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8.5. List four ways that public health workers support hospital or institutional personnel.

Self-Study Modules on Tuberculosis

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

8.1. What are the three 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 treatment as indicated
  • Test populations at high risk for TB infection and disease to detect infected persons, and provide treatment for latent TB infection to prevent progression to active TB

To accomplish these goals, public health workers may be assigned to make routine visits to hospitals or other institutional settings (for example, nursing homes, correctional facilities, homeless shelters) to gather information and interview TB patients and plan for patients' follow-up care.

8.2. What are the four basic steps in the process for conducting TB surveillance and providing case management in hospitals and institutions?

The four basic steps in the process for conducting TB surveillance and providing case management in hospitals or institutions are

  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
  3. Conduct an initial interview with every patient who has suspected or confirmed TB
  4. Plan for each TB patient's follow-up care upon discharge from the hospital or institution

8.3. What are the serious consequences of a lapse in communication between patients and public health workers?

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.

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. (page 11)

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 type help they provide for conducting>

Key Staff Help Available
A. Infection control practitioner B: Mycobacteriology results, including smear and culture results
B. Laboratory staff A: Reporting of TB cases; infectiousness and isolation procedures
C. Pharmacy staff E: Patient contacts; outbreak information
D. Radiology staff C: Prescriptions; purchase records
E. Hospital epidemiologists or employee health service staff D X-rays; current or baseline films
F. Discharge planners G: Patient records from prior hospitilizations or other health care facility
G. Medical records staff F: Patient locating information; plans for follow-up health care

8.5. List four ways that public health workers support hospital or institutional personnel.

8.5. List four ways that public health workers support hospital or institutional personnel. (page 12)

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, assisting with contact investigations, and monitoring the progress of TB patients in the facility.

8.6. What are some of the roles of the health department staff in the surveillance and case management of TB patients in correctional facilities?

Health department staff should help develop programs to train correctional facility staff to

  • Create TB control policies and procedures

  • Perform, read, and record tuberculin skin tests

  • Identify signs and symptoms of TB disease

  • Initiate and observe therapy

  • Monitor medication side effects

  • Collect diagnostic specimens

  • Educate inmates

  • Maintain record systems

  • Provide tracking and patient record system

  • Ensure released inmates complete therapy

8.7. What can correctional facilities do to help ensure completion of therapy for inmates released or referred while being treated for TB infection or disease?

It may be necessary for correctional facility staff to request health departments and receiving facilities to formally notify them of the arrival of referred inmates on DOT who are released or transferred into the jurisdiction. This is a very important component of a good TB control program, since persons who are lost to follow-up are at high risk of never completing therapy, developing drug-resistant TB disease, and spreading TB to others. Inmates on DOT for LTBI who are released or transferred to other correctional facilities should also be referred for follow-up treatment.

8.8. Name three things that will increase the suspicion of TB disease.

The presence of any of the following will increase the suspicion of TB disease:

  • A positive AFB smear

  • A positive tuberculin skin-test result

  • An abnormal, unstable chest radiograph

8.9. Under the classification system for TB, give the class (0-5) for each type listed.

5 TB suspected

3 Current TB disease

1 Exposure to TB, no evidence of infection

4 Previous TB disease (not current)

0 No exposure to TB, not infected

2 TB infection, no disease

8.10. Explain the two basic methods for identifying suspected or confirmed TB cases, and how they are put into practice.

The two basic methods for identifying suspected or confirmed TB cases are

  • Routine case reporting

  • Active case finding

Routine case reporting is the required reporting of suspected or confirmed TB cases to a public health authority. In routine case reporting, physicians and other persons (for example, infection control practitioners, pharmacists, laboratory staff) submit reports of suspected or confirmed TB cases, as they are detected, to a public health authority that collects and analyzes the information. In active case finding, the TB program identifies unreported cases of disease by actively searching for TB cases through, for example, laboratory and pharmacy audits; active case finding can be designed and implemented in several ways, depending on local needs and practices. In addition to the public health worker's responsibilities with cases routinely reported to the TB program, he or she may also be doing active case finding to identify suspected or confirmed TB cases that have not been reported.

