Observational study of organisational responses of 17 US hospitals over the first year of the COVID-19 pandemic.

OBJECTIVES: The COVID-19 pandemic has required significant modifications of hospital care. The objective of this study was to examine the operational approaches taken by US hospitals over time in response to the COVID-19 pandemic. DESIGN, SETTING AND PARTICIPANTS: This was a prospective observational study of 17 geographically diverse US hospitals from February 2020 to February 2021. OUTCOMES AND ANALYSIS: We identified 42 potential pandemic-related strategies and obtained week-to-week data about their use. We calculated descriptive statistics for use of each strategy and plotted percent uptake and weeks used. We assessed the relationship between strategy use and hospital type, geographic region and phase of the pandemic using generalised estimating equations (GEEs), adjusting for weekly county case counts. RESULTS: We found heterogeneity in strategy uptake over time, some of which was associated with geographic region and phase of pandemic. We identified a body of strategies that were both commonly used and sustained over time, for example, limiting staff in COVID-19 rooms and increasing telehealth capacity, as well as those that were rarely used and/or not sustained, for example, increasing hospital bed capacity. CONCLUSIONS: Hospital strategies during the COVID-19 pandemic varied in resource intensity, uptake and duration of use. Such information may be valuable to health systems during the ongoing pandemic and future ones.

Inpatient boarding definitions and mitigation strategies: A cross-sectional survey of academic emergency departments in the United States.

OBJECTIVE: Conceptually, inpatient boarding is a result in the delay of admitting patients from the Emergency Department (ED) to inpatient units, but there is no consistent definition across academic EDs. The purpose of this study was to evaluate the definition of boarding across academic EDs, and to identify mitigation strategies used by EDs to alleviate crowd management. METHODS: This was a cross-sectional survey of boarding-related questions (i.e., boarding definitions and practices) that were embedded into the annual benchmarking survey conducted by the Academy of Academic Administrators of Emergency Medicine and the Association of Academic Chairs of Emergency Medicine. Results were descriptively assessed and tabulated. RESULTS: Of the 130 eligible institutions, 68 participated in the survey. Approximately 70% of institutions reported starting the boarding clock at the time of ED admission, while 19% reported that the clock started with the completion of inpatient orders. Approximately 35% of institutions considered patients boarded within 2 h, while 34% considered patients boarded >4 h after admission decision. In response to ED overcrowding brought on by inpatient boarding, 35% reported using hallway beds for patient care. Surge capacity measures reported included having a high census/surge capacity plan (81%), going on ambulance diversion (54%), and institutional use of a discharge lounge (49%). CONCLUSIONS: We found that definitions for boarding varied widely. Inpatient boarding has serious consequences to patient care and well-being, suggesting the need for standardized definitions to describe inpatient boarding.

Exploring the role of the potential surface in the behaviour of early warning signals.

The theory of critical slowing down states that a system displays increasing relaxation times as it approaches a critical transition. These changes can be seen in statistics generated from timeseries data, which can be used as early warning signals of a transition. Such early warning signals would be of value for emerging infectious diseases or to understand when an endemic disease is close to elimination. However, in applications to a variety of epidemiological models there is frequent disagreement with the general theory of critical slowing down, with some indicators performing well on prevalence data but not when applied to incidence data. Furthermore, the alternative theory of critical speeding up predicts contradictory behaviour of early warning signals prior to some stochastic transitions. To investigate the possibility of observing critical speeding up in epidemiological models we characterise the behaviour of common early warning signals in terms of a system's potential surface and noise around a quasi-steady state. We then describe a method to obtain these key features from timeseries data, taking as a case study a version of the SIS model, adapted to demonstrate either critical slowing down or critical speeding up. We show this method accurately reproduces the analytic potential surface and diffusion function, and that these results can be used to determine the behaviour of early warning signals and correctly identify signs of both critical slowing down and critical speeding up.

Long-Term Impacts of a Targeted Intervention in the Emergency Department on Inpatient Prescribing Practices.

