Increasing demand for critical care, with limited potential for comparable expansion of supply, may strain the abilities of ICUs to provide high-quality care in an equitable fashion. Efforts to counter the untoward consequences for the quality and ethics of critical care delivery are limited by the absence of a specific and validated metric of ICU capacity strain.

This manuscript presents a conceptual framework for ICU capacity strain, considers what data elements may contribute to it, and suggests methods for determining the optimal metric. Next, it outlines the range of potential consequences of increased capacity strain, in terms of both the quality and ethics of care delivered. Finally, consideration is given to how untoward consequences of ICU capacity strain might be mitigated through better understanding of what makes some ICUs better able than others to withstand temporal fluctuations in the demand for their services.

Development of an appropriately accurate and parsimonious measure of ICU capacity strain may augment the precision of future critical care outcomes research by reducing unexplained variance attributable to temporal fluctuations in ICU-level factors; elucidate organizational characteristics that make some ICUs better able to withstand high-capacity strain without substantive degradations in quality; and enhance the transparency of critical care rationing while helping to improve its equity and efficiency, thereby promoting the ethics of this inevitable practice.

Changes in healthcare financing increasingly rely upon patient cost-sharing to control escalating healthcare expenditures. These changes raise new challenges for physicians that are different from those that arose either under managed care or traditional indemnity insurance. Historically, there have been two distinct bases for arguing that physicians should not consider costs in their clinical decisions--an "aspirational ethic" that exhorts physicians to treat all patients the same regardless of their ability to pay, and an "agency ethic" that calls on physicians to be trustworthy advisors to their patients. In the setting of greater patient cost-sharing, physicians' aspiration and agency roles increasingly conflict. Satisfactorily navigating the new terrain of consumer-driven healthcare requires physicians to consider these two roles and how they can best be reconciled so as to maximize quality of care while respecting the heterogeneity of patients' financial resources and willingness to pay.

To evaluate the adequacy of patient data and clinical information transmitted to the radiological departments by the referring clinicians in view of the justification demands concerning the radiological examinations, as those are described in the Radiation Protection Regulations of the European Union Nations.

Request forms for 1708 patients referred to radiology department and 410 referred to the CT department were evaluated concerning the proper completion of the form fields. Furthermore, for CT examinations a more detailed evaluation was carried out, to assess the rationalistic use of CT within the diagnostic algorithm.

Not properly completed request forms to both departments were observed, however, the omissions were more prominent for the referrals to the radiology department, where the age and the probable clinical diagnosis was not given in 81.5 and 46% of the forms, respectively. Furthermore, the emergency indication was less cautiously used compared to the CT requests. For the CT department 33.3% of requests were justified and the final diagnosis was included in the referring doctor's probable clinical diagnosis. U/S was the examination of choice in 51% of the cases where an examination should have been performed before CT and in 70.6% of the cases where an alternative examination was proposed.

The inadequate transmission of clinical information and the large number of not fully justified CT requests observed in this study are typical examples of the various problems that radiologists have to face in order to apply the justification directives.

Emergency medicine has an integral role in the establishment of universal access to health care for all persons living in the United States. Currently, emergency departments provide the only unfunded mandate available to millions of American residents who otherwise have no access to health care coverage. Any effort to establish universal care must accept health care rationing as a basic principle, and establish a minimum standard of benefits to which all human beings are entitled in this country. People and employers should be allowed to purchase additional care based on their willingness and ability to pay, but under no circumstances should anyone be denied a basic package of health care benefits. Emergency care must be part of those basic benefits. Emergency medicine charges should be structured so that they are not unduly onerous to society, and should reflect true expenses, including marginal costs for nonurgent care. Emergency physicians (EPs) and hospital administrations should recognize their critical role in serving society in roles that are not strictly medical, and allocate resources to benefit the general population in the greatest way. This role will be expanded to include preventive care, to provide for basic pharmacologic coverage as needed, and to provide necessary immunizations when traditional primary care has failed. We have a moral obligation to recognize that resources are limited and to allocate them so as to benefit the greatest number of patients in the greatest way. As members of the medical profession best equipped to assume such a task, it is incumbent upon EPs to act as advocates to the public to enable us to fulfill this mission.