Guidelines aim to help detect TB in the ED

'Cookbook' simplifies CDC recommendations

A significant portion of tuberculosis patients are first diagnosed in emergency departments, and yet many facilities don't have written guidelines and are not detecting as many cases as they could be, according to researchers at the Francis J. Curry National Tuberculosis Center in San Francisco.

"There is a gap between federal recommendations and how they apply to a specific setting, like an emergency department, which is quite different than a clinic," says Elizabeth Stoller, MPH, director of the center.

Guidelines bridge the gap

To help bridge that gap, the center has just published a set of guidelines for identifying and triaging persons with infectious TB who come into the emergency department.1 About 3,000 copies of the guidelines for effective practices will be set out to hospitals around the country and will be available on the Internet later this year.

The need for the guidelines became apparent after researchers at the center surveyed emergency departments and found that many nurse managers thought they were doing TB triage but in fact were not, says Janet Abernathy, RN, principal environmental health and safety specialist at the center.

"They say that they know what the symptoms of TB are and if someone comes in who looks like he or she might have TB, they ask [him or her] questions," she says. "But when you pull the charts on confirmed TB patients admitted through ED, what we found pretty much across the board was no TB screening had been done on them."

The missed opportunities from lack of TB screening, at least in California, are considerable. In 1994, nearly 25% of TB cases in San Francisco and Los Angeles were seen in hospital emergency departments. If the same proportion of TB cases were diagnosed in emergency departments across the state, an estimated 1,200 cases would have been presented in those facilities that year, Abernathy notes.

Reports of TB transmission to health care workers and patients in emergency departments have been well documented. A 1995 case, for example, resulted in an outbreak even though an undiagnosed TB patient had been in the emergency department for only two hours.2

High-risk patients entering an emergency department setting, where staff are often rushed and perform multiple tasks, makes for a volatile mix that is not conducive to the complex and elaborate guidelines for preventing and controlling TB in other health care settings, Stoller and Abernathy note.

While the pressures of the ED may explain some of those missed opportunities, it appears that staff may lack training and tools needed to diagnose TB. The center conducted site visits at a sample of seven emergency departments in the state to assess the accuracy and reliability of information used to reduce the risk of TB transmission in those settings. TB control policies and procedures were reviewed, triage procedures were observed, and key staff were interviewed.

"The most surprising finding was that if you asked people who are in charge of the TB program if they do triage for TB, almost 100% say they are. And yet nearly all of those we looked at were not," Abernathy says. "It's not that they were trying to be untruthful to us. They really believed they were doing it."

Chart reviews at emergency departments found that many patients were not screened for respiratory symptoms. And even when they were, screening often did not include TB-specific symptoms, such as hemoptysis, weight loss, or cough, she notes.

Stoller agrees that more attention is needed to educate ED staff. "A lot of staff in emergency department settings have questions about infection control and prevention of TB transmission," she tells TB Monitor.

The document presents a typical case of how easy TB symptoms can be overlooked when a patient comes into an emergency department for a non-TB-related emergency. A 39-year-old Mexican woman fell off a ladder and came to the emergency department with a broken arm. Only after the woman asked for something to treat her productive cough was her chest X-ray read for TB - six hours after she had been in the ED.

Hoping to prevent those types of cases, the center developed a set of guidelines that simplify CDC guidelines into plain and simple language.

"These people have nine million things to do, so we tried to include workable tools that would help them, more like a cookbook, so you can tear out pages for quick reference," Abernathy says.

The guidelines, which concentrate on risk assessment and triage of TB patients, are appropriate not just for emergency departments but urgent care centers and other facilities that treat persons who walk in off the street, she notes.

Starting with good risk assessment

The guidelines begin by providing information on how EDs can assess the likelihood of TB transmission in their facilities. Risk assessment work sheets are provided, as well as methods for calculating conversion rates at a facility. That process will help determine whether the ED is at low, moderate, or high risk for TB transmission, which will determine what level of triage will be needed.

The guidelines introduce three levels of triage procedures they suggest EDs consider for early identification of suspected TB patients. The guidelines take into account that a rural hospital that has not seen a TB case in three years will not need the same level of triage as an urban hospital serving a high proportion of foreign-born patients, Abernathy says, adding that the guidelines also discuss the advantages and disadvantages of each approach.

Level A, the most stringent, would require written TB symptoms and risk-factor screening of all patients who enter the emergency department regardless of their presenting complaint. Level C, on the other hand, allows the facility to define its own criteria for determining what type of patients are screened.

Once a suspected TB patient has been identified, the guidelines provide recommendations for isolating patients. This next step can cause complications because most departments are not equipped with negative pressure rooms, Abernathy notes. Segregating patients in exam rooms and masking them provides an adequate alternative until a diagnosis is made, and the patient can be moved. In addition, the guidelines discuss how to deal with stable but infectious TB patients sitting in the waiting room.

The last section of the guidelines provides information and work sheets on evaluating an ED TB triage program, primarily through making a retrospective review of patient charts.

[Editor's note: For more information about the guidelines, contact the Francis Curry National TB Center at (415) 502-4600. Or visit its Web site: http//www.nationalTBcednter.edu.]

References

1. Francis J. Curry National Tuberculosis Center. Identifying Persons with Infectious TB in the Emergency Department: A Guideline for Establishing Effective Practices. San Francisco; 1998.

2. Griffith D, Hardeman J. Tuberculosis outbreak among healthcare workers in a community hospital. Am J Resp Crit Care Med 1995; 152:808-811.