many serious diagnostic errors as do those scheduled to work 16 hours or less. They're also twice as likely to crash their cars, and they suffer 61% more needlestick injuries, he told the IOM committee.

Limits instituted by the American Council on Graduate Medical Education in 2003 mark shifts of 24–30 hours as acceptable. The council's "common duty hour standards" call for a 24-hour limit on continuous duty, with an additional 6 hours allowed for continuity and the transfer of care, as well as an 80-hour weekly limit averaged over 4 weeks. Programs can request an increase of up to 8 hours a week and can apply for further exemptions.

Residents must also have a minimum rest period of 10 hours between duty periods, 1 in 7 days free from patient care responsibilities, and in-house call no more than every third night, averaged over a 4-week period, the standards say.

The American Council on Graduate Medical Education says that it has issued citations to individual programs for duty hour violations and has done resident surveys that demonstrate a compliance rate of 94%.

Others argue, however, that enforcement is inadequate and that an independent body is needed to ensure compliance with the rules. Culture and tradition are so entrenched, they say, that too little has changed and that residents routinely underreport hours for fear of retaliation.

"I'm a resident who said one thing on a survey and did another thing in real life," Dr. Sunny Ramchandani, past chair of the AMA Residents and Fellows Section, told the IOM committee. "I'd have a 30-hour shift, work at least 34 hours, and report 16."

Part of the problem is that residents' workloads tend to remain the same even when shifts are shortened. Surveys of faculty and program directors taken by the American College of Physicians indicate that, even under the current rules, there is often less time for both formal and informal education, less time for ambulatory training, less time at the bedside, and a loss of continuity in care.

"Changing duty hours means changing everything," from work flow and coverage strategies to transfer-of-care techniques and the "very fundamentals of how patients are treated" and what residents are responsible for, said Dr. Ethan Fried, director of graduate medical education at St. Luke's-Roosevelt Hospital Center in New York.

Hospitals in New York state have been dealing with work hour limits and supervision requirements since 1988, several years after the death of Libby Zion in a teaching hospital spurred the state to act.

Changes made at Dr. Fried's hospital mean that a patient may now be admitted by one team of residents, treated by another, and discharged by yet another. "And it's up to educators to help residents integrate these experiences," he said. "I [still] don't know whether I can."

In Europe, the IOM committee was reminded, physicians and other health care workers are prohibited from working more than 13 hours straight or more than 48–56 hours per week. And for decades, physicians in New Zealand have worked with 16-hour shift limits and 72-hour weekly limits.

Different methods of graduate medical education financing and other health system differences make comparisons difficult, however. Here in the United States, Dr. Fried said, "with duty hour restrictions coming at the same time as patient volumes have increased, as acuity (of illness) in teaching hospitals has increased, and even as our treatments have become higher-stakes treatments, we have the perfect storm."

The multibillion dollar wound-care industry has brought a myriad of new support surface options as well as dressings and wound treatments, but nothing works like a "back-to-basics" approach, experts say.

Has optimal practice changed in any significant way since the Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention and treatment came out in 1992 and 1994, asked Rita A. Franz, Ph.D. "I don't think so."

Experts are excited by the potential of ultrasound technology that is being pilot tested in nursing homes for early detection of pressure ulcers.

But at this point, most of the advancements made since the early ′90s have been "advancements in the absence of science," or the absence of scientific evidence for efficacy, said Dr. Franz, Kelting dean and professor in the University of Iowa's College of Nursing in Iowa City

Data suggest, for instance, that patients likely to develop a pressure ulcer should be treated with a pressure-reducing surface or device. A 2004 Cochrane review, in fact, showed that compared with standard hospital mattresses, a variety of devices can lower the incidence of pressure ulcers by about 60%—but experts have been largely unsuccessful in comparing support surfaces based on meaningful functional characteristics, leaving no one device or type of device scientifically superior.

The science of pressure ulcers—etiology, causes, and classification—is still evolving, as is the science of quality measurement. But, despite the change and uncertainties, the vigilance with which nursing homes are attempting to bring the "basics" more consistently and successfully into everyday practice is increasing, and providers are beginning to see results of their efforts.

