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Self-Study Modules on Tuberculosis

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

Plan for Follow-up Care

Figure 8.12 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 4, Plan for follow-up care is highlighted.

Quality Assurance

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

Public health workers assigned to hospitals and institutions can play a key role in carrying out these responsibilities; however, practices will vary from facility to facility and often the infection control practitioner, hospital epidemiologist, or employee health department will be primarily responsible for quality assurance. Public health workers should collaborate with a facility's staff to monitor the patient's care throughout the hospital or institutional stay. This means assessing the patient's care periodically, after a case has been reported and the initial patient interview has taken place, and reporting any problems to the TB program.

Complete Diagnostic Evaluation.

A complete diagnostic evaluation includes

  • A medical history
  • A physical examination
  • A Mantoux tuberculin skin test
  • A chest radiograph
  • Any appropriate bacteriologic or histologic examinations (for example, AFB smear and culture)

This evaluation provides valuable information not only for the medical diagnosis of TB, but also for assessing the patient's degree of infectiousness and the possibility of disease caused by drug-resistant organisms. If the medical history reveals a history of TB disease, the public health worker should gather additional information from the TB program and from the former provider, if possible; this information should be supplied to the patient's current provider.

Persons suspected of having pulmonary or laryngeal TB should have at least three sputum specimens examined by smear and culture. In addition, follow-up bacteriologic examinations are important for assessing the patient's infectiousness and response to therapy. Public health workers should therefore monitor patients' laboratory results throughout their stay in the facility to ensure that cases are appropriately managed. To detect any drug resistance as soon as possible, the initial M. tuberculosis isolate should always be tested for its drug susceptibility pattern.

Adequate Regimen. Regimens for the treatment of TB must contain multiple drugs to which the organisms are susceptible. Therefore, the public health worker should help ensure appropriate care by reporting the following problems to a supervisor:

  • The use of a non-standard 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. The public health worker needs to be familiar with the standard TB treatment regimens and with local levels of drug resistance (see Module 5, Treatment of Tuberculosis Infection and Disease, and the latest American Thoracic Society/CDC treatment recommendations for standard regimens). 

Measures to Promote Adherence. As mentioned previously, the public health worker will begin an assessment of the patient's potential adherence during the initial interview. Throughout the stay in the facility, the patient's adherence with the treatment regimen should be monitored and the patient should be educated about TB disease. If problems arise while the patient is in the facility that create barriers to the patient's adherence (for example, moves within the facility, staffing problems), the public health worker should ensure that adherence barriers are promptly addressed and resolved. 

In addition to the duties mentioned above, public health workers assigned to hospitals and institutions may become involved in

  • Infection-control activities within the facility, including ongoing tuberculin skin-testing programs
  • Contact investigations within the facility
  • The administration and monitoring of treatment for LTBI for patients or employees
  • Data collection for epidemiological research

It is important to keep in mind that the public health worker's first priority should be the prompt identification and appropriate management of active TB cases.

Discharge Planning

Discharge planning is the preparation of a detailed plan for comprehensive care of a hospitalized or institutionalized patient after that patient's discharge. For patients who leave a hospital or institution, discharge planning is necessary to ensure continuity of treatment and quality care. Discharge planning for TB patients should begin soon after a suspected or confirmed TB case is reported. It is usually a team effort, led by a nurse or a facility's discharge planner. In some cases, a case manager assigned by the public health department may be in charge of planning for a patient's discharge. Team members often include at least two or more of the following:

  • The discharge planner or case manager
  • Nurses or therapists involved in the patient's care
  • A social worker
  • The patient's physician
  • Expert consultants, if required
  • DOT outreach worker

An institution-based public health worker can also provide input and share responsibility for ensuring that the TB patient is appropriately managed after discharge.

The discharge planning team should meet while the patient is in the facility to review the patient's treatment plan and develop an adherence plan. An adherence plan is a written plan that is based on the patient's understanding and acceptance of the TB diagnosis, that addresses barriers to adherence, and that details the method chosen to deliver treatment and monitor adherence for that specific patient. If possible, the patient should be included in this meeting to aid in decision-making. 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 should be developed with input from the patient and from other key staff and health care providers. Adherence often improves if the patient, the family (if possible), and the public health worker develop an agreement that spells out the adherence plan and states the responsibilities of the patient and of his or her providers (see Module 9, Patient Adherence to Tuberculosis Treatment, for further information).

