Moving Out

Flashback:

Colonial Hospitalists

250 years of admissions and discharge

The hospital-based physician must deal with many arcane and Byzantine criteria for admission, care, and discharge of patients. There are regulations for record-keeping and concerns about length of stay. Becoming a staff member may involve physician credentialing, and practitioners from other states or countries have to meet more rigorous standards.

This previous paragraph was not written about modern-day America. These issues are lifted from the “Rules and Regulations of the Pennsylvania Hospital” approved by the Board of Managers in 1752.1 The Pennsylvania Hospital was founded that year under the guidance of Benjamin Franklin. The facility was dedicated to care for the sick and poor. Among the biggest obstacles to its creation was fundraising. Franklin’s accounts of the early years of this institution included a final page with a useful form for donating money.

ADMISSION AND DISCHARGE CRITERIA

In 1752 there were 15 rules for admission and discharge of patients, as well as regulations for patients’ behavior while hospitalized. Among the most interesting:

1. No patients can be admitted if deemed incurable, lunaticks [sic] excepted, nor any case not requiring special services of a hospital.
2. No admits for smallpox, itch, or other infectious distempers unless proper apartments [isolation] available. Admits found to have the above will be discharged.
3. No admits of women with small children. Hospital will not maintain childcare facilities.
4. Persons admitted as above must provide funds for their own burial in case of their own demise.
5. 5. One bed to be held for a trauma case.
6. Patients will be discharged when cured or judged incurable
7. All cured patients must sign a release stating their cure and the benefit received from the hospital for use by the hospital managers.
8. No patient may leave the facility without a physician release. They may not swear or curse, get drunk, behave rudely or indecently, on pain of expulsion at first admonition.
9. No patient may gamble or beg.
10. Patients will aide in nursing other patients when able. This will include washing and ironing the linen and cleaning the rooms.

The Hospital Management Board was responsible for choosing a staff of six practitioners to manage these patients. There were guidelines for who could fill this job.

RULES FOR CHOICE OF PHYSICIANS AND SURGEONS

There were the rules in place in 1752 for choosing physicians and surgeons who could work in the hospital; the most interesting was that applying practitioners must be 27 years old, have served an apprenticeship in Philadelphia, have studied “physick” or surgery for seven years or more, and have undergone an exam by six hospital practitioners. Visiting practitioners had to reside in the city for three years before applying and then had to qualify under the same criteria.

LENGTH OF STAY

There was a significant interest in abstracting the admit diagnosis, length of stay, and outcome. The disposition of patients admitted during the first two years of the hospital’s existence, ending in April 1754 was presented in a modern format.

There were 117 admissions, with 60 cures. Eleven patients were relieved, though not cured. Seven were deemed incurable, 10 were taken away by friends, and 10 died. Three were discharged for irregular behavior, and 16 remained hospitalized.

The most common admission diagnosis was ulcers, representing almost a third of all admits, followed by lunacy. Other frequent diagnoses were dropsy (congestive heart disease), scrophulous and scorbutic diseases (extrapulmonary tuberculosis and scurvy) and rheumatism.

The highest mortality was for consumption, at 100%. The two patients admitted with flux (diarrhea) and prolapsus ani also died. Dropsy carried a 33% mortality rate, without the benefit of the latest medical innovation, foxglove (digitalis), which would be described a few decades later.2 Also notable is death from scurvy, the cure for which was described in 1753 by James Lind.3

The managers were pleased with the performance of the facility. They believed that their efforts had resulted in “good” for the 60 persons afflicted with “various distempers” who were cured and that many had received considerable relief. This was accomplished despite the limited amount of funds available, thanks to careful attendance afforded to the sick and poor, as well as proper diet and availability of medicines. Based on these favorable reports, the Board of Managers requested further funding.

Two hundred and fifty years later, physicians face many of the same issues, including admission and discharge criteria, concerns about funding, and practice regulation. Their actions continue to be monitored, and it is likely that the same will be true in the future. Hospital administrators remain frugal, and we are admonished, in the words of Benjamin Franklin, writing in Poor Richard’s Almanac, “A penny saved is a penny earned.”

—Jamie Newman, MD, FACP

REFERENCES

1. Franklin B. Some Account of the Pennsylvania Hospital 1754. (Facsimile Edition.) Baltimore: The Johns Hopkins Press; 1954.
2. Withering W. An Account of the Foxglove and Some of Its Medical Uses. Birmingham, England: M. Swinney; 1785.
3. Lind J. A Treatise of the Scurvy. Edinburgh, Scotland: Sands, Murray and Cochran; 1753.