Certified nursing assistants (CNAs) check patients at Virtua Health and Rehabilitation Centers every day, looking for changes in the skin and reporting such changes immediately to nurses. Nurses also perform head-to-toe skin checks weekly on each patient. In addition, every resident who leaves for a diagnostic test, appointment, or family visit for at least 2 hours receives a full skin check upon returning to a nursing home unit.

Pressure reduction is also thorough: In addition to mattress replacements and overlays for at-risk residents, all residents who cannot reposition themselves have their calves and heels floated on pillows at night, for example. All wheelchairs and geriatric chairs have cushions.

Bed-bound residents are turned every 2 hours, and residents in wheelchairs and geriatric chairs are repositioned every hour. Moisture barriers are used routinely for incontinent patients.

The 2-hour turning/repositioning schedule that is commonly accepted as a standard goal was never subjected to a randomized trial, Dr. Franz notes, but evolved from the results of an observational study done years ago in London on the relationship between amounts of spontaneous nighttime movement and pressure ulcer incidence.

Even without evidence of a casual relationship between good nutrition and pressure ulcer prevention—and with disappointing results of nutritional intervention trials—it still seems only logical to promote good nutrition "on the front lines."

Dr. Jeffrey M. Levine of the Cabrini Wound Healing Center and St. Vincent's Medical Center in New York, encourages physicians to "relearn" the art of wound care that physicians used to study and practice. "Unfortunately, wound care has fallen by the wayside for contemporary doctors." He said he hopes to see new standards and techniques both for pressure relief and for the early detection and assessment of skin breakdown that can lead to the development of advanced stages of pressure ulcers.

With Medicare's upcoming reimbursement changes for hospital-acquired pressure ulcers, hospitals will turn to nursing homes for advice as they revamp their skin assessment programs and educate physicians, he said.

"Acute care has a lot to learn from the long-term care environment," he said. "The long-term care community has been far advanced in their skin care" and advanced in the application of basic processes. The back-to-basics approach that Dr. Levine teaches extends well beyond prevention and into management. "We need to evaluate the wound, keep it clean and moist, remove debris, feed the patient, and treat infections," he said.

The multibillion dollar wound-care industry has brought a myriad of new support surface options as well as dressings and wound treatments, but nothing works like a "back-to-basics" approach, experts say.

Has optimal practice changed in any significant way since the Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention and treatment came out in 1992 and 1994, asked Rita A. Franz, Ph.D. "I don't think so."

Experts are excited by the potential of ultrasound technology that is being pilot tested in nursing homes for early detection of pressure ulcers.

But at this point, most of the advancements made since the early ′90s have been "advancements in the absence of science," or the absence of scientific evidence for efficacy, said Dr. Franz, Kelting dean and professor in the University of Iowa's College of Nursing in Iowa City

Data suggest, for instance, that patients likely to develop a pressure ulcer should be treated with a pressure-reducing surface or device. A 2004 Cochrane review, in fact, showed that compared with standard hospital mattresses, a variety of devices can lower the incidence of pressure ulcers by about 60%—but experts have been largely unsuccessful in comparing support surfaces based on meaningful functional characteristics, leaving no one device or type of device scientifically superior.

The science of pressure ulcers—etiology, causes, and classification—is still evolving, as is the science of quality measurement. But, despite the change and uncertainties, the vigilance with which nursing homes are attempting to bring the "basics" more consistently and successfully into everyday practice is increasing, and providers are beginning to see results of their efforts.

Certified nursing assistants (CNAs) check patients at Virtua Health and Rehabilitation Centers every day, looking for changes in the skin and reporting such changes immediately to nurses. Nurses also perform head-to-toe skin checks weekly on each patient. In addition, every resident who leaves for a diagnostic test, appointment, or family visit for at least 2 hours receives a full skin check upon returning to a nursing home unit.

Pressure reduction is also thorough: In addition to mattress replacements and overlays for at-risk residents, all residents who cannot reposition themselves have their calves and heels floated on pillows at night, for example. All wheelchairs and geriatric chairs have cushions.