The discharge team may identify problems other than TB that patients are encountering. 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 potentially infectious patients with significant adherence problems; in some areas, DOT is the standard of care.

When patients have serious problems, the discharge team has an opportunity to help them by providing appropriate referrals for support and assistance. By helping patients with these other difficulties, providers and public health workers are also helping patients successfully complete TB therapy. Table 8.6 presents some examples of the service providers the public health worker may want to contact for eligible patients. Relationships with such providers can often be improved by means of formal referral agreements and educational sessions for staff about TB, including information on services the TB program has to offer.
 

Table 8.6
Service Providers with Benefits for Eligible TB Patients

Service Provider Examples of Benefits Available to Qualified Persons
Public health nursing services Integrated home health care
Public health clinic services
Patient incentives
HIV/AIDS services HIV testing, counseling, and treatment programs
Patient support groups
Meal programs
Housing services Temporary shelter
Location of available housing options
Social services Food stamps
Medicaid
Unemployment or disability support
Emergency assistance programs Shelter for battered women
Placements for victims of child abuse
Substance abuse treatment programs Detoxification programs
Methadone treatment programs

In some cases, the patient and his or her family may already be receiving visits from social workers or public health nurses for other conditions or problems; if this is the case, the discharge team should get their input whenever possible. By helping to coordinate care provided to a single patient, the public health worker can often improve patient adherence and maximize the use of public health resources. However, confidentiality is an important issue in working with other agencies, and must not be compromised.

An appointment for DOT or for continued monitoring should be made at a location that is convenient (and preferably, familiar) to the patient. Whenever possible, the provider for the patient's follow-up care should come to the hospital or institution to meet the patient and explain the program that will be followed. The discharge planner or case worker should notify the provider of the date of discharge when it becomes known and of any changes in the treatment plan or adherence plan.

The public health worker is responsible for conveying relevant information on discharged patients to the TB program. This information is very important for co-workers assigned to the case who will provide follow-up care in the community.

Patients No Longer in the Facility

The public health worker may need to review the medical record of a patient who has been discharged, has left the facility against medical advice, or has died. In addition, it is sometimes important to review the medical record from a patient's prior hospitalization or stay in an institution. When a patient is no longer in the facility, the patient's medical record is sent to the medical records department. To access these records, the public health worker will usually complete a medical record request form, providing the patient's name and either a medical record number or the patient's date of birth. Each facility has a specific procedure for requesting patient records; the public health worker should become familiar with the procedure used in the facility or facilities in which he or she works.

The medical records of patients who have been discharged often will not have clearly labeled sections, even though they will still be organized in the same manner as in-patient records. If the patient has been discharged, a discharge summary may be included in the medical record; this is a document written by the patient's physician that contains a brief summary of all important information from the entire hospitalization or stay in the institution. The discharge summary contains the patient's discharge diagnosis and often includes a plan for follow-up care. Although it is usually a good place to start, the discharge summary should not be used in place of a thorough record review.

Many patients are discharged before final culture and susceptibility results are known; the public health worker may need to find the patient's laboratory results and forward them to the current provider. If a patient is discharged while still infectious (for example, with positive AFB sputum smears), it is especially important that the patient, his or her providers, and household members know this and be able to act accordingly. Household members who have already been exposed do not usually need to take special precautions, but unexposed persons -- especially HIV-infected persons and children -- should not be in contact with a patient who is still infectious.

Other information included in the medical record can help to

  • Locate a patient who has been lost to follow-up care
  • Identify a patient's next of kin
  • Locate information about contacts

Finally, the medical record may contain information about the patient's next scheduled clinic appointment or provider in the community.

If a patient has died while in the facility, there will usually be a death report and a pathology report in the medical record. These reports should be reviewed along with the rest of the medical record for information relevant to the contact investigation.

