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Experience with a Prolonged Respiratory Care Unit
Experience with a Prolonged Respiratory Care Unit Frank]. Indihar, M.D.;o and Dennis P. Forsberg, C.R.T.T.t
A major medical social problem at present is the need for care of patients with chronic or prolonged m· ness. This is particularly true in the case of respiratory disease, which bas undergone major strides in prolonging life through the increased use of respirators and improved metbods of medical care. In response to this need, St. Paul, Minnesota's Bethesda Lutheran Medical Center opened a prolonged respiratory care unit on
Aug 21, 1979. A review and genen) assessment of this operation is presented. At the time of this review, the unit bas been open for approximately 18 months. The obvious benefits in terms of patient care cost as weD as the improvement in patient quality of Be inherent in this type of specialized unit, which bas an adequately trained staff, are described.
"Chronic, long term, or prolonged illness has
facilities because of the complexities of equipment required and variable reimbursement practices. However, a successful model for care of these patients exists in Europe, particularly in France and
been receiving increased attention in recent years as the major medical social problem of our time."! It is well recognized that modem medical technology has increased the life expectancy of patients with chronic debilitating respiratory disease, as well as other illnesses that have been treated to the extent that they may be classified as having prolonged illness. Prolonged care may be defined as treatment of an acute disease process over a long period of time. The emphasis is no longer on whether to provide treatment in the face of a prognosis of incurability, but on how best to care for such patients with every facility at our disposal.' Prolonged illness is not a hopeless condition; rather, it implies a continuity of the disease, which calls for continuity in the treatment.' Further implied in this concept is that the patient's condition is in a constant state of flux, with each state of the illness requiring a variance in the type of care rendered. This type of care is determined by the patient's physical illness, the activities of daily living that he is able to assume, and, concomitantly, the amount of assistance that must be supplied by others. In many instances, patients with prolonged respiratory illnesses are unable to care for themselves at home, and social service agencies and hospitals are unable to place them in long-term care ·Medical Director, Prolonged Respiratory Care Unit, Bethesda Lutheran Medical Center, St. Paul, and Clinical Assistant Professor, University of Minnesota Medical School, Minneapolis. tTechnical Director, Cardia-Respiratory Unit, Bethesda Lutheran Medical Center, St. Paul. Reprint requests: Mr. Forsberg, Bethesda Lutheran Hospital, 559 Capitol Blvd, St. Paul, Minnesota 55103
CHEST, 81: 2, FEBRUARY, 1982
Sweden.P
It therefore became apparent that a prolonged respiratory care center needed to be developed in the United States to provide for patients who required long-term ventilatory support, oxygen therapy, tracheostomy care, and other specialized respiratory therapy modalities. In response to this need, the Bethesda Lutheran Medical Center developed a 24-bed Prolonged Respiratory Care Unit in August 1979. This unit has decreased the perpatient daily cost by a unique combined respiratory therapy-nursing-purchasing cost approach and has provided an invaluable aid to the patients and hospitals of the upper Midwest with its pioneer respiratory care project. DESCRIFIlON OF THE
UNIT
The Prolonged Respiratory Care Unit received approval for its formation from the Foundation for Health Care Evaluation, which is the local Professional Standards Review Organization (PSRO), in April 1979. An acute care subprovider number was obtained from Medicare-Medicaid, which allowed the hospital to provide rates varying from standard charges. The unit varies from a regular nursing station in several ways. The organizational structure includes the Associate Director of Nursing and the Technical Director of Respiratory Therapy as Co-Directors of the unit. They coordinate the administrative func-
EXPERIENCE WITH A PROLONGED RCO 189
• tions of the unit under the supervision of a Medical Director. Daily patient care activities are jointly coordinated by the head nurse and chief therapist on the unit. Respiratory therapy and nursing personnel are assigned to the unit on a permanent basis. There are seven full-time employees assigned to the therapist staff and 20 full-time employees assigned to nursing services. This allows for two staff therapists and five nursing service personnel on day and afternoon shifts and one staff therapist and two nursing service personnel on nights, seven days a week. The therapist staff is included in the per day charge for the unit and eliminates the necessity of charging additional fees for their services. The average man hours per patient-day on the unit, which includes therapists and nursing staff, has been 8.2 hours through the first 16 months. Social services, dietary services, volunteer, and