Systematic Utilization of Data for Analysis of a Pediatric Emergency-Room Experience

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. 266 PEDIATRICS Vol. 55 No. 2 February 1975

Systematic

Utilization

of Data

for Analysis

of a Pediatric

Emergency-Room

Experience

George A. Lamb, M.D., Howard L. Weinberger, M.D., Herbert Schneiderman, M.D., and

Bruce Goldstein, M.D.

From the Department of Pediatrics, State University of New York, Upstate Medical Center, Syracuse

ABSTRACT. This report describes the systematic use of

emergency-room data to (1) define the experiences of a

group of pediatric interns in their emergency-room rotation

(especially as they relate to their role as future pediatric

practitioners), (2) evaluate, supervise, and learn from their

performance in this primary care setting, and (3) provide an

ongoing weekly list of illnesses diagnosed in the emergency

room as an epidemiological sentinel for the larger

commu-nity. The future applications of this type of systematic

ap-proach, perhaps with computer technology, offer the

op-portunity for comparison of delivery, quality, and cost of

health care between various sources of primary care

(emer-gency-room facilities, private physicians’ offices,

neighbor-hood health centers, and health maintenance

organiza-tions). Pediatrics, 55:226, 1975, INTERN, EMERGENCY ROOM,

EDUCATION.

Considerable concern has been expressed re-garding the applicability of pediatric training for the present and future practice of pediatrics. In-deed, it is the responsibility of the directors of training programs to review continually the goals of their programs and their ability to accomplish them.

Descriptions of pediatric practice presented in recent years have included Geppert’s pediatric practice in a military situation’ in 1958 and Breese et al.’s small pediatric group practice in Upstate New York2 in 1966. More recently, pa-pers have appeared describing the “practices” of internship,35 attempting to show the relevance (or lack thereof) of these training experiences to

later pediatric practice. Levine et al.4 felt that the internship experience was too heavily orientated to unusual inpatient pediatric patients whereas Wallace and Siiber’s5 analysis was quite different, perhaps because of the different types of pediatric inpatients seen in the two training programs.

Recently the American Academy of Pediatrics has suggested, and many educational programs have implemented, the comparison of pre- and post-training testing to evaluate at least the con-tent of knowledge obtained during the training program.6 However, this does not evaluate the quality of functioning of individual house officers, either as trainees or as potential pediatric practi-tioners.

This paper describes the systematic use of emergency-room data to review the experience of a group of pediatric interns in their emergency-room rotation. The benefits of this systematic ap-proach (easily amenable to computer technology) described herein include the supervision of the quality of care rendered by the intern, the educa-tional inputs generated by the evaluation of mdi-viduai or group experiences, and an epidemiologi-cal sentinel of illnesses within the community.

(Received March 27; revision accepted for publication July

15, 1974.)

ADDRESS FOR REPRINTS: (G.A.L.) Department of

Pre-ventive and Social Medicine, Harvard Medical School, 25

Shattuck Street, Boston, Massachusetts 02115.

at Viet Nam:AAP Sponsored on September 8, 2020

www.aappublications.org/news

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TABLE I

DESCRIPTION OF EMERGENCY-ROOM ROTATION BY INTERN,

1971-1972

RESULTS DESCRIPTION OF THE INTERNSHIP

PROGRAM

The pediatric training program at the S.U.N.Y. Upstate Medical Center has been developed to in-elude considerable experience in the deiivery of ambulatory care. Thus, in the study year July 1971 to June 1972, from three to five months of the in-tern’s (PL-1) rotation was in the ambulatory set-ting. In addition, each intern participated in a continuing program in which families with chron-ic illnesses were followed throughout the year.

The pediatric emergency room at the State University Hospital, Syracuse, New York, pro-vides access to medical care for children without appointments. As is true of many emergency rooms throughout the country, the illnesses of the majority of children do not represent true emer-gencies in the medical sense, but rather illnesses and concerns usually handled by the primary medical provider. The pediatric intern is assigned to the emergency room every third 24-hour per-iod while participating in the activities of the am-bulatoiy division and thus has the option of sche-duling individual revisits in the appointment

din-ic for personal follow-up.