Bed-bound residents are turned every 2 hours, and residents in wheelchairs and geriatric chairs are repositioned every hour. Moisture barriers are used routinely for incontinent patients.

The 2-hour turning/repositioning schedule that is commonly accepted as a standard goal was never subjected to a randomized trial, Dr. Franz notes, but evolved from the results of an observational study done years ago in London on the relationship between amounts of spontaneous nighttime movement and pressure ulcer incidence.

Even without evidence of a casual relationship between good nutrition and pressure ulcer prevention—and with disappointing results of nutritional intervention trials—it still seems only logical to promote good nutrition "on the front lines."

Dr. Jeffrey M. Levine of the Cabrini Wound Healing Center and St. Vincent's Medical Center in New York, encourages physicians to "relearn" the art of wound care that physicians used to study and practice. "Unfortunately, wound care has fallen by the wayside for contemporary doctors." He said he hopes to see new standards and techniques both for pressure relief and for the early detection and assessment of skin breakdown that can lead to the development of advanced stages of pressure ulcers.

With Medicare's upcoming reimbursement changes for hospital-acquired pressure ulcers, hospitals will turn to nursing homes for advice as they revamp their skin assessment programs and educate physicians, he said.

"Acute care has a lot to learn from the long-term care environment," he said. "The long-term care community has been far advanced in their skin care" and advanced in the application of basic processes. The back-to-basics approach that Dr. Levine teaches extends well beyond prevention and into management. "We need to evaluate the wound, keep it clean and moist, remove debris, feed the patient, and treat infections," he said.

The multibillion dollar wound-care industry has brought a myriad of new support surface options as well as dressings and wound treatments, but nothing works like a "back-to-basics" approach, experts say.

Has optimal practice changed in any significant way since the Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention and treatment came out in 1992 and 1994, asked Rita A. Franz, Ph.D. "I don't think so."

Experts are excited by the potential of ultrasound technology that is being pilot tested in nursing homes for early detection of pressure ulcers.

But at this point, most of the advancements made since the early ′90s have been "advancements in the absence of science," or the absence of scientific evidence for efficacy, said Dr. Franz, Kelting dean and professor in the University of Iowa's College of Nursing in Iowa City

Data suggest, for instance, that patients likely to develop a pressure ulcer should be treated with a pressure-reducing surface or device. A 2004 Cochrane review, in fact, showed that compared with standard hospital mattresses, a variety of devices can lower the incidence of pressure ulcers by about 60%—but experts have been largely unsuccessful in comparing support surfaces based on meaningful functional characteristics, leaving no one device or type of device scientifically superior.

The science of pressure ulcers—etiology, causes, and classification—is still evolving, as is the science of quality measurement. But, despite the change and uncertainties, the vigilance with which nursing homes are attempting to bring the "basics" more consistently and successfully into everyday practice is increasing, and providers are beginning to see results of their efforts.

Certified nursing assistants (CNAs) check patients at Virtua Health and Rehabilitation Centers every day, looking for changes in the skin and reporting such changes immediately to nurses. Nurses also perform head-to-toe skin checks weekly on each patient. In addition, every resident who leaves for a diagnostic test, appointment, or family visit for at least 2 hours receives a full skin check upon returning to a nursing home unit.

Pressure reduction is also thorough: In addition to mattress replacements and overlays for at-risk residents, all residents who cannot reposition themselves have their calves and heels floated on pillows at night, for example. All wheelchairs and geriatric chairs have cushions.

Bed-bound residents are turned every 2 hours, and residents in wheelchairs and geriatric chairs are repositioned every hour. Moisture barriers are used routinely for incontinent patients.

The 2-hour turning/repositioning schedule that is commonly accepted as a standard goal was never subjected to a randomized trial, Dr. Franz notes, but evolved from the results of an observational study done years ago in London on the relationship between amounts of spontaneous nighttime movement and pressure ulcer incidence.

Even without evidence of a casual relationship between good nutrition and pressure ulcer prevention—and with disappointing results of nutritional intervention trials—it still seems only logical to promote good nutrition "on the front lines."

