Download Clinical Pathway for managing Tuberculosis Suspects/Cases in

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Clinical Pathway: Managing Tuberculosis
Suspects/Cases in Corrections
TB case management in correctional facilities can be a challenge to administrators and infection
control staff who have not worked with tuberculosis for some time. There are many components that
must be accomplished, including identification and isolation, reporting, diagnosis and treatment, and
planning for the eventual release of the inmate. Through the use of this form, the medical staff can
identify all the steps needed when caring for a case of tuberculosis, infectious or not.
BEST PRACTICE: Case management is best done in conjunction with the local health department
whenever possible.
This form can aid in the day to day tasks required when caring for an inmate with tuberculosis (TB).
Through the use of this form, the nurse completing these tasks can be assured that all aspects of TB
are complete and up to date, and any areas where further assistance is required can be identified
early in treatment.
Terminology and Definitions
Airborne Infection Isolation (AII) Room – Formerly, negative pressure isolation room, an AII Room is a
single-occupancy patient/inmate-care room used to isolate persons with a suspected or confirmed airborne
infectious disease. Environmental factors are controlled in AIIRs to minimize the transmission of infectious
agents that are usually transmitted from person to person by droplet nuclei associated with coughing or
aerosolization of contaminated fluids. AIIRs should provide negative pressure in the room (so that air flows
under the door gap into the room); and an air flow rate of 6-12 Air Changes per Hour (ACH) (6 ACH for
existing structures, 12 ACH for new construction or renovation); and direct exhaust of air from the room to
the outside of the building or recirculation of air through a HEPA filter before returning to circulation (MMWR
2005; 54 [RR-17])
Break in Exposure – date the infected individual was isolated/removed from the contacts.
Conversion – A tuberculin skin test increase of 10mm or more within a 2-year period, regardless of age
(i.e., 5/10/05 – TST = 4mm, tested again 3/17/07 – TST = 16mm.)
Test Conversion Rate – calculation is identified by dividing the number of conversions among
workers by the number of workers who were tested and had prior negative results during a certain
period.
Contacts – contacts are categorized and assessed according to priority, and include high-priority and
medium priority. A contact is a person who has shared the same air space with a person who has TB
disease for a sufficient amount of time to allow possible transmission of M. tuberculosis.
High-priority - those persons most likely to become infected (were in close proximity of the
infectious case and for prolonged periods of time) and most likely to develop active TB disease once
infected (HIV+, other immune compromised, drug users, silicosis, etc.).
Medium-priority – those persons who spent time with or was physically close to the inmate and,
once infected, may develop active TB disease (low body weight, diabetes, organ transplant,
cancers, renal disease, etc.
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Low-priority – those persons with short duration of exposure (includes officers and staff who do not
have prolonged exposure).
Exposure – the length of time spent with a person with active infectious TB disease during his/her
infectious period.
Index Case – the first inmate that comes to your attention as a TB case
Infectious Period – the period during which a person with TB disease might have transmitted M.
tuberculosis organisms to others. For inmates with positive AFB sputum smear results, the infectious
period begins 3 months before the collection date of the first positive smear result or the date of
collection for the first consistently negative smear results. For inmates with negative AFB sputum
smear results, the infectious period extends from 1 month before the symptom onset date and ends
when the inmate is placed into airborne infection isolation (AII), whichever is earlier.
Latent TB Infection – a person infected with the bacteria Mycobacterium tuberculosis. The person
with LTBI shows no signs or symptoms of active TB, and has a negative chest x-ray and negative
symptom screen.
Suspect – a person in whom the diagnosis of TB disease is being considered, regardless of whether
anti-TB therapy has been started.
BEST PRACTICE: Begin and complete the contact investigation in conjunction with the local health
department whenever possible.
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INMATE
NAME
ID #
DOB
Clinical Pathway: Managing Tuberculosis
Suspects/Cases in Corrections
Name of person completing this form:
Name of Health Department Staff Assist:
Title:
________
Title:
Instructions: Initial and Date after each task. Observe Respiratory Precautions when speaking with infectious tuberculosis (TB)
suspects/cases. Assure proper isolation and treatment of suspect/case.
