ABSTRACT
STUDY OBJECTIVES: To assess institutional performance of key diagnostic and therapeutic interventions and to identify areas amenable to improvement in the management of community-acquired pneumonia (CAP). DESIGN: A chart-based retrospective study. SETTING: Cook County Hospital, a large, urban, public teaching hospital. PATIENTS: Adult inpatients with a hospital discharge diagnosis of CAP. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Fifty hospital admissions were reviewed. Only 25 patients (50%) had two specimens obtained for blood culture, and sputum was sent for Gram's stain and culture for only 11 patients (22%). Approximately one third of the patients had portable anterior-posterior instead of standard posterior-anterior and lateral chest radiographs performed. Physicians in the emergency department (ED) tended to be less likely to note the presence of multilobar infiltrates or pleural effusions than the attending radiologists. The antibiotic regimens employed in the ED and on the inpatient wards were widely variable. The mean time from hospital entry until administration of the first dose of antibiotics was 5.5 h for the 18 patients for whom treatment was initiated in the ED vs 16.1 h for the 27 patients admitted through the ED for whom therapy was deferred until ward admission (p < 0.001, Student's t test). CONCLUSIONS: Institutional variations in the performance of basic diagnostic and therapeutic interventions for patients with CAP may be substantial. The local performance of these key processes of care should be assessed to help direct the formulation of institutional practice guidelines for the management of CAP.
Subject(s)
Pneumonia/therapy , Practice Guidelines as Topic , Adult , Chicago , Community-Acquired Infections/diagnosis , Community-Acquired Infections/physiopathology , Community-Acquired Infections/therapy , Female , Hemodynamics , Hospitals, Public , Hospitals, Urban , Humans , Male , Middle Aged , Patient Care Management , Pneumonia/diagnosis , Pneumonia/drug therapy , Pneumonia/physiopathology , Retrospective StudiesABSTRACT
OBJECTIVE: Patients admitted to the pulmonary isolation service to rule out tuberculosis (TB) were prospectively studied to identify predictors of smear-positive TB. METHODS: History of symptoms--cough, sputum production, fever, weight loss, night sweats, hemoptysis, anorexia, and dyspnea; medical history--TB, tuberculin skin test (TST) status, TB contact; and social factors--crowding index, history of incarceration or living in a shelter, and employment status were obtained in face-to-face interviews. Chest x-rays (CXRs) were scored as typical, atypical, or negative. Serial morning sputa were collected. RESULTS: Complete data were collected on 101 patients; 44 had pulmonary TB; 33 patients were smear positive and considered infectious; 11 patients were smear negative but culture positive. There was no difference between TB and non-TB patients with respect to HIV status and social risk factors. Significant differences were found between patients who were smear positive for TB and smear negative with respect to cough, sputum, and typical CXR (79%, 76%, and 79% sensitivity, respectively). Eleven patients without TB had an atypical CXR and denied cough, sputum, and weight loss. Only one patient with TB presented this way. CONCLUSION: Even in high-risk populations, symptoms of cough, sputum, weight loss for less than 2 weeks, and the absence of a typical CXR are strong negative predictors for TB.