Background: In 2009, researchers successfully implemented an intervention to decrease the inappropriate prescribing of multivitamin infusions (MVIs) in the emergency department (ED) for patients presenting with alcohol-related illnesses. Objective: The purposes of our study were to determine the impact of the 2009 intervention on hospital-wide prescribing practices of vitamin therapies for alcohol-related illnesses, and to evaluate its long-term sustainability. Methods: A retrospective observational cohort study was conducted at a 60,000-visit ED, 811-bed academically-affiliated tertiary referral hospital with an average census of 515 and 714 patients in 2009 and 2019, respectively. Patients were included if they presented to the ED from 2009 to 2019 with an alcohol-related illness as defined by ICD-9 and ICD-10 codes. The primary outcome was the change in the monthly average of MVIs ordered inpatient within the first four months compared to the last four months of the study period. Secondary outcomes included changes in the mean distribution (MD) per month of thiamine administrations in the ED and inpatient setting, and MVIs ordered in the ED. Results: The MD of MVIs ordered per month decreased by 3.5% (95% CI -5.3, -1.7) in the inpatient setting and decreased by 1.4% (95% CI -2.5, -.3) in the ED from the beginning to the end of our study period. Conclusions: This study suggests the effects of an intervention made in the ED sustained impact over a 10-year timeframe, and decreased the use of MVIs in both the ED and hospital-wide.

Is the Emergency Department an Inappropriate Venue for Code Status Discussions?

BACKGROUND: Historically, it has been assumed that the Emergency Department (ED) is a place for maximally aggressive care and that Emergency Medicine Providers (EMPs) are biased towards life-prolonging care. However, emphasis on early recognition of code status preferences is increasingly making the ED a venue for code status discussions (CSDs). In 2018, our hospital implemented a policy requiring EMPs to place a code status order (CSO) for all patients admitted through the ED. We hypothesized that if EMPs enter CSDs with a bias toward life-prolonging care, or if the venue of the ED biases CSDs towards life-prolonging care, then we would observe a decrease in the percentage of patients selecting DNR status following our institution's aforementioned CSO mandate. METHODS: We present a retrospective analysis of rates of DNR orders placed for patients admitted through our ED comparing six-month periods before and after the implementation of the above policy. RESULTS: Using quality improvement data, we identified patients admitted through the ED during pre (n=7,858) and post (n=8,069) study periods. We observed the following: after implementation DNR preference identified prior to hospital admission from the ED increased from 0.4% to 5.3% (relative risk (RR) 12.5; 95% CI: 5.2-29.9), defining CS in the ED setting at the time of admission increased from 2.4% to 98.6% (p <0.001), and DNR orders placed during inpatient admission was unchanged (RR=0.97 (95% CI = 0.88-1.07)). DISCUSSION: Our results suggest that the ED can be an appropriate venue for CSDs.

Can SPEcies At Risk of pesticides (SPEAR) indices detect effects of target stressors among multiple interacting stressors?

Pesticides are increasingly recognised as a threat to freshwater biodiversity, but their specific ecological effects remain difficult to distinguish from those of co-occurring stressors and environmental gradients. Using mesocosms we examined the effects of an organophosphate insecticide (malathion) on stream macroinvertebrate communities concurrently exposed to a suite of stressors typical of streams in agricultural catchments. We assessed the specificity of the SPEcies At Risk index designed to determine pesticide effects in mesocosm trials (SPEARmesocosm). This index determines the log abundance proportion of taxa that are considered physiologically sensitive to pesticides. Geographic variation in pesticide sensitivity within taxa, coupled with variation between pesticides and the effects of co-occurring stressors may decrease the accuracy of SPEARmesocosm. To examine this, we used local pesticide sensitivity assessments based on rapid toxicity tests to develop two new SPEAR versions to compare to the original SPEARmesocosms index using mesocosm results. We further compared these results to multivariate analyses and community indices (e.g. richness, abundance, Simpson's diversity) commonly used to assess stressor effects on biota. To assess the implications of misclassifying species sensitivity on SPEAR indices we used a series of simulations using artificial data. The impacts of malathion were detectable using SPEARmesocosm, and one of two new SPEAR indices. All three of the SPEAR indices also increased when exposed to other agricultural non-pesticide stressors, and this change increased with greater pesticide concentrations. Our results support that interactions between other non-pesticide stressors with pesticides can affect SPEAR performance. Multivariate analysis and the other indices used here identified a significant effect of malathion especially at high concentrations, with little or no evidence of effects from the other agricultural stressors.

Use of a Bidirectional Text Messaging System for Emergency Department Follow-Up Versus Usual Follow-Up.