Obtain sputum containers (3-6) from the health department (HD) or laboratory. Collect sputum specimens on 3 separate days or at least 8 hours apart (with one
first morning specimen) If unable to expectorate, may need sputum induction either on-site at facility, HD or local hospital). Remember: Always wear a N95
mask when working with a TB suspect, and anytime a TB suspect is out of isolation, they should wear a surgical mask until no longer infectious. They do not have
to wear a mask while alone in a negative AII room.
Note: At any point during incarceration the inmate is released or transferred to another facility, complete information must be sent along with
the inmate.
INITIAL WHEN
DONE
DATE
COMPLETED
Immediately place tuberculosis (TB) suspect in negative airborne infection isolation (AII) room.
Instruct inmate and staff on how to obtain a witnessed sputum specimen, including the need for immediate refrigeration
after collection and ensuring the container (both inner and outer) is labeled correctly, prior to sending specimen to the
Health Department or state laboratory.
Obtain, collect and route sputum specimen (witnessed) from the state lab for acid fast bacillus (AFB) smear, nucleic acid
amplification (NAA) test, Mycobacterium tuberculosis Direct (MTD) test and culture.
Obtain medical history including signs, symptoms and duration of symptoms of TB disease.
Ensure the physician/ARNP/PA performs a physical examination.
Offer HIV counseling and testing. Draw blood for HIV test. Obtain baseline tests/results if applicable, (i.e., liver enzymes
such as Serum glutamic oxaloacetic transaminase (SGOT) and Serum glutamic pyruvic transaminase (SGPT), bilirubin,
creatinine, complete blood count (CBC), platelet count, uric acid, as ordered).
Day 1
Place TST at this time, if not already done.
Obtain weight/perform baseline visual acuity/testing for red/green color blindness if applicable.
Obtain chest x-ray (CXR) if no recent one is available. Place surgical mask on inmate when transporting.
Notify HD of suspect/case by phone and in writing using appropriate TB medical report and treatment plan.
Instruct the inmate about the need for medications and reactions/side effects of medications, and include the need for
directly observed therapy (DOT).
Provide educational information about TB and plan for future care, including the need for monthly clinic visits to see the
physician, nurse, or health department TB program staff.
Discuss findings with physician and obtain prescription for four-drug therapy. Medications: (Rifampin, Isoniazid,
Pyrazinamide and Ethambutol) as appropriate.
Administer medications using strict DOT (DOT = Directly Observed Therapy = swallowing, not simply delivery of
medications)
Discuss medical release forms and have inmate sign as necessary.
Provide TB education and document in the medical record. Have inmate sign the TB Acknowledgement Form (if available).
Begin planning for eventual release from facility using Discharge/Release Planning Forms.
Begin contact investigation in collaboration with the HD case manager (if contact investigation is needed) per your HD’s
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INITIAL WHEN
DONE
DATE
COMPLETED
instructions. As appropriate, you may be instructed to wait until the sputum results return. Determine this in conjunction
with the HD TB Program. NOTE: Use the Clinical Pathway: TB Contact Investigation for Corrections if available.
Report the suspect/case to the Corrections Administration (as per your protocol)
Place written information in classifications/release folder for notification to medical/health department case manager
prior to release from facility.
Estimate the infectious period:
FROM (date)
TO (date)
Obtain (early morning) sputum specimen or perform sputum induction. (Note: Label appropriately and send to health
department/state lab for smear, NAA (or MTD) and culture).
Day 2
Observe for strict DOT (swallowing of medications), including checking the amount of medication.
Examine the medication administration record (MAR) for refusals/medication missing, etc.
Obtain sputum results from day 1 (1st specimen) if available.
Read TST and record results in chart in mm (if applicable).
NOTE: Check Day 1 for any tasks unfinished.
Review results and consult with physician/health department case manager if TST+ and/or +AFB/MTD.
Obtain sputum results from day 2 (2nd specimen) if available. Ensure reports are in medical record.
Day 3
Review CXR report/film with physician/health department case manager and ensure report is in medical record.
Continue DAILY DOT with four-drug therapy for next 2 months as directed by physician or until directed otherwise by
health department case manager/physician. Monitor for non-adherence. (Note: twice weekly is not recommended in
corrections)
NOTE: Check Day 2 for any tasks unfinished.
