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Module 8: Tuberculosis Surveillance and Case Management in Hospitals
Answers To Case Studies

8.1. As the new public health worker at the state prison (or in any other facility to which you are assigned), you are asked to attend a staff meeting where you have the opportunity to present to the administration a description of your job, your role at the facility, and the process you use to conduct your work. Because you suspect that the facility director has some misunderstandings about TB control, you are quite pleased to have this opportunity. You begin to prepare diligently for the meeting.

  • What will you tell the director about the primary goals of TB prevention and control?

    The three primary goals of TB prevention and control are to

    • Identify and treat persons who have active TB disease
    • Identify and evaluate exposed contacts, offering appropriate therapy as indicated
    • Test populations at high risk for TB infection and disease, offering treatment for LTBI to infected persons as indicated
    • To accomplish these goals, you have been assigned to make routine visits to the facility to gather information and interview patients who have suspected or confirmed cases of TB disease. The focus of your job is to gather information, interview patients, plan for patients' follow-up care, and collaborate with staff.

    To accomplish these goals, you have been assigned to make routine visits to the facility to gather information and interview patients who have suspected or confirmed cases of TB disease. The focus of your job is to gather information, interview patients, plan for patients' follow-up care, and collaborate with staff.

     

  • How will you describe your role at the facility and the process you use to conduct your work?

    You should present the basic process for conducting TB surveillance and providing case management in facilities such as hospitals or institutions.  This process includes the following steps:

  1. Identify suspected or confirmed TB cases as soon as possible and report them to the TB control program.
  2. Collect information from the patient's medical record and other sources that will help maintain contact with the patient and manage his or her disease.
  3. Conduct an initial interview with every patient who has suspected or confirmed TB to establish a good relationship and begin the necessary steps for a thorough contact investigation.
  4. Plan for each TB patient's follow-up care upon discharge from the hospital or institution.

Health department staff should

  • Designate a specific person to work with correctional facilities
  • Ensure that cases of TB are promptly reported, counted, and recorded
  • Provide information from the TB registry in the health department so that information from the TB registry can be cross-matched with names of inmates admitted into correctional facilities to identify persons with TB disease who fail to report their TB history
  • Assist correctional facilities in developing, implementing, and updating
    • TB control policies and procedures
    • Training and educational programs
    • Tracking and patient record systems
    • HIV prevention programs
  • Ensure that released inmates complete therapy
  • Assist with contact investigations in and outside correctional facilities
  • Analyze TB morbidity in correctional facilities
  • Provide or refer to expert clinical consultation
  • Ensure access to adequate laboratory services

8.2. A public health worker is conducting active case finding in the laboratory of a small community hospital. The AFB logbook contains the following entries:

Specimen AFB Smear Result Culture Result
349 3+ Pending
362 0 M. tuberculosis
367 2+ M. avium intracellulare
  • Determine the classification for each specimen using the TB classification system and determine which specimens the public health worker should follow up.

    Specimen 349 has a positive AFB smear result and a pending culture result, making this case a Class 5 TB suspect. Specimen 362 has a negative AFB smear result but a positive culture for M. tuberculosis, confirming a diagnosis of TB (Class 3). Specimen 367 was AFB-positive, but grew M. avium intracellulare in culture; specimen 367 therefore contains nontuberculous mycobacteria and should not be recorded.

  • What should the public health worker record?

    For specimens 349 and 362, the public health worker should record the patient's

    • Name
    • Date of birth
    • Medical record number
    • Laboratory number
    • Date of specimen collection
    • Type of specimen
    • AFB smear result (with quantification)
    • Culture result (with species identification)
    • Drug susceptibility pattern
    • Case report number (if indicated)

    The public health worker should check the date of collection for specimen 349; culture results should be available within 10 to 14 days of specimen collection (depending on the laboratory's average turnaround times). In addition, the public health worker should determine when drug susceptibility results will be available for specimen 362 (and for specimen 349 if it is positive for M. tuberculosis); these results should be collected and made available to the provider as soon as possible.

