A 5-year time study analysis of emergency department patient care efficiency.

STUDY OBJECTIVES: We conducted a 5-year time study analysis of emergency department patient care efficiency. Our specific aims were (1) to calculate the main ED patient care time intervals to identify areas of inefficiency, (2) to measure the effect of ED and inpatient bed availability on patient flow, (3) to quantitatively assess the effects of administrative interventions aimed at improving efficiency, and (4) to evaluate the relationship between waiting times to see a physician and the number of patients who leave without being seen (LWBS) by a physician. METHODS: Seven 1-week ED patient flow time studies were conducted from September 1993 to July 1998 using identical study design and methodology. Patients presenting with complaints of chest pain, abdominal pain, vaginal bleeding, and extremity injury were included to represent the level of severity of patient conditions seen in our Los Angeles County hospital ED. The calculated time intervals representing the main phases of evaluation and treatment were (1) triage presentation to completion of registration, (2) completion of registration to ED treatment area entry, (3) ED treatment area entry to initial medical assessment, (4) triage presentation to initial medical assessment, (5) initial medical assessment to disposition order, and (6) disposition order to patient discharge from the ED. Total ED lengths of stay (LOS) were also calculated as overall measures of efficiency. Time intervals were compared depending on the availability of ED and hospital inpatient beds. The effects of administrative interventions on the specific time intervals were assessed. The relationship between the median waiting time to see a physician and the number of LWBS patients was evaluated. Administrative interventions were implemented by a special interdepartmental continuous quality improvement committee. Interventions were aimed at specific sources of delay and inefficiency identified by the time studies. RESULTS: Eight hundred twenty-six patients were included in the 7 time studies. The unavailability of ED and inpatient beds was associated with significant delays. There was a significant reduction of the median total ED LOS from 6.8 hours to 4.6 hours over the first 5 periods, presumably resulting from the administrative interventions. Median total ED LOS, however, increased from 4.6 hours to 6.0 hours during the last 2 periods, possibly as a result of an increase in our ED patient census and reductions in both nursing and physician staffing imposed by the recent Los Angeles County fiscal crisis. The number of LWBS patients was closely correlated to waiting time to see a physician ( r =0.79, beta=5.20, P =.033). CONCLUSION: Time studies are an effective method of identifying areas of patient care delay. In our ED, targeted administrative interventions apparently reduced the total ED LOS and improved overall efficiency. Despite initial decreases in ED LOS, efficiency appeared to be adversely affected by reductions in nursing and physician staffing and increases in our patient census. The strength of the relationship between waiting times to see a physician and the number of LWBS patients suggests that decreasing waiting times may reduce the number of LWBS patients.     

Emergency department contributors to ambulance diversion: a quantitative analysis

STUDY OBJECTIVE: We determine the relationship between physician, nursing, and patient factors on emergency department use of ambulance diversion. METHODS: Data were collected at 1 ED in Toronto, Ontario, Canada, on the duration of ambulance diversion during consecutive 8-hour intervals from January to December 1999 (intervals=1,095). By using time series methods, the association between ambulance diversion and nurse hours, physician on duty, and boarded patients was determined. Covariates included patient volume, assessment time, and boarding time. RESULTS: A total of 37,999 patients were treated in the ED over the study period (2% major trauma, 16% ambulance arrivals, and 22% admitted). Nurse hours per interval averaged 60. A mean of 3.2 admitted patients were boarded in the ED each interval. For admitted patients, the time from registration to admission order and from admission order to ED departure averaged 5.2 and 3.5 hours, respectively. There was no ambulance diversion during 170 (15.5%) intervals, whereas 17 (1.5%) intervals were continuously on diversion. In time series analyses, ambulance diversion increased with the number of admitted patients boarded in the ED (6.2 minutes per patient; 95% confidence interval [CI] 2.6 to 9.8 minutes), the number admitted per interval (4.6 minutes per patient; 95% CI 0.1 to 9.1 minutes), assessment time (9.9 minutes per hour; 95% CI 3.3 to 16.5 minutes), and boarding time (11.3 minutes per hour; 95% CI 5.6 to 17.0 minutes). Thirteen of 15 emergency physicians were not associated with ambulance diversion, 1 was associated with reduced use (-36.3 minutes; 95% CI -65.2 to -7.5 minutes), and 1 was associated with increased use (47.6 minutes; 95% CI 4.5 to 90.6 minutes). ED nurse hours were not associated with diversion. Ambulance-delivered patient volume was associated with diversion (5.2 minutes per patient; 95% CI 2.7 to 7.8 minutes), but walk-in patients and patients with major trauma were not. CONCLUSION: Admitted patients in the ED are important determinants of ambulance diversion, whereas nurse hours and most emergency physicians are not. Reducing the volume of walk-in patients is unlikely to lessen the use of diversion.     

