Policy Template



PURPOSE

This Procedure/Protocol is to provide specific information to follow in order to prevent the transmission of Tuberculosis in the workplace.

The prevention of tuberculosis transmission at Westlake Hospital is the responsibility of the Infection Control Committee. The plan includes the following basic approaches:

1. Preventing the generation of infection droplet nuclei and preventing the spread of infectious droplet nuclei into the general air circulation.

2. Following guidelines for cleaning of contaminated items.

3. Conducting surveillance for tuberculosis transmission on to healthcare facility personnel through proper placement of patients and our annual Skin Test Program.

4. Collaboration with the local TB authority.

PERSONNEL

All patient caregivers who may come in contact with a patient diagnosed with Pulmonary TB or being ruled out for Pulmonary TB.

COMPETENCIES

N/A

SUPPORTIVE DATA

Center for Disease Control TB Control Guidelines

PROCEDURE/PROTOCOL

1. Preventing the generation of infectious droplet nuclei by:

1. Early identification and treatment of persons with tuberculosis infection.

1. Evaluation: for TB should occur in persons at increased risk of TB.

2. Diagnostic: the tuberculin skin test is the only method currently available which demonstrated infection with M. Tuberculosis in the absence of active tuberculosis.

3. Preventative Therapy: Persons with positive skin tests should be evaluated for preventive therapy according to current guidelines. (Refer to Morbidity and Mortality Weekly Report (MMWR) located in the Library, 1990:39, RR-8).

2. Early identification and treatment of persons with active tuberculosis who may have a persistent cough or other symptoms compatible with tuberculosis, such as weight loss, anorexia, fever, and/or night sweats should be screened and isolated until TB is ruled out.

1. Admitting: Personnel will notify the Infection Control Coordinator or the Clinical Manager when Admitting is notified of an admission with a diagnosis of TB or rule out TB. The patient will be assigned an airborne precautions room with negative pressure in the event a negative pressure room is not available a room equipped with a high efficiency filtration unit will be assigned to the patient. The patient will be given a high efficiency mask to wear during transport to the room.

2. Nursing: Personnel will assess new admissions via the symptom check located in the Admission History Booklet and institute Airborne Precautions if indicated. Contact the Infection Control Coordinator or Clinical Manager with any questions. Notify the physician after you institute precautions.

3. Medical Imaging: Radiologists will contact the attending physician and Infection Control Coordinator or Clinical Manager if their interpretation of the chest x-rays includes suspect TB.

4. Rehabilitation: Patients with active TB will not be admitted to this unit.

5. Operating Room: Reference TB Control Plan for Surgical Services.

6. Laboratory: Will notify the physician, the Infection Control Coordinator and nursing unit/Clinical Manager of any positive AFB specimens.

7. Physicians and Office Staff: Will be asked to notify the department (i.e., Medical Imaging, Lab, Registration, or Admitting) that a suspect TB patient needs a hospital service. Office staff will be asked to send the patient with a mask to wear before entering the hospital building. Receiving department will schedule patient at lowest volume time and instruct patient on where to receive service as quickly as possible.

8. Registration Area: Upon notification of an outpatient with a diagnosis of TB or rule out TB or here for a sputum specimen for AFB or to follow up of a positive tuberculin skin test (TST), the clerk will instruct the patient on wearing a high efficiency mask and notify the receiving department that the patient has arrived so appropriate precautions can be taken.

9. Respiratory Care: Reference policies: Sputum Induction and Pulmonary Function Testing in Patients with Known or Suspected Pulmonary TB.

10. Emergency Room: Personnel will complete symptom check during triage and place patient in airborne precautions if TB is suspected. A high efficiency mask will also be placed on the patient and a TB( N-95) respirator will be worn by health care workers.

3. Any patient suspected or known to have infectious TB must be placed in airborne precautions in a negative pressure room. (Rooms that are negative pressure at Westlake Hospital are LDRP #2, ICU #3, ER #11 and Decontam. Room, Medical Imaging #4 and #5)

1. Isolation room doors must be kept closed to maintain control over the direction of air flow.

2. Health care workers who enter a room in which Airborne Precautions are in place, must wear TB (N95) respirator. Any staff not trained/fit tested with a respirator are not to enter room.