  • Specimen #362 was collected from a patient who is not on the public health worker's list of current suspected or confirmed TB cases in the hospital. What should be done?

    Whenever active case finding has identified an unreported TB case, the public health worker should alert the facility's staff and a supervisor in the TB program. These persons should all work together to make sure a report is promptly submitted and to assess the cause of the failure to report. In this case, the AFB smear was negative and so the case may not have come to the attention of the infection control practitioner. As soon as the culture result was available, the laboratory should have notified both the hospital and the TB program.

8.3. Another public health worker is conducting active case finding in a large residential facility for the mentally ill. The public health worker goes to the facility's pharmacy to review information about patients receiving TB medications. For the current week, she notes that prescriptions of TB medications were filled for the following patients:

Patient ID Medication Orders Filled
X309 Isoniazid
D904 Isoniazid, pyrazinamide, rifampin, ethambutol
P251 Isoniazid, rifampin
Q321 Ciprofloxacin, amikacin
  • What patients should the public health worker record for follow-up? Why?

    Information found in the pharmacy records can be used to identify patients who are placed on two or more TB medications (and therefore may have active TB disease, not only TB infection). In this case, the public health worker should record information regarding patients D904 and P251. They are both receiving at least two drugs used to treat TB. Patient X309 is receiving INH only and is most likely on a regimen for treatment for LTBI. Patient Q321 is receiving second-line drugs ciprofloxacin and amikacin. These drugs are primarily used to treat diseases other than TB; therefore, pharmacy surveillance does not usually include these drugs.

  • Patient P251 is not known to the TB program as a reported suspected or confirmed TB case. What should be done?

    Whenever active case finding has identified an unreported TB case, the public health worker should alert the facility's staff and a supervisor in the TB program. These persons should work together to make sure a report is promptly submitted and to assess the cause of the failure to report.

8.4. You have received notification of a suspected TB case in Hospital Y and have located the patient's medical record. The admission note reads as follows:

This is a 35 y.o. man presenting with a productive cough, CP, and hemoptysis. On exam he is found to be cachectic with coarse breath sounds bilaterally. Lab values are significant for a low WBC. He has a cavity in the LUL on CXR. Most likely diagnosis is TB, however will r/o pneumonia.

  • Does this information confirm a diagnosis of TB? (Hint: Use the medical glossary in the appendix for help with the abbreviations.)

    A TB case is usually confirmed by a positive culture for M. tuberculosis. At this point, this man has a suspected TB case (Class 5); a suspected case is one for which the diagnosis is pending due to an incomplete medical evaluation. This patient has symptoms of TB disease: a productive cough with bloody sputum (hemoptysis) and chest pain. The suspicion of TB disease is increased by his chest radiograph findings: a cavity in the upper lobe of his left lung.

  • What additional information is needed and where will you look for it?

    You need more information on the patient's diagnostic evaluation, including skin test results, smear results, and culture results. You should follow the daily progress notes chronologically to find skin test results. The administration of the PPD should be noted, followed by the results (in millimeters of induration) 48 to 72 hours later. If no results are given and the PPD has not yet been read, you should ask a nurse to read the skin test with you and document the result in the patient's record.

    Your source for smear and culture results should be the actual report included in the laboratory results section or the laboratory's records. When smear or culture results are listed in the laboratory results section as pending, record the specimen number and date of submission and collect the results from the laboratory, provided adequate time has been elapsed since specimen collection. Be sure to verify all laboratory results listed in the progress notes, because these may not be accurate.

    You should also gather information on the current treatment regimen from the medication record section. Some hospitals or institutions use a separate book to record all medications administered to patients on a specific ward. As treatment progresses, you will want to evaluate the patient's response to treatment, including specific TB symptoms and smear and culture results on specimens collected after treatment has begun. The medical record may also contain information on potential barriers to adherence; to help evaluate the patient's potential adherence to therapy, it is important to note pertinent social history.

