Self-Study Modules on Tuberculosis
Module 8: Tuberculosis Surveillance and Case Management in Hospitals
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 treatment as indicated
- Test populations at high risk for TB infection and disease to detect infected persons, and provide treatment for latent TB infection (LTBI) to prevent progression to active TB
To accomplish these goals, public health workers (employee of the health department, often a public health advisor, outreach worker, or a nurse) may be assigned to make routine visits to hospitals or other institutions to gather information, interview TB patients, and plan for patients' follow-up care. Institutions include residential facilities where groups of people live, such as nursing homes, correctional facilities, or homeless shelters. They can also include out-patient facilities such as drug treatment centers or health department clinics. To be successful, the public health worker should know what information is needed, where it is located, how to locate and interview patients, and how to collaborate productively with hospital or institutional staff.
Surveillance is the ongoing systematic collection, analysis, and interpretation of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know in public health programs. Case management is a system in which a specific health department employee is assigned primary responsibility for the patient, systematic regular review of patient progress is conducted, and plans are made to address any barriers to adherence. Four steps included in the basic process for conducting TB surveillance and case management in hospitals or institutions are
- Identify suspected or confirmed TB cases as soon as possible and report them to the TB control program
- Collect information from the patient's medical record and other sources
- Conduct an initial interview with every patient who has suspected or confirmed TB
- Plan for each TB patient's follow-up care upon discharge from the hospital or institution
These steps are summarized in Figure 8.1, which will appear throughout this module as each step in the surveillance and case management process is highlighted and further defined.
Figure 8.1 Process for TB surveillance and case management
This is a flow chart that describes the four processes for TB Surveillance and Case Management in Hospitals and Institutions: including, (1) Identifying suspected or confirmed TB cases; (2) Collect patient information; (3) Conduct an initial interview; (4)Plan for follow-up care.
Public health workers need skills in communication and collaboration to conduct TB surveillance and case management. Conducting TB surveillance and providing case management in hospitals or institutions requires that public health workers have good interpersonal skills because of the number of persons involved and the complexity of situations that can arise. The two basic skills that are needed to successfully carry out the steps in this process are
Because providing complete treatment to TB patients requires long-term follow-up, communication is essential both with the patients and with the health care workers who care for them. A lapse in communication can have serious consequences. For example, poor communication can cause a patient to receive incomplete or inadequate treatment and therefore remain ill or infectious. Incomplete treatment is a serious failure for TB prevention and control because
- Additional persons may be exposed to TB
- Patients may be rehospitalized with serious complications of TB
- Patients may develop multidrug-resistant TB
Effective communication, good surveillance procedures, and efficient case management can help prevent such serious consequences.
Key hospital or institutional staff with whom a public health worker may collaborate closely to conduct TB surveillance and case management include
- Infection control practitioners
- Laboratory staff, including technicians (specifically those who work in mycobacteriology)
- Pharmacy staff
- Radiology department staff
- Hospital epidemiologists or employee health services staff
- Discharge planners or case managers
- Medical records staff
The infection control practitioner is a trained health care professional (often a nurse) who is responsible for controlling and preventing the spread of infectious diseases in a hospital or other health care setting; the hospital epidemiologist is a specially trained person who studies the causes of outbreaks and other health problems in a health care setting. These and other important staff are included in Table 8.1, which indicates examples of how such persons can help public health workers conduct TB surveillance and case management.
The key staff who collaborate with TB public health workers vary from hospital to hospital and from institution to institution. Generally, one person has the lead responsibility for TB surveillance; it is important to identify and collaborate closely with this person for surveillance activities. A good collaborative relationship can be built on
- Mutual understanding of each person's role and responsibilities
- Respect for the specific demands and limitations of each person's job (for example, schedule constraints, limits of authority, procedures to protect confidentiality)
- Good communication with adequate notice in advance of specific needs or problems, complete explanations of procedures or medical information as required, and openness about potential sources of disagreement
- Prompt negotiation of problems or conflicts, using a neutral third party if necessary
- A good collaborative relationship takes time and commitment to develop; however, it is well worth the effort.
A good collaborative relationship takes time and commitment to develop; however, it is well worth the effort.
Examples of How Key Staff Can Help with TB Surveillance and
|Key Staff||Help Available|
|Infection control practitioners||Reporting of TB cases; information on infectiousness and isolation procedures|
|Laboratory staff||Mycobacteriology results, including smear and culture results|
|Pharmacy staff||Prescription orders and purchase records|
|Radiology department staff||X-ray reports and copies of current or baseline films for receiving health care provider|
|Hospital epidemiologists or employee health services staff||Patient contacts within the hospital or other health care facility; outbreak information|
|Discharge planners or case managers||Patient locating information and plans for follow-up health care|
|Medical records staff||Patient records from prior hospitalizations or stays in a health care facility|
|Hospital ward or institution-based clerks||Patient locating information and current status of medical records|
|Infectious disease and AIDS case workers||Information about ongoing care and health problems affecting TB treatment|
|Physicians and nurses||Reporting of TB cases; clarification of a patient's current regimen and TB diagnosis|
|Social workers||Information on housing, financial, or social problems that may affect treatment outcome|
|Emergency room (ER) staff||Information on patient admissions through the ER|
|Parole workers (if any)||Patient locating information and potential treatment problems|
- Depends on the organization of the hospital or institution
- In some jurisdictions, laboratory or pharmacy staff may also report cases with positive mycobacteriology tests or patients taking two or more TB drugs
A first step in establishing a good working relationship in a hospital or institution is for a public health worker to introduce himself or herself to key staff and explain his or her role as a liaison between the facility and the TB program. It may be helpful for the public health worker to show the staff an official letter of introduction from the TB program stating the purpose of his or her assignment and the legal authority of the TB program.
As liaisons with the TB program, public health workers support hospital or institutional staff by
- Providing important information on a patient's TB history
- Providing information on services available through the TB program
- Supplying educational materials for patients and hospital or institutional staff
- Helping to plan for follow-up care for TB patients upon discharge
In addition, public health workers assigned to hospitals and institutions support the TB program by
- Conducting active case finding (identifying unreported cases of disease by actively searching for them)
- Assisting with contact investigations
- Monitoring the progress of TB patients in the facility
|Study Questions 8.1-8.5
8.1. What are the three primary goals of TB prevention and control?
8.2. What are the four basic steps in the process for conducting TB surveillance and providing case management in hospitals and institutions?
8.3. What are the serious consequences of a lapse in communication between patients and public health workers?
8.4. Below is a list of several hospital or institution
staff with whom public health workers collaborate to
conduct TB surveillance and case management. Match the
key staff with the type of help they provide for conducting
TB surveillance and case management.
8.5. List four ways that public health workers support hospital or institutional personnel.