Background: The use of text messaging is a growing trend. Usual care for follow-up with patients (no dedicated communication) has proven unreliable, and alternative communication methods may be beneficial. Introduction: The objective was to evaluate the effect of text messaging as a means of follow-up communication compared to usual care on patient satisfaction among patients discharged from the emergency department (ED). Materials and Methods: Participants completed a baseline survey about their text message usage and ED visit satisfaction. The participants completed a follow-up survey 2 weeks later. Participants randomized to text messaging received a text message at 24 h, 1 week, and 2 weeks after discharge. Control participants received usual care (typically no dedicated communication). Bivariate analyses were performed, and intent-to-treat and per protocol analyses were completed to examine follow-up satisfaction with ED communication/care. Results: A total of 802 subjects were recruited (text messaging-398 subjects, usual care-404 subjects). In the intent-to-treat analysis, text messaging subjects were not more likely to report satisfaction with follow-up communication (adjusted odds ratio [aOR] 0.90 [0.46-1.75]) or follow-up care (aOR 0.66 [0.30-1.46]) than usual care subjects. In per-protocol analysis, text messaging subjects had 2.95 (1.52-5.73) higher odds of reporting satisfaction with follow-up communication and 3.24 (1.46-7.16) higher odds of reporting satisfaction with follow-up care. Discussion: The use of text messaging for follow-up, when comparing satisfaction with follow-up communication and follow-up care after discharge, performs at least equally as well as usual follow-up. Conclusions: Text messaging is a provider time-saving and resource-conserving technology allowing health care providers to potentially reach a larger proportion of patients, making it a valuable form of follow-up communication.

Using sideline concussion tests in the emergency department.

PURPOSE: Traumatic brain injury (TBI) is a significant cause of death and disability in the United States. Many patients with TBI are initially treated in the emergency department (ED), but there is no evidence-based method of detecting or grading TBI in patients who have normal structural neuroimaging. This study aims to evaluate the validity of two common sideline concussion tests. The Concussion Symptom Severity Score (CSSS) and modified Balance Error Scoring System (mBESS) tests are well-validated sideline tests for concussion, but have not been validated in the setting of non-sport-related concussion, in settings other than the sideline or athletic training room or in moderate or severe TBI. PATIENTS AND METHODS: One hundred forty-eight subjects who had sustained a TBI within the previous 72 hours and 53 healthy control subjects were enrolled. CSSS and mBESS were administered. Clinical outcomes were followed up prospectively. RESULTS: The CSSS was collected in 147 TBI subjects but only 51 TBI subjects were able to complete the mBESS. The CSSS was collected for all 53 control subjects, and the mBESS was completed for 51 control subjects. The mean CSSS for TBI and control subjects was 32.25 and 2.70, respectively (P < 0.001). The average mBESS for TBI and control subjects was 7.43 and 7.20, respectively (P = 0.82). CSSS greater than 5.17 was 93.43% sensitive and 69.84% specific for TBI. CONCLUSION: The mBESS is poorly tolerated and, among those who can complete the test, not sensitive to TBI in the ED. The CSSS is both sensitive to TBI and well tolerated.

Achieving regionalization through rural interhospital transfer.

Regionalization of emergency medical care aims to provide consistent and efficient high-quality care leading to optimal clinical outcomes by matching patient needs with appropriate resources at a network of hospitals. Regionalized care has been shown to improve outcomes in trauma, myocardial infarction, stroke, cardiac arrest, and acute respiratory distress syndrome. In rural areas, effective regionalization often requires interhospital transfer. The decision to transfer is complex and includes such factors as capabilities of the presenting hospital; capacity at the receiving hospital; and financial, geographic, and patient-preference considerations. Although transfer to a comprehensive center has proven benefits for some conditions, the transfer process is not without risk. These risks include clinical deterioration, limited resource availability during transport, vehicular crashes, time delays for time-sensitive care, poor communication between providers, and neglect of patient preferences. This article reviews the transfer decision, financial implications, risks, and considerations for patients undergoing rural interhospital transfer. We identify several strategies that should be considered for development of the regionalized emergency health care system of the future and identify areas where further research is necessary.

Measurement of oxygen concentration delivered via nasal cannulae by tracheal sampling.

