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Self-Study Modules on Tuberculosis

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Module 8: Tuberculosis Surveillance and Case Management in Hospitals
Summary

The three primary goals of TB prevention and control are

  • To identify and treat persons who have active TB disease
  • To identify and evaluate exposed contacts, offering appropriate treatment as indicated
  • To 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 may be assigned to make routine visits to hospitals or other institutional settings to gather information and interview TB patients and plan for patients' follow-up care. The following steps are included in the basic process for conducting TB surveillance and providing case management in hospitals or institutions:

Process for TB Surveillance and Case Management in Hospitals and Institutions

  1. Identify suspected or confirmed TB cases.
  2. Collect patient information.
  3. Conduct an initial interview.
  4. Plan for follow-up care.

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 failures such as incomplete or inadequate treatment.

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 this person and collaborate closely with him or her for surveillance activities. As liaisons with the TB program, public health workers support hospital or institution 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 institution staff
  • Helping to plan for follow-up care for TB patients upon discharge

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. In addition, the public health worker can help effectively transfer the care of a patient from a hospital or institution to a provider in the community.

State and local health departments should form close working relationships with correctional facility officials. Health departments can assist correctional facilities in formulating, implementing, and evaluating essential TB control activities.
 

  1. Identify suspected or confirmed TB cases

    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 unreported 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.

    Within a hospital or institution, public health workers can conduct active case finding by collaborating closely with the infection control practitioner and monitoring the use of negative-pressure isolation rooms that may be used to isolate patients with suspected TB disease.

    In addition to these activities, 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.

  2. Collect patient information

    It is important to collect information on reported TB cases in order to

    • Complete all necessary forms for reporting requirements, in accordance with local laws and regulations
    • Determine the need for and scope of a contact investigation
    • Be alerted to the presence of drug resistance or potential adherence problems
    • Gather background information needed to conduct the initial interview
    • Plan for and arrange the patient's care both during and after hospitalization or stay in an institution

    For each reported TB case, the public health worker should review the patient's medical record and summarize information that is pertinent to TB treatment. The medical record contains a wealth of information, but finding specific information can be difficult unless the public health worker knows where to look.

  3. Conduct an initial 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

  4. Plan for follow-up care

    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

    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.

    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.

Process for TB Surveillance and Case Management in Hospitals and Institutions

  1. Identify suspected or confirmed TB cases.
    • Know the current case definition and criteria for the classification of suspected and confirmed TB cases.
    • Gather information to verify cases reported routinely to the TB program.
    • Identify unreported cases through periodic active case finding in the laboratory and pharmacy.
  2. Collect patient information.
    • Locate the patient.
    • Identify available information sources.
    • Review the medical record.
  3. Conduct an initial interview.
    • Establish the basis for a trusting relationship.
    • Gather patient addresses and names of contacts.
    • Begin a patient assessment.
  4. Plan for follow-up care.
    • Assure quality care during the patient's stay.
    • Plan for discharge from the facility.
    • Gather information on patients who are discharged, leave the facility, or die.

Additional Reading

American Lung Association/American Thoracic Society. Treatment of tuberculosis and tuberculosis infection in adults and children. Am J Respir Crit Care Med. 1994;149:1359-1374.

American Thoracic Society/Centers for Disease Control. Control of tuberculosis in the United States. Am Rev Resp Dis. 1992;146(6):1623-1633.

American Thoracic Society/Centers for Disease Control. Diagnostic standards and classification of tuberculosis. Am Rev Resp Dis. 1990;142:725-735.

California Inter-Jurisdictional Referral Desk Protocol for Tuberculosis Cases and Suspects. Berkeley, CA: California Dept. of Health Services, Tuberculosis Control Branch; Jan. 1999.

Centers for Disease Control and Prevention. Case definitions for infectious conditions under public health surveillance. MMWR. 1997;46(RR-10):40-41.

Centers for Disease Control and Prevention. Controlling TB in Correctional Facilities. U.S. Department of Health & Human Services, Public Health Service 1995.

 
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