Dr. Jeffrey M. Levine of the Cabrini Wound Healing Center and St. Vincent's Medical Center in New York, encourages physicians to "relearn" the art of wound care that physicians used to study and practice. "Unfortunately, wound care has fallen by the wayside for contemporary doctors." He said he hopes to see new standards and techniques both for pressure relief and for the early detection and assessment of skin breakdown that can lead to the development of advanced stages of pressure ulcers.

With Medicare's upcoming reimbursement changes for hospital-acquired pressure ulcers, hospitals will turn to nursing homes for advice as they revamp their skin assessment programs and educate physicians, he said.

"Acute care has a lot to learn from the long-term care environment," he said. "The long-term care community has been far advanced in their skin care" and advanced in the application of basic processes. The back-to-basics approach that Dr. Levine teaches extends well beyond prevention and into management. "We need to evaluate the wound, keep it clean and moist, remove debris, feed the patient, and treat infections," he said.

WASHINGTON — Five years after the establishment of across-specialty rules to limit resident work hours, the issue of trainee schedules in teaching hospitals is again under the microscope as a continuing threat to patient safety—and this time an Institute of Medicine committee has been forewarned that specific “workable” solutions are needed.

The schedules in teaching hospitals “belie virtually all the tenets of providing good health care. How can we profess to provide the best possible quality of care when we know we have staff members who are operating at levels of sleep deprivation so severe that they are similar to someone driving under the influence of alcohol?” Dr. Carolyn Clancy, director of the federal Agency for Health Care Research and Quality, asked at a meeting sponsored by the Institute of Medicine.

The IOM's Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules, which held the first of four workshops in December, was formed at the request of Rep. John D. Dingell (D-Mich.) and colleagues on the House Committee on Energy and Commerce as part of an investigation into preventable medical errors. The IOM will publish a report including strategies and actions for implementing safe work schedules in February 2009.

The issue of residents' work hours received relatively little attention in the IOM's landmark 1999 report on medical errors, experts said at the workshop, despite several decades of research on the effects of sleep deprivation on human performance and research more specifically showing an impaired ability of interns to read ECGs after long shifts.

Since then—and especially within the past several years—various studies have demonstrated the effects of sleep deprivation in medical residents and have shown that reductions in work hours can reduce errors, physicians told the committee.

A prospective, national survey of more than 2,700 interns, for instance, showed that residents were seven times more likely to report a harmful fatigue-related error when they worked five or more 24-hour shifts in a month than when they worked no 24-hour shifts. They were four times more likely to report a fatal error.

And in a randomized controlled trial, residents had twice as many EEG-documented attention failures at night when working the traditional schedule of 24- to 30-hour shifts than when working a 16-hour maximum. Both studies were led by researchers at Harvard University, Boston.

Dr. Christopher P. Landrigan, who directs the Sleep and Patient Safety Program at Brigham and Women's Hospital, Boston, said the Harvard research has also shown that residents working 24- to 30-hour shifts make five times as many serious diagnostic errors as do those scheduled to work 16 hours or less. They're also twice as likely to crash their cars, and they suffer 61% more needlestick injuries, he told the IOM committee.

Limits instituted by the American Council on Graduate Medical Education in 2003 mark shifts of 24–30 hours as acceptable. The council's “common duty hour standards” call for a 24-hour limit on continuous duty, with an additional 6 hours allowed for continuity and the transfer of care, as well as an 80-hour weekly limit averaged over 4 weeks. Programs can request an increase of up to 8 hours a week and can apply for further exemptions.

Residents must also have a minimum rest period of 10 hours between duty periods, 1 in 7 days free from patient care responsibilities, and in-house call no more often than every third night, averaged over a 4-week period, the standards say.

The council said it has issued citations to individual programs for duty hour violations and has done resident surveys that demonstrate a compliance rate of 94%.

Others argue, however, that enforcement is inadequate and that an independent body is needed to ensure compliance with the rules. Culture and tradition are so entrenched, they say, that too little has changed and that residents routinely underreport hours for fear of retaliation.

“I'm a resident who said one thing on a survey and did another thing in real life,” Dr. Sunny Ramchandani, past chair of the AMA Residents and Fellows Section, told the IOM committee. “I'd have a 30-hour shift, work at least 34 hours, and report 16.”