8.5. Ms. Bouzide, a 34-year-old mother of four children, has been hospitalized for 3 days for TB disease. She had a severe coughing attack and collapsed on the street before being brought in by an ambulance service. Ms. Bouzide is now well enough for an initial interview; her husband will also be present. You have gathered information from the medical record before the interview and have discussed Ms. Bouzide's case with a social worker. Here is a brief summary of the background information:

  • Smear results: 3+ on 5/26/99
  • Culture results: pending
  • Radiograph report: cavitary lesions in right upper lobe
  • Family history: grandmother died of TB in 1978
  • Social history: immigrated from Morocco in 1997
  • Employment: odd jobs (laundry, tailoring, child care)
  • How can you plan the interview so that you establish a good relationship with the patient?

    For your interview, you should plan ahead and allow adequate time to address your objectives. You should maintain control of the interview by clearly outlining and following your objectives, leaving time for Ms. Bouzide and her husband to raise any questions or concerns about her illness. It will also be best if the interview takes place under conditions that encourage effective communication. These conditions include

  • Arranging for privacy and maintaining confidentiality and assuring Ms. Bouzide that all sensitive information will be kept private
  • Creating an environment relatively free of distractions and interruptions (for example, after physician or nursing rounds)
  • Listening attentively and respectfully to Ms. Bouzide and her husband (for example, sit down near her and use open, relaxed body language)
  • Being objective and nonjudgmental (for example, be patient, not accusatory, and never show frustration)

The initial interview with Ms. Bouzide is very important in establishing the foundation for a good relationship. You should introduce yourself to the patient and her husband, clearly stating your title and role with the TB program and the purpose of the interview: to exchange information that will help Ms. Bouzide complete a TB regimen and to identify her contacts. It is very important to confirm her address and phone number after discharge and to get the address of at least one other contact. Ms. Bouzide's husband and children should be evaluated as soon as possible; you should immediately set up a home visit with her husband. You should also collect information on other family members and friends, her contacts at the various odd jobs she has had, and anyone else who may have been exposed since Ms. Bouzide has been symptomatic.

You should use the initial interview to begin an assessment of Ms. Bouzide's knowledge, feelings, and beliefs about TB. Because her grandmother died of TB many years ago, she may have some knowledge of the disease and its treatment as well as some fears of the importance and consequences of her own disease. She will probably be very concerned about her children as well as other factors such as when she will be able to work again, how she will pay for her treatment, and the impact her treatment will have on her family and friends. You should discuss the importance of adherence to the TB treatment regimen and answer any questions Ms. Bouzide has about the treatment plan; an adherence plan can be developed at this or at subsequent interviews.

If you can make Ms. Bouzide and her husband feel comfortable and listen carefully to their questions, the initial interview can help lay the foundation for a relationship based on mutual trust.

  • What additional information will you need from Ms. Bouzide to begin a contact investigation?

    First, you need to confirm Ms. Bouzide's address, making sure that she will be there after discharge from the facility. Then you should begin the contact investigation by asking questions for the following reasons:

    • To find out more about Ms. Bouzide's symptoms to help determine the period of infectiousness
    • To find out places where she spent time while she was infectious
    • To identify Ms. Bouzide's contacts, get the contacts' addresses or other locating information (if available), and find out how long the contacts were exposed to the patient while she was infectious

    Her coughing attack, positive AFB smear result, and cavitary lesions on the chest radiograph indicate that Ms. Bouzide is probably infectious. You need to know how long her cough has lasted and when she began to feel ill.

    You need complete information on Ms. Bouzide's contacts at home, and a detailed history of her employment activities during the time she has had symptoms of TB. It is especially important to find out whether she was involved with child care during this time period; if so, skin testing of any exposed children will be a high priority. Module 6, Contact Investigations for Tuberculosis contains more information on this subject.