Promptness of antibiotic therapy in acute bacterial meningitis

We reviewed 135 cases of acute community-acquired bacterial meningitis at a municipal teaching hospital during a six-year period, with special emphasis on promptness of initial antimicrobial therapy. Overall mortality was 5% for the 121 childhood cases, compared to 43% for the 14 adult cases (P less than .001). The mean duration between arrival in the emergency department and the administration of appropriate antibiotics was 2.1 hours for the pediatric cases, compared to 4.9 hours for the adult cases (P less than .02). Factors that may contribute to delays in institution of appropriate antimicrobial therapy for adult patients with meningitis include the relative infrequency of this condition, the presence of concomitant disease processes, and the frequent practice of obtaining a computed tomography scan prior to performing lumbar puncture. Prompt institution of antimicrobial therapy for acute meningitis, especially for adult pneumococcal meningitis, remains a major challenge for emergency physicians.     

Antibiotic timing and errors in diagnosing pneumonia

BACKGROUND: The percentage of patients with community-acquired pneumonia (CAP) whose time to first antibiotic dose (TFAD) is less than 4 hours of presentation to the emergency department (ED) has been made a core quality measure, and public reporting has been instituted. We asked whether these time pressures might also have negative effects on the accuracy of diagnosis of pneumonia. METHODS: We performed a retrospective review of adult admissions for CAP for 2 periods: group 1, when the core quality measure was a TFAD of less than 8 hours; and group 2, when the TFAD was lowered to less than 4 hours. We examined the accuracy of diagnosis of CAP by ED physicians. RESULTS: A total of 548 patients diagnosed as having CAP were studied (255 in group 1 and 293 in group 2). At admission, group 2 patients were 39.0% less likely to meet predefined diagnostic criteria for CAP than were group 1 patients (odds ratio, 0.61; 95% confidence interval, 0.42-0.86) (P = .004). At discharge, there was agreement between the ED physician's diagnosis and the predefined criteria for CAP in 62.0% of group 1 and 53.9% of group 2 patients (P = .06) and between the ED physician's admitting diagnosis and that of the discharging physician in 74.5% of group 1 and 66.9% of group 2 patients (P = .05). The mean (SD) TFAD was similar in group 1 (167.0 [118.6] minutes) and group 2 (157.8 [96.3] minutes). CONCLUSION: Reduction in the required TFAD from 8 to 4 hours seems to reduce the accuracy by which ED physicians diagnose pneumonia, while failing to reduce the actual TFAD achieved for patients.     

Continuity of antibiotic therapy in patients admitted from the emergency department

STUDY OBJECTIVE: We describe discontinuities in antibiotic therapy in patients with community-acquired pneumonia admitted from the emergency department (ED) to an inpatient unit. METHODS: We performed a retrospective cohort study of patients with community-acquired pneumonia admitted from the ED to the internal medicine service at an academic tertiary care hospital between July 1997 and June 1999. We characterized the frequency of antibiotic delays after arrival on the inpatient unit in relation to antibiotic dosing intervals. We performed paired analysis on the patients treated both with an antibiotic dosed every 6 hours and an antibiotic dosed every 24 hours. RESULTS: Three hundred seventy-five patients were identified. The mean age was 61 years. Sixty-two percent were female. Five hundred fifty-one antibiotic doses were started in the ED and continued on the inpatient unit, with 177 ordered every 6 hours, and 351 ordered every 24 hours. Seventy-five percent of the antibiotics dosed every 6 hours and 19% of the antibiotics dosed every 24 hours were delayed more than 30 minutes (P <.001). Analysis of the 146 patients receiving both an antibiotic dosed every 6 and 24 hours showed that the first inpatient dose of antibiotics administered every 6 hours were 10 times more likely to be delayed than antibiotics dosed every 24 hours (95% confidence interval 5.0 to 23). The median delay for antibiotics dosed every 6 hours was 258 minutes (range 45 to 3,360 minutes), and the median delay for antibiotics dosed every 24 hours was 192 minutes (range 32 to 2,124 minutes). CONCLUSION: Discontinuous therapy, represented through a delayed first inpatient antibiotic dose, is common in patients with community-acquired pneumonia admitted from the ED. Although the effect on outcome is unknown, theoretical concerns should lead emergency physicians to consider using longer-acting antibiotics to minimize delayed therapy.     