BACKGROUND AND OBJECTIVE: Oxygen is used in many clinical scenarios, however the variable performance of nasal cannulae makes determining the precise fraction of inspired oxygen (FiO2 ) difficult. We developed a novel method for measurement of the tracheal FiO2 using a catheter placed via bronchoscopy. We investigate the effects of oxygen delivery, respiratory rate, mouth position and estimated minute ventilation (VE ) on the FiO2 delivered by nasal cannulae. METHODS: The catheter was placed in 20 subjects. Tracheal gas concentrations were analysed during six 5-min treatments controlling for oxygen delivery rate, respiratory rate and mouth position. Ventilation was monitored with respiratory inductive plethysmography (RIP). The FiO2 delivered by nasal cannulae was compared between treatments, and we investigated the relationships among the FiO2 , alveolar partial pressure of oxygen (PA O2 ) and VE . RESULTS: The FiO2 increased by 0.038/L/min of oxygen. Respiratory rate had a significant effect on the FiO2 . A normal respiratory rate of 15 breaths/min and oxygen supplementation via nasal cannula at 2 L/min resulted in an FiO2 of 0.296; however, FiO2 decreased by 0.012 at 20 breaths/min and 0.004 at 10 breaths/min. The mean FiO2 decreased by 0.024 with the mouth open. The FiO2 and PA O2 were observed to decrease with increasing VE . CONCLUSIONS: Continuous measurement of the FiO2 using a transtracheal catheter provides detailed insight into inspiratory changes of the FiO2 delivered by nasal cannulae. Our study confirms that respiratory rate, VE and mouth position significantly influence the inspired oxygen concentration. These parameters should be accounted for when prescribing oxygen.

Implementation of smoking cessation guidelines in the emergency department: a qualitative study of staff perceptions.

BACKGROUND: The US Public Health Service smoking cessation practice guideline specifically recommends that physicians and nurses strongly advise their patients who use tobacco to quit, but the best approach for attaining this goal in the emergency department (ED) remains unknown. The aim of this study was to characterize emergency physicians' (EPs) and nurses' (ENs) perceptions of cessation counseling and to identify barriers and facilitators to implementation of the 5 A's framework (Ask-Advise-Assess-Assist-Arrange) in the ED. METHODS: We conducted semi-structured, face-to-face interviews of 11 EPs and 19 ENs following a pre-post implementation trial of smoking cessation guidelines in two study EDs. We used purposeful sampling to target EPs and ENs with different attitudes toward cessation counseling, based on their responses to a written survey (Decisional Balance Questionnaire). Conventional content analysis was used to inductively characterize the issues raised by study participants and to construct a coding structure, which was then applied to study transcripts. RESULTS: The main findings of this study converged upon three overarching domains: 1) reactions to the intervention; 2) perceptions of patients' receptivity to cessation counseling; and 3) perspectives on ED cessation counseling and preventive care. ED staff expressed ambivalence toward the implementation of smoking cessation guidelines. Both ENs and EPs agreed that the delivery of smoking cessation counseling is important, but that it is not always practical in the ED on account of time constraints, the competing demands of acute care, and resistance from patients. Participants also called attention to the need for improved role clarity and teamwork when implementing the 5 A's in the ED. CONCLUSIONS: There are numerous challenges to the implementation of smoking cessation guidelines in the ED. ENs are generally willing to take the lead in offering brief cessation counseling, but their efforts need to be reinforced by EPs. ED systems need to address workflow, teamwork, and practice policies that facilitate prescription of smoking cessation medication, referral for cessation counseling, and follow-up in primary care. The results of this qualitative evaluation can be used to guide the design of future ED intervention studies. TRIAL REGISTRATION: ClinicalTrials.gov registration number NCT00756704.

The emergency department action in smoking cessation (EDASC) trial: impact on cessation outcomes.

INTRODUCTION: The focus on acute care, time pressure, and lack of resources hamper the implementation of smoking cessation guidelines in the emergency department (ED). The purpose of this study was to determine whether an emergency nurse- initiated intervention based on the 5A's (Ask-Advise-Assess-Assist-Arrange) framework improves quit rates. METHODS: We conducted a pre-post implementation trial in 789 adult smokers who presented to two EDs in Iowa between August 13, 2008 and August 4, 2010. The intervention focused on improving delivery of the 5A's by ED nurses and physicians using academic detailing, charting/reminder tools, and group feedback. Performance of ED cessation counseling was measured using a 5A's composite score (ranging from 0 to 5). Smoking status was assessed by telephone interview at 3- and 6-month follow-up (with biochemical confirmation in those participants who reported abstinence at 6-month follow-up). RESULTS: Based on data from 650 smokers who completed the post-ED interview, there was a significant improvement in the mean 5A's composite score for emergency nurses during the intervention period at both hospitals combined (1.51 vs. 0.88, difference = 0.63, 95% confidence interval [CI] [0.41, 0.85]). At 6-month follow-up, 7-day point prevalence abstinence (PPA) was 6.8 and 5.1% in intervention and preintervention periods, respectively (adjusted odds ratio [OR] = 1.7, 95% CI [0.99, 2.9]). CONCLUSIONS: It is feasible to improve the delivery of brief smoking cessation counseling by ED staff. The observed improvements in performance of cessation counseling, however, did not translate into statistically significant improvements in cessation rates. Further improvements in the effectiveness of ED cessation interventions are needed.