chaplaincy services are also permanently assigned to the unit, but their personnel are not included in the unit's manpower statistics. Physical Medicine and Occupational Therapy services are available at no cost on a one-time consultive basis. Thereafter, if continued use of these services is required, charges are incurred at the same rate as in the acute care hospital. Central supply items and pharmaceuticals are purchased, because of predictability of need, in 30-day supply quantities, thereby eliminating expensive handling charges that occur with daily ordering in an acute care facility. All other ancillary services are available to the patients at the same cost as in the acute care setting. With regard to staff responsibilities, the therapists provide ventilator management, respiratory therapy treatments, oxygen therapy and monitoring, airway care, pulmonary education, and rehabilitation, together with diversional activities. The nursing service, in addition to collaborating on providing the latter three activities, also supplies the medical supervision necessary. Both the respiratory and nursing services serve as liaisons to the physicians and administrative staff. All patients considered for admission to the unit must be older than 15 years of age and have a primary or secondary respiratory problem. They must have a completed application form, which includes a history, diagnosis and problem list, financial information, activities of daily living estimation, respiratory therapy modalities listing, and medication enumeration. Based on this information, patient admission is considered from three areashome, another care facility, or another nursing unit in Bethesda Hospital. An Admissions Committee composed of the Medical Director, Unit Co-Directors, Head Therapist,
190 INDIHAR, FORSBERG
Table I-Anal,.. . 01 Palierd ..4dmiaioJU (N=89) No. of Patients (%) Admissions by area Bethesda Medical Center Other metropolitan hospitals Homes Skilled nursing facility Out-of-town hospital Level of Care
20 49 12 4 4
20
1
31 38
2 3 Diagnosis COPD Closed head injury Neuronnuscular disorder
72 (73)
5 11
Sex Male Female
45
44
Age distribution, yr
20-30
4
1 6
30-40 40-50 50-60
13
22
60-70 70-80
37 (42) 6
80-90
Head Nurse, Concurrent Review Committee Coordinator, and Unit Social Worker classifies patients in three levels of care depending on the degree of daily living in which the patient can engage and the type of respiratory support needed. Three levels of patient care are as follows. Levell: Self-Sufficient Patients These patients, mostly independent in activities of daily living, require daily respiratory care, te, oxygen therapy, aerosol therapy, rehabilitation, and education, etc, that could not be provided in another setting. The local PSRO established further criteria for admission of these patients, including an arterial oxygen tension test result of <55 mm Hg at rest on room air, an FEV l of <700 ml, and a FEV1 of < 1,400 mi. In addition, documentation was necessary to indicate the reason that the patients could not maintain themselves at home or in another type of facility, and what activities would be undertaken to attempt to correct this situation.
Level 2: Intermediate Care Patients Patients in this level perform only minimal activities of daily living and require extensive respiratory care, te, ventilator support, tracheostomy care, chest physical therapy, etc.
Level 3: Intensive Care Patients These patients can perform no activities of daily living and have total dependence on nursing and respiratory care.
CHEST, 81: 2, FEBRUARY, 1982
Respiratory therapists and nurses assigned to the unit may suggest changes in patient classification with the concurrence of the attending physician. The Utilization Review Coordinator reviews the patient records with the head nurse and therapist, and with their advice may also suggest changes in classification. Questionable patients are brought before the entire Admissions Committee for review. Review of these patients by the entire committee continues throughout their stay. After the 3O-day review, level 1 patients continue to be reviewed every 30 days, level 2 patients every 60 days, and level 3 patients quarterly. If changes in care levels are promulgated, this change is communicated to the physician and effected by the business office. If the patient's continued stay on the unit is questioned, the physician is asked to document the necessity for the patient's continued stay. If it is determined that a patient has no further need for the unit, efforts are made to assist the physician, patient, and family in obtaining suitable placement, PATIENT ANALYSIS
