EDs in front-line fight against incoming TB
EDs in front-line fight against incoming TB
Triage efforts stave off undiagnosed admissions
Aggressive triaging efforts for tuberculosis in hospital emergency departments (EDs) are heading off admission of undiagnosed cases and later exposures to staff and patients, clinicians report.
For example, an infection control professional at University Hospitals of Cleveland reviewed and improved ED triaging efforts as part of implementing an overall TB Care Path at the hospital. Under the new protocol, triage nurses assess risk factors that include cough and classic symptoms, history, medications, demographics, and living conditions.
’Luckily, we didn’t have any nosocomial transmission, but we noticed our numbers going up [of admitted TB cases],” says Julie Taoras, RN, BSN, CIC, infection control nurse.
In reviewing TB controls at the hospital, Taoras found a lack of expedient identification and isolation of patients at risk for TB. In order to promote early and appropriate recognition of TB, she and her colleagues developed a multidisciplinary institution-wide collaborative care path for TB that began the front-line fight in the ED.
’About 75% of our TB patients that are admitted usually come through the ED,” Taoras says. ’Now, what we are doing is the nurses triage [patients] before they are even registered. They ask some questions, and if they come in with any one of those complaints then they are masked and sent off for X-ray. It’s kind of like an automatic standard of care now.”
Improvements in TB control were reflected by a lack of PPD skin-test conversions in the ED and other high-risk areas, and prompt placement of admitted patients into isolation rooms. Diagnostic evaluation for TB also has improved with earlier submission of respiratory specimens for AFB smear and culture, early availability of results, and more rapid processing of specimens by the microbiology laboratory, she says. In addition, these diagnostic improvements led to earlier discontinuation of isolation in patients when TB was excluded.
In the absence of such programs, however, many hospital EDs may still be putting workers and patients at risk of TB acquisition, notes David Talan, MD, FACEP, chairman of the department of emergency medicine at Olive View-UCLA Medical Center in Los Angeles. The author of several studies on TB in the ED, Talan outlined his findings recently in New Orleans at a conference of the American College of Emergency Physicians.
For example, a recent survey of 446 facilities to determine existing infection control policies and facilities in EDs found that only 56% had triage criteria for screening TB patients, and that only 20% had TB isolation rooms meeting Centers for Disease Control and Prevention criteria for negative-pressure air exchanges, he reports.1 In facilities without isolation rooms, high-efficiency particulate air filters and/or UV lights were used in 19% and 10%, respectively. In addition, sputum induction was carried out in 58% of EDs, but only 7% of the hospitals were conducting the procedure in properly ventilated areas.
’Emergency departments caring for patients with or at risk of TB should consider instituting triage protocols, avoiding risky procedures such as sputum induction, and installing appropriate ventilation facilities,” Talan advises.
The resurgence of TB has been greatest among minorities, substance abusers, the homeless, people of low socioeconomic status, and those with HIV infection. Many may present for medical care in the ED, as one study found 71% of all patients diagnosed with pulmonary TB presented through the ED, he adds.2 Transmission is further fueled by crowded conditions and prolonged waiting, especially in busy inner-city EDs where TB is likely to be common. Infection can spread quickly under such conditions, as for example at a Los Angeles area public hospital, where 31% of employees reported that they had converted to positive skin tests while employed in the ED.3
References
1. Moran GJ, Fuchs MA, Jarvis WR, et al. Tuberculosis infection control practices in United States emergency departments. Ann Emerg Med 1995; 26:3,283-3,289.
2. Moran GJ, McCabe F, Morgan MT, et al. Delayed recognition and infection control of tuberculosis patients in emergency departments. Ann Emerg Med 1995; 26:290-295.
3. Sokolove P, Mackey D, Wiles J, et al. Exposure of emergency department personnel to tuberculosis: PPD testing during an epidemic in a community. Ann Emerg Med 1994; 24:3,418-3,421.
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