8.11. How can public health workers use the information found in laboratories and pharmacies?

Public health workers may make routine visits to the pharmacies and to the mycobacteriology and pathology laboratories used by the facilities to which they are assigned for TB surveillance. With the collaboration of laboratory or pharmacy staff, public health workers can use the information found there to

  • Actively search for unreported TB cases

  • Confirm suspected TB cases once the medical evaluation is completed

  • Monitor the progress of reported TB patients (for example, through sputum and culture conversion or prescription refills)

  • Collect information on possible drug resistance and the adequacy of the current regimen

8.12. What drugs are the focus of pharmacy surveillance?

In most areas of the country, the initial regimen for treating TB disease should include four first-line TB drugs: (page 35)

  • Isoniazid (INH)

  • Rifampin (RIF)

  • Pyrazinamide (PZA) and either

  • Ethambutol (EMB) or streptomycin (SM)

The focus of pharmacy surveillance is the identification of patients who are placed on two or more first-line TB drugs. The reason for specifying two or more drugs is because patients who may be on isoniazid (INH) therapy only are most likely on a regimen for treatment for LTBI and not a regimen for the treatment of TB disease.

8.13. How should a public health worker locate a patient in a facility and where would he or she find patient addresses?

To locate a hospitalized patient or an institutional resident, the public health worker should call the central information number, if available, or check with the information desk receptionist. He or she should ask for the patient's current room number and ward or building location, as well as a phone number, if available. If necessary, the public health worker may need to go to the admissions or administrative office. Because patients are often transferred from ward to ward or from room to room, it is important to get current locating information. If a patient with suspected or confirmed TB disease has left the facility or has died, record any available patient addresses (for example, home address, next of kin, receiving facility) from the medical record and report this immediately to the TB program.

8.14. Where can smear and culture results for a reported TB case be found?

A hospital's mycobacteriology laboratory has a logbook or database containing AFB smear results, culture results, and drug susceptibility patterns. The pathology laboratory will have the results of AFB smears done on any tissue specimens submitted. Although a computer database or the patient's medical record will also have much of this information, it may not be complete or accurate; laboratory reports are the definitive source for laboratory results and should always be reviewed or obtained.

8.15. Describe seven main sections of the patient's medical record.

The main sections of the patient's medical record are as follows:

  • Identification data, including the patient's name, address, social security number, date of birth, and other demographic information (may be a separate registration form)

  • Progress notes, in which all physicians and other specialists continuously record patient information during a patient's hospital stay; they are an important resource for information and may include nurses' notes and notes from other ancillary staff

  • Nurses' notes, in which the nurses who directly care for the patient continuously record information, including the patient's symptoms, medications given, and scheduled procedures or activities, and may be included in the progress notes section

  • Physician's orders, in which the physician(s) prescribes medications, orders laboratory tests or procedures (for example, bronchoscopy or gastric aspiration), and delivers other patient-care instructions to staff. Medication orders specify date, name of medication, dosage, and duration of treatment (in days or in number of doses)

  • Medication record, an information sheet on which the nurses record the date, time, and amount of prescribed medications given to the patient during hospitalization or care in a facility; may not be included in patient's medical record (for example, may be kept in a separate medication logbook)

  • Laboratory results, records presenting the results of every laboratory test that has been done on the patient, such as AFB smear examinations, cultures, and drug susceptibility tests performed in a laboratory

  • Radiology reports, reports summarizing all radiology procedures performed on the patient (for example, chest radiographs or CT scans)

8.16. Why is it important to gather information on the patient's potential adherence?

It is important to collect information on the patient's potential adherence in order to plan for and arrange the patient's care both during and after hospitalization or stay in an institution. Information about potential adherence problems may come from the patient's medical record, social worker, nursing staff and physicians, and family members or other visitors.

To help evaluate the patient's potential adherence to therapy, it is important to note pertinent social history. The public health worker should find out if the patient is foreign-born or speaks a language other than English; if so, the public health worker will need a translator for the patient interview and subsequent care. The public health worker should look for and note a history of residence in a congregate setting such as a prison, nursing home, hospital, or shelter. Also note any history of drug or alcohol abuse, homelessness, mental health problems, or previous nonadherence.

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

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 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

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

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

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

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)

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

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 (if available) or other locating information, and find out how long the contacts were exposed to the patient while he or she was infectious

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

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

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

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.

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

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.

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

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. 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.

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

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.

  • The state health department TB control officers 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.


 
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