A review of the patients admitted to the unit from Aug 21, 1979, through Jan 31, 1981, is summarized in Table 1, showing the number of admissions, initial level of care required, patient classification, and current status/ disposition. Patients were admitted to the unit from facilities throughout Minnesota. During this time 89 patients were admitted to the unit, 23 patients were discharged to their homes, eight transferred to other care facilities when their respiratory status improved, 23 patients died, 14 patients were discharged, admitted to our Intensive Care Unit, and readmitted at a later date, and 21 remained on the unit as permanent residents. As detailed in Table 1, only 22 percent of the patients were admitted from Bethesda, and 70 percent of these were readmissions from the Intensive Care Unit, indicating the regional appeal of this type of facility. Level 3 represented the most frequently used level of care, with 43 percent of the admissions. The major diagnostic group was COPD, with 81 percent of the admissions. There was an equal distribution of male and female admissions; the largest age group was in the 70 to 80 years range, or 42 percent of the admissions. There were 28 applications rejected because they did not meet the admission criteria. Although most of these patients were admitted to reside on the unit as their permanent domicile, significant numbers of patients were discharged to their homes or long-term care facilities after extensive pulmonary rehabilitation and education. It
CHEST, 81: 2, FEBRUARY, 1982
is our impression, although difficult to substantiate statistically at this time, that these patients are doing well at home and have had few readmissions to the acute hospital setting. Continued follow-up of these patients is being conducted to try to support this impression. Of particular gratification was that four young patients with closed head injuries and "coma vigils" regained consciousness after several months of extensive respiratory and physical therapy support. All of these patients are undergoing rehabilitation efforts at other medical facilities. UNIT COST ADVANTAGE
The patients' per-day rate includes room and board, nursing and respiratory care, all respiratory therapy equipment and treatments, as well as aerosolized respiratory therapy medications. All other ancillary services mentioned earlier are likewise included in the room rate. Specialized care and consultation, as well as individualized medications, are charged at prevailing rates. These all-inclusive rates are therefore significantly lower than those in an acute care setting. The average cost of the level 3 patient is $143.01/day compared with $465.81/ day in an acute care setting; for level 2 patients, $121.911 day compared with $196.22; and for level 1 patients, $98.52/ day compared with $188.24. These costs are based on the average per-day costs of Minneapolis-St. Paul acute care hospital tabulations. There were 121,471 hours of oxygen therapy, 39,102 hours of mechanical ventilation, and 12,648 various respiratory therapy modalities, including 269 pulmonary rehabilitation classes, used on the unit. This represented a cost savings of $452,051.00 over the period covered by this report, based on the average charge in the metropolitan area for respiratory therapy procedures. CONCLUSION
It is increasingly evident that this Prolonged Respiratory Care Unit, which has been open for 18 months, has answered the needs of society in providing care at a reasonable cost for patients with prolonged respiratory disease or complications. The unit has been well used, with all of its beds filled and further admissions being limited by availability of physical space and qualified nursing and respiratory therapy staff. Many different types of patients were admitted throughout this period, indicating the diverse needs of the patient population in Minnesota. A number of patients will continue to live on the unit for the duration of their disease process; a significant number of patients have been discharged to their homes following their pulmonary
EXPERIENCE WITH A PROLONGED RCU 191
education and rehabilitation. Also of significance is the number of patients who were discharged to other care facilities following the resolution of their respiratory disease processes. The cost benefits of this type of unit are likewise presented The suspected future cost benefits in decreasing rehospitalization for patients who have participated in and understood the rehabilitationeducation program are difficult to assess and will be studied as more data are accumulated.
ACKNOWLEDGMENT: Margaret McFadden, C.R.T.T., provided technical assistance.
1 Field M. Patients are people. In: A medical social approach to prolonged illness. New York: Columbia University Press, 1967:8-21 2 Goldberg A. Report on residency for independent living of the handicapped in Every, France and Sweden. Chicago: Children's Memorial Hospital Publications, 1980: 1-22
Pulmonary Med.icine 1982 - A Comprehensive Approach The course, Pulmonary Medicine 1982-A Comprehensive Approach, will be held April 1-3·at the Marriott Hotel, Philadelphia. Sponsors are the American Lung Association of Pennsylvania, Pennsylvania State Society, American Association for Respiratory Therapy; Pennsylvania Thoracic Society and Pennsylvania Chapter, American College of Chest Physicians. For information, contact Joyce C. Waite, American Lung Association of Pennsylvania, 1135 East Chocolate Avenue, Hershey, Pennsylvania 17033 (717:533-6851).
18th Annual Arizona Chest Symposium The 18th Annual Arizona Chest Symposium, sponsored by the University of Arizona Health Sciences Center, will be held April 1-3 at the Doubletree Inn, Tucson. Contact: Linda Alpert, R.N., PO Box 42195, Tucson, Arizona 85733 (602:327-5451, ext 5110).
