Download Hospital TB Exposure

Hospital TB Exposure
Lessons Learned
A bit about PRMC
• Owned by Essent Healthcare, located in
Paris, Texas
Two campuses:
North with Women’s and
Children’s Services, Rehab, Senior
Transitions, Pediatrics; space
rented to Dubuis LTAC and a SNF
South with Medical/Surgical Units,
ICU, Orthopedics, and Oncology
Area and Population Served: Northeast Texas and Southeast Oklahoma
Average daily census: about 100
So my story begins
6/12/08 ran by micro
to pick up lab reports
on my way to the
office.
• Culture report from
the state with culture
positive
Mycobacterium
Tuberculosis on an
employee, not just
any employee, a RT.
Immediate Action
• Called Vicki Harris at Region 5/6 – she
was at day 2 of the seminar – left her a
voice mail message.
• Called Sandi Williams in Sulphur Springs –
she was at day 2 of the seminar – left a
voice mail message.
• Faxed both of them – usual report form,
rad reports, lab, anything I could find
• Notified my boss
• Notified Employee Health
• Notified Human Resources
Who (of the wwww)
• Baby Boomer age, Filipino Respiratory
Therapist, became ill in the later part of 2007
with weight loss, a cough, fatigue, BUT had
arthritis and chronic renal insufficiency.
• Hospitalized in February and X-rays worrisome
– for cancer. 28mm cavitary mass medially in
the right apex. Dang.
• Bronch as an outpatient in May – AFB smear
negative.
What
• Active TB in a person the doctor thought
had lung cancer.
• Fortunately the TB was not resistant.
Why
• Why me?
• Why this employee?
– Because of BCG vaccination and a past positive
attributed to the BCG vaccination, this employee had
not gotten PPD testing for years. Annual CXRs were
done until 2003, then we just got CXRs as indicated
per symptom review. This employee denied
symptoms.
– This employee was on etanercept (Embrel) and
Humira, which are TNF blockers (suppressing the
immune system), and both have black box warnings
about potential infections, including TB.
When
• Determine exposure time period
– Time symptoms began to time placed on
medical leave (break in contact)
Where
• This employee worked 7p to 7a shift on
North campus
• Was hospitalized on South Campus
• Bronch lab is on South Campus
• Main radiology department is on South
Campus
First lesson learned
• A person who is smear negative can be
culture positive for TB.
• Smear negative = less infectious, but
these patients do contribute to TB
transmission – about 13% to 17%
•
•
Lancet 1999 Feb 6; 353 (9151): 444-9
Clin Infect Dis. 2008 Nov 1: 47 (9): 1135-42
Second lesson learned
• Prior BCG vaccination does not mean the
person doesn’t get a PPD test.
•
CDC Division of Tuberculosis Elimination Fact sheet BCG Vaccine, last reviewed 05/18/2008
Third lesson learned
• Don’t let people make excuses on the
symptom review.
Fourth lesson
• Ask about immunosuppressent meds that
employees may be on – build that into
your TST questionnaire “Are you on any
medications that can suppress the
immune system, such as prednisone,
Remicaid, Humira, or Enbrel?”
Planning
• Conference call with the Region 6/24/08
– Discussed plan of action
• Determining and testing hospital employee
contacts
• Testing all foreign born employees
• Determining patient contacts
Investigation
•
•
•
•
•
•
Schedule
Time Card
Treatment sheets
Billing records
Code Blue sheets
Review of the Medical Records of all patients seen by RT during the
contact time
Pt
Name
Age
BD
Adm
and D/C
Date
DX
Imm Comp?
AIDs
Steroids
# of RT
treatments
Comments
• Who were exposed during employee’s hospitalization?
–
–
–
–
–
–
–
–
Rad
ER and nursing unit
Physicians – ER, admitting, consulting
Lab phlebotomists
RTs
Diet clerk
ER
Housekeeping
• Who were exposed when employee came in for bronch?
–
–
–
–
Other patients and their family members in the waiting room
Bronch lab staff
Rad
Registration staff and people in the registration office waiting to be
registered
• Co-workers exposed from November 2007 to June 2008
• Classes this employee attended (ACLS, Customer Service, etc)
Others for the State to consider
• Family
• Close Community contacts
• Physician Office waiting room exposures
Second Conference Call 7/2/08
• Still pulling charts and reviewing them for
exposure
• Testing of employees hadn’t started yet –
got in trouble
• The urgency of getting all this done was
well communicated to me
• Reviewed airflow – we don’t re-circulate
air, it is all vented outside
Planning for community testing
July 17, 2008
Re: Possible Tuberculosis (TB) exposure during your hospital stay
Dear Patitent:
Your health is our first priority – both while you are in our hospital and when you go home.