As noted by Wingert,3 supervision of these rela-tively inexperienced medical personnel is essen-tial. In addition to the on-site availability of resi-dent and attending coverage, each emergency-room record was reviewed daily and, where mdi-cated, discussed by a resident or attending pedia-trician with the intern providing the care. The data generated in this study have allowed an overall evaluation of the group’s pediatric experi-ence and a close estimation of the quality of their “practice.” Lenoski et at. referred to the potential for using computerized data for quality control, but do not describe its use in this manner in any detail.7

METHODS

The process of data collection started in the middle of July 1971. Each intern completed the medical record for each child seen in the emer-gency room in the traditional long-hand manner. All emergency-room records (for infants and chil-then) were examined and coded by an individual specffically trained for these purposes. The in-formation extracted included descriptive data about the child (age, sex), time of day brought for

#{176}Acopy of the data collection and code sheet is available

on request. The training of a data collector was

accom-plished in four hours. The coding and card punching of the

20 to 30 daily records was accomplished in approximately

three hours and cost approximately $130.00 per month.

Intern Ambulatory Service (mo) No.of 24-Hour Emergency-Room Shifts No. of Patients Seen Average No. of Patients

Seen Per 24-Hour Shift

1 5 50 1,062 21.2

2 3 30 713 23.8

-s--

30 752 25.1

4 3 30 662 22.1

5 5 47 1,146 24.4

6 3 30 746 24.9

7 4 43 943 21.9

8 4 40 984 24.6

9 5 47 825 17.6

Total 35 347#{176} 7,833 22.6

#{176}Theremainder of nights covere d by othe r personnel.

care as well as the diagnoses (primary, secondary, tertiary), laboratory tests ordered and their re-sults, treatments prescribed, and disposition for each case. No attempt was made to document the validity of the intern’s medical record or diagnosis nor to test the reliability of the coding.

A program describing the occurrence of diag-noses was written at a cost of $500.00 and a week-ly readout printed listing the individual diagnoses (fracture, otitis media, varicella, etc.) for the pre-ceding 1-week, 4-week, and 13-week periods ($40.00 per month). This provided us with an on-going epidemiological record of the type of illness seen in that Emergency Room similar to that de-scribed by Nahmais and McCroan.8 The relation-ship between intern function and diagnostic cate-gory was accomplished by mechanical sorting of cards preparatory to establishing a computer pro-gram.

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TABLE II TABLE IV

268 EMERGENCYROOM EXPERIENCE

CLINICAL DIAGNOsEs OF PATIENTS OF PRIVATE

PEDIATRIC PRACTICE AND OF INTERNS’ EMERGENCY-ROOM EXPERIENCE Diagnoses Breese No. et al.2 % Present No. Study %

Infectious 1,263 80.4 4,583 53.6

Cold, tracheitis,

croup, bronchitis 333 21.2 1,489 18.1

Streptococcal illness 297 18.9 146 1.8

Otitis Media 211 13.4 726 8.8

FUO 97 6.2 59 0.7

GIandGU 96 6.1 734 8.9

Pneumonia 37 2.4 123 1.5

Cervical adenitis 34 2.2 18 0.2

Tonsillitis, non-stop 26 1.7 560 6.8

Aseptic meningitis 0 0 67 0.8

Other 132 8.4 661 8.0

Non-infectious 307 19.6 3,656 44.4

Allergy,skin 116 7.4 589 7.1

Injury 107 6.8 2,31 1 28.0

Chronic diseases NL NL 327 4.0

Other 84 5.4 429 5.2

Total 1,570 100.0 2,239 100.0

#{176}Diagnosis of “well child” not included (1,014 in Breese

et aUs survey and 377 in the interns’ experience).

TABLE III

DIAGNOSES OF ACCIDENTS AND HEMOPHILIA BY INTERN,

1971-1972

Accidents hemophilia

%of %of No.