BEST PRACTICE: work with your custody staff to ensure the inmate’s custody record is flagged to
prevent release until medical is notified of impending release. Begin planning for potential release.
Ensure medical staff is informed prior to inmate release.
Day 5 – Week 2
Day 4
Obtain sputum results and other labs from day 3 (3rd specimen) if available.
Continue to monitor MAR to ensure inmate is taking medications and no side effects are noted.
Check release status with classifications/release personnel to see if any changes have occurred, including pending
transfers/releases to other facilities.
Contact laboratory/HD for results of lab tests, (NAA/MTD), baseline tests (if not yet reported to HD/correctional facility).
Ensure HD has same information.
If smear negative for M. tb., discuss with HD case manager/physician for continuation/changes in scope of contact
investigation. (Note: continue with treatment until evidence proves non-infectiousness per HD)
Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking medications.
Check release status with classifications/release personnel as per instructions above.
Week 3
Continue medications (monitor MAR) as directed by HD case manager/physician.
Obtain sputum x 3 for smear and culture every 2 weeks (or per local HD protocol) until negative for smear/culture.
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Check release status with classifications/release personnel
Clinic visit with physician, ARNP, PA, or RN for evaluation of status and medications, include a complete chart review by
health personnel.
Week 4
Check weight, visual acuity, red/green colorblindness, as applicable. Draw and monitor SGOT and uric acid if on PZA as
ordered.
Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as prescribed.
Contact laboratory/HD case manager for culture results (may take 4-6 weeks) if not yet received.
Review all labs with physician/HD case manager. Conduct a monthly case management team meeting to discuss inmate’s
progress, include HD case manager. Monitor MAR for DOT..
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Check release status with classifications/release personnel.
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Weeks 5-7
INITIAL WHEN
DONE
DATE
COMPLETED
Obtain sensitivity results from laboratory if culture results have returned. If sensitive to all medications, discuss with HD
physician/case manager the possibility of discontinuing Ethambutol now.
Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as prescribed.
Check release status with classifications/release personnel.
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Ensure inmate continues regularly scheduled clinic visits with physician, ARNP, PA, or RN, to include complete chart review
and MAR review.
Draw SGOT and uric acid if still on PZA/other labs as ordered. Obtain and record weight.
If still on Ethambutol, check visual acuity and color blindness.
Week 8
Obtain CXR; review results with the physician and include comparison with previous x-ray to determine if inmate’s x-ray is
improving, worsening or stable.
Cultures and sensitivity studies should be back by now. If not, check with the laboratory. (Note: If sensitive to all
medications, ask physician for order to discontinue EMB and PZA, which is generally discontinued after 2 months of
treatment. If the smears and cultures have not converted to negative, the inmate needs to be re-evaluated for possible
resistance to one or more TB medications. If this happens, additional specimens and sensitivity studies should be done.
(Note: if the inmate has not received 2 months of PZA, may need to treat for 9 months as ordered by physician.)
Discuss with HD case manager/physician if this suspect is a TB case or LTBI. Is other information needed to make this
determination? Note on progress notes if additional information is needed. (Note: If inmate is a TB case, the HD will
report to State Health Office.)
Discuss with the inmate if s/he is improving/feeling better with medications.
Continue DOT as directed. Continue to monitor MAR to ensure the inmate is taking medications.
NOTE: If the inmate is not a TB case and is identified as LTBI, discontinue treatment as ordered by the HD TB physician.
Conduct monthly case management team meeting to discuss inmate’s progress. Include county HD case manager and all
other team members (medication nurse, physician, etc.) BEST PRACTICE: Recommend including custody or classification
supervisor.
Check release status with classifications/release personnel for change in scope.
Discuss continuation of contact investigation with HD case manager/physician if applicable.
NOTE
If the inmate has cavitary lesions in their lungs, or if their culture is positive after 2 months of treatment with four drugs that the inmate is sensitive to,
treatment should be extended to a minimum of 4 months after the inmate converts the cultures to negative per CDC guidelines. Discuss with HD staff.
Weeks
9-11
Continue to collect sputum x3, if smears and cultures are still positive. If negative, collect sputa as directed by HD TB program
staff.
Continue DOT. If inmate has been on daily DOT for 2 months, begin twice or thrice weekly DOT after discussion with HD case
manager/physician.