That is why we write to inform you that, during your recent stay, you may have been exposed to tuberculosis – commonly
known as “TB.” TB is a treatable disease that affects the lungs and can be passed from an infected individual through
the air.
To determine if you have been infected, we are asking patients who may have been exposed to TB at the hospital between
November 2007 and June 2008 to get a simple, free skin test. Even if you do not experience any symptoms, we
encourage you to come take the test so that we can identify if you are infected and begin any necessary treatment.
We are offering this test jointly with the Texas Department of State Health Services out of an abundance of caution and so
that we follow guidelines and best practices to ensure our patients receive the medical attention they need.
The testing schedule is as follows:
Dates/Times:July 22nd, 23rd, and 25th, 2008; drop-in hours from 9:00 a.m. – 4:00 p.m. daily
Location:
Conference Room A& B at the PRMC South Campus
(See enclosed map for directions)
What to bring:
If you have tested positive in the past, and have the test result, please bring that document
with you.
Cost:
Free
About the test:
This simple test injects a small amount of testing fluid underneath your skin on your forearm.
Within 48-72 hours, you will need to return to the testing site so that a medical professional can
check for any reaction to the test, which may signal infection.
Enclosed is a fact sheet about TB, how it is spread and what the symptoms are. If you have any questions, please feel
free to call Danielle Mead with the Texas Department of State Health Services Tuberculosis Elimination Division, at
903-737-0268.
Sincerely,
Christopher W. Dux
Chief Executive Officer
Mary Fitzwater, RN, BSN
Infection Prevention and Control
Fifth lesson learned
• The state eats lunch
Publicity
• Local and regional newspapers, radio, TV
• Local blogs
The-Paris-site
Essent Healthcare, Inc., the owner of the hospital, didn’t like what was being ... the
newspapers are having such a hard time: Yesterday's news printed today. .....
About Me. fac_p: Paris, TX, United States. View my complete profile ...
the-paris-site.blogspot.com/ - 142k - Cached - Similar pages
TB: PRMC tests for patient exposure - Topix
Read full story from Paris Texas. Read All 6 Comments .... We take news from
over 60000 sources and categorize those stories to over 40600 locations and ...
www.topix.com/county/lamar-tx/2008/07/tb-prmc-tests-for-patient-exposure - 56k Cached - Similar pages
Sixth lesson learned
• Tell the hospital
switchboard where to
send calls
• Plan for millions of
phone calls and have
a script of what to say
• Understand that some
callers will be angry
Clinic Planning
• Large space
• Plenty of seating
• Cookies, bottled water,
soft drinks, juice
• Coloring books and
crayons
• Literature about TB in
English and Spanish
• Signage
• Parking
• Accessibility for the
handicapped
Seventh lesson learned
• Anticipate the
need for
interpreters
Clinic
• Sign in sheets
• Tuberculosis contact
Screening Form
• http://www.dshs.state.
tx.us/idcu/disease/tb/f
orms/#reporting
First Clinic Attendance
• 627 came in for TSTs
• 416 returned for reading
• Those that didn’t return were sent letters to
return for the second round of TSTs planned for
October
• 7 previous positives, none agreed to start
preventive medication
• 3 converts and all agreed to start on preventive
medication
• 2 children started on window treatment
Eighth lesson learned
• TB meds taste like swamp water
• High-risk contacts (including children under 4 years of
age) with a negative skin test reaction less than 10 to 12
weeks after their exposure should start treatment for
LTBI and be retested after the window period ends. This
is called window period prophylaxis. If the second skin
test reaction is negative, treatment for LTBI is usually
stopped. If the second skin test reaction is positive, they
should continue taking treatment for LTBI.
http://www.cdc.gov/tb/pubs/ssmodules/default.htm
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5412a1.htm
Ninth lesson learned
• Contract with the
state for the hospital
to do chest x-rays
Tenth lesson learned
• Plan for those people who didn’t make it to the
clinic, but need to be tested or want to be tested
Second Clinic in October
• The state sent letters
to 250 people who
needed a second TST
• 120 returned
• Both of the children
tested 0 mm at the
second test, and
window treatment
was stopped
New Employee Health policies
• PPD unless known
positive is documented –
don’t take employee word
for it
• PPD regardless of BCG
vaccination
• Employees converting to
positive get referred to
the health department
http://www.cdc.gov/tb/pubs/Posters/Mantoux.htm