Part of the problem is that residents' workloads tend to remain the same even when shifts are shortened.

“Changing duty hours means changing everything,” from work flow and coverage strategies to transfer-of-care techniques and the “very fundamentals of how patients are treated” and what residents are responsible for, said Dr. Ethan Fried, director of graduate medical education at St. Luke's-Roosevelt Hospital Center in New York.

Hospitals in New York state have been dealing with work hour limits and supervision requirements since 1988, several years after the death of Libby Zion in a teaching hospital spurred the state to take action.

Changes made at Dr. Fried's hospital mean that a patient may now be admitted by one team of residents, treated by another, and discharged by yet another. “And it's up to educators to help residents integrate these experiences,” he said. “I [still] don't know whether I can.”

In Europe, the IOM committee was reminded, physicians and other health care workers are prohibited from working more than 13 hours straight or more than 48–56 hours per week.

Different methods of graduate medical education financing and other health system differences make comparisons difficult, however. Here in the United States, Dr. Fried said, “with duty hour restrictions coming at the same time as patient volumes have increased, as acuity (of illness) in teaching hospitals has increased, and even as our treatments have become higher-stakes treatments, we have the perfect storm.”

WASHINGTON — Five years after the establishment of across-specialty rules to limit resident work hours, the issue of trainee schedules in teaching hospitals is again under the microscope as a continuing threat to patient safety—and this time an Institute of Medicine committee has been forewarned that specific “workable” solutions are needed.

The schedules in teaching hospitals “belie virtually all the tenets of providing good health care. How can we profess to provide the best possible quality of care when we know we have staff members who are operating at levels of sleep deprivation so severe that they are similar to someone driving under the influence of alcohol?” Dr. Carolyn Clancy, director of the federal Agency for Health Care Research and Quality, asked at a meeting sponsored by the Institute of Medicine.

The IOM's Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules, which held the first of four workshops in December, was formed at the request of Rep. John D. Dingell (D-Mich.) and colleagues on the House Committee on Energy and Commerce as part of an investigation into preventable medical errors. The IOM will publish a report including strategies and actions for implementing safe work schedules in February 2009.

The issue of residents' work hours received relatively little attention in the IOM's landmark 1999 report on medical errors, experts said at the workshop, despite several decades of research on the effects of sleep deprivation on human performance and research more specifically showing an impaired ability of interns to read ECGs after long shifts.

Since then—and especially within the past several years—various studies have demonstrated the effects of sleep deprivation in medical residents and have shown that reductions in work hours can reduce errors, physicians told the committee.

A prospective, national survey of more than 2,700 interns, for instance, showed that residents were seven times more likely to report a harmful fatigue-related error when they worked five or more 24-hour shifts in a month than when they worked no 24-hour shifts. They were four times more likely to report a fatal error.

And in a randomized controlled trial, residents had twice as many EEG-documented attention failures at night when working the traditional schedule of 24- to 30-hour shifts than when working a 16-hour maximum. Both studies were led by researchers at Harvard University, Boston.

Dr. Christopher P. Landrigan, who directs the Sleep and Patient Safety Program at Brigham and Women's Hospital, Boston, said the Harvard research has also shown that residents working 24- to 30-hour shifts make five times as many serious diagnostic errors as do those scheduled to work 16 hours or less. They're also twice as likely to crash their cars, and they suffer 61% more needlestick injuries, he told the IOM committee.

Limits instituted by the American Council on Graduate Medical Education in 2003 mark shifts of 24–30 hours as acceptable. The council's “common duty hour standards” call for a 24-hour limit on continuous duty, with an additional 6 hours allowed for continuity and the transfer of care, as well as an 80-hour weekly limit averaged over 4 weeks. Programs can request an increase of up to 8 hours a week and can apply for further exemptions.

Residents must also have a minimum rest period of 10 hours between duty periods, 1 in 7 days free from patient care responsibilities, and in-house call no more often than every third night, averaged over a 4-week period, the standards say.

The council said it has issued citations to individual programs for duty hour violations and has done resident surveys that demonstrate a compliance rate of 94%.

