Tuberculosis control in New York City hospitals.

OBJECTIVES: To assess the implementation of tuberculosis (TB) control measures in New York City hospitals in 1992 and determine trends during the subsequent 2 years. METHODS: The 22 acute care facilities with the largest number of hospitalized TB patients in 1991 were selected for inclusion in the study. Medical and laboratory records of the 10 most recent acid fast bacilli (AFB) smear-positive patients in each of the selected facilities in 1992, 1993, and 1994 were reviewed by using a standardized questionnaire to determine risk factors for TB, previous history of TB, clinical signs and symptoms, AFB laboratory turnaround times, emergency department contact, timing of isolation, timing of treatment, case reporting, and status on discharge. The patients' rooms were evaluated for TB environmental control measures if the patient was still on respiratory isolation precautions. RESULTS: More than one third of patients were admitted with a previous history of TB, 31% were admitted with a cavitary lesion on chest x-ray examination, and 48% were known to have HIV infection. Eighty-five percent were admitted from the emergency department where they stayed for up to 116 hours (mean stay: 17 hours). The proportion of patients placed in AFB isolation on admission to the floor increased from 75% in 1992 to 84% in 1994. The proportion of patients given a minimum of four anti-TB drugs increased from 88% in 1992 to 94% in 1994. Patients "on isolation" were sharing rooms with up to nine other patients in 1992, whereas no patients were sharing rooms in the 1994 survey. In 1992, 51% of the rooms were under negative air flow with respect to the corridor. During the 1994 survey, 80% of rooms were under negative air flow. Between 1992 and 1994, the proportion of AFB isolation rooms with dust/mist respirators increased from 28% to 76% (p < 0.00001). Approximately 25% of discharged patients left against medical advice (no trend over time). The proportion of medically discharged patients with three negative AFB smears before discharge increased from 26% to 48% (p = 0.03) and the proportion referred for directly observed therapy increased from 15% to 53% (p = 0.00001). CONCLUSION: TB control efforts in New York City hospitals improved dramatically between 1992 and 1994. The ultimate control of TB will continue to depend on the coordinated efforts within and between health care facilities, providers, and the community.

A strategy to enhance accountability in health care delivery.

The New York State Department of Health surprised many in the hospital industry and medical community when, in June 1987, it proposed as regulation that the governing body of each acute care hospital appoint a medical director who would be assigned responsibility for the direction of the organized medical staff. Such a proposal, without modification, has been incorporated in the New York State Hospital Code--Minimum Standards, effective January 1, 1989. While a strong case can be made for this position in hospitals, its value has long been recognized by a wide variety of organizations.