Total No. No. Total No. No. Total

Ex-In- of Diag- Ob- Di- Ex- Ob- Diag- pect-tern noses served agnos&s pected#{176}served noses ed#{176}

1 1,199 279 23.2 321.3 30 2.5 27.6

2 801 246 30.7 214.7 19 2.4 18.4

3 812 251 30.9 217.6 27 3.3 18.7

4 717 164 22.9 192.2 16 2.2 16.5

5 1,313 336 25.6 351.9 24 1.8 30.2

6 815 211 25.9 218.4 24 2.9 18.7

7 1,013 275 27.1 271.5 22 2.2 23.3

8 1,050 278 26.5 281.4 20 1.9 24.2

9 896 271 30.2 240.1 20 2.2 20.6

Total 8,616 2,31 1 26.8 2,31 1 202 2.3 202

#{176}Thenumber of diagnoses of accidents and hemophilia

ex-pected assuming equal distribution among interns (see text).

DIAGNOSES OF PHARYNGITIS AND UNDIFFERENTiATED UPPER RESPIRATORY TRACT INFECTION BY INTERN, 1971-1972

In-tern Total No.of Diag-noses Pharyngi % of No. Total Ob- Diag-served noses tis#{176} Undiffcrentiat % of

No. No. Total

Ex- Ob-

Diag-pectedt noses

ed URI

No.

Ex-pecte&

1 1,199 97 8.1 97.1 178 14.8 170.3

2 801 90 11.2 64.9 59 7.4 113.7

3 812 53 6.6 65,8 82 10.1 115.3

4 717 60 8.3 58.1 170 23.7 101.8

5 1,313 149 11.3 106.4 170 12.9 186.4

6 815 54 6.7 66.0 127 15.6 115.7

7 1,013 67 6.6 82.1 150 14.8 143.8

8 1,050 69 6.5 85.1 166 15.8 149.1

9 896 62 6.9 72.6 121 13.5 127.2

Total 8,616 701 8.1 698.1 1,223 14.2 1,223.3

#{176}Includes pharyngitis and tonsillitis.

tThe number of diagnoses of pharyngitis and

undifferenti-ated upper respiratory tract infection assuming equal

dis-tribution among interns (see text).

This is almost twice the number of total outpa-tients seen by other interns4’5 and more closely ap-proximates the pediatric practitioner’s experi-ence.2 Since more than one diagnosis was accept-able for each patient, a total of 8,616 diagnoses were recorded for the 7,833 patients, or 1.1 diag-noses per patient visit.

Using a classification similar to Breese et al.’s2 the distribution of clinical diagnoses for the intern group is depicted in Table II. Since well children are unlikely to visit an emergency room (the diag-nosis was made in less than 5% of 8,616 instances), this diagnosis is excluded from the analysis. As might be expected, injuries were more commonly seen in the emergency-room experience (28.0%) than in private practice (6.8%). The distribution of other diagnoses in the interns’ emergency-room experience was similar to that of Breese et al. ‘s practice. Some of the more minor differences may have been due to epidemic disease (aseptic men-ingitis in the intern’s experience), culture accessi-bility (higher frequency of streptococcal infection in Breese et al.’s practice), or differences in diag-nostic ability of the experienced versus inexper-ienced pediatrician.

This table also provides the first description of the experience of a group of interns in an

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TABLE V TABLE VI

TREATMENT OF PHARYNGITIS BY INTERN AND CULTURE

RESULTS, 1971-1972 Intern No.of Diag-nosesof Pharyn-gitis#{176} % Cul-tured % Treated No Cul-ture Nega-tive Cul-ture Treated Positive Culturet All Pa-tients