Physician in triage improves emergency department patient throughput

To determine if a physician in triage (PIT) improves Emergency Department (ED) patient flow in a community teaching hospital. This is an interventional study comparing patient flow parameters for the 3-month periods before and after implementation of a PIT model. During the interventional time an additional attending physician was assigned to triage from 1 p.m. to 9 p.m. daily. Outcome measures were median time to attending physician evaluation, median length of stay (LOS), number of patients who left without being seen (LWBS), and total time and number of days on ambulance diversion. Non-normally distributed values were compared with the Wilcoxon rank sum test. Proportions were compared with Chi-square test. Outcome measures were available for 17,631 patients, of whom 8,620 were seen before the initiation of PIT, and 9,011 were seen after PIT was implemented. For all patients, the median time from registration to attending physician evaluation was reduced by 36?min (1:41 to 1:05, p?相似文献   

Brain-derived neurotrophic factor protects against multiple forms of brain injury in bacterial meningitis

BACKGROUND: Brain-derived neurotrophic factor (BDNF) blocks activation of caspase-3, reduces translocation of apoptosis-inducing factor (AIF), attenuates excitotoxicity of glutamate, and increases antioxidant enzyme activities. The mechanisms of neuroprotection suggest that BDNF may be beneficial in bacterial meningitis. METHODS: To assess a potentially beneficial effect of adjuvant treatment with BDNF in bacterial meningitis, 11-day-old infant rats with experimental meningitis due to Streptococcus pneumoniae or group B streptococci (GBS) were randomly assigned to receive intracisternal injections with either BDNF (3 mg/kg) or equal volumes (10 mu L) of saline. Twenty-two hours after infection, brains were analyzed, by histomorphometrical examination, for the extent of cortical and hippocampal neuronal injury. RESULTS: Compared with treatment with saline, treatment with BDNF significantly reduced the extent of 3 distinct forms of brain cell injury in this disease model: cortical necrosis in meningitis due to GBS (median, 0.0% [range, 0.0%-33.7%] vs. 21.3% [range, 0.0%-55.3%]; P<.03), caspase-3-dependent cell death in meningitis due to S. pneumoniae (median score, 0.33 [range, 0.0-1.0] vs. 1.10 [0.10-1.56]; P<.05), and caspase-3-independent hippocampal cell death in meningitis due to GBS (median score, 0 [range, 0-2] vs. 0.88 [range, 0-3.25]; P<.02). The last form of injury was associated with nuclear translocation of AIF. CONCLUSION: BDNF efficiently reduces multiple forms of neuronal injury in bacterial meningitis and may hold promise as adjunctive therapy for this disease.     

Intervention to decrease emergency department crowding: does it have an effect on return visits and hospital readmissions?

STUDY OBJECTIVES: We evaluate the effect of a multifaceted intervention to decrease emergency department crowding on the incidence of return visits to the ED or a hospital ward. The intervention included increased emergency physician coverage, the designation of physician coordinators, and new hospital policies regarding laboratory, consultation, and admission procedures. METHODS: The incidence of return visits within 7 days of discharge was estimated in samples from 2 populations (ie, patients discharged from the ED and patients discharged from the hospital) and during a 12-month period before and a 12-month period after the implementation of the intervention. Return visits were categorized into the following groups: (1) scheduled or not and (2) related or not to initial visit. Logistic regression was used in subsamples to assess the effect of the intervention while controlling for potential confounders. By using information from the provincial medical services database, variation between the periods before and after implementation of the intervention in the incidence of return visits to any ED was compared between the study hospital and 2 external control hospitals. RESULTS: No difference was found in the incidence of return visits between the periods before and after implementation of the intervention, either for patients discharged from the ED (all returns: 11.0% versus 12.4%, 95% confidence interval on difference [CID] -1.5% to 4.3%; unscheduled-related returns: 6.5% versus 5.8%, 95% CID -2.8% to 1.6%) or the hospital (all returns: 6.8% versus 6.6%, 95% CID -2.5% to 2.1%; unscheduled-related returns: 4.2% versus 4.0%, 95% CID -2.0% to 1.7%). This lack of effect remained even after controlling for potential confounders. Variation between the periods before and after implementation of the intervention in the incidence of return to any ED was similar in the 3 hospitals examined. CONCLUSION: Our successful hospital intervention to decrease crowding reduced the mean length of stay for patients discharged from the ED from 13.8 to 5.9 hours, without resulting in increased return visits to the ED or hospital readmission.     

