Missed Opportunities to Diagnose Tuberculosis Are Common Among Hospitalized Patients and Patients Seen in Emergency Departments (original) (raw)
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Delay in Diagnosis among Hospitalized Patients with Active Tuberculosis—Predictors and Outcomes
American Journal of Respiratory and Critical Care Medicine, 2002
Delayed diagnosis of active pulmonary tuberculosis (TB) among hospitalized patients is common and believed to contribute significantly to nosocomial transmission. This study was conducted to define the occurrence, associated patient risk factors, and outcomes among patients and exposed workers of delayed diagnosis of active pulmonary TB. Among 429 patients newly diagnosed to have active pulmonary TB between June 1992 and June 1995 in 17 acute-care hospitals in four Canadian cities, initiation of appropriate treatment was delayed 1 week or more in 127 (30%). This was associated with atypical clinical and demographic patient characteristics, and after adjustment for these characteristics, with admission to hospitals with low TB admission rate of 0.2-3.3 per 10,000 admissions (odds ratio [OR]: 7.4; 95% confidence interval [CI]: 3.2,17.5) or intermediate TB admissions of 3.4-9.9/10,000 (OR: 2.3; CI: 1.6,3.2) as well as potentially preventable (late) intensive care unit admission (OR: 16.8; CI: 2.0,144) and death (OR: 3.3; CI: 1.7,6.5]). In hospitals with low TB admission rates, initially missed diagnosis, smear-positive patients undergoing bronchoscopy, late intensive care unit admission (OR: 2.3; CI: 0.1,56), and death (OR: 3.8; CI: 1.2,12.1) were more common than in hospitals with high TB admissions (Ͼ 10/ 10,000); a similar trend was seen in hospitals with intermediate TB admissions. Even after adjustment for workers' characteristics and ventilation in patients' rooms tuberculin conversions were disproportionately high in hospitals with low and intermediate TB admission rates and significantly higher in hospitals with overall TB mortality rate above 10% (OR: 2.5; CI: 1.6,3.7). In the hospitals studied, as the rate of TB admissions decreased, the likelihood of poor outcomes and risk of transmission of TB infection per hospitalized patient with TB increased. Institutional risk of TB transmission was poorly correlated with number of patients with TB and better correlated with indicators of patient care such as delayed diagnosis and treatment and overall TB-related patient mortality.
2011
Objective: Emergency department presentation of active pulmonary tuberculosis (TB) can be highly variable and atypical. Appropriate patient stratification may require the assessment of non-clinical criteria. The aim of this study was to determine unique presentation, risk factors and outcomes in the population of TB patients that present to a public emergency department (PED), as well as to identify those factors associated with ED discharge without a diagnosis of TB during a potentially contagious visit. Methods: Epidemiological characteristics were determined for every patient diagnosed with TB in Arizona for 2000-2008. From these, the 1501 presenting in Maricopa County, Arizona for 2000-2008 were selected for further analysis. Presentation at the only PED in the county was determined by retrospective chart review. Potentially contagious TB patients presenting at the PED were analyzed on the basis of the absence or presence of a TB diagnosis during a potentially contagious visit. Results: Of the study population, 150 (12.0% of pulmonary TB patients) presented to the PED within one month of a verified diagnosis of active pulmonary TB. Patients presenting to the public emergency department were more likely to be male, Hispanic, homeless, HIV-positive, current resident of a correctional facility or a long-term care facility, or to have a recent history of substance abuse. Furthermore, PED patients were more likely to have multidrug resistant TB and to die before completion of treatment. Patients reported a median distance of 4.6 miles from their residence to the PED, with only 10.8% reporting a distance of greater than 15 miles. Comparison of potentially contagious TB patient visits demonstrated that patients were significantly less likely to receive a diagnosis of TB when presenting with a traumatic or orthopedic chief complaint, denying cough, hemoptysis, dyspnea, fever or chills, having a normal pulmonary exam and/or chest x-ray, being unresponsive during questioning, or reporting a recent history of both homelessness and excess alcohol use. Baseline sensitivity for the diagnosis of TB during a potentially contagious visit was 78.2%. Modeling revealed an increase in sensitivity to 97.9% if patients were assessed for altered mental status, pulmonary or infectious chief complaint, abnormal vital signs, or history of substance abuse or foreign birthplace. Conclusions: In this study, TB patients presenting to the public
American journal of infection control, 2017
A delayed diagnosis of tuberculosis (TB) in the hospital may lead to nosocomial exposure, placing employees and other patients at risk. A lack of prompt infection control measures for suspected cases at the time of admission may require complicated and expensive contact investigations. The purpose of this study was to estimate the person-hour costs required by infection control staff to investigate a single hospital-based TB exposure. Electronic data were extracted from 2 tertiary hospitals and 1 community hospital in a large health care system in metropolitan New York City to identify pulmonary TB cases unsuspected at admission. All cases were reviewed by infection prevention and control (IPC) staff to identify exposures. From 2010-2014, 34 pulmonary TB cases which necessitated a contact investigation were identified. IPC staff calculated an average of 15-20 hours of work per exposure plus 30 minutes of follow-up for each exposed staff member. For exposures, time from admission to ...