192 INDIHAR, FORSBERG
CHEST, 81: 2, FEBRUARY, 1982
A major medical social problem at present is the need for care of patients with chronic or prolonged m· ness. This is particularly true in the case of respiratory disease, which bas undergone major strides in prolonging life through the increased use of respirators and improved metbods of medical care. In response to this need, St. Paul, Minnesota's Bethesda Lutheran Medical Center opened a prolonged respiratory care unit on
Aug 21, 1979. A review and genen) assessment of this operation is presented. At the time of this review, the unit bas been open for approximately 18 months. The obvious benefits in terms of patient care cost as weD as the improvement in patient quality of Be inherent in this type of specialized unit, which bas an adequately trained staff, are described.
"Chronic, long term, or prolonged illness has
facilities because of the complexities of equipment required and variable reimbursement practices. However, a successful model for care of these patients exists in Europe, particularly in France and
been receiving increased attention in recent years as the major medical social problem of our time."! It is well recognized that modem medical technology has increased the life expectancy of patients with chronic debilitating respiratory disease, as well as other illnesses that have been treated to the extent that they may be classified as having prolonged illness. Prolonged care may be defined as treatment of an acute disease process over a long period of time. The emphasis is no longer on whether to provide treatment in the face of a prognosis of incurability, but on how best to care for such patients with every facility at our disposal.' Prolonged illness is not a hopeless condition; rather, it implies a continuity of the disease, which calls for continuity in the treatment.' Further implied in this concept is that the patient's condition is in a constant state of flux, with each state of the illness requiring a variance in the type of care rendered. This type of care is determined by the patient's physical illness, the activities of daily living that he is able to assume, and, concomitantly, the amount of assistance that must be supplied by others. In many instances, patients with prolonged respiratory illnesses are unable to care for themselves at home, and social service agencies and hospitals are unable to place them in long-term care ·Medical Director, Prolonged Respiratory Care Unit, Bethesda Lutheran Medical Center, St. Paul, and Clinical Assistant Professor, University of Minnesota Medical School, Minneapolis. tTechnical Director, Cardia-Respiratory Unit, Bethesda Lutheran Medical Center, St. Paul. Reprint requests: Mr. Forsberg, Bethesda Lutheran Hospital, 559 Capitol Blvd, St. Paul, Minnesota 55103
CHEST, 81: 2, FEBRUARY, 1982
Sweden.P
It therefore became apparent that a prolonged respiratory care center needed to be developed in the United States to provide for patients who required long-term ventilatory support, oxygen therapy, tracheostomy care, and other specialized respiratory therapy modalities. In response to this need, the Bethesda Lutheran Medical Center developed a 24-bed Prolonged Respiratory Care Unit in August 1979. This unit has decreased the perpatient daily cost by a unique combined respiratory therapy-nursing-purchasing cost approach and has provided an invaluable aid to the patients and hospitals of the upper Midwest with its pioneer respiratory care project. DESCRIFIlON OF THE
UNIT
The Prolonged Respiratory Care Unit received approval for its formation from the Foundation for Health Care Evaluation, which is the local Professional Standards Review Organization (PSRO), in April 1979. An acute care subprovider number was obtained from Medicare-Medicaid, which allowed the hospital to provide rates varying from standard charges. The unit varies from a regular nursing station in several ways. The organizational structure includes the Associate Director of Nursing and the Technical Director of Respiratory Therapy as Co-Directors of the unit. They coordinate the administrative func-
EXPERIENCE WITH A PROLONGED RCO 189
• tions of the unit under the supervision of a Medical Director. Daily patient care activities are jointly coordinated by the head nurse and chief therapist on the unit. Respiratory therapy and nursing personnel are assigned to the unit on a permanent basis. There are seven full-time employees assigned to the therapist staff and 20 full-time employees assigned to nursing services. This allows for two staff therapists and five nursing service personnel on day and afternoon shifts and one staff therapist and two nursing service personnel on nights, seven days a week. The therapist staff is included in the per day charge for the unit and eliminates the necessity of charging additional fees for their services. The average man hours per patient-day on the unit, which includes therapists and nursing staff, has been 8.2 hours through the first 16 months. Social services, dietary services, volunteer, and chaplaincy services are also permanently assigned to the unit, but their personnel are not included in the unit's manpower