8.6. Mr. Donald is a 26-year-old homeless man who is unemployed. He is also a heavy drinker and uses crack. On admission to the city hospital, Mr. Donald had been complaining of a cough and night sweats. His temperature was 101 F, and he had lost a lot of weight. He was started on TB medications on the day of admission.

In the daily progress notes over the 2 weeks following admission, it was noted that the patient's cough and night sweats subsided, his temperature came down to 98.6 F, and his weight increased by 5 pounds.

Mr. Donald's illness was reported as a suspected TB case by the infection control practitioner. Now that he is feeling better, he keeps threatening to walk out of the hospital to go back to the streets. You need to meet Mr. Donald for an initial patient interview.

  • What will your objectives be during that interview?

    Again, the initial patient interview is very important and should be used to establish the foundation for a good relationship with Mr. Donald based on mutual trust and understanding. When you meet Mr. Donald, you should introduce yourself, clearly stating your title and role with the TB program and the purpose of the interview: to exchange information that will help Mr. Donald complete a TB treatment regimen and to identify his contacts. Because Mr. Donald already seems restless in the hospital, it is crucial that you verify and obtain at least one other address of someone who will always know where Mr. Donald is. Even if he doesn't know the names of contacts, you can begin an investigation if you have a home address and the address of his favorite bar, as well as any other places he usually spends time.

    You should stress to the patient the seriousness of his disease and the need for adequate treatment. If possible, begin an assessment of Mr. Donald's knowledge, feelings, and beliefs about TB. You should detail to him the treatment plan and discuss the importance of adherence to the TB treatment regimen. Before the interview, you should consult with Mr. Donald's physician and staff nurse, the infection control practitioner, and the social worker prior to meeting with the patient so that you can prepare for the interview with adequate background information. It may be appropriate to discuss incentives with Mr. Donald, if it seems he is not motivated to complete treatment.  Be honest and firm about the seriousness of the need for treatment, and try to address any questions or concerns the patient has.

  • How will you conduct an assessment of Mr. Donald to determine potential adherence?

    To assess Mr. Donald's potential adherence problems, you will need to learn as much as possible about him, including the patient's

  • Medical history and current health problems
  • Ethnic background and primary language(s)
  • Knowledge and beliefs about TB
  • Ability to take responsibility for following his TB treatment plan or DOT arrangement
  • Resources (for example, family, other social support, finances, interpretive services)
  • Barriers to treatment (for example, mental or psychological problems, homelessness, in addition to his  alcohol problem)
  • History of adherence to previous TB regimens or other medication regimens

You should ask Mr. Donald about the points listed above, focusing on the identification of those problems  most important to him as treatment begins. 

Because TB treatment often begins abruptly, patients may have difficulties changing their behaviors as expected. Mr. Donald is already expressing an unwillingness to cooperate with his providers; this unwillingness may be due to his desire to go have a drink or it may be related to other feelings or beliefs that Mr. Donald has about TB disease or medical care. You should assess the extent of Mr. Donald's dependence on alcohol and question him about

  • Previous experiences with medication or hospitalization
  • Family or social support
  • His current living situation
  • Whether he has a need for assistance from social programs
  • His knowledge, feelings, and beliefs about TB

If mental illness is a factor, you should consult the social worker, psychiatrist, or psychologist who is providing mental health care to the patient. If Mr. Donald has family members or friends who are aware of his condition, you may want to ask them about his ability to complete a treatment regimen. DOT may be the best option for Mr. Donald's care, especially if you identify significant potential barriers to his adherence to a TB regimen; the possibility of an alcohol abuse treatment program might also be discussed.

At this interview or subsequent interviews, you should identify differences between what you believe and what Mr. Donald believes. That way, you will have time to correct his misinformation and provide the necessary education. If Mr. Donald's ideas are different from your own, you should accept that he has different views, and then make sure he knows your point of view about TB. You can make it clear that even if you do not share his views, you respect them. This will improve your relationship and make Mr. Donald more likely to be adherent.