Heart & Lung: The Journal of Acute and Critical Care, 2015
Objective: To identify and evaluate factors associated with delayed recognition of pulmonary tuberculosis (TB) in the emergency department (ED). Background: Delayed recognition of pulmonary TB in ED may precipitate mortality and morbidity. Methods: Medical records of newly diagnosed TB patients admitted to four hospitals in Taiwan were retrospectively reviewed. Patients were divided into two groups based on ED physicians' recognition or not of TB and statistically compared to identify differences in their characteristics. Results: 310 newly diagnosed TB patients were identified; 150 were unrecognized in the ED. Cough, chest tightness, general malaise, and body weight loss were more common for those with recognized TB. Older age (65 yrs, P ¼ 0.035) and chronic renal insufficiency (P ¼ 0.005) were associated with delayed TB recognition. Conclusion: Older age and chronic renal insufficiency are risk factors for delayed TB while in the ED. Typical symptoms should heighten alertness for recognizing TB.
A Missed Tuberculosis Diagnosis Resulting in Hospital Transmission
Infection Control & Hospital Epidemiology, 2014
Objective.To find the source of tuberculin skin test conversions among 38 hospital employees on 1 floor during routine testing January–February 2010.Methods.Record review of patients at a private hospital during September-December 2009 and interviews with hospital employees. Names of patients from the state tuberculosis (TB) registry were cross-referenced with hospital records for admissions. Mycobacterium tuberculosis genotype results in the county and adjacent counties were examined, and contacts were evaluated for TB infection and disease.Results.One of the 38 employees, a nurse, was diagnosed with pulmonary TB with a matching M. tuberculosis genotype and drug resistance pattern (isoniazid monoresistant) to those of a county jail inmate also recently diagnosed with pulmonary TB. The nurse had no known contact with that inmate; however, another inmate in his 20's from the same jail had been hospitalized under that nurse's care in October 2009. That young man died, and a po...
Laboratory Reporting of Tuberculosis Test Results and Patient Treatment Initiation in California
Journal of Clinical Microbiology, 2004
Prompt laboratory reporting of tuberculosis (TB) test results is necessary for TB control. To understand the extent of and factors contributing to laboratory reporting delays and the impact of reporting delays on initiation of treatment of TB patients, we analyzed data from 300 consecutive culture-positive TB cases reported in four California counties in 1998. Laboratory reporting to the specimen submitter was delayed for 26.9% of smear-positive patients and 46.8% of smear-negative patients. Delays were associated with the type of laboratory that performed the testing and with delayed transport of specimens. Referral laboratories (public health and commercial) had longer median reporting time frames than hospital and health maintenance organization laboratories. Among patients whose treatment was not started until specimens were collected, those with delayed laboratory reporting were more likely to have delayed treatment than patients with no laboratory reporting delays (odds ratio [OR] of 3.9 and 95% confidence interval [CI] of 1.6 to 9.7 for smear-positive patients and OR of 13.1 and CI of 5.3 to 32.2 for smear-negative patients). This relation remained after adjustment in a multivariate model for other factors associated with treatment delays (adjusted OR of 25.64 and CI of 7.81 to 83.33 for smear-negative patients). These findings emphasize the need to reduce times of specimen transfer between institutions and to ensure rapid communication among laboratories, health care providers, and health departments serving TB patients.
Tuberculosis cases missed in primary health care facilities: should we redefine case finding?
The International Journal of Tuberculosis and Lung Disease, 2013
Setting This study was conducted in Cape Town in two primary healthcare facilities in a subdistrict with a high prevalence of bacteriologically-confirmed pulmonary TB. Objective To determine the proportion of adults with respiratory symptoms who attend healthcare facilities but are not examined for, nor diagnosed with TB, in facilities where routine TB diagnosis depends on passive case finding.
Missed appointments at a tuberculosis clinic increased the risk of clinical treatment failure
The Southeast Asian journal of tropical medicine and public health, 2006
We investigated the charts of 381 new smear-positive tuberculosis patients at Khon Kaen Medical School during 1997-2001 using World Health Organization definitions to evaluate associations among treatment success or failure (defaulted, failed, died, or not evaluated) and tuberculosis clinic contact, demographics and clinical characteristics of the patients. Multinomial logistic regression was used for three-category outcome analysis: treatment success, transferred-out and clinical treatment failure. The treatment success and clinical treatment failure rates were 34.1% and 34.4%, respectively. About 46.5% and 85.8% of patients missed appointments at the tuberculosis clinic in the treatment success and treatment failure groups, respectively. The results show that patients who were absent from the tuberculosis clinic were 5.95 times more likely to have clinical treatment failure than treatment success, having adjusted for the effect of transfering-out and the effect of the treatment re...
Diagnosis Delay among Newly Tuberculosis Patients Admitted in a Community Hospital
Journal of Epidemiology and Preventive Medicine, 2017
Objective: To determine the diagnostic delay in newly diagnosed tuberculosis (TB) patients admitted to a community hospital in Qatar. Design: The study was conducted from January 2013 today 2016. The following information was collected from patient file: Age, sex, nationality, tuberculosis type, time of symptoms onset, time of the confirmatory test, and the time of visiting an HCP before the admission encounter. Results: Of the 390 TB patients included in the study, 281 (72.1%) were from South East Asian countries, 325 (83.3%) patients were males and 65 (16.7%) were females, mean age was 32.4 years. Of the 390 patients, 89.7% (350 patients) had pulmonary tuberculosis and 40(10.3%) patients had non-pulmonary localization. The median total delay was 30 days (15;60 days), while the patient delay was 10 days (4;27 days) and the system delay was 3 days (3;7.8 days). For pulmonary tuberculosis, the total delay was 30 days and for non-pulmonary localization was 15 days. Conclusion: The study provides an insight about the delay in the diagnosis of TB at a community hospital in Qatar. Additional studies should be conducted to evaluate the delay in a representative national sample and to identify the factors associated with patients' delays, which could be used to strengthen the national program for tuberculosis control.