Others argue, however, that enforcement is inadequate and that an independent body is needed to ensure compliance with the rules. Culture and tradition are so entrenched, they say, that too little has changed and that residents routinely underreport hours for fear of retaliation.

“I'm a resident who said one thing on a survey and did another thing in real life,” Dr. Sunny Ramchandani, past chair of the AMA Residents and Fellows Section, told the IOM committee. “I'd have a 30-hour shift, work at least 34 hours, and report 16.”

Part of the problem is that residents' workloads tend to remain the same even when shifts are shortened.

“Changing duty hours means changing everything,” from work flow and coverage strategies to transfer-of-care techniques and the “very fundamentals of how patients are treated” and what residents are responsible for, said Dr. Ethan Fried, director of graduate medical education at St. Luke's-Roosevelt Hospital Center in New York.

Hospitals in New York state have been dealing with work hour limits and supervision requirements since 1988, several years after the death of Libby Zion in a teaching hospital spurred the state to take action.

Changes made at Dr. Fried's hospital mean that a patient may now be admitted by one team of residents, treated by another, and discharged by yet another. “And it's up to educators to help residents integrate these experiences,” he said. “I [still] don't know whether I can.”

In Europe, the IOM committee was reminded, physicians and other health care workers are prohibited from working more than 13 hours straight or more than 48–56 hours per week.

Different methods of graduate medical education financing and other health system differences make comparisons difficult, however. Here in the United States, Dr. Fried said, “with duty hour restrictions coming at the same time as patient volumes have increased, as acuity (of illness) in teaching hospitals has increased, and even as our treatments have become higher-stakes treatments, we have the perfect storm.”

WASHINGTON — Five years after the establishment of across-specialty rules to limit resident work hours, the issue of trainee schedules in teaching hospitals is again under the microscope as a continuing threat to patient safety—and this time an Institute of Medicine committee has been forewarned that specific “workable” solutions are needed.

The schedules in teaching hospitals “belie virtually all the tenets of providing good health care. How can we profess to provide the best possible quality of care when we know we have staff members who are operating at levels of sleep deprivation so severe that they are similar to someone driving under the influence of alcohol?” Dr. Carolyn Clancy, director of the federal Agency for Health Care Research and Quality, asked at a meeting sponsored by the Institute of Medicine.

The IOM's Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules, which held the first of four workshops in December, was formed at the request of Rep. John D. Dingell (D-Mich.) and colleagues on the House Committee on Energy and Commerce as part of an investigation into preventable medical errors. The IOM will publish a report including strategies and actions for implementing safe work schedules in February 2009.

The issue of residents' work hours received relatively little attention in the IOM's landmark 1999 report on medical errors, experts said at the workshop, despite several decades of research on the effects of sleep deprivation on human performance and research more specifically showing an impaired ability of interns to read ECGs after long shifts.

Since then—and especially within the past several years—various studies have demonstrated the effects of sleep deprivation in medical residents and have shown that reductions in work hours can reduce errors, physicians told the committee.

A prospective, national survey of more than 2,700 interns, for instance, showed that residents were seven times more likely to report a harmful fatigue-related error when they worked five or more 24-hour shifts in a month than when they worked no 24-hour shifts. They were four times more likely to report a fatal error.

And in a randomized controlled trial, residents had twice as many EEG-documented attention failures at night when working the traditional schedule of 24- to 30-hour shifts than when working a 16-hour maximum. Both studies were led by researchers at Harvard University, Boston.

Dr. Christopher P. Landrigan, who directs the Sleep and Patient Safety Program at Brigham and Women's Hospital, Boston, said the Harvard research has also shown that residents working 24- to 30-hour shifts make five times as many serious diagnostic errors as do those scheduled to work 16 hours or less. They're also twice as likely to crash their cars, and they suffer 61% more needlestick injuries, he told the IOM committee.

Limits instituted by the American Council on Graduate Medical Education in 2003 mark shifts of 24–30 hours as acceptable. The council's “common duty hour standards” call for a 24-hour limit on continuous duty, with an additional 6 hours allowed for continuity and the transfer of care, as well as an 80-hour weekly limit averaged over 4 weeks. Programs can request an increase of up to 8 hours a week and can apply for further exemptions.

