Title : Investigating the investigations: A retrospective study of diagnostic practices in high risk patients with suspected pulmonary tuberculosis.
Abstract:
Introduction: Tuberculosis (TB) remains a significant global public health challenge. Although England is classified as a low-incidence country with 7.7 cases per 100,000 population, Wolverhampton reports a markedly higher incidence of 19.9 cases per 100,000. This retrospective study aimed to assess whether investigations recommended by national guidelines for suspected TB are consistently completed in an acute district general hospital (DGH) serving a diverse urban population in Wolverhampton. Recommended investigations include serial sputum sampling for TB, TB polymerase chain reaction (PCR), HIV screening, and chest radiography.
Method:We conducted a retrospective review of patients coded with a primary diagnosis of TB who presented to the emergency department with high-risk features suggestive of TB between January 2023 and February 2025. Inclusion criteria included clinical symptoms such as shortness of breath, haemoptysis, weight loss, and malaise, as well as high-risk demographic factors including recent travel to TB-endemic regions, known TB contact, intravenous drug use, or immunocompromised status. Patients were excluded if they were paediatric, incorrectly coded, or had a known or active TB diagnosis prior to presentation. Completion of the recommended TB workup was defined as having undergone chest radiography, serial sputum sampling or TB PCR testing, and HIV screening.
Results: A total of 64 patients were identified, of whom 41 met the inclusion criteria. Among these, 26 were admitted to hospital and 15 discharged from the emergency department. Complete TB investigations were performed in 42% of admitted patients compared to 20% of those discharged. Notably, two admitted patients diagnosed with TB had not undergone HIV screening, and similarly, one discharged patient who tested positive for TB had also not received HIV screening. Additionally, four admitted patients had not undergone TB PCR testing or serial sputum sampling.
Conclusion: Adherence to national guidelines for TB investigations among high-risk patients presenting with suspected TB remains suboptimal, with significant disparities observed between admitted and discharged patients. These gaps in investigation practices may contribute to ongoing community transmission of TB. Enhanced emphasis on HIV screening and adherence to recommended investigations, including serial sputum sampling, is imperative.
Implication for future practice: Emergency department clinicians may benefit from targeted training to improve recognition of high-risk features and to ensure initiation of appropriate investigations. The development and implementation of a clear, evidence-based clinical pathway for TB risk assessment and diagnostic workup in emergency settings could improve investigation consistency and facilitate earlier diagnosis, thereby potentially reducing TB transmission in the community.
