In this issue...
Criteria for Discharge from a Hospital to Home
Criteria for Discharge from Isolation in a Hospital/HealthCare Setting
Dates, Dates, Dates -What is the True Date of That Sputum Specimen?
Monitoring for Appropriateness of Treatment - Is that Treatment Plan/Dosage Correct?
The Division of TB Control successfully hosted the TB Outreach Worker and Nurse retreats in September and October 2002! The previous Outreach Worker retreat was in 1998, and to date, the nurse TB retreat was the first of its kind. The Division is grateful to the health districts for sending their TB representatives to these two programs; and the enthusiastic and studious retreat participants who enabled the success of the two retreats.
There is no minimum number of days that a patient must be hospitalized for smear positive, pulmonary TB before being discharged to a home setting. Patients, who are clinically stable and well enough to be discharged from the hospital AND who are not suspected to have multi-drug resistant tuberculosis, may be released, despite the presence of positive sputum smears, if the following criteria are met:
1.The patient is on an appropriate, treatment regimen, which, based on current state and national guidelines, includes an adequate number of drugs to which the strain is either known or likely to be susceptible. In Virginia, a patient should be initially started on a four-drug regimen consisting of isoniazid, rifampin, pyrazinamide and ethambutol. Streptomycin may be considered as an alternative to ethambutol in the rare instance when the latter is medically contraindicated.
2.The patient has a stable, verifiable address.
3.There is confidence that the patient will adhere to treatment and isolation instructions provided at the time of discharge.
4.The patient either lives alone or is returning to an environment where there are no children or immunosuppressed individuals in residence.
5.The patient will not be discharged to any type of congregate living situation (e.g. nursing home, correctional facility, group home, etc.).
6.The patient does not require social services or home care in which the provider will be spending several hours a day with the patient.
Assessment that the above criteria are met is an important responsibility of the local health department, not the hospital or primary care provider. Reviewing the written treatment plan, which according to the Code of Virginia (§ 32.1-50) and associated regulations, must be approved by the Local Health Director (or his/her designee) prior to discharge is a critical step in fulfilling this responsibility. A hospital visit by the nurse case manager prior to discharge is extremely important in order to gather pertinent information and to assess follow-up plans in the community following discharge. In most instances, a visit to the home may be needed to fully assess the home environment and verify that above criteria are met.
Because of the risk of transmitting tuberculosis to other vulnerable populations in a hospital setting, the criteria for release from isolation are more stringent than those for release to home isolation. In order to be released from isolation in an inpatient or congregate living setting, the patient must demonstrate clinical and bacteriologic response to treatment. The following three criteria must be met:
1.Three consecutive negative AFB smears from sputum specimens taken on different days.
2.Current treatment with an appropriate anti-TB regimen to which the strain is known or likely to be susceptible.
3.Clinical response to treatment, i.e. the resolution of fever, the resolution or near resolution of cough.
The decision to transfer a hospitalized patient from an isolation to non-isolation room within the institution should be made by institutional staff. However, input from the local health department may be requested and reference should be made to current national guidelines on preventing transmission of TB in health care facilities (MMWR 1994; 43(No. RR-13)).
Occasionally, there seems to be confusion over which date to use when calculating the date of smear conversion or the date of culture conversion. Which is more correct? The date of the specimen? Or the date the report was received? Whether stating the dates of positive smears or cultures or the date that conversion occurred, the correct date to use is always the date of specimen collection.
Example:
J.S. had positive sputum smears reported to the health department on 7/12/02. These specimens were reported as positive for M. tuberculosis on 7/25/02 and were also pan-susceptible to the primary anti-tuberculosis drugs. On 8/14/02, DCLS reported that specimens collected on 8/5/02, 8/6/02 and 8/7/02 were all smear negative. On 8/24/02, DCLS reported that the 8/6/02 and 8/5/02 specimens were growing M. tuberculosis. Sputum specimens were again sent on 9/8/02. These specimens were collected on 9/4/02, 9/5/02, and 9/7/02. On 9/10/02, DCLS reported that this second set were all smear negative. On 10/28/02, DCLS reported that the cultures of all three specimens were negative.
Example Question 1: On which of the following dates did smear conversion occur?
8/07/02
8/14/02
8/25/02
Example Question 2: On which of the following dates did culture conversion occur?
9/10/02
9/05/02
10/28/02
Click here for the answers.