8.7. You are the public health worker assigned to the Buena Vista residential home for the elderly. There are currently two TB patients in the facility who are taking TB medications. They have been reported to the TB program and will remain in the facility for the duration of their TB treatment.

  • What are your concerns for ensuring the quality of their case management?

    It is the responsibility of the TB program to ensure that every suspected or confirmed TB case that is reported receives

    • A complete diagnostic evaluation
    • An adequate regimen of TB medications
    • Appropriate measures to promote adherence and completion of therapy

    You should ensure that the diagnostic evaluation for each patient is complete (i.e., medical history, physical examination, Mantoux tuberculin skin test, chest radiograph, and bacteriologic or histologic examinations as appropriate). You may also use the results of this evaluation to assess each patient's degree of infectiousness and the possibility of disease caused by drug-resistant organisms. To detect any drug resistance as soon as possible, the initial M. tuberculosis isolate should always be tested for its drug susceptibility pattern.

    In addition, you should ensure that the treatment regimen used is adequate for each patient. Regimens for the treatment of TB must contain multiple drugs to which the organisms are susceptible. Therefore, you should help ensure appropriate care by reporting the following problems to a supervisor:

    • The use of a nonstandard regimen to treat TB disease
    • The use of a three-drug regimen instead of four drugs, in an area with high levels of drug resistance (a prevalence of INH-resistant TB of 4% or greater) or in treating a patient at high risk for drug resistance
    • The addition of a single drug to a failing regimen
    • These problems can all lead to treatment failure and the emergence of drug-resistant tubercle bacilli.

    These problems can all lead to treatment failure and the emergence of drug-resistant tubercle bacilli.

    You should also monitor patients' adherence to the treatment regimen and educate each patient about TB disease. If problems arise while the patient is in the facility that create barriers to a patient's adherence (for example, moves within the facility, staffing problems), you should ensure that adherence barriers are promptly addressed and resolved.

While reviewing the patients' medical records, you find that drug susceptibility testing has not been done on either patient's isolate. Both patients are currently on a standard, three-drug regimen that is appropriate for your local area. However, you are somewhat disturbed to find out that one patient, Mr. Sichler, was homeless for a time and wandered from shelter to shelter in a nearby city (with high drug resistance rates) before coming to Buena Vista.

  • What should you do?

    In areas where less than 4% of cases are resistant to INH (first drug susceptibility test only), three drugs (INH, RIF, and PZA) may be adequate for the initial regimen, provided the patient has no risk factors for drug-resistant disease. As mentioned above, the initial M. tuberculosis isolate should always be tested for its drug susceptibility pattern. In this case, Mr. Sichler may well be receiving an inadequate treatment regimen, because he is at high risk for drug resistance. You should report this problem to a supervisor and to the patient's physician. If the TB program has any records of Mr. Sichler's previous regimen, you should supply this information to the patient's provider.

8.8. You have just been assigned to work in the state prison, which houses several hundred prisoners and usually has three to six TB cases per year. Currently, two prisoners are taking TB medication and seven are on regimens for the treatment for LTBI. Before you were assigned to the prison, the standard procedure when prisoners with TB disease were released was to notify the health department. The health department would make an appointment for the patient and, if the patient did not come, send a reminder card to the patient's address prior to incarceration (supplied by the prison administration). The treatment completion rate for these cases has been very low.

  • One of the prisoners with TB disease is near the end of his sentence and has a hearing coming up in a few days. What can you do to plan for his release?

    For TB patients who leave an institution such as a correctional facility, discharge planning is necessary to ensure continuity of treatment and quality care. When a prisoner with TB disease is released from the facility, the public health worker is usually responsible for ensuring that the TB patient is appropriately managed after discharge. Depending on available staff, you may work alone on this planning or as part of a team including prison medical staff.