An intervention to improve antibiotic delivery and sputum procurement in patients hospitalized with community-acquired pneumonia

STUDY OBJECTIVES: To determine if an educational intervention targeting emergency department (ED) and medicine staff could successfully decrease the time to antibiotic delivery (door-to-drug delivery time [DDD]) for patients admitted through the ED with community-acquired pneumonia (CAP). DESIGN: Prospective, multidisciplinary team-based educational project. Demographics, outcomes, and processes of care including DDD and sputum procurement for patients with CAP were determined during a baseline period and compared to the same parameters for patients with CAP presenting after the educational intervention was administered to ED and medicine staff. SETTING: Barnes-Jewish Hospital, a large Midwest teaching institution affiliated with the Washington University School of Medicine. PATIENTS: Consecutive adult patients admitted through the ED with CAP. INTERVENTION: Multidisciplinary in-service education administered to ED physicians and nurses, and medicine housestaff, which emphasized the importance of rapid antibiotic delivery and procurement of preantibiotic expectorated sputum. RESULTS: Mean DDD improved from 413 to 291 min (p = 0.02), with more patients receiving antibiotics in the ED (46% vs 69%; adjusted odds ratio [OR], 2.3; 95% confidence interval [CI], 1.0 to 4.9). Sputum procurement improved from 11.5 to 25.4% (adjusted OR, 3.3; 95% CI, 1.1 to 9.9). There were no observed differences for inpatient mortality or length of stay. CONCLUSION: This multidisciplinary team intervention significantly improved the time to initiation of antibiotics and procurement of sputum for patients with CAP.     

Delays in the suspicion and treatment of tuberculosis among hospitalized patients

BACKGROUND: Despite increased awareness of tuberculosis, delays in management are common. OBJECTIVE: To investigate management delays among hospitalized patients with tuberculosis. DESIGN: Retrospective cohort study. SETTING: The Barnes-Jewish-Christian Health System, a network of eight community and tertiary-care facilities serving the St. Louis, Missouri, metropolitan area. PATIENTS: All 203 patients with tuberculosis hospitalized in the Barnes-Jewish-Christian Health System from 1988 to 1996. MEASUREMENTS: Time from admission to first consideration of the diagnosis (suspicion interval), first consideration and treatment initiation (treatment interval), and admission and treatment initiation (overall management interval) were determined. Delays were defined as intervals longer than 24 hours. RESULTS: The overall management interval (median, 6 days [5th and 95th percentiles, 1 and 52 days]) exceeded 24 hours in 152 patients (74.9% [95% CI, 68.9% to 80.9%]). The suspicion interval (median, 1 day [5th and 95th percentiles, 0 and 16 days]) exceeded 24 hours in 54 patients (26.6% [CI, 20.5% to 32.7%]), and the treatment interval (median, 3 days [5th and 95th percentiles, 0 and 51 days]) was prolonged in 130 patients (64.0% [CI, 57.4% to 70.6%]). Overall management delays of more than 10 and 25 days occurred in 33.5% (CI, 27.0% to 40.0%) and 18.7% (CI, 13.3% to 24.1%) of patients, respectively. The 55 patients with smears that were positive for acid-fast bacilli had a median treatment interval of 3 days (5th and 95th percentiles, 0 and 33 days); in 58.2% of patients (CI, 45.2% to 71.2%), this interval exceeded 24 hours. CONCLUSIONS: Delays in initiation of treatment were more common than delays in the initial suspicion of tuberculosis. Both types of delays were common even in patients with disease that was confirmed by a positive smear. These data illustrate a need for improved education of physicians about the benefits of early initiation of therapy for tuberculosis.     

