Objectives: Published discrepancy rates between emergency department (ED) and hospital discharge (HD) diagnoses vary widely (from 6.5 to 75.6%). The goal of this study was to determine the extent of diagnostic discrepancy and its impact on length of hospital stay (LOS), up-triage to the intensive care unit (ICU) and in-hospital mortality. Methods: A retrospective chart review of adult patients admitted from the ED to a hospitalist service at a tertiary hospital was performed. The ED and HD diagnoses were compared and classified as concordant, discordant, or symptom diagnoses according to predefined criteria. Logistic regression analysis was conducted to examine the associations of diagnostic discordance with in-hospital mortality and up-triage to the ICU. A linear regression model was used for the length of stay. Results: Of the 636 patients whose records were reviewed, 418 (217 [51.9%] women, with a mean age of 64.1 years) were included. Overall, 318 patients (76%) had concordant diagnoses, while 91 (21.77%) had discordant diagnoses. Only 9 patients (2.15%) had symptom diagnoses. A discordant diagnosis was associated with increased mortality (OR: 3.64; 95% CI: 1.026-12.91; p=0.045) and up-triage to the ICU (OR: 5.51; 95% CI: 2.43-12.5; p<0.001). The median LOS was significantly greater for patients with discordant diagnoses (7 days) than for those with concordant diagnoses (4.7 days) (p=0.004). Symptom diagnosis did not affect the mortality or ICU up-triage. Conclusions: One in five hospitalized patients had discordant HD and admission diagnoses. This diagnostic discrepancy was associated with significant impacts on patient morbidity and mortality.

Background: Most adults with bacterial meningitis and meningococcal septicaemia present to junior doctors who have limited experience of these conditions. In contrast to paediatric practice, data from industrialized countries with regard to current hospital management practice are lacking. Aim: To examine whether current practice meets recommended standards in hospital management of community-acquired bacterial meningitis and meningococcal septicaemia among adults. Design: National audit of medical records. Methods: We conducted a survey of all patients with acute bacterial meningitis and meningococcal septicaemia admitted to 18 randomly selected acute hospitals in England and Wales between 1 January 2000 and 31 December 2001. All stages of care, including pre-hospital management, initial hospital assessment, record keeping, and ongoing hospital and public health management, were assessed. Results: We identified 212 cases of bacterial meningitis and meningococcal septicaemia; 190 cases remained in the final analysis. Clinical record keeping did not meet acceptable standards in 33% of cases. Parenteral antibiotics were given within 1 h of hospital arrival in 56% of cases, increasing to 79% among those with an initial differential diagnosis that included bacterial meningitis or meningococcal septicaemia. A full severity of illness assessment was made in 27%. The quality of clinical practice varied widely between hospitals. This was most pronounced in the timeliness of consultant review (p < 0.0005). Discussion: The quality of adult clinical practice for bacterial meningitis and meningococcal septicaemia needs improvement. This study provides a tool for developing targeted interventions to improve quality of care and outcome among adults with life-threatening infections, both in the UK and in other countries.