Residents must also have a minimum rest period of 10 hours between duty periods, 1 in 7 days free from patient care responsibilities, and in-house call no more often than every third night, averaged over a 4-week period, the standards say.

The council said it has issued citations to individual programs for duty hour violations and has done resident surveys that demonstrate a compliance rate of 94%.

Others argue, however, that enforcement is inadequate and that an independent body is needed to ensure compliance with the rules. Culture and tradition are so entrenched, they say, that too little has changed and that residents routinely underreport hours for fear of retaliation.

“I'm a resident who said one thing on a survey and did another thing in real life,” Dr. Sunny Ramchandani, past chair of the AMA Residents and Fellows Section, told the IOM committee. “I'd have a 30-hour shift, work at least 34 hours, and report 16.”

Part of the problem is that residents' workloads tend to remain the same even when shifts are shortened.

“Changing duty hours means changing everything,” from work flow and coverage strategies to transfer-of-care techniques and the “very fundamentals of how patients are treated” and what residents are responsible for, said Dr. Ethan Fried, director of graduate medical education at St. Luke's-Roosevelt Hospital Center in New York.

Hospitals in New York state have been dealing with work hour limits and supervision requirements since 1988, several years after the death of Libby Zion in a teaching hospital spurred the state to take action.

Changes made at Dr. Fried's hospital mean that a patient may now be admitted by one team of residents, treated by another, and discharged by yet another. “And it's up to educators to help residents integrate these experiences,” he said. “I [still] don't know whether I can.”

In Europe, the IOM committee was reminded, physicians and other health care workers are prohibited from working more than 13 hours straight or more than 48–56 hours per week.

Different methods of graduate medical education financing and other health system differences make comparisons difficult, however. Here in the United States, Dr. Fried said, “with duty hour restrictions coming at the same time as patient volumes have increased, as acuity (of illness) in teaching hospitals has increased, and even as our treatments have become higher-stakes treatments, we have the perfect storm.”

BETHESDA, MD. – Recurrent abdominal pain appears to be part of a larger syndrome of somatization and anxiety, Lynette Dufton reported at a meeting sponsored by the National Institutes of Health Pain Consortium.

Physiologic factors may contribute to pain episodes in children with recurrent abdominal pain, “but I think anxiety is a key part of this,” said Ms. Dufton of Vanderbilt University in Nashville, Tenn.

“Providers should assess comorbid psychological symptoms in these children, and maybe refer them for [therapies such as] cognitive-behavioral therapy,” she said in an interview at her poster presentation on the study.

Using various parent and child reports of somatization and anxiety, different measures of stress reactivity, and the “cold pressor” test of pain tolerance and sensitivity, Ms. Dufton compared 21 children with recurrent abdominal pain (9 boys) with 21 children with a diagnosed anxiety disorder (11 boys) and 21 children who were well (9 boys). The children in each group had a mean age of either 11 or 12 years.

A total of 67% of the children with recurrent abdominal pain–a problem experienced by 8%–25% of school-aged children–met criteria for an anxiety disorder, compared with 100% of the children with anxiety and 6% of the well children.

On parent and self-reports of somatization and anxiety, such as the Child Behavior Checklist for Ages 6–18 (CBCL/6–18) and the Youth Self-Report, children with recurrent abdominal pain rated significantly higher on internalizing symptoms, such as anxiety and somatic complaints, than did well children.

They did not differ from children with anxiety disorders on the CBCL's measures of anxiety, but they did report significantly more somatic complaints, Ms. Dufton said.

Children with recurrent abdominal pain also reported different levels of stress reactivity on various measures from those reported by well children. On one self-reported measure–the “Responses to Stress Questionnaire”–those children exhibited higher levels of stress reactivity than both well and anxious children.

The cold pressor test measures the length of time one can keep one's hand and arm in ice-cold water (pain tolerance) and rates pain at 40 seconds using a visual analog scale (pain sensitivity). Unexpectedly, there were no differences in pain tolerance among the groups of children, Ms. Dufton said.