Community acquired acute bacterial meningitis in children and adults: an 11-year survey in a community hospital in Israel

OBJECTIVES: We aimed to investigate the association between the presenting clinical manifestations of bacterial meningitis and the duration of time elapsed before lumbar puncture and start of antibiotic treatment. DESIGN: Retrospective epidemiologic study using the clinical records in Barzilai Medical Center Emergency Department between 1988 and 1999. RESULTS: 97 patients, 72 children and 25 adults with ABM were identified. 30 of 97 (31%) were diagnosed by the primary physicians at primary care units. Acute meningitis was suspected by emergency department (ED) physicians in 51% of the referred patients. Patients with a scarce clinical picture at hospital arrival (those without fever, headache or nuchal rigidity) showed a trend toward a longer median delay until a diagnostic lumbar puncture was performed and antibiotic therapy was started (median of 14.7 h compared with 2.1 h for those with severe clinical picture) (p<0.02). Nevertheless, the clinical outcome for the total cohort did not yield a significant difference when analyzed regarding the duration of time between arrival to emergency department and antibiotic treatment initiation (p>0.3). CONCLUSIONS: The interval before diagnosis of community acquired ABM in both children and adults is longer for those patients who present to the emergency department with an atypical clinical picture, mostly, without fever and without nuchal rigidity. Until bacterial meningitis can be effectively prevented, we can expect this life-threatening infection to continue to cause diagnostic and medical difficulties.     

Patient and health care system delays in pulmonary tuberculosis diagnosis in a low-incidence state.

SETTING: Tuberculosis (TB) patients reported to the Maryland Department of Health and Mental Hygiene from 1 June 2000 to 30 November 2001. OBJECTIVE: To determine the extent of delayed diagnosis of TB and to assess patient and provider factors associated with delays. DESIGN: A prospective cohort study. RESULTS: Median patient, health care and total delays were 32, 26 and 89 days, respectively, for 158 patients. Non-white (relative hazard [RH] 0.62; 95% CI 0.39-0.98) and less educated (RH 0.43; 95% CI 0.26-0.72) patients had longer patient delays. English-speaking patients (RH 0.40; 95% CI 0.24-0.68) had increased health care delays, as did patients who received a diagnosis of a respiratory illness and non-TB antibiotics (RH 0.69; 95% CI 0.49-0.96) prior to a TB diagnosis. Patients first presenting to a private physician (51 days) rather than a hospital emergency room (18 days; RH 1.87; 95% CI 1.05-3.33) or public health clinic (10 days; RH 1.79; 95% CI 1.21-2.63) had longer health care delays. When a TB diagnostic tool (chest radiograph or AFB culture) was utilized, a more rapid diagnosis of TB was made. CONCLUSION: Education of the patient population about TB symptoms might reduce delays. Increased physician awareness of the current epidemiology of TB and better use of available diagnostic tools will reduce delays and may reduce TB transmission.     

Pediatric bacterial meningitis: is prior antibiotic therapy associated with an altered clinical presentation?

STUDY HYPOTHESIS: The clinical features of children treated with oral antibiotics before the diagnosis of bacterial meningitis differ from those who receive no antibiotics. DESIGN: Retrospective case series. SETTING: University medical center. PARTICIPANTS: Two hundred fifty-eight children 24 months old or younger with bacterial meningitis hospitalized during a 12-year period. Eighty-three children were treated with oral antibiotics before the diagnosis of meningitis, and 175 children were not. INTERVENTIONS: None. METHODS: The emergency department chart and hospital records were reviewed for presenting demographic, historical, physical examination, and laboratory features. Clinical features of pretreated and untreated patients were compared. RESULTS: Pretreated children demonstrated less frequent temperature of 38.3 C or higher, altered mental status and a longer duration of symptoms before diagnosis, with more frequent vomiting; ear, nose, and throat infections; and physician visits in the week before detection of meningitis (P less than .05 for all comparisons). There was no difference in incidence of upper respiratory symptoms, seizures, nuchal rigidity, Kernig's and Brudzinski's signs, focal neurologic signs, mortality, and length of hospitalization between groups. CONCLUSION: Clinical features of children who have taken antibiotics before the detection of meningitis differ significantly from those who have not undergone antibiotic therapy. Physicians should be aware of these differences when evaluating young children on antibiotics for the possibility of meningitis.     

Adjunctive corticosteroids in adults with bacterial meningitis

Bacterial meningitis is a complex disorder in which neurologic injury is caused, in part, by the causative organism and, in part, by the host’s own inflammatory response. In studies of experimental bacterial meningitis, adjuvant treatment with corticosteroids, specifically dexamethasone, has beneficial effects. On the basis of these experimental studies, several clinical trials were undertaken to determine the effects of adjunctive corticosteroids in patients with bacterial meningitis. On the basis of overall benefit without detrimental effects by subgroup analysis, dexamethasone therapy should be initiated before or with the first dose of antibiotic and should be continued in most patients with community-acquired acute bacterial meningitis. For patients with a low suspicion of meningitis but an urgent need for antibiotics before cerebrospinal fluid can be obtained, we recommend initiation of treatment with dexamethasone, with discontinuation of dexamethasone therapy as soon as the diagnosis has been excluded.     

