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Module 8: Tuberculosis Surveillance and Case Management in Hospitals
Reading Material

Conduct an Initial Interview

Figure 8.10  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. Step 3, Conduct an initial interview is highlighted.

The Initial Interview

Once a TB case has been reported and information has been collected on the patient, the public health worker should prepare for the initial patient interview. 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 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

In addition, the initial interview (Figure 8.11) is a good opportunity for the public health worker to

  • Get to know the patient
  • Educate the patient about TB
  • Look for factors that may affect the patient’s adherence to treatment
  • Arrange a follow-up visit with the patient (see Module 9, Patient Adherence to Tuberculosis Treatment)

Figure 8.11 Patient interview.

This is a picture of a health care worker conducting a patient interview in a hospital setting.

The initial interview provides a good opportunity for the public health worker to gather information from the patient. However, the public health worker should keep in mind that as patients first learn of their new TB diagnosis, they may not be ready to give or receive detailed information. The patient may be overwhelmed and may be experiencing fear over the diagnosis of TB disease. The patient may still be very sick and may be unable or unwilling to participate fully in a patient interview. The public health worker should be aware of these factors that can affect the initial patient interview and should plan accordingly to educate patients and schedule follow-up interviews.

The public health worker’s relationship with the patient will develop over time as treatment progresses and the patient’s health improves; however, the initial interview is often the patient’s first encounter with the public health system and so it is very important. If possible, the public health worker should consult with the patient's physician and staff nurse, the infection control practitioner, and the social worker prior to meeting with the patient so that he or she can prepare for the interview with adequate background information.

The initial interview marks the beginning of the public health worker’s relationship with a patient and therefore requires a certain amount of planning. For the initial interview to be successful, a public health worker should

  • Have a clear understanding of the interview’s objectives
  • Plan the interview so that each objective is given adequate time

  • Listen to the patient’s concerns about TB and its treatment

  • Share information freely with the patient

The public health worker should prepare for the interview by determining if an interpreter will be needed. In addition, the public health worker should be familiar with interviewing techniques such as asking open-ended questions (see Module 6, Contact Investigations for Tuberculosis and Module 9, Patient Adherence to Tuberculosis Treatment).

Establishing a Trusting Relationship

It is very important to establish a trusting relationship with the patient. Trust implies a firm reliance by the patient on the integrity, ability, and character of the public health worker. If a patient trusts or has confidence in his or her public health worker, he or she is more likely to be willing and able to follow instructions and advice and to adhere to a regimen. The initial interview is a good time to begin to develop trust. In all likelihood the establishment of a true trusting relationship between the public health worker and the patient will develop over time through various interactions that will test the relationship. However, the foundation from which a trusting relationship can be established begins at the initial interview.

As the public health worker interviews the patient, the patient may divulge sensitive information about lifestyle choices and illegal behaviors. It is extremely important that the health care worker safeguard this information and assure the patient that this information will not be shared with authorities or others. For additional information on how to develop a trusting relationship with the patient, as well as possible consequences for failing to do so, see Module 6, Contact Investigations for Tuberculosis and Module 7, Confidentiality in Tuberculosis Control.

When the public health worker first meets a patient, he or she should introduce himself or herself by name and title, clearly stating his or her role with the TB program, and the purpose of the interview: to exchange information that will help the patient complete a TB treatment regimen and to identify the patient’s contacts.

Because it is important to make the patient as comfortable as possible, the public health worker should ensure that the interview takes place under conditions that encourage effective communication. These conditions include

  • Arranging for privacy and maintaining confidentiality and assuring the patient 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 the patient (for example, sit down near the patient and use open, relaxed body language)
  • Being objective and nonjudgmental (for example, be patient, not accusatory, and never show frustration)

Once the public health worker has introduced himself or herself, he or she should maintain control of the interview, keeping the interview objectives in mind. If the public health worker loses control and is too easily distracted (for example, by complaints about hospital food or small talk about current events), this sends a strong, negative message to the patient that can result in subsequent problems, including nonadherence. Effectively directing the interview is best accomplished by

  • Demonstrating self-confidence
  • Persistence in meeting the interview objectives
  • Good faith in wanting to help the patient solve potential problems

Different patients may require different approaches, so the public health worker’s plan should be flexible whenever possible. For example, some patients will prefer a very direct and efficient interview; others may have questions or wish to share some concerns with the public health worker.