(Note: if HIV+, administer medications minimally 3x week).
Check release status with classifications/release personnel.
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Repeat CXR if needed.
Week 12
Monthly clinic visit with physician, ARNP, PA, or RN, including chart review.
Draw SGOT/labs as ordered. Obtain and record weight.
Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as prescribed.
Conduct monthly case management team meeting to discuss inmate’s progress. Include county HD case manager and all other
team members (medication nurse, physician, etc.) BEST PRACTICE: Recommend including custody or classification supervisor.
Check release status with classifications/release personnel.
Weeks
13-15
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as prescribed.
Check release status with classifications/release personnel.
Discuss continuation of contact investigation with HD case manager/physician if applicable.
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INITIAL
WHEN
DONE
DATE
COMPLETED
Monthly clinic visit with physician, ARNP, PA, or RN, to include complete chart and MAR review.
Week 16
Draw SGOT/labs if ordered. Obtain and record weight.
Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as prescribed.
Conduct monthly case management team meeting to discuss inmate’s progress. Include county HD case manager and all other
team members (medication nurse, physician, etc.) BEST PRACTICE: Recommend including custody or classification supervisor.
Check release status with classifications/release personnel.
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Weeks
17-19
Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as prescribed.
Continue contact investigation if applicable.
Check release status with classifications/release personnel.
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Monthly clinic visit with physician, ARNP, PA, or RN, to include chart review and MAR review.
Week 20
Draw SGOT/labs as ordered. Obtain and record weight.
Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as prescribed.
Conduct monthly case management team meeting to discuss inmate’s progress. Include HD case manager and all other team
members. BEST PRACTICE: Recommend including custody or classification supervisor in team meetings.
Check release status with classifications/release personnel.
Weeks
21-23
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as prescribed.
Check release status with classifications/release personnel.
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as prescribed.
If treatment has been completed, obtain final chest x-ray and sputum, if able.
Weeks
24-26
Ensure the inmate’s final clinic visit with physician/clinician (if applicable). Review chart for completion of therapy or need for
treatment continuation.
Complete certificate of completion for TB treatment card (if applicable). Place in inmate’s property.
Notify HD case manager of completion of therapy (if applicable).
Review chart for completion of contact investigation, etc. May need to continue after inmate’s treatment has completed (after
week 26).
Check release status with classifications/release personnel.
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Week 27 to End of Treatment
(if applicable)
Continue contact investigation if applicable.
Transfers
or Releases
Continue DOT as directed (if applicable). Continue to monitor MAR to ensure inmate is taking all medications as prescribed.
In the event the inmate is transferred or released prior to completion of treatment, medications must be sent with the inmate, along with a copy of the
medical administration record (MAR), copies of chest x-rays/results and copies of any lab work the inmate has obtained during his/her incarceration.
Monitor release status with classifications/release personnel.
Conduct monthly case management team meeting to discuss inmate’s progress. Include HD case manager and all other team
members.
Discuss need for continuation of treatment if needed with HD case manager/physician.
Update treatment plan to reflect ongoing care of inmate.
Draw SGOT and other labs as needed. Obtain and record weight regularly.
Document number of doses in clinical record.
The local HD TB nurse case manager should also be given copies of the above information, to ensure the HD record is up to date.
Contact the agency/local HD prior to release/discharge for continuity of care (if applicable).
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BEST PRACTICE: If the inmate has cavitary lesions in their lungs, or if their culture is positive after 2 months of treatment with four drugs that the inmate
is sensitive to, treatment should be extended to a minimum of 4 months after the inmate converts the cultures to negative.
COMMENTS/NOTES
Note: Indicate N/A (= Not Applicable) if task does not need to be done or does not apply. This indication will ensure that the task was not missed or
overlooked by staff.
NURSE
NAME OF PERSON COMPLETING CLINICAL PATHWAY
Signature
Title
Initials
Date
Title
Initials
Date
HD CASE
MANAGER
HEALTH DEPARTMENT STAFF ASSISTING WITH CLINICAL PATHWAY
Signature
AT ANY POINT, IF THE INMATE IS RELEASED
OR TRANSFERRED TO ANOTHER FACILITY,
COMPLETE INFORMATION MUST BE SENT
ALONG WITH THE INMATE
NAME
ID #
DATE OF BIRTH
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