1 97 83.5 18.8 56.1 66.7 52.6

2 90 78.9 68.4 48.9 75.0 60.0

3 53 90.6 40.0 29.7 72.7 39.6

4 60 83.3 50.0 72.2 100.0 75.0

5 149 79.7 58.1 30.6 35.0 36.9

6 54 74.1 42.9 66.7 53.8 57.4

7 67 91.0 00.0 25.6 33.3 25.4

8 69 79.7 50.0 60.5 66.7 59.4

9 62 90.0 37.5 36.4 60.0 40.3

Total 701 82.5 46.3 44.7 61.6 48.5

#{176}Includes pharyngitis and tonsillitis.

tPositive indicates growth of any bacitracin-sensitive

$-hemolytic Streptococci.

gency room setting. Tables III and IV describe the distribution of selected conditions as diagnosed by individual intern. In each table the expected number for a specffic condition represents the number of such diagnoses which each intern might be expected to make, if there were a ran-dom distribution of patient contacts over the en-tire year.t Thus, in Table III one can see that the observed number of instances of accidental injury and hemophilia by intern is within the range of what would be expected by chance alone. These two conditions are apparently seen and diagnosed throughout the year by all interns with equal fre-quency. However, in Table IV there are signifi-cant differences between the observed and ex-pected number of diagnoses for types of upper respiratory tract infections for some interns. For example, interns 2 ad 5 made the diagnoses of pharyngitis or tonsillitis more often than expected and the diagnoses of undifferentiated upper

respi-tThe number expected for each intern equals that

in-tern’s total number of diagnoses multiplied by the average

percentage of this diagnosis for the entire group. For

exam-ple in Table III, intern 1 made the diagnosis of accident in

279 instances. Since 26.8% of all the diagnoses established

by the intern group were accidents, the expected number

for intern 1 would be his (her) total number of diagnoses

times this percentage: 1199 X 26.8 = 321.3.

RESULTS OF X-RAYS BY ANATOMICAL AREA, 1971-1972

Area No. , No. Positive0 % Nega , No. tive %

Chest 232 82 35.3 150 64.7

Skull 164 6 3.7 158 96.3

Long bones 43 27 62.8 16 37.2

Hand 50 38 76.0 12 24.0

Feet 32 14 43.8 18 56.2

Other 379 159 42.0 220 58.0

Total 900 326 36.2 574 63.8

#{176}Positive indicates any abnormalityby x-ray.

TABLE VII

LUMBAR PUNCTURE RESULTS BY INTERN, 1971-1972

Lumbar Punctures

Positive0

Intern No. No. %

1 21 6 28.6

2 26 6 23.1

3 22 8 36.4

4 4 1 25.0

5 17 6 35.3

6 16 3 18.7

7 18 7 38.9

8 20 14 70.0

9 20 11 55.0

Total 164 62 37.8

#{176}Positive indicates (1) more than 10 white cells of any kind;

(2) protein of greater than 40 mg/100 ml; and/or (3) CSF

glu-cose level less than one half that of blood glucose.

ratory tract infection less often than expected. The reverse was true for intern 8. This may

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90

270 EMERGENCY-ROOM EXPERIENCE

80

70

60

p.-z Id U 50

Id

40

30

20

I0

FI;. I. Frequency distribution of diagnostic group by week, 1972.

The collection and the computer display of the diagnoses on a weekly basis allowed a current re-view of the types of illnesses as seen in the emer-gency room, often before bacterial or viral results are obtainable. For purposes of this presentation this can be depicted on a weekly (Fig. 1) basis. In addition, the data might be depicted by diagnosis for an entire year and then compared with anoth-er year’s experience. Figure 2 clearly shows the

1971 epidemic of aseptic meningitis (due to echo-viruses 4 and 9) which did not recur in 1972 (Fig. 3).

Another benefit derived from this survey is a delineation of the usefulness of laboratory tests in establishing various diagnoses. Table V indicates a high percentage of throat cultures (82.5%) ob-tamed by our house staff on children with a diag-nosis of pharyngitis. One quarter of all the

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PYOGENIC MENINGITIS 0

5

4

AUG. SEPT. OCT. NOV. DEC. JAN. FEB. MAR. APR. MAY JUNE

ASEPTIC MENINGITIS

U,

‘Ii

U)

4

I.)

