Download Hospital Discharge of TB Patients

Hospital Discharge of TB Patients:
Collaborating with the Health
Department
Diana Nilsen, MD
Bureau of Tuberculosis Control
NYC Department of Health and Mental Hygiene
Today’s Presentation
 Epidemiology of TB in NYC, 2011
 Discuss the rationale for discharging infectious TB
patients from the hospital
 Describe the new health code reporting
requirements
– Submission of hospital discharge plans
– Submission of treatment plans
 Provide an update on hospital discharge plan
submissions
 Discuss common issues related to hospital
discharges
No. of Cases
Reported TB Cases
United States, 1982–2010*
11,182 cases
Year
*Updated as of July 21, 2011
Tuberculosis Cases and Rates
New York City, 1982 – 2011*
689 Cases in 2011
Number of Cases
4,000
Rate/100,000
60
Case Rate
# Cases
3,500
51.1
50
3,000
40
2,500
2,000
21.4
30
1,500
8.5
20
1,000
10
500
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
00
01
02
03
04
05
06
07
08
09
10
11
0
Year
*Rates
based on official Census data and intercensal estimates prior to 2000. Rates for 2000 to 2006 are
based on intercensal estimates, and for 2007 to 2011on 2008-2010 American Community Survey.
US* and Non-US-Born TB Cases†
New York City, 1982-2011
Number of Cases
3,132
1,010
*Puerto
†There
Rico and U.S. Virgin Islands are included as US-born
was 1 case with unknown country of birth in 2011.
Top 10 Countries of Birth of Foreign-born Persons, NYC
TB Cases
2011
N
2010
N
China
104
China
104
Mexico
49
Dominican Republic
41
Bangladesh
33
Ecuador
41
Dominican Republic
31
Mexico
35
Ecuador
30
Bangladesh
30
Haiti
30
Philippines
28
India
30
India
26
Nepal
19
Haiti
23
Philippines
16
Pakistan
20
Puerto Rico
15
Guyana
16
Tuberculosis rates1 by United Hospital Fund (UHF) neighborhood,
New York City, 2009-2011
Trend in HIV-Infection and TB
New York City, 1992-2011
Number of Cases
% of TB/HIV Infected Cases
1,400
50
% TB/HIV+
1,200
40
# TB/HIV+
1,000
800
34 33
33
31
30
26
22 22
600
18
18
15
400
200
16 16 15
20
13 13
11
9
7
9
10
0
92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11
Year
8
HIV-Infected TB Patients
New York City, 1992-2011
Top 10 Medical Facilities First Evaluating Patients for
TB- New York City, 2011
Facility Name
# of cases
% cases
1. Elmhurst Hospital Center
41
6
2. New York Hospital Medical Center of Queens
35
5
3. Bellevue Hospital Center
34
5
4. Maimonides Medical Center
32
5
5. Lincoln Medical and Mental Health Center
24
3
6. Kings County Hospital Center
23
3
7. Beth Israel, Queens Hospital Center
21
3
8. Lutheran Medical Center
13
3
9. Coney Island Hospital
12
2
10. Montefiore Medical Center, Bronx-Lebanon
Medical Center
11
2
18. Lenox Hill Hospital
10
TB Reporting Requirements
Article 22 of the New York State Public
Health Law and Articles 11 and 13 of
the New York City Health Code require
that suspected and confirmed cases of
tuberculosis be reported to the local
health authority, i.e., DOHMH, within 24
hours
Reporting TB Cases
 Suspected or confirmed TB patients may be reported
by telephone at (212) 788-4162 or 347-396-7400
– A completed Universal Reporting Form (URF) must follow
within 48 hours by faxing it to the Bureau of Tuberculosis
Control at (212) 788-4179
 The URF can also be completed online, by first creating
an account on NYCMED at
www.nyc.gov/health/nycmed
– Support for NYCMED is available by calling (888) NYCMED9
Reporting by
Healthcare Providers
 Providers are required by law to report
within 24 hours any case with:
• AFB+ smear from any site
• Nucleic Acid Amplification (NAA) test + for
Mycobacterium tuberculosis (M. tb)
• Culture + for M. tb
• >=2 anti-TB medications for suspected or
confirmed TB
• Clinically suspected TB
• Pathology findings consistent with TB
– Child < 5 years old with + TST
(regardless of BCG)
Reporting by Laboratories
Laboratories are required by law* to report within
24 hours :
– AFB + smears
– Cultures + for M. tuberculosis (M. tb)
– Any culture result associated with an AFB+ smear
(even if negative for M. tb)
– Rapid diagnostic (NAA) tests identifying M. tb
– Results of susceptibility tests on M. tb cultures
– Pathology findings consistent w/ TB
*Articles 11 and 13, Sections 11.03, 11.05 and 13.03 NYC Public Health Code
Pathology Findings Suggestive of
TB










Presence of acid-fast bacilli (AFB)
Caseating/non-caseating granuloma
Tubercles
Fibro-caseous lesions
Necrotizing/non-necrotizing granuloma
Langhans giant cells/multinucleated Langhans
cells
Epithelioid cells/Epithelioid granuloma
Necrotizing inflammation