BETHESDA, MD. – Recurrent abdominal pain appears to be part of a larger syndrome of somatization and anxiety, Lynette Dufton reported at a meeting sponsored by the National Institutes of Health Pain Consortium.

Physiologic factors may contribute to pain episodes in children with recurrent abdominal pain, “but I think anxiety is a key part of this,” said Ms. Dufton of Vanderbilt University in Nashville, Tenn.

“Providers should assess comorbid psychological symptoms in these children, and maybe refer them for [therapies such as] cognitive-behavioral therapy,” she said in an interview at her poster presentation on the study.

Using various parent and child reports of somatization and anxiety, different measures of stress reactivity, and the “cold pressor” test of pain tolerance and sensitivity, Ms. Dufton compared 21 children with recurrent abdominal pain (9 boys) with 21 children with a diagnosed anxiety disorder (11 boys) and 21 children who were well (9 boys). The children in each group had a mean age of either 11 or 12 years.

A total of 67% of the children with recurrent abdominal pain–a problem experienced by 8%–25% of school-aged children–met criteria for an anxiety disorder, compared with 100% of the children with anxiety and 6% of the well children.

On parent and self-reports of somatization and anxiety, such as the Child Behavior Checklist for Ages 6–18 (CBCL/6–18) and the Youth Self-Report, children with recurrent abdominal pain rated significantly higher on internalizing symptoms, such as anxiety and somatic complaints, than did well children.

They did not differ from children with anxiety disorders on the CBCL's measures of anxiety, but they did report significantly more somatic complaints, Ms. Dufton said.

Children with recurrent abdominal pain also reported different levels of stress reactivity on various measures from those reported by well children. On one self-reported measure–the “Responses to Stress Questionnaire”–those children exhibited higher levels of stress reactivity than both well and anxious children.

The cold pressor test measures the length of time one can keep one's hand and arm in ice-cold water (pain tolerance) and rates pain at 40 seconds using a visual analog scale (pain sensitivity). Unexpectedly, there were no differences in pain tolerance among the groups of children, Ms. Dufton said.

BETHESDA, MD. – Recurrent abdominal pain appears to be part of a larger syndrome of somatization and anxiety, Lynette Dufton reported at a meeting sponsored by the National Institutes of Health Pain Consortium.

Physiologic factors may contribute to pain episodes in children with recurrent abdominal pain, “but I think anxiety is a key part of this,” said Ms. Dufton of Vanderbilt University in Nashville, Tenn.

“Providers should assess comorbid psychological symptoms in these children, and maybe refer them for [therapies such as] cognitive-behavioral therapy,” she said in an interview at her poster presentation on the study.

Using various parent and child reports of somatization and anxiety, different measures of stress reactivity, and the “cold pressor” test of pain tolerance and sensitivity, Ms. Dufton compared 21 children with recurrent abdominal pain (9 boys) with 21 children with a diagnosed anxiety disorder (11 boys) and 21 children who were well (9 boys). The children in each group had a mean age of either 11 or 12 years.

A total of 67% of the children with recurrent abdominal pain–a problem experienced by 8%–25% of school-aged children–met criteria for an anxiety disorder, compared with 100% of the children with anxiety and 6% of the well children.

On parent and self-reports of somatization and anxiety, such as the Child Behavior Checklist for Ages 6–18 (CBCL/6–18) and the Youth Self-Report, children with recurrent abdominal pain rated significantly higher on internalizing symptoms, such as anxiety and somatic complaints, than did well children.

They did not differ from children with anxiety disorders on the CBCL's measures of anxiety, but they did report significantly more somatic complaints, Ms. Dufton said.

Children with recurrent abdominal pain also reported different levels of stress reactivity on various measures from those reported by well children. On one self-reported measure–the “Responses to Stress Questionnaire”–those children exhibited higher levels of stress reactivity than both well and anxious children.

The cold pressor test measures the length of time one can keep one's hand and arm in ice-cold water (pain tolerance) and rates pain at 40 seconds using a visual analog scale (pain sensitivity). Unexpectedly, there were no differences in pain tolerance among the groups of children, Ms. Dufton said.