statistics. Physical Medicine and Occupational Therapy services are available at no cost on a one-time consultive basis. Thereafter, if continued use of these services is required, charges are incurred at the same rate as in the acute care hospital. Central supply items and pharmaceuticals are purchased, because of predictability of need, in 30-day supply quantities, thereby eliminating expensive handling charges that occur with daily ordering in an acute care facility. All other ancillary services are available to the patients at the same cost as in the acute care setting. With regard to staff responsibilities, the therapists provide ventilator management, respiratory therapy treatments, oxygen therapy and monitoring, airway care, pulmonary education, and rehabilitation, together with diversional activities. The nursing service, in addition to collaborating on providing the latter three activities, also supplies the medical supervision necessary. Both the respiratory and nursing services serve as liaisons to the physicians and administrative staff. All patients considered for admission to the unit must be older than 15 years of age and have a primary or secondary respiratory problem. They must have a completed application form, which includes a history, diagnosis and problem list, financial information, activities of daily living estimation, respiratory therapy modalities listing, and medication enumeration. Based on this information, patient admission is considered from three areashome, another care facility, or another nursing unit in Bethesda Hospital. An Admissions Committee composed of the Medical Director, Unit Co-Directors, Head Therapist,
190 INDIHAR, FORSBERG
Table I-Anal,.. . 01 Palierd ..4dmiaioJU (N=89) No. of Patients (%) Admissions by area Bethesda Medical Center Other metropolitan hospitals Homes Skilled nursing facility Out-of-town hospital Level of Care
20 49 12 4 4
20
1
31 38
2 3 Diagnosis COPD Closed head injury Neuronnuscular disorder
72 (73)
5 11
Sex Male Female
45
44
Age distribution, yr
20-30
4
1 6
30-40 40-50 50-60
13
22
60-70 70-80
37 (42) 6
80-90
Head Nurse, Concurrent Review Committee Coordinator, and Unit Social Worker classifies patients in three levels of care depending on the degree of daily living in which the patient can engage and the type of respiratory support needed. Three levels of patient care are as follows. Levell: Self-Sufficient Patients These patients, mostly independent in activities of daily living, require daily respiratory care, te, oxygen therapy, aerosol therapy, rehabilitation, and education, etc, that could not be provided in another setting. The local PSRO established further criteria for admission of these patients, including an arterial oxygen tension test result of <55 mm Hg at rest on room air, an FEV l of <700 ml, and a FEV1 of < 1,400 mi. In addition, documentation was necessary to indicate the reason that the patients could not maintain themselves at home or in another type of facility, and what activities would be undertaken to attempt to correct this situation.
Level 2: Intermediate Care Patients Patients in this level perform only minimal activities of daily living and require extensive respiratory care, te, ventilator support, tracheostomy care, chest physical therapy, etc.
Level 3: Intensive Care Patients These patients can perform no activities of daily living and have total dependence on nursing and respiratory care.
CHEST, 81: 2, FEBRUARY, 1982
Respiratory therapists and nurses assigned to the unit may suggest changes in patient classification with the concurrence of the attending physician. The Utilization Review Coordinator reviews the patient records with the head nurse and therapist, and with their advice may also suggest changes in classification. Questionable patients are brought before the entire Admissions Committee for review. Review of these patients by the entire committee continues throughout their stay. After the 3O-day review, level 1 patients continue to be reviewed every 30 days, level 2 patients every 60 days, and level 3 patients quarterly. If changes in care levels are promulgated, this change is communicated to the physician and effected by the business office. If the patient's continued stay on the unit is questioned, the physician is asked to document the necessity for the patient's continued stay. If it is determined that a patient has no further need for the unit, efforts are made to assist the physician, patient, and family in obtaining suitable placement, PATIENT ANALYSIS