3. The patient should remain in the isolation room with the door closed and should be instructed to cover nose and mouth with tissue during coughing and sneezing. The patients must be transported by staff that have been fit tested with a TB (N95) respirator. If the patient must leave the room (e.g., for a medical procedure that cannot be done at bedside) while potentially infectious, he/she should wear a high efficiency mask. In the event that they need O2, attempt to us a nasal cannula with the high efficiency mask over the O2 tubing.

4. Airborne Precautions may be discontinued in a suspect pulmonary TB patient when the patient has three consecutive AFB negative smears collected on three different days or TB is ruled out and a doctor’s order is written to discontinue isolation.

5. When an infectious pulmonary TB patient has been documented to have received at least 14 days of effective therapy, is clinically improved and has three consecutives AFB negative sputum smears collected on three consecutive days, the isolation may be discontinued.

4. Probability of TB is increased with a history of:

• Positive tuberculin skin test.

• History of previous TB.

• Membership in a group at high risk of TB.

• History of exposure to TB.

• Any immunocompromised patient with an abnormal chest x-ray (i.e., HIV).

5. Tuberculin skin test (TST):

1. The Mantoux technique (intradermal injection of 0.1 ml purified protein derivative (PPD) containing 5 tuberculin units (TU) should be used as a diagnostic aid to detect tuberculosis infection. Although tuberculin skin tests are less than 100% sensitive and specific for detection of infection with M. Tuberculosis, no better diagnostic method has been devised. Tuberculin skin tests should be interpreted according to current guidelines. (See interpretation 5.3).

2. A negative skin test does not rule out tuberculosis disease or infection. Because of the possibility of a false-negative result, the tuberculin skin test should never be used to exclude the possibility of active tuberculosis among persons for whom the diagnosis if being considered, even if reactions to other skin test antigens are positive. Persons with HIV infection are more likely to have false-negative skin tests than are persons without HIV infection.

3. Interpretation:

INTERPRETATION OF THE

MANTOUX TUBERCULIN SKIN TEST

5mm 10mm 15mm

λ λ λ

|5 or more mm duration is |10 or more mm induration |15 or more mm induration |

|considered positive for the |is considered positive for |is considered positive for: |

|highest risk groups: |other high-risk groups: | |

| | | |

|Immunosuppressed |Foreign-born persons from |Persons who do not have any of the risk factors |

|Persons: |high TB prevalence |mentioned. |

|- HIV Infection |countries. | |

|Immunosuppressive Therapy | | |

|Hematologic disease |Low income populations. | |

|Reticuloendonthelial Disease | | |

|Cancer |Substance abusers (IVDUs). | |

|End stage renal failure |Residence of: | |

| |Correctional institutions. | |

|Recent TB contacts |Nursing Homes. | |

| | | |

|Persons with abnormal |Persons over age 70. | |

|chest x-ray consistent with TB. |(see next page for additional details) | |

| |Employees of : | |

| |Hospitals | |

| |Mycobacterial labs. | |

| | | |

| |Persons who provide | |

| |Service to high risk groups. | |

| | | |

| |Persons with medical conditions | |

| |known to increase TB risk: | |

| |Diabetes mellitus. | |

| |Prolonged corticosteroid RX. | |

| |Post gastrectomy. | |

| |Chronic malabsorption | |

| |syndrome. | |

| |Silicosis | |

| |Below ideal body weight by | |

| |10% or more. | |

4. Tuberculin skin testing is performed by injecting .1 ml of PPD (Purified Protein Derivative) containing 5 tuberculin units (intermediate strength) into the volor surface of the forearm. Results are read between 48 to 72 hours. (For more detailed information, refer to the tuberculosis skin test administration and reading policy.)

• Chest x-ray

• Bacteriology: Smear and culture examination of three sputum specimens collected on different days is the main diagnostic procedure for pulmonary tuberculosis. Early morning specimens provide higher quality diagnostic specimen. Negative smears do not exclude the diagnosis of TB. A positive sputum culture provides a definite diagnosis of TB but requires 4-8 weeks for species identification.