I’.

0

“I

m

z

1971- 72

FIG. 2. Childhood meningitis by week, State University Hospital, 1971-1972.

tures yielded group A fl-hemoiytic Streptococci, and the range of positive cultures was from 17% to 34%. There was no difference in the percentage cultured or the percentage positive at different times of day or by degrees of fever in the child.

A second example of the importance of this type of survey in assessing laboratory use is in di-agnostic radiology. In Table VI one notes that the radiographic study of the skull was seldom posi-tive whereas radiographs were helpful in diagnos-ing abnormalities of the extremities (presumably accidental injury) and of intermediate value in the diagnoses of chest abnormalities. This type of information could be of considerable importance in a cost-benefit analysis of various laboratory

tests,9 since costs could also be calculated for

the known positive and negative results. The use-fuiness of the laboratory in confirming the clinical diagnosis of meningitis is depicted in Table VII. Lumbar punctures were positive about one third of the time (37.8%). The variation of positive taps among the interns (19% for intern 6 to 70% for in-tern 8) probably reflects the different epidemiolo,-gic experiences of the different interns or their di-agnostic acumen. This study cannot indicate how

often the diagnosis of meningitis was missed and the spinal fluid not examined. However, it does give us an estimate of the number of lumbar punc-tures usually performed for each diagnosis of men-ingitis. Thus, in the experience of our interns, about one of three children clinically suspected of having meningitis will have this confirmed by spi-nal fluid examination, although there is consider-able variability among the group.

The systematic survey of the interns’ experi-ence in the emergency room provides us with the ability to begin to evaluate the quality of medical care, at least in regard to certain “standard-treat-ed” conditions.

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2

$972 - 73

25 I S IS 22 I S IS 3013 27 II 7

fiB. MAR. APR. MAY JUNt ASEPTIC MENINGITIS

272 EMERGENCY-ROOM EXPERIENCE

6

U)

I” U

UI

z

PYOGENIC MENINGITIS 0

a

is 6 $3 V 3 $0 7 24 31 7 $421 28 5 2 19 2 9 30 7 $4 2$ 4 II IS

JUNE JULY AUG. SEPT. OCT. NOV. DEC. JAN.

Fic. 3. Childhood meningitis by week, State University Hospital, 1972-1973.

infection before the culture results were known, although the other positive ones were treated after the results became known. In addition, this table allows us to identify interns 2, 4, 6, and 8 who were consistently “high users” of antibiotics. This is of obvious relevance to quality control and education.

DISCUSSION

This systematic survey has allowed us to de-scribe the experience of the group of interns in the emergency room for an entire year. Although it does not involve all the experjences of the intern in our program, it does allow us to compare the

type of patients seen in our emergency-room set-ting to that described for other internships4’5 and for pediatric practice.2 As previously noted, it also describes the variations in the diagnoses made by a group of interns and provides the description ne-cessary to begin to comment on the appropriate-ness of this experience.

It should be noted that throughout the period of data collection,. daily chart review by a senior resident and/or faculty member continued. Al-though we are committed to this sampling

meth-od of quality supervision, it is evident that it is a very inefficient way to get an overview of the care provided.

Since the use of the computer to survey the ex-perience of house officers in the emergency room setting was suggestedby Lenoski etal.,7 many other uses of this approach have become evident. Our data must be evaluated within the limitations im-posed upon them by the recognition that the re-corded diagnosis depends upon the intern’s ability to make the correct diagnosis, to use appropriate terminology, and to record accurately. One meth-od of ascertaining the accuracy of a diagnosis by this systematic system (computerized or not) would be if a particular diagnosis consistently ap-peared more than would be expected for an mdi-. vidual intern. In some conditions, this could be ex-plained because of variations in the epidemiology of different infections at different times of year. Our data indicate that hemophilia, a diagnosis es-tablished by history, was equally distributed among the interns, as could be expected. On the other hand, the diagnoses of undifferentiated upper respiratory tract infection and pharyngitis were not distributed equally among the interns