A review of the patients admitted to the unit from Aug 21, 1979, through Jan 31, 1981, is summarized in Table 1, showing the number of admissions, initial level of care required, patient classification, and current status/ disposition. Patients were admitted to the unit from facilities throughout Minnesota. During this time 89 patients were admitted to the unit, 23 patients were discharged to their homes, eight transferred to other care facilities when their respiratory status improved, 23 patients died, 14 patients were discharged, admitted to our Intensive Care Unit, and readmitted at a later date, and 21 remained on the unit as permanent residents. As detailed in Table 1, only 22 percent of the patients were admitted from Bethesda, and 70 percent of these were readmissions from the Intensive Care Unit, indicating the regional appeal of this type of facility. Level 3 represented the most frequently used level of care, with 43 percent of the admissions. The major diagnostic group was COPD, with 81 percent of the admissions. There was an equal distribution of male and female admissions; the largest age group was in the 70 to 80 years range, or 42 percent of the admissions. There were 28 applications rejected because they did not meet the admission criteria. Although most of these patients were admitted to reside on the unit as their permanent domicile, significant numbers of patients were discharged to their homes or long-term care facilities after extensive pulmonary rehabilitation and education. It
CHEST, 81: 2, FEBRUARY, 1982
is our impression, although difficult to substantiate statistically at this time, that these patients are doing well at home and have had few readmissions to the acute hospital setting. Continued follow-up of these patients is being conducted to try to support this impression. Of particular gratification was that four young patients with closed head injuries and "coma vigils" regained consciousness after several months of extensive respiratory and physical therapy support. All of these patients are undergoing rehabilitation efforts at other medical facilities. UNIT COST ADVANTAGE
The patients' per-day rate includes room and board, nursing and respiratory care, all respiratory therapy equipment and treatments, as well as aerosolized respiratory therapy medications. All other ancillary services mentioned earlier are likewise included in the room rate. Specialized care and consultation, as well as individualized medications, are charged at prevailing rates. These all-inclusive rates are therefore significantly lower than those in an acute care setting. The average cost of the level 3 patient is $143.01/day compared with $465.81/ day in an acute care setting; for level 2 patients, $121.911 day compared with $196.22; and for level 1 patients, $98.52/ day compared with $188.24. These costs are based on the average per-day costs of Minneapolis-St. Paul acute care hospital tabulations. There were 121,471 hours of oxygen therapy, 39,102 hours of mechanical ventilation, and 12,648 various respiratory therapy modalities, including 269 pulmonary rehabilitation classes, used on the unit. This represented a cost savings of $452,051.00 over the period covered by this report, based on the average charge in the metropolitan area for respiratory therapy procedures. CONCLUSION
It is increasingly evident that this Prolonged Respiratory Care Unit, which has been open for 18 months, has answered the needs of society in providing care at a reasonable cost for patients with prolonged respiratory disease or complications. The unit has been well used, with all of its beds filled and further admissions being limited by availability of physical space and qualified nursing and respiratory therapy staff. Many different types of patients were admitted throughout this period, indicating the diverse needs of the patient population in Minnesota. A number of patients will continue to live on the unit for the duration of their disease process; a significant number of patients have been discharged to their homes following their pulmonary
EXPERIENCE WITH A PROLONGED RCU 191
education and rehabilitation. Also of significance is the number of patients who were discharged to other care facilities following the resolution of their respiratory disease processes. The cost benefits of this type of unit are likewise presented The suspected future cost benefits in decreasing rehospitalization for patients who have participated in and understood the rehabilitationeducation program are difficult to assess and will be studied as more data are accumulated.
ACKNOWLEDGMENT: Margaret McFadden, C.R.T.T., provided technical assistance.
1 Field M. Patients are people. In: A medical social approach to prolonged illness. New York: Columbia University Press, 1967:8-21 2 Goldberg A. Report on residency for independent living of the handicapped in Every, France and Sweden. Chicago: Children's Memorial Hospital Publications, 1980: 1-22
Pulmonary Med.icine 1982 - A Comprehensive Approach The course, Pulmonary Medicine 1982-A Comprehensive Approach, will be held April 1-3·at the Marriott Hotel, Philadelphia. Sponsors are the American Lung Association of Pennsylvania, Pennsylvania State Society, American Association for Respiratory Therapy; Pennsylvania Thoracic Society and Pennsylvania Chapter, American College of Chest Physicians. For information, contact Joyce C. Waite, American Lung Association of Pennsylvania, 1135 East Chocolate Avenue, Hershey, Pennsylvania 17033 (717:533-6851).
18th Annual Arizona Chest Symposium The 18th Annual Arizona Chest Symposium, sponsored by the University of Arizona Health Sciences Center, will be held April 1-3 at the Doubletree Inn, Tucson. Contact: Linda Alpert, R.N., PO Box 42195, Tucson, Arizona 85733 (602:327-5451, ext 5110).
192 INDIHAR, FORSBERG
CHEST, 81: 2, FEBRUARY, 1982