The Emergency Department Action in Smoking Cessation (EDASC) trial: impact on delivery of smoking cessation counseling.

OBJECTIVES: The focus on acute care, time pressure, and lack of resources hamper the delivery of smoking cessation interventions in the emergency department (ED). The aim of this study was to 1) determine the effect of an emergency nurse-initiated intervention on delivery of smoking cessation counseling based on the 5As framework (ask-advise-assess-assist-arrange) and 2) assess ED nurses' and physicians' perceptions of smoking cessation counseling. METHODS: The authors conducted a pre-post trial in 789 adult smokers (five or more cigarettes/day) who presented to two EDs. The intervention focused on improving delivery of the 5As by ED nurses and physicians and included face-to-face training and an online tutorial, use of a charting/reminder tool, fax referral of motivated smokers to the state tobacco quitline for proactive telephone counseling, and group feedback to ED staff. To assess ED performance of cessation counseling, a telephone interview of subjects was conducted shortly after the ED visit. Nurses' and physicians' self-efficacy, role satisfaction, and attitudes toward smoking cessation counseling were assessed by survey. Multivariable logistic regression was used to assess the effect of the intervention on performance of the 5As, while adjusting for key covariates. RESULTS: Of 650 smokers who completed the post-ED interview, a greater proportion had been asked about smoking by an ED nurse (68% vs. 53%, adjusted odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.3 to 2.9), assessed for willingness to quit (31% vs. 9%, adjusted OR= 4.9, 95% CI = 2.9 to 7.9), and assisted in quitting (23% vs. 6%, adjusted OR = 5.1, 95% CI = 2.7 to 9.5) and had arrangements for follow-up cessation counseling (7% vs. 1%, adjusted OR = 7.1, 95% CI = 2.3 to 21) during the intervention compared to the baseline period. A similar increase was observed for emergency physicians (EPs). ED nurses' self-efficacy and role satisfaction in cessation counseling significantly improved following the intervention; however, there was no change in "pros" and "cons" attitudes toward smoking cessation in either ED nurses or physicians. CONCLUSIONS: Emergency department nurses and physicians can effectively deliver smoking cessation counseling to smokers in a time-efficient manner. This trial also provides empirical support for expert recommendations that call for nursing staff to play a larger role in delivering public health interventions in the ED.

Implementing evidence-based changes in emergency department treatment: alternative vitamin therapy for alcohol-related illnesses.

STUDY OBJECTIVE: We sought to test the effectiveness of an intervention designed to replace multivitamin infusions with alternative vitamin therapies when treating emergency department (ED) patients who present with alcohol-related illnesses. Most patients presenting to the ED with alcohol-related illnesses are not vitamin deficient, and thus the routine use of multivitamin infusions may be unnecessary. METHODS: We created an educational document that included background literature, the costs of administering multivitamin infusions, and recommended alternative vitamin therapies. We then educated each emergency physician and changed the default electronic physician order entry in EPIC to an alternative vitamin treatment. RESULTS: There were no differences in monthly alcohol-related ED visits between the preintervention (June 2008 to May 2009; mean 204; SD 17) and postintervention (June 2009 to May 2010; mean 217; SD 20) periods. A mean of 32 (SD 3.6) multivitamin infusions was administered each month preintervention; the postintervention mean was 1.1 (SD 2.7) multivitamin infusions per month. The difference was 31 multivitamin infusions per month (95% confidence interval 28 to 34 infusions). The overall percentage of patients receiving vitamin therapy after the intervention was approximately half that of those receiving multivitamin infusions before, 6.8% (SD 2.4%) versus 16% (SD 2.0%), difference 8.7% (95% confidence interval 6.8% to 11%). CONCLUSION: Our educational and order entry intervention was effective in changing physician vitamin prescribing behavior in ED patients with an alcohol-related illness.