• Bronchoscopy and biopsy may be indicated in some cases.

5. Treatment: Refer to Morbidity and Mortality Weekly Report (MMWR) located in the Library (May 21, 1993, Vol. 42 No. RR-7).

6. Preventing spread of infectious droplet nuclei by environmental controls.

1. Ventilation: Once infectious droplet nuclei have been released into room air, they should be eliminated or reduced with efficiency of filtration and appropriate face masks.

1. Local exhaust ventilation.

2. General ventilation.

• Dilution and removal of contamination with a recommended minimum of 6 air changes per hour for isolation and treatment rooms based on comfort and odor control consideration.

• Room air flow patterns.

• Facility air flow direction.

• TB isolation rooms – negative pressure.

3. Monitor negative TB isolation rooms:

1. The Negative Pressure Rooms (see #3) are monitored daily by the Facilities Department.

2. Facilities personnel shall complete the test in the following manner.

• Close the room door, hold the smoke tube near the bottom of the door parallel to the door approximately 2 inches in the front door.

• Generate a small amount of smoke by gently squeezing the bulb.

• If the room is at negative pressure, the smoke will travel under the door and into the room.

• If the room is not at negative pressure, the smoke will be blown outward or will stay stationary.

3. Document the results on the appropriate form.

• Test passes – no further action required.

• Test fails – Facilities Department will notify the manager or designee of the area or the Clinical Manager on the off shifts and weekends, the Admitting Department and the Infection Control Coordinator.

• If the room is being used for a TB or rule out TB patient, transfer the patient to another Negative Pressure room. In event no other Negative Pressure room is available, use the portable HEPA filtration machine (stored in the Facilities Department).

4. Upon completion of the corrective action, Facilities Department will notify the manager of the area or designee, Admitting Department, and the Infection Control Coordinator that the room may be used for TB or rule out TB patients.

2. Decontamination: Cleaning, disinfecting and sterilizing.

1. The same routine, daily cleaning procedures used in other hospital rooms should be used when cleaning the room of patients who are in Airborne Precautions for TB.

2. Standard cleaning, disinfection and sterilization procedures should be followed by set policy.

7. Preventing spread of infectious droplet nuclei by work practice controls.

1. Respiratory Protection Program includes the use and selection of respiratory protection equipment, i.e., TB (N95) respirator and High Efficiency Mask (HEM).

1. All Managers/Supervisors are responsible for assessing, maintaining and monitoring compliance with all elements of the Respiratory Protection Program including to assure that the appropriate respirator for each employee is available.

2. It is the responsibility of the physician caring for the patient to initiate by verbal/written order, airborne precautions when TB is suspected or confirmed. The nurse caring for the patient or the Infection Control Coordinator may also institute Airborne Precautions when indicated and then notify the physician.

3. The nurse caring for the patient is responsible for initiating and maintaining the appropriate level of precautions. This includes the procurement of the proper respiratory protection equipment and posting of the Airborne Precautions sign on the outside of the patient’s door. The patient’s door must remain closed at all times.

4. All personnel are responsible for complying with all elements of the Respiratory Protection Program. Personnel are responsible for wearing the respiratory equipment that they have been fit tested or trained for and maintaining the equipment in clean operable condition.

5. Hospital employees must undergo an initial fit test and training prior to using a TB ( N95) Respirator and annually. This respiratory protection is recommended by CDC and OSHA. Medical evaluation is completed prior to fit testing. Only these employees are allowed to enter the rooms of patients suspected or confirmed to have TB.

6. Medical staff will be offered fit testing and training for the TB ( N95) respirator annually.

2. TB Mask (N95 Particulate Filter Respirator)

1. TB (N95) respirator shall be worn by employees in those circumstances in which a suspected or known exposure and potential transmission of TB may occur. These circumstances include:

• When the patient’s signs and symptoms and laboratory data suggest a high potential for infection (inpatient and outpatient);

• For transport of suspected/confirmed TB patients outside of their room. Employee must wear TB (N 95) respirator when going inside the room to pick up the patient to transport. Once the patient has a HEM in place prior to leaving their room and both the patient and the employee are outside the patient’s room, the employee may remove his/her TB (N 95) respirator.

