Decision instrument for the isolation of pneumonia patients with suspected pulmonary tuberculosis admitted through US emergency departments.

STUDY OBJECTIVE: Many patients with pneumonia are admitted to respiratory isolation for possible tuberculosis (TB), but most do not have active TB. We created a decision instrument to predict which pneumonia patients do not need admission to a TB isolation bed. METHODS: The design was a prospective case series conducted in 11 university-affiliated, urban, US emergency departments (EDs) (EMERGEncy ID NET). Participants were patients admitted to the hospital through the ED with a diagnosis of pneumonia or suspected TB. The main outcome measure was derivation and validation of a sensitive decision instrument to identify patients not having TB (and not requiring isolation) according to clinical data and chest radiographs. RESULTS: Of 5,079 pneumonia patients, 224 (4.4%) had pulmonary TB according to sputum cultures or tissue staining. The instrument derived to predict which patients did not have pulmonary TB included no TB history or previous positive tuberculin skin test result, nonimmigrant, not homeless, not recently incarcerated, no recent weight loss, and no apical infiltrate or cavitary lesion on plain chest radiograph. When tested on the validation subgroup, the decision instrument exhibited a negative predictive value of 99.7% (95% confidence interval [CI] 99.1% to 99.9%), and a sensitivity of 96.4% (95% CI 91.1% to 99.0%). CONCLUSION: A decision instrument can accurately predict which patients with pneumonia do not require admission to TB isolation rooms.

Antibiotic use for emergency department patients with upper respiratory infections: prescribing practices, patient expectations, and patient satisfaction.

STUDY OBJECTIVE: Physicians often prescribe antibiotics to patients even when there is no clear indication for their use. Previous studies examining antibiotic use in acute bronchitis and upper respiratory infections have been conducted in primary care settings. We evaluate the factors that physicians in the emergency department (ED) consider when prescribing antibiotics (eg, patient expectations) and the factors associated with patient satisfaction. METHODS: Ten academic EDs enrolled adults and children presenting with symptoms consistent with upper respiratory infection. Enrolled patients were interviewed before their physician encounter and were reinterviewed before discharge and 2 weeks later. Physicians were interviewed about factors that influenced their management decisions, including their perceptions of patients' expectations. Patients with a single diagnosis of uncomplicated acute bronchitis or upper respiratory infection were included for analysis. RESULTS: Of 272 patients enrolled, 68% of bronchitis patients and 9% of upper respiratory infection patients received antibiotics. Physicians were more likely to prescribe antibiotics when they believed that patients expected them (odds ratio [OR] 5.3; 95% confidence interval [CI] 2.9 to 9.6), although they were able to correctly identify only 27% of the patients who expected antibiotics. Satisfaction with the ED visit was reported by 87% of patients who received antibiotics and 89% of those not receiving antibiotics. Satisfaction with the visit was reported by 92% of patients who believed they had a better understanding of their illness but only by 72% of those who thought they had no better understanding (OR 4.4; 95% CI 2.0 to 8.4). CONCLUSION: Physicians in our academic EDs prescribed antibiotics to 68% of acute bronchitis patients and to fewer than 10% of upper respiratory infection patients. Physicians were more likely to prescribe antibiotics to patients who they believed expected them, although they correctly identified only about 1 in 4 of those patients. Patient satisfaction was not related to receipt of antibiotics but was related to the belief they had a better understanding of their illness.

Epidemiology of animal exposures presenting to emergency departments.

OBJECTIVES: To describe the epidemiology of emergency department mammalian animal exposures and to compare adult and pediatric exposure characteristics. METHODS: This was a prospective case series of patients presenting with animal exposure-related complaints from July 1996 to July 1998. Eleven university-affiliated, geographically diverse, urban emergency departments (EMERGEncy ID NET) participated. RESULTS: A total of 1,631 exposures (80.5%) were from dogs, 267 (13.2%) from cats, 88 (4.3%) from rodents or rabbits, 18 (0.9%) from raccoons and wild carnivores, eight (0.4%) from livestock, nine (0.4%) from monkeys, and five (0.2%) from bats. Compared with adults, children were more likely to be bitten by dogs (odds ratio [OR], 2.9; 95% confidence interval [CI] = 2.2 to 3.8) or hamsters, gerbils, and rabbits (OR, 2.6; 95% CI = 0.79 to 9.2); to be bitten on the head, neck, or face (OR, 6.7; 95% CI = 5.2 to 8.6); and to be petting or playing with the animal at the time of exposure (OR, 2.6; 95% CI = 2.1 to 3.3). CONCLUSIONS: Animal exposures are a common source of injury seen in the emergency department. These findings have potentially important public health implications in terms of emphasizing the need to effectively implement education programs for parents and children.

Antibiotic use for emergency department patients with acute diarrhea: Prescribing practices, patient expectations, and patient satisfaction.

STUDY OBJECTIVE: Physicians commonly prescribe antibiotics to meet patient expectations, even when antimicrobials are unnecessary. We evaluated factors emergency physicians consider in prescribing antibiotics to patients with diarrhea and examined patient expectations, physician-perceived patient expectations, and patient satisfaction. METHODS: Adults and children presenting with acute diarrhea to 1 of 10 academic emergency departments (EDs) were enrolled in this prospective observational cohort study. Adult patients and guardians of enrolled children were asked about treatment expectations before their physician encounter and about satisfaction with their medical care at discharge. Physicians were asked about factors influencing management decisions and their perceptions of patients' expectations. RESULTS: Of 104 patients enrolled, 25% received antibiotics. Physicians were more likely to prescribe antibiotics when features suggestive of bacterial enteritis were present (unadjusted odds ratio [OR] 2.5; 95% confidence interval [CI] 1.1 to 3.9). Physicians were also more likely to prescribe antibiotics when they believed patients expected them (unadjusted OR 2.3; 95% CI 1.1 to 4.4) but correctly identified such expectations in only 33% of instances. Satisfaction with care was reported by 100% of patients receiving antibiotics and 90% of those not receiving antibiotics (95% CI for difference of 10%, 3% to 17%). CONCLUSION: Physicians in academic EDs prescribe antibiotics for acute diarrhea to about 1 patient in 4 and are more likely to do so if signs or symptoms compatible with bacterial enteritis are present. Physicians' assessments of patients' expectations for therapy were accurate in only 1 of 3 patients but were nevertheless associated with antibiotic prescription. Patient satisfaction was weakly associated with receipt of antibiotics.