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Tuberculosis: a missed opportunity for early diagnosis at the front line?
  1. Tanuj S Lad,
  2. Geoffrey E Packe
  1. Newham University Hospital, Bart's NHS Trust, London, UK
  1. Correspondence to Dr Tanuj S Lad, Newham University Hospital Chest Clinic, Bart's NHS Trust, Shrewsbury Road, Forest Gate, London E7 8QP, UK; tanujlad{at}yahoo.com

Abstract

Introduction The incidence of tuberculosis (TB) has increased over the last two decades. Many patients with TB preferentially access healthcare via the emergency department (ED) prediagnosis, presenting an early opportunity for diagnosis.

Methods We looked at the number of patients who presented to ED in the 3 months prior to TB notification, and their outcomes.

Results 42% of all notifications had accessed ED prior to notification. The majority were hospitalised, with a proportion of these patients previously attending ED only to be discharged. 37% of patients were discharged from ED with many having TB symptoms, and only a minority referred onto TB clinic.

Conclusions The ED is often the first contact that urban TB patients have with healthcare. Healthcare professionals should ensure this diagnosis is not missed in high incidence areas as it has significant clinical and infection control consequences.

  • infectious diseases, bacterial
  • respiratory
  • emergency department

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Introduction

More than 9000 cases of tuberculosis (TB) are reported every year in the UK.1 ,2 In 2011, over 3500 cases of TB were reported among London residents, with the borough of Newham continuing to have one of the highest number of cases.2 TB thrives among the impoverished, vulnerable and those disconnected from mainstream society. Access to primary healthcare can be difficult and often strained, especially among the homeless, substance and alcohol abusers and immigrants from high prevalence countries.3 Given that this group is often geographically mobile, they will commonly rely on the emergency department (ED) for healthcare. Thus ED is potentially a major point of contact for TB patients within the urban healthcare system.4 ,5 We studied how frequently patients attended ED in the 3 months prior to their TB diagnosis and their outcomes.

Methods

This is a retrospective analysis of TB patients attending Newham University Hospital ED in the 3 months prior to their notification (between January 2011 and June 2011). Information was gathered on the number of attendances and their outcomes (discharged/admitted/referred). Formal ethical review was not necessary for this retrospective observational review of patient data as per National Research Ethics Service guidance (NHS Health Research Authority).

Results

There were 180 TB notifications in Newham between January 2011 and June 2011. Seventy-six (42%) of these patients had accessed ED in the 3 months prior to notification. Of these 76 patients, 38 had pulmonary disease and majority were foreign born with only five being born in the UK. Median age was 31 years (range 13–70 years). Forty-eight (63%) of those that had accessed ED were admitted. Nine (19%) of those admitted had previously attended ED with TB-related symptoms only to be discharged without follow-up.

Twenty-eight (37%) were discharged from ED, with 21 (75%) having one or more TB symptoms (cough, haemoptysis, night sweats, breathlessness, lymphadenopathy and fever). Of these, only six (29%) were referred on to TB clinic. The remaining patients with documented TB symptoms were discharged with no follow-up, with over half subsequently returning to ED for hospital admission.

Discussion

Just under half of all TB notifications presented to ED prior to notification reflecting the difficulties this patient population has in accessing primary healthcare and emphasising the role that ED has in their care. Many discharged from ED had TB symptoms without ongoing referral. These patients were subsequently hospitalised upon re-presentation to ED. The missed opportunity to diagnose and the subsequent hospitalisation of these patients highlights the concern that there was clinical deterioration at re-presentation.

These missed opportunities to diagnose TB have been detailed by Long et al, who described 50% of their TB patients who attended ED during the 6 months preceding diagnosis. Each patient made on average 2.2 ED visits, and 70% of hospitalisation for TB was preceded by an ED attendance.5 Crucially, patients were more likely to have attended the ED shortly before a definitive diagnosis of TB was made, highlighting an important diagnostic opportunity. A comparable study by Smith et al6 in an inner city hospital showed that a third of their TB patients had ED attendances in the 6 months prior to notification, with the diagnosis missed in almost a quarter of cases. A large proportion of their patients did not have access to primary care. Our department performed a similar study 10 years ago, where we found 50% ED attendance pre-TB diagnosis, with over half having symptoms that were missed at the time of assessment.7

Failure to diagnose TB poses clinical implications as typical ED attendees with TB are more likely to be older, have smear/culture-positive respiratory disease and at most risk of morbidity and mortality from TB.5 Given that patients are more likely to access ED prior to definitive TB diagnosis being made,5 it is imperative that TB is considered during these attendances.

The hospital front line is heavily used by urban TB patients prediagnosis. Teams working in this environment should have a high index of suspicion of TB infection in patients, regardless of their reason for ED attendance.

References

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Footnotes

  • Contributors TL developed the idea, collated data, and edited the final manuscript. TL, along with GP, prepared the initial manuscript. GP assisted with final manuscript, design and editing.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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