Pitfalls in the care of patients with tuberculosis. Common errors and their association with the acquisition of drug resistance

OBJECTIVE

To determine, among a group of patients with multidrug-resistant pulmonary tuberculosis, whether there had been management practices that deviated from established guidelines, and whether these decisions were associated with the acquisition of multidrug resistance and adverse medical sequelae.

DESIGN

Case series.

SETTING

Referral center.

PATIENTS

All patients with pulmonary tuberculosis admitted to the National Jewish Center for Immunology and Respiratory Medicine in 1989 through 1990.

INTERVENTIONS

The records of all patients referred to this institution for the treatment of tuberculosis in 1989 through 1990 were reviewed to ascertain the nature of management decisions that might have been associated with the acquisition of drug resistance.

MAIN OUTCOME MEASURES

Standards of practice as defined by the American Thoracic Society, the Centers for Disease Control and Prevention, and the American College of Chest Physicians were compared with these management decisions to determine whether "errors" had been made, resulting in treatment failure and the development of acquired drug resistance.

RESULTS

Among the 35 study patients, errors were detected in the management decisions in 28; there was an average of 3.93 errors per patient. The most common errors were the addition of a single drug to a failing regimen, failure to identify preexisting or acquired drug resistance, initiation of an inadequate primary regimen, failure to identify and address noncompliance, and inappropriate isoniazid preventive therapy. The multidrug resistance acquired through the errors resulted in prolonged hospitalizations, treatment with more toxic drugs, and high-risk resectional surgery. The costs for this "salvage therapy" were extraordinary, averaging $180,000 per patient.

CONCLUSIONS

Aggressive professional education, tighter control on the provisions of care for tuberculosis patients, and the committing of additional resources to tuberculosis control programs are vital in improving the care of tuberculosis patients and limiting the development of acquired drug resistance.

Learning from experience. In AIDS treatment, knowledge means quality

Recent clinical studies have revealed startling differences in mortality for AIDS patients in low- versus high-experience hospitals. But how can low-experience hospitals learn from high-experience ones?

Towards the audit of geriatric day hospitals: a pilot project in west Surrey/north east Hampshire

Following the recommendation of a report on the performance of two geriatric day hospitals (GDHs) in West Surrey and North East Hampshire District Health Authority in 1988, a pilot study was set up to assess the efficacy of a proposed form of audit involving multidisciplinary teams. An outcome measure which consisted of four different scales was developed and agreed upon by the multi-professional team. These scales were used to work out a composite index (Patient Achievement Inventory-PAI). In addition, a new data form was designed for collection of patient data. To carry out this prospective clinical audit, targets were agreed for each patient, and progress was measured against them. Sixty-one (61) patients were studied (30 and 31 per respective hospital). Data form completion was 90 per cent and 81 per cent respectively. The PAI index proved to be reliable (kappa index of agreement = 0.72), and useful as an outcome measure. However, because the PAI index is made up of ordinal scales, it can only be used to measure change within individuals, not between them. The outcome measures, data forms and the continuous audit of these two GDHs proved to be meaningful and acceptable in practice.

1992 annual guide. A guide to the best

Here are miniprofiles of the 43 hospitals that emerged as the top choices of doctors surveyed in 16 specialties. Phone numbers let you follow up with questions of your own.

Audit of bronchial artery embolisation in a specialist respiratory centre

OBJECTIVE

To audit the use of bronchial arteriography and embolisation for controlling haemoptysis.

DESIGN

Retrospective review of radiological and clinical data.

SETTING

Brompton and National Heart Hospitals.

PATIENTS

35 patients with severe pulmonary disease in whom 58 bronchial arteriograms were obtained between 1 January 1984 and 31 December 1989 with the intention of bronchial artery embolisation for controlling haemoptysis.

MAIN MEASURES

Rate of technical success and cessation of haemoptysis; detailed evaluation of patients, particularly those with major haemoptysis (> 100 ml expectorated blood); and retrospective assessment of the appropriateness of the procedure in each.