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and thus may represent inaccuracies in separating these diagnostic categories. As depicted in Table IV, interns 2 and 5 diagnosed pharyngitis more often than expected and undifferentiated upper respiratory tract infection less often than expect-ed. Since one would expect these two diagnoses to appear together epidemiologically, it would ap-pear that the interns diagnosed these entities dif-ferently from their cohorts. A direct result of this finding has been an attempt to define more specif-ically the criteria necessary to make various diag-noses and also to allow for the recording of symp-toms (fever, headache, backpain, etc.) when spe-cific diagnoses could not be established. It is our impression that this sharpened the use of diag-nostic categories by this group of interns.

Lenoski and Wingert developed normative data regarding diagnostic efficiency of laboratory tests ordered by pediatric emergency-room physi-cians in a university medical center hospital.1#{176} For instance, 21 lumbar punctures were performed in order to document one positive result (4.8%). Gu-ruraj et al., on the other hand, reported that 16% of lumbar punctures yielded positive results in an-other emergency-room setting.1’ In the present study only three spinal taps were performed for each positive result (33%; Table VII). This may have reflected a different epidemiological pattern (i.e., our outbreak of asceptic meningitis), differ-ent diagnostic acumen, or different admiistra-tive policy. In any event, this striking difference suggests that more such normative data should be generated and perhaps that each hospital should develop its own such data. A similar approach has been suggested for hospital care by the Profession-al Activity Study and by Sanazaro et al.’2 and now by the Professional Standards Review Organiza-tion.13 With this in mind, we have begun collect-ing similar data regarding children visiting the emergency room of a community hospital which is staffed by a group of more experienced physi-cians. These data will permit comparisons be-tween different services providing primary care.

Another distinct advantage of the computer-ized aspect of this survey has been the current (i.e., weekly) reporting of diagnoses. Although these epidemiological data have not yet been as fully developed as that described by Nahmias and McCroan,8 they did serve as a sentinel for the kinds of illnesses in the area and were not limited to infectious diseases. As other deliverers of medi-cal care to infants and children become involved, we feel these data will become even more helpful to the community.

Perhaps the most important result of the initial year’s experience with the computer survey was

the assistance it provided in the evaluation and, hopefully, the improvement of patient care by in-dividual interns. Here, the example of the diag-nosis and treatment of pharyngitis is quite clear. Most physicians feel it is necessary to obtain cul-tures from children with pharyngitis to determine the presence or absence of group A $-hemolytic Streptococcus1419 and to prescribe accordingly. As described by the Committee on rheumatic Fever,20 many pediatric house officers are not fully aware of this information, and indeed our data would support the fact that pediatric interns do not consistently carry out optimum manage-ment of the child with pharyngitis. Starfield et al.’s information seems to imply that the same prob-lem occurs in the private practice of pediatrics.19 Thus, perhaps a similar systematic evaluation of the quality of the private practice of pediatrics is warranted, at least as a pilot project. Following the analysis of the pharyngitis data, the use and abuse of cultures and antibiotics was discussed in-dividually with the interns. Table V also served as an excellent educational device to discuss the dif-ficulties of diagnosis in pharyngitis and its treat-ment.

Since this was the first year of the systematic survey of our emergency-room experience, we did not evaluate some information that will undoubt-edly be of considerable interest. First, as men-tioned previously, the quality of care rendered in this setting will be compared with that of a near-by emergency room staffed and supervised in a different manner. Second, by including the cost of each emergency-room visit (already available to the computer), we will be able to document the cost as well as the quality of care. Finally, as more experience is generated and with the more re-fined diagnostic criterion, we plan to document and evaluate the change in the intern’s quality of patient care throughout the year as a result of the feedback from the data generated by the sys-tematic survey.

SUMMARY

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274 EMERGENCY.ROOM EXPERIENCE

pharyngitis were cultured in 74% to 91% of in-stances whereas treatment of noncultured phar-yngitis occurred in 0% to 68% of instances. Al-though not documented, we feel that there was a distinct educational benefit both for individual in-terns and for the entire group by the presentation and discussion of the data. This approach should have considerable value in comparing the quality and cost of various methods of delivery of health care.