If the patient is being seen in an out-patient clinic (a clinic that cares for non-hospitalized patients with a particular type of problem; for example, chest, infectious disease, AIDS, pediatric) associated with a hospital, the medical record may be found in the medical records department or in the clinic files, if an appointment date is near. If the medical record is in the out-patient clinic, the public health worker must request it from the clinic supervisor or a nurse, following the clinic's procedure for record requests.

HIV-infected patients will often be referred to an infectious disease clinic for follow-up care or prophylaxis against opportunistic infections after their discharge. If this happens, a case manager is usually assigned to the patient. This person can often be helpful in arranging follow-up care for TB disease and providing social services, such as housing, that may be available through AIDS- or HIV-related programs.

Inter-jurisdictional Referrals

Some patients who are in a hospital or another institution may actually reside in a different health jurisdiction other than the one in which the hospital or institution is located. Likewise, some patients may move to another jurisdiction upon discharge from the hospital or institution or at some other point during their treatment. For example, a TB patient who is paroled or released from a correctional facility may actually reside in a health jurisdiction other than the one where the correctional facility is located. Similarly, seasonal migrant farm workers may move between health jurisdictions often.

A patient may move to a health jurisdiction within the same state or to another state. The public health worker needs to be familiar with the guidelines and case referral processes in their health jurisdiction in order to transfer information on TB patients who move, as well as facilitate follow-up to ensure TB patients' continuity of care. The end goal is completion of therapy for all TB patients.

When a patient leaves a health jurisdiction before completing TB therapy, patient information should be sent to the patient's destination health jurisdiction. The following procedures should be followed:

  • Patients who are on antituberculosis treatment or treatment for LTBI should be given records they can take with them to indicate their current treatment and diagnostic status. Special care should be taken to instruct such persons on how to take their medications and how and where to get additional medication and medical care at the destination sites.
  • All relevant medical information should be forwarded to the destination jurisdiction. Some jurisdictions use a standard form when referring patients between health jurisdictions. See Figure 8.13 as an example of a referral form.
  • The state health department TB control officer should be contacted and apprised of the need for follow-up and the next possible destination of the patient.
  • Although sharing necessary information between health departments is encouraged to ensure continuity of care, as well as protect the public, measures should be taken to ensure confidentiality.
  • All information received on the TB patient, including TB laboratory reports, after the TB patient departs for another area should be immediately telephoned, faxed, or expeditiously mailed to the receiving jurisdiction following procedures to maintain patient 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.
  • The referring jurisdiction should follow up and maintain communication as needed until the patient is located in the destination jurisdiction.

Receiving jurisdictions also have responsibilities to ensure the continuity of care for TB patients, as well as the accountability of the cases. Public health workers in receiving jurisdictions should be prepared to receive the TB patient from the referring jurisdiction and resume patient care.

If a forwarding address is provided by the referring jurisdiction, the receiving jurisdiction should try to verify and visit the forwarding address. The receiving jurisdiction should make every effort to locate referred TB patients. The receiving jurisdiction should maintain communication with the referring jurisdiction to ensure continuity of care. If the patient cannot be located, and reasonable attempts to locate the patient have been made, the receiving jurisdiction should notify the referring jurisdiction of their inability to locate the patient. The receiving and referring jurisdictions should work with the state TB controllers in their area to inform them of the situation and discuss other options for locating the patient.

Figure 8.13 Sample referral form used by California. California Department of Health Services, Division of Communicable Disease Control, Tuberculosis Branch. California Inter-jurisdiction Referral Desk Protocol; 1999.

This is a sample a confidential referral form used by the State of California.
 

Study Questions 8.22-8.25

8.22. Describe the responsibility of the TB program to every suspected or confirmed TB case.

8.23. Explain the purpose of discharge planning and briefly describe the public health worker's role in discharge planning for a TB patient.

8.24. Explain how to find information on a patient who has been discharged, left the facility, or died.

>8.25. Explain the procedures for sending patient information from one health jurisdiction to another.

Answers 


 
Case Study 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?
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?

Answers 


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

Answers 


 
Case Study 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?

Answers 


 
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