Chronic granulomatous lesions/chronic
inflammation with granuloma formation
Giant cells
Background- Discharge Planning
Outpatient Treatment of TB
 TB patients could be treated successfully as
outpatients with the advent of modern
chemotherapy
 No significant difference between hospital and
outpatient treatment
– Cure rates
– Spread of infection
Main determinant of cost of treatment is
INPATIENT admission
(Tuberculosis Chemotherapy Centre, Madras. Bull WHO 1959:21-144:51-339)
Treatment of TB in India
 Tuberculosis Chemotherapy Centre, Madras,
compared home treatment of TB with sanatorium
– Treatment at home is satisfactory
 Crowded living conditions, low nutritional
standards, low income
 Major risk to contacts lies in exposure to the
infectious case BEFORE diagnosis
Tuberculosis Chemotherapy Centre, Madras. Bull WHO 1960, 23; 463-510
Successful Treatment of TB
Requirements for successful treatment include:
 Prescription of the correct chemotherapy
 Compliance with medication doses
– Achieved as outpatient with DOT
 Completion of a minimum number of doses
All of which can be done as an outpatient!
Risks of Hospitalization
Nosocomial transmission to:
– Health care workers
– Vulnerable patients
Anxiety for the patient who is isolated
– Feeling of isolation
– Removal from social supports
– Loss of control over one’s life
NYC Guidelines for Hospitalization
and Discharge
Developed to ensure that only patients who need it
are admitted and hospitalized
Infectious patients could be discharged in the
appropriate circumstances
– TB can be dangerous for other hospitalized patients
– Patients should be treated as OUTPATIENTS unless they
meet certain criteria
– Patients become noninfectious quickly once on treatment
Criteria for Discharge
• Clinical improvement
• Tolerating anti-TB meds
• Patient must be reported to DOH (212-788-4162 or 347-3967400), but must be reported via URF as well
• Electronic URF filled out within 24 hrs.
• Patient should have sputa for AFB
• CXR should be done
• Involvement of DOHMH in discharge planning with submission
of discharge plan to DOHMH
– Referral to DOH clinic and DOT
Instructions given to patient and household members if they
were exposed to an infectious patient
Pg 128
NYC Health Code Amendment
Care of TB Patients in NYC
 In 2009, 83% (255/308) of respiratory smear
positive TB patients were hospitalized
 In NYC, approximately 50% of TB cases are treated
by a private provider
 Collaboration between DOHMH and community
health care providers removes barriers and fosters
achievement of key public health objectives
NYC Health Code Amendment
New York City Health Code Article 11 Section 21(4)
amended June 16, 2010
1. Hospitals/providers must obtain approval from health
department at least 72 business hours before discharging
infectious TB patients
2. Providers must submit proposed treatment plan to NYC
Health Department within one month of treatment
initiation for all persons newly diagnosed with active TB
disease
New requirement communicated to hospital providers
(June and November 2010)
Process for Submitting Hospital
Discharge Plans
Discharge Plan Approval Process
72 hrs before discharge
Within 1 business day
Determination
Approved
Provider submits
Hospital Discharge
Approval Request Form
to DOHMH
via fax
DOHMH physician
•reviews discharge plan
•makes determination
•communicates with
hospital provider
Not applicable
Disapproved
Provider
•discusses discharge
plan issues with DOHMH
•revises plan
•informs DOHMH
Outcomes of Discharges
Approved: criteria for discharge met
Not approved: additional actions or
information needed
Not applicable: extrapulmonary TB cases,
noninfectious cases, atypical mycobacterium
(NTM)
Hospital Discharge Form
Hospital Discharge Approval Request Form
(TB 354) and Instructions
Hospital Discharge Planning Checklist for
Tuberculosis Patients
Available on NYC Health Department’s
website: www.nyc.gov/health/tb
What the DOHMH Would Like From
Providers
 Complete and legible forms
 Expected date of discharge
 Appropriate contact information for the treating
physician/attending MD
 Notification of any issues with medications, side effects
or abnormal lab values
 Specialized nursing needs : PICC lines, injections
 Discharge to congregate settings or home care agency
referrals
 Discharges to other jurisdictions requiring interstate
notification
 How many days of medication provided to patient
 Follow-up appointment date –should be close to date of
discharge
What Does the DOHMH Need to Do
Prior to Discharge?