REFERENCES

1. Geppert, L. J.: Composition of pediatric practice at a

permanent army base in the antibiotic era. Pediat-rics,22:336, 1958.

2. Breese, B. B., Disney, F. A., and Talpey, W.: The

na-ture of a small pediatric group practice. Pediatrics,

38:264, 1966.

3. Wingert, W. A.: The utilization of the intern in a

pedi-atric outpatient setting. J. Med. Educ. 41:756, 1966.

4. Levine, M. D., Robertson, L. S., and Alpert, j. J.: A

de-scriptive study of a pediatric internship. Pediatrics,

44:986, 1969.

5. Wallace, P. D., and Silber, D. L.: Analysis of a straight

pediatric internship. J. Pediatr., 79:110, 1971.

6. Burg, F. D., and Wright, F. H.: The 1971 pretest of the

American Board of Pediatrics. Pediatrics, 50:462,

1972.

7. Lenoski, E. F., Hanes, B., and Wingert, W. A.:

Com-puter processing of pediatric emergency room

data. JAMA, 204:797, 1968.

8. Nahmias, A. J., and McCroan, J. E.: A community

sur-veillance system of infectious diseases in the greater

Atlanta area. Am. J. Public Health, 56:408, 1966.

9. Bell, R. S., and Loop, J. W.: The utility and futility of

radiographic skull examinations for trauma. N. Engl.

J. Med, 281:236, 1971.

10. Lenoski, E. F., and Wingert, W. A.: The diagnostic

effi-ciency of laboratory tests ordered by pediatric

emer-gency room physicians. Read before the Ambulatory

Pediatric Association, Atlantic City, N.J., April 1971.

11. Gururaj, V. J., Russo, R. M., Allen, J. E., and

Herszko-wicz, R.: To tap or not to tap: What are the best

in-dicators for performing a lumbar puncture in an

out-patient child? Clin. Pediatr., 12:488, 1973.

12. Sanazaro, P. H., Goldstein, R. L., Roberts, J. S.,

Maglott, D. B., and McAllister, J. W.: Research and

development in quality assurance: The experimental

Medical Care Review Organization Program. N.

Engl. J. Med., 287:1125, 1972.

13. Welch, C. E.: Professional Standards Review

Organiza-tions-Problems and prospects. N. Engl. J. Med.,

280:291, 1973.

14. Negus, V. E.: Acute tonsillitis: Diagnosis, treatment

and complications. Practitioner, 150:1, 1943.

15. Brumfitt, W., O’Crady, F., and Stabler, J.D. H.: Benign

streptococcal sore throat. Lancet, 11:419,1959.

16. Gosslings, W. R. 0., Valkenburg, H. A., Bots, A. W.,

and Lorrier, J.C.: Attack rates of streptococcal

phar-yngitis, rheumatic fever and glomerulonephritis in

the general population. N. Engl. J. Med., 268:687,

1963.

17. Feinstein, A. R., and Spagnuolo, M.: Sore throats,

strep-tococcal infections and prevention of rheumatic

fever. J. Chronic Dis., 15:623, 1962.

18. Ross, P. W.: Antibiotic treatment of sore throat in

Ed-inburgh children. Practitioner, 209:47, 1972.

19. Starfield, B., Seidel, H., Carter, C., Carvin, W., and

Sed-don, J.: Pediatric practice: Performance and

prob-lems. Pediatrics, 52:344, 1973.

20. Committee on Rheumatic Fever, Council on

Rheumat-ic Fever and Congenital Heart Disease, American

Heart Association: House officers’ knowledge of

Croup A streptococcal pharyngitis and its

manage-ment. Am. J. Dis. Child., 124:47, 1972.

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1975;55;266

Pediatrics

George A. Lamb, Howard L. Weinberger, Herbert Schneiderman and Bruce Goldstein

Experience