RESULTS

58 procedures were performed, nine of which were unsuitable for detailed analysis. Nine procedures were for minor haemoptysis, which subsequently recurred, and 40 for recent major haemoptysis in 26 patients with cystic fibrosis (16) aspergilloma (six), bronchiectasis (three), and an unknown diagnosis (one). The median total volume of haemoptysis in the episode before the procedure was 680 ml (range 270-2200 ml). Embolisation was technically successful in 33/40 procedures, in 17 of which, however, major haemoptysis recurred within 10 days of the procedure, leaving 16 clinically and technically successful procedures in 15 patients. Five patients (three with aspergilloma, two with cystic fibrosis) died of haemoptysis despite attempted embolisation.

CONCLUSION

Success rate of bronchial artery embolisation was 40%(16/40).

IMPLICATIONS

Bronchial artery embolisation is probably not justified for minor haemoptysis or when performed more than one week after a major haemoptysis. Repeat arteriograms during a single period of haemoptysis are seldom useful. With these criteria 43% fewer procedures would have been performed with no loss of clinical benefit.

Variability among geriatricians in the evaluation of functional disabilities and rehabilitation needs of the elderly

A formal variability study has been carried out in a geriatric hospital in Genoa, Italy, in order to estimate the degree of agreement between geriatricians in disability and functional assessment, recommendation for rehabilitation treatments, need for mobility and daily activities aids, and decisions about optimal place of treatment (own home, sheltered housing, old peoples' home, nursing home). Sixteen long-stay geriatric patients, average age 83 years, were visited by eight geriatricians, a patient receiving from two to five visits. The participating physicians could visit the patients at their leisure, had access to clinical records and could interview a nurse well acquainted with the patient. A marked variability was observed for most items, e.g. the agreement concerning the recommendation for individual physiotherapy was only 52%. The results of this study may not be generalized to other situations and to actual practice; however, variability studies of this kind, that assess diagnosis habits, treatment and managerial decisions at the same time, may be useful to pinpoint the most important problems and to stimulate professionals' participation in proper Quality Assurance projects.

Lessons for providers from a purchaser's perspective

On Jan. 1, 1991, the John Hancock National Transplant Program (JHNTP) became operational, matching kidney, heart, liver, and bone marrow transplant patients from a potential pool comprising more than two million covered lives, with organ transplant programs at 14 institutions across the country. Conceptualizing the program and selecting and contracting with the transplant centers took more than 18 months. This article shares some of the insights from that process that are pertinent to providers of transplant services and to others considering entering this or other forms of specialized contracting.

Marketing specialty hospitals in the 1990s: making patients the best marketing spokespeople

These are a few of the ways that a health care provider can influence the patient's perception of the treatment received. That impression is a lasting one. A positive referral can be a strong marketing tool that generates revenue and goodwill. If an institution provides quality health care services in a comfortable environment, then patients can easily be encouraged to tell their families and friends about their experiences in the institution.

1991 best hospitals. A guide to the best

The 45 hospitals identified as the giants in their specialties are profiled below. Beyond size and daily room rates, you'll find special features from kosher menus to schooling for young patients. The ratio of nurses to beds is one measure of how much TLC you can expect. (Because the ratio reflects full-time employment, the number of nurses per bed on any 8-hour shift will be about one third of that indicated.) Phone numbers are provided so you can follow up with your own questions.

A fail-safe system for ophthalmic group practice

If a mistake is made by a staff member, the error is detected and corrected automatically by other staff members before the patient is affected. In employing the Fail-Safe System, all personnel must accept that mistakes are inevitable but can be kept to a minimum through staff cooperation. The two key points of the Fail-Safe System are the correct receipt and transmission of information and, once the information is received, the ability of the receiver to assess the correctness of the information. The five subsystems of the Fail-Safe System are the improvement of each employee's medical knowledge; the mastering of correct pronunciation; the mastering of correct writing; the maintenance of a constructive atmosphere in the hospital; and a trouble reporting and analysis process.

Change of hearts

Some very caring companies are now directly contracting with centers of excellence, which specialize in organ transplants and other cutting-edge procedures.