2. Every time the employee applies a TB (N95) respirator, they are responsible for a face fit check.

3. A TB (N95) respirator must be changed as soon as feasible if it becomes contaminated with blood/body fluids, wet, or if it becomes misshapen so as to compromise the provision of an appropriate seal.

4. A used TB (N95) respirator should be discarded in regular hospital waste unless it is saturated with free flowing blood/body fluid, then it must be discarded in a biohazard bag in the potentially infectious medical waste receptacles (PIMW).

3. High Efficiency Mask (HEM) – yellow mask

1. Indications for the use of HEM’s:

• When the patient in Airborne Precautions requires transport outside of their room;

• For all outpatients/visitors suspected of having TB

• For all visitors entering a room where the patient is in Airborne Precautions

2. A HEM is worn under those circumstances where Airborne Precautions are required but a TB (N95) respirator is not required (i.e.; patient with chickenpox )

3. An HEM should be changed as soon as is feasible if it becomes wet. It should also be changed if it becomes contaminated with blood or body material.

4. A used HEM should be discarded in regular hospital waste unless it is saturated with free flowing blood/body fluid, then it must be discarded in a biohazard bag in the potentially infectious medical waste (PIMW) receptacles.

• The following table provides information regarding the selection of appropriate respirator equipment for the health care worker.

|Hazard |N95 |High Efficiency Mask|

| |Respirator |(HEM) |

|Patient with cavitary lung lesion on chest x-ray |+ | |

|- cause TB or cause unknown | | |

|Patient with military lung lesion on chest x-ray |+ | |

|- cause unknown | | |

|When patient has chronic pneumonia which is thought to be suggestive TB |+ | |

|Pending or positive sputum smear for AFB and identification of organism is TB or is unknown |+ | |

|Performing a sputum induction when suspect or known TB |+ | |

|Performing Bronchoscopy when suspect or known TB |+ | |

|Performing an autopsy (if aerosolization is likely to occur when suspect or known TB |+ | |

|Patient with Measles (Rubeola) or Varicella (Chickenpox) in | |+ |

|airborne precautions the health care worker is susceptible to Measles or Chickenpox. | | |

4. Training and Fit Test Program for the TB (N95) respirator– personnel required to wear a TB (N95) respirator must be fit tested and/or trained prior to use of a respirator. The TB (N95) respirator must be fit tested annually.

1. All personnel required to wear a respirator during the performance of job duties that have a physiological change (i.e., plastic facial surgery, weight loss of 10-20 pounds, broken nose), should inform their manager/supervisor. Additional fit testing may be required.

2. All personnel undergoing a fit test must be NPO (nothing by mouth) for a minimum of 15 minutes prior to being tested.

3. Procedure for Fit Test

1. Fit test kits are stored in Employee Health Department and each department.

2. Training will include the following:

• explanation of signs

• equipment application and fitting instructions

• equipment removal instructions

• equipment storage

• equipment usage

• equipment disinfection

• alarms and warning signals

3. Documentation must be obtained on the following forms:

• Medical Evaluation Form – Employee Health Service for placement in the employee’s file.

• TB Mask Qualitative Fit Testing and Training for TB Mask Form. Form to be completed by Employee Health.

• White copy – EHS for placement in employee file.

• Yellow copy – Department Manager

5. Procedure for Fit Test Failure (EHS Program): To provide a process for assessing the reasons for medical evaluation and/or TB mask failure and to offer alternate respirator options.

1. Based on the reason(s) for TB mask fit test failure, the trainer will opt to do one or more of the following:

1. Perform another fit test with Bitrex Solution.

2. Perform fit test with another TB mask respirator (3M)

2. The manager must be aware of the inventory of appropriate respirators for employee to use and be familiar with the process by which to obtain respirators in the system.

8. Procedure specific precautions to diagnose or rule out TB:

1. Bronchoscopy

1. See Surgical Services Policy Procedure (TB Control Plan for Surgical Services)

2. Should be performed in rooms with adequate ventilation, a minimum of 6 air changes per hour, good distribution of air and air exhausted directly to the outside and negative pressure.