Steroids in adults with acute bacterial meningitis: a systematic review

Bacterial meningitis is uncommon but causes significant mortality and morbidity, despite optimum antibiotic therapy. A clinical trial in 301 patients showed a beneficial effect of adjunctive steroid treatment in adults with acute community-acquired pneumococcal meningitis, but data on other organisms or adverse events are sparse. This led us to do a quantitative systematic review of adjunctive steroid therapy in adults with acute bacterial meningitis. Five trials involving 623 patients were included (pneumococcal meningitis=234, meningococcal meningitis=232, others=127, unknown=30). Overall, treatment with steroids was associated with a significant reduction in mortality (relative risk 0.6, 95% CI 0.4-0.8, p=0.002) and in neurological sequelae (0.6, 0.4-1, p=0.05), and with a reduction of case-fatality in pneumococcal meningitis of 21% (0.5, 0.3-0.8, p=0.001). In meningococcal meningitis, mortality (0.9, 0.3-2.1) and neurological sequelae (0.5, 0.1-1.7) were both reduced, but not significantly. Adverse events, recorded in 391 cases, were equally divided between the treatment and placebo groups (1, 0.5-2), with gastrointestinal bleeding in 1% of steroid-treated and 4% of other patients. Since treatment with steroids reduces both mortality and neurological sequelae in adults with bacterial meningitis, without detectable adverse effects, routine steroid therapy with the first dose of antibiotics is justified in most adult patients in whom acute community-acquired bacterial meningitis is suspected.     

Comparison between cerebrospinal fluid concentrations of glucose, total protein, chloride, lactate, and total amino acids for the differential diagnosis of patients with meningitis

The purpose of this study was to compare the ability of cerebrospinal fluid (CSF) concentrations of glucose, protein, chloride, lactate, and total amino acids, as well as CSF/blood glucose ratio to distinguish bacterial meningitis from aseptic meningitis. 56 patients with proven bacterial meningitis, 102 patients with aseptic meningitis, and 108 controls were investigated. On admission CSF lactate determination was the most sensitive and the most efficient test to distinguish bacterial meningitis from aseptic meningitis. In patients with bacterial meningitis reexamined after 24-48 h of treatment with antibiotics and compared with patients with aseptic meningitis also reexamined 24-48 h after admission determination of CSF total amino acids was the most sensitive and efficient test.     

Improving the quality of pneumonia care that patients experience

PURPOSE: Although many hospitals have reported attempts to reduce length of stay for patients hospitalized with community-acquired pneumonia, few have included efforts to educate patients to prepare them for earlier discharges. We aimed to improve patients' knowledge about pneumonia and their experiences with inpatient care as part of a multifaceted intervention that included attempts to reduce unnecessary time on intravenous antibiotics and length of hospital stay. METHODS: We developed guidelines for the appropriate duration of intravenous antibiotics in patients with community-acquired pneumonia and collected baseline data retrospectively on patients discharged from October 1996 through April 1997. We surveyed these patients to assess knowledge and experience with care. Beginning in July 1997, we conducted a series of physician and nurse educational interventions (lectures, feedback of performance data, one-on-one education by peers). Patients received education about pneumonia from their nurses and a specially developed educational brochure. Following the interventions, we collected clinical and survey data on patients with pneumonia discharged from October 1997 through April 1998. RESULTS: Among patients who responded to the survey (163 in the preintervention period; 114 in the postintervention period), fewer reported that no one went out of the way to help them (preintervention, 37% [n = 60]; postintervention, 6% [n = 7]; P = 0.001), more reported that they received all the information they needed to recover (75% [n = 122] vs. 94% [n = 107], P = 0.02), and more reported that they were told about danger signals of relapse (46% [n = 75] vs. 60% [n = 68], P = 0.03). Mean (+/- SD) time on intravenous antibiotics decreased from 5.0 +/- 3.7 days to 4.3 +/- 3.3 days (P = 0.04). CONCLUSION: The interventions improved patients' knowledge and experiences with care, while decreasing time on intravenous antibiotics.