The public health worker will need to pause from time to time to ask the patient if he or she has questions or is concerned about specific aspects of the contact investigation or treatment plan, which is a written plan detailing the medical regimen as ordered by the physician, including periodic monitoring for adverse reactions and other follow-up care. When the public health worker asks for input from the patient, he or she should be sure to wait long enough so that the patient knows that the worker sincerely wants a response; if the public health worker pauses only for a few seconds, the patient may sense that the worker is rushed and may not be completely open with the public health worker.

Patient Addresses and Contacts

The public health worker should gather or confirm locating information for the patient after discharge. This is an essential component of the initial interview and should never be left out. After the interview, the public health worker should make a telephone call or field visit to verify locating information. In some instances, a patient may have no permanent residence, or may be unable or unwilling to return to a former residence; undocumented immigrants may be particularly unwilling to leave a residential address. If this is the case, ask the patient where he or she can be found during the day or if there is anyone who will always know his or her location. This is crucial so that a home visit can be made after the patient’s discharge or if the patient leaves the facility against medical advice. (In addition, the public health worker should use the initial interview to obtain missing information or clarify contradictory information from the medical record.)

A contact investigation should be done whenever a person is found to have or is suspected of having infectious pulmonary or laryngeal TB disease (e.g., with sputum smears that are positive for AFB) (see Module 6, Contact Investigations for Tuberculosis). The purpose of a contact investigation is to

  • Identify people exposed to someone with infectious TB disease
  • Screen these people for TB infection and TB disease
  • Provide treatment for infection or disease as needed

The contact investigation should be started during the initial patient interview, with three main objectives in mind:

  • Find out more about the patient’s symptoms to help determine the period of infectiousness
  • Find out places where the patient spent time while he or she was infectious
  • Identify the patient’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 he or she was infectious

See Module 6, Contact Investigations for Tuberculosis for more information on gathering information on symptoms, places, and contacts.

Patient Assessment

The public health worker will need to learn as much as possible about his or her patient in order to assess potential adherence problems. The public health worker will need to learn about 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 their 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, substance abuse, homelessness)
  • History of adherence to previous TB regimens or other medication regimens

Doing a patient assessment means talking to a patient to get information on the points listed above, with a particular emphasis on identifying the problems most important to the patient as treatment begins. Because TB treatment often begins abruptly, patients may have difficulties changing their behaviors as expected. Some patients may be lost to follow-up care unless special efforts are made to identify their needs. If the patient is too sick and family members are present, the public health worker should discuss the need for adherence to treatment and possible barriers with them.

When the public health worker begins to work with a patient, it is important to ask what the patient believes about TB disease and treatment. If the patient does not understand the importance of finishing treatment, adherence will be very difficult. Therefore, the public health worker should identify differences between what he or she believes and what the patient believes early in treatment. That way, the public health worker will have time to correct the patient’s misinformation and provide the necessary education.

During the public health worker’s initial interview, he or she will begin to identify areas in which the patient needs education and will evaluate the patient’s ability to adhere to a treatment regimen. For example, asking a patient what problems the illness has caused him or her can help the public health worker assess the strength of family and social support; potential job-related problems; and, to some extent, the problem-solving skills of the patient (see Module 9, Patient Adherence to Tuberculosis Treatment).

When a patient’s ideas are different from the public health worker’s, the public health worker should accept that the patient has different views, and then ensure that the patient has accurate TB knowledge. The public health worker can make it clear that even if he or she does not share the patient’s views, the public health worker respects them. Knowing and respecting the patient’s views will improve the public health worker’s relationship with the patient and make the patient more likely to be adherent.

In summary, a planned initial interview is very important to the successful management of TB patients. The public health worker should document the results of this interview, including educational topics covered, and note any information that is missing or pending. Subsequent interviews can be used to gather this information and provide further education and counseling to the patient.

Study Questions 8.17-8.21

8.17. What should the initial patient interview be used to do? Name four primary objectives.

8.18. List four things that are necessary for a successful initial interview between the public health worker and the patient.

8.19. Under what conditions should the initial interview take place? List four conditions that encourage effective communication.

8.20. List the three main objectives of a contact investigation that should be kept in mind during the initial patient interview.

8.21. List seven things that the public health worker will need to learn about his or her patient in order to assess potential adherence problems.

Answers

 

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

Answers

 

Case Study 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 101E 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 98.6E 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?
  • How will you conduct an assessment of Mr. Donald to determine potential adherence?

Answers


 
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