Field staff need to interview patient to elicit
contacts
Home assessment should be done
Patient to agree to home isolation and DOT
– Sign agreements for both
Follow up appointment is made
Update on Hospital Discharge Plan
Submissions
November 1- March 1, 2011
Acid Fast Bacilli Sputum Smear Positive
TB Patients
Sputum smear positive
TB patients *
97
Discharged smear
positive
48 (50%)
Plan
submitted
22 (46%)
No plan
submitted
26 (54%)
*Suspected and confirmed
Discharged smear
negative
16 (17%)
Plan
submitted
9 (56%)
No plan
submitted
7 (44%)
Still in hospital
33 (34%)
Plan
submitted
10 (27%)
No plan
submitted
23 (73%)
Patients Discharged While Acid Fast Bacilli
Sputum Smear Positive (n=48)
5
No plan submitted
Plan submitted
4
3
2
1
0
H1
H2
H3
H4
H5
H6
H7
H8
H9
H10
H11
H12
H13
H14
H15
H16
H17
H18
H19
H20
H21
H22
H23
H24
H25
H26
H27
Number of patients
6
Hospital
Compliance With Health Code Time
Requirements
Median days from discharge plan
submission to planned discharge was 1 day
(range: -4 to 5)
– 23% (9/41) of plans submitted did not have a
planned discharge date
Median number of days for DOHMH
physician to respond to treating MD was 0
days (range: <1-3)
Initial Approval Status of Discharge Plan
Submissions
Not
Applicable
5%
Disapproved
41%
Pending
2%
Approved
52%
Reasons For Initial Disapproval*
#
%
Home assessment not complete
6
27
Discharge plan form incomplete
5
23
DOT not offered/agreed
4
18
Discharged to congregate
setting/unstable residence
3
14
Inadequate treatment regimen
2
9
Children <5 in house not evaluated
2
9
*Discharge plans may be disapproved for more than one reason
Discharge of Non-NYC Residents
NYC DOHMH will communicate discharge plans
with patient’s local health department prior to
discharge/transfer
Infectious TB patient will be discharged only
upon approval of local health department
If a patient is being discharged to a verifiable NYC
address, a discharge plan must be submitted
Discharge of NYC Residents
from Non-NYC Hospital
• NYC DOHMH will work with discharging
hospital &/or the local public health
authorities to ensure discharge plans
conform to NYC standards
Process for Submitting
Treatment Plans
Treatment Plan Approval Process
Within 1 month of
treatment start date
DOHMH case manager
•contacts treating
provider
• obtains completed
treatment plan form
DOHMH physician
•reviews treatment plan
•makes determination
•communicates with
provider
Treating provider
•discusses treatment
plan issues with
DOHMH
•revises plan
•informs DOHMH
TB Treatment Plan Form
NYC Health Department case manager will
provide the treatment plan form to treating
physician for completion
Treatment plan form does not replace Report
of Patient Services Form (TB 65)
Future Considerations
• Continue collaboration with
hospitals/providers
• Monitor submission of hospital
discharge/treatment plans
• Outreach to hospitals/providers
experiencing issues with plans
• Continue to evaluate impact of initiative
Conclusion
Submit discharge plans for infectious TB
patients within 72 business hours of planned
discharge
Submit treatment plans within one month of
treatment initiation
Ensure forms are complete/accurate
Refer to NYC DOHMH guidelines & resources
Call 311 to consult with DOHMH TB experts
Acknowledgements
NYC DOHMH Bureau of TB Control Provider
Outreach Project Working Group
NYC DOHMH Bureau of TB Control Staff
NYC Infection Control Nurses and
Practitioners
For Consultation call:
311
DOHMH TB Hotline 212-788-4162
www.nyc.gov/health/tb