3. Personnel in the room with patients suspicious of TB during bronchoscopy must wear a TB (N95) respirator.

2. Cardiopulmonary

1. Sputum induction performed on patients who may have tuberculosis should be carried out in a negative pressure room or a room equipped with a high efficiency filtration unit.

2. Personnel in the room performing the induction must wear a TB (N95) respirator (see Sputum Induction Policy).

3. Pulmonary function testing on known or rule out TB patients will not be done- (see policy; Patients with Known or Suspected Pulmonary TB).

3. Aerosolized treatments:

1. All patients should be screened for active TB prior to and during aerosolized treatment.

2. Treatments performed on patients who may have tuberculosis should be carried out in a negative pressure room.

3. Personnel in the room during treatment must wear a TB (N95) respirator.

4. Endotracheal intubation/suctioning:

1. Intubated patients who may have active tuberculosis must be placed in Airborne Precautions in a negative pressure room.

2. Personnel performing endotracheal suctioning or intubation on patients who may have active TB must wear a TB (N95) respirator.

9. General

1. Ambulatory patients who have pulmonary symptoms of uncertain etiology should be instructed to cover their mouths and noses when coughing or sneezing; they should spend a minimum of time in common waiting areas.

2. When emergency-medical-response personnel or others must transport patients with confirmed or suspected active tuberculosis, a high efficiency mask should be placed on the patient. If this is not possible, the worker should wear a TB (N95) respirator if they have been fit tested or a high efficiency mask. If feasible, the rear windows of the vehicle should be kept open and the heating and air conditions system set on a non-recirculating cycle.

3. Emergency-response personnel should be included in the follow-up of contracts of a patient with infectious tuberculosis. (See hospital policy Transportation Agency, Notification of Communicable Disease.)

4. If home health care services will be utilized after discharge or the patient is transferred to another facility the accepting agency must be notified of the precautions required.

5. If immunocompromised persons or young children live in the home with a patient who has infectious pulmonary or laryngeal tuberculosis, they should be temporarily relocated until the patient is no longer infectious.

10. Screening of health care facility personnel:

1. Post job offer testing Mantoux.

2. Annual TB screening.

3. Documented in-house exposure.

4. History of positive TB skin testing – symptoms check/chest X-ray. For new entries and an annual symptom check.

5. Screening evaluation:

1. Infection Control Coordinator, chairperson and employee health nurse shall review data related to the occurrence of Tuberculosis including tuberculin skin test results amongst the patients.

2. EHS will monitor pre-employment, the annual screening programs and any follow-up testing after exposures. All records will be maintained in EHS.

3. Data collected will be reported to the Infection Control Committee.

11. Reporting to the public health authorities: When tuberculosis is suspected or diagnosed, the Infection Control Coordinator will report to the public health authorities so that appropriate contact investigation can be performed within 7 calendar days.

12. Training:

1. Training about occupational hazards related to Tuberculosis and protective measures are done for new employees and annually thereafter on Healthstream.

13. Program Evaluation

1. Evaluate TB patient’s risk assessment in the medical records.

2. Analysis of the Tuberculin Skin Test Program at least annually, or when the number of TB patients increases, or anytime a cluster of TB conversions is noted.

3. Engineering Evaluation:

1. Review logs periodically of the daily negative pressure checks of rooms in use for TB patients.

2. Review engineering controls for dedicated TB isolation rooms annually.

4. Assessment of adherence to the TB Control Plan will be carried out on an ongoing basis by the Infection Control Coordinator.

5. The evaluation of the TB Control Program will be reported to the Infection Control Committee annually or more frequently if indicated and make recommendations of changes as needed. The TB Authority Annual Report will be reviewed as part of the evaluation process.

6. Review and Update:

This TB Control Plan and the department specific plans will be reviewed and updated annually whenever such updating is indicated by changes in requirements or job exposure. These reviews and updates will be the responsibility of the Infection Control Committee.

7. Enforcement:

Compliance with this plan is mandatory and failure to comply with any part of the plan will be dealt with according to Human Resource Policy and Procedure entitled Progressive Discipline.

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