    If possible, the patient should be included in discharge planning to aid in decision-making. You should review both the treatment plan and the adherence plan. The treatment plan includes the details of the medical regimen as ordered by the physician, as well as plans for monitoring for adverse reactions and other follow-up care. The adherence plan, which is based on the patient's understanding and acceptance of the TB diagnosis, addresses barriers to adherence and details the method chosen to deliver treatment and monitor adherence for that specific patient. For this patient, specific incentives may be necessary to ensure that he keeps a follow-up appointment.

    The follow-up appointment for DOT or for continued monitoring should be made at a location that is convenient (and preferably, familiar) to the patient. As a representative of the TB program, you should discuss follow-up care with the patient and explain the program that will be followed. You should notify the TB program of the date of discharge when it becomes known and of any changes in the treatment plan or adherence plan. This information is very important for coworkers assigned to the case who will provide follow-up care in the community.

  • What information will you need from this patient during your initial interview that will help discharge planning?

    The initial patient interview is very important and should be used to

    • Establish the foundation for a good relationship with the patient based on mutual trust and understanding
    • Confirm what the patient's address will be after discharge and gather information on the patient's contacts who may have been infected with M. tuberculosis
    • Begin an assessment of the patient's knowledge, feelings, and beliefs about TB
    • Discuss the importance of adherence to the TB treatment regimen

    Depending on when the case was diagnosed, the contact investigation may have been done previously. If the patient developed TB disease while in the facility, his contacts (for example, cell mates, officers, cleaning staff) should have been screened for TB infection according to the prison's infection-control plan.

    You should try to identify problems other than TB that the patient may encounter on reentering the community. These problems may include other medical conditions, inadequate housing, poverty, family dysfunction, physical abuse, child abuse and neglect, or substance abuse. Unless these problems are addressed, patients may have serious barriers that prevent them from adhering to the prescribed regimen and keeping clinic appointments. DOT is strongly recommended for patients with potentially significant adherence problems. Some TB programs have collaborated with parole officers assigned to the patient after release; if this is the case, their input and support can be valuable.

8.9. You are a health care worker at the Gryson County Health Department. You have been working closely with Juan Garcia, a 35-year-old Hispanic agricultural worker. Mr. Garcia was diagnosed with TB about 2 months ago. You have been giving DOT to Mr. Garcia at a local farm where he picks oranges. Orange season is coming to an end and you realize that Mr. Garcia will soon be heading North to look for more work. You have spoken to him about where he will be going next. He tells you that he is going to a farm in the next state. He is not exactly sure where it is, but he thinks he remembers the farm is located near a town called Jasper.

  • What steps will you take before Mr. Garcia leaves to ensure the continuity of care?

You should find out Mr. Garcia's destination and follow these procedures to help Mr. Garcia continue his TB care:

  • Give Mr. Garcia copies of his records he can take to indicate his current treatment and diagnostic status. Mr. Garcia should also be instructed on how to take his medication during his travel to the next jurisdiction and how and where to get additional medication and medical care at each of the possible destinations.
  • Contact the receiving jurisdictions to let them know that Mr. Garcia may be relocating to their jurisdiction. All relevant medical information should be forwarded to the destination jurisdictions.
  • The state department TB control offices should be contacted and apprised of the need for follow-up and the next possible destination of Mr. Garcia.
  • Although sharing information about Mr. Garcia is encouraged to maintain continuity of care, measures should be taken to ensure confidentiality.
  • All information received about Mr. Garcia (laboratory reports, etc.) after he departs for another area should be immediately telephoned, faxed, or expeditiously mailed to the possible receiving jurisdictions following procedures to maintain Mr. Garcia's confidentiality.
  • Out-of-state communications regarding TB care should be routed through state health departments to ensure that the information is transmitted and that necessary follow-up is initiated.
  • You should follow up and maintain communication as needed until Mr. Garcia is located in the destination jurisdiction.

 
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