Application of lean manufacturing techniques in the Emergency Department.

BACKGROUND: "Lean" is a set of principles and techniques that drive organizations to continually add value to the product they deliver by enhancing process steps that are necessary, relevant, and valuable while eliminating those that fail to add value. Lean has been used in manufacturing for decades and has been associated with enhanced product quality and overall corporate success. OBJECTIVES: To evaluate whether the adoption of Lean principles by an Emergency Department (ED) improves the value of emergency care delivered. METHODS: Beginning in December 2005, we implemented a variety of Lean techniques in an effort to enhance patient and staff satisfaction. The implementation followed a six-step process of Lean education, ED observation, patient flow analysis, process redesign, new process testing, and full implementation. Process redesign focused on generating improvement ideas from frontline workers across all departmental units. Value-based and operational outcome measures, including patient satisfaction, expense per patient, ED length of stay (LOS), and patient volume were compared for calendar year 2005 (pre-Lean) and periodically after 2006 (post-Lean). RESULTS: Patient visits increased by 9.23% in 2006. Despite this increase, LOS decreased slightly and patient satisfaction increased significantly without raising the inflation adjusted cost per patient. CONCLUSIONS: Lean improved the value of the care we delivered to our patients. Generating and instituting ideas from our frontline providers have been the key to the success of our Lean program. Although Lean represents a fundamental change in the way we think of delivering care, the specific process changes we employed tended to be simple, small procedure modifications specific to our unique people, process, and place. We, therefore, believe that institutions or departments aspiring to adopt Lean should focus on the core principles of Lean rather than on emulating specific process changes made at other institutions.

Feasibility of acute clinical trials during aerial interhospital transfer.

BACKGROUND AND PURPOSE: In rural America, patients are often first seen at a small community hospital and then transferred to a tertiary care center by helicopter for further care. If acute clinical research were feasible during the aerial interhospital transport, more patients might be enrolled in trials at a critical earlier stage. METHODS: Prospective data were collected for all aerial transfers of a university-based helicopter service from April 2005 to January 2006. Flight nurses were educated about stroke research and offered certification and participation. Data collected included patient characteristics and the availability of relatives to provide surrogate consent. RESULTS: All 12 flight nurses completed the institutional review board certification requirements and collected data on 215 transfers. Sixty-one patients had acute stroke or myocardial events (MIs). The median time from symptom onset to helicopter arrival at an outside hospital was 213 minutes (range, 90 to 2135) for ischemic stroke (n=12), 186 (45 to 1332) for intracranial hemorrhage (n=28), and 157 (47 to 1044) for MI (n=21). A relative was available in >74% of those transfers. A trial with a 4-hour window would permit enrollment of 67% of the ischemic strokes, 82% of intracranial hemorrhage cases, and 76% of MI patients. CONCLUSIONS: Clinical trials are feasible during aerial interhospital transport of patients. Flight nurses became successful investigators in clinical research and were exposed to potentially eligible patients with the ability to consent either directly or through surrogates. This approach could improve current clinical trial recruitment in rural areas, as well as permit testing of inflight ancillary interventions to improve outcome during patient transport.

An alternative method of determining standard of care in alleged cases of malpractice.

BACKGROUND: Physician experts hired and prepared by litigants provide most information on standard of care for medical malpractice cases. Because this information may not be objective or accurate, we examined the feasibility and potential value of surveying peer physicians to assess standard of care. METHODS: The survey method was evaluated for a medical malpractice case involving a patient hospitalized with abdominal pain. An abstract of the medical record was created that included the patient characteristics and physician decisions most likely to influence patient outcome. The abstract and questionnaire were sent to 16 academic family physicians and to 20 randomly chosen primary care physicians in Iowa who practiced in communities of similar size to the defendant's community. RESULTS: All 16 academic and 18 (90%) community physicians completed the survey. All respondents judged the patient as presenting with an acute abdomen, and 89% of the community physicians and 100% of the academic physicians judged the care as below standard. More than half the physicians surveyed listed the autopsy diagnosis (perforated ulcer) in their differential. CONCLUSION: Surveys of randomly selected physicians are feasible to perform for medical malpractice cases. A pro-physician bias has little if any influence on the results.