Protect yourself when caring for TB patients

ED nurses at Carondelet St Mary’s Hospital in Tucson, AZ, did the right thing when caring for a woman with cough and chills: They suspected tuberculosis (TB) and put her into isolation.

"The chest-X-ray showed a cavitation, but all other tests were negative," reports Diana Platt Lopez, RN, BSN, clinical educator for emergency services.

A month later, the woman returned with the same complaint and again received an X-ray. "However, she was not put in isolation this time since everything looked the same," says Platt Lopez.

The woman was admitted, and sputum samples came back positive for TB. "There was about a three-day lapse with about 50 exposures before she was placed in isolation," she says.

It is better to put into a patient into isolation and rule out TB even if the individual has been worked up recently and found to be negative, warns Platt Lopez, adding that the best rule of thumb is, "When in doubt, isolate until proven otherwise."

To reduce risks when caring for patients with possible tuberculosis, you must take the following actions:

• Limit exposure in waiting rooms.

Masks or tissues should be readily available in the waiting room, but you also may need to instruct patients to cover mouths when coughing to prevent the aerosolization of their sputum, says Platt Lopez.

"The Pima County Health Department’s TB clinic relayed to me that a tissue folded in half and placed over the patient’s mouth and nose and held firmly is just as effective as wearing a mask in controlling the spread of TB," she adds.

Explain to patients that you don’t want them catching anything else from other patients and vice versa, advises Platt Lopez. "It is amazing how many children cough without even using their hand to cover their mouths, and the parents are sitting right there and don’t intercede to teach them," she says. "In that case, I teach the child and parent at the same time."

Fold a tissue in half and cover your mouth with it while coughing, then have the patient demonstrate this in return, recommends Platt Lopez. The ED posts signs demonstrating, "Cover your cough" in English and Spanish.

• Err on the side of caution when determining whether to isolate a patient.

To assess the need for isolation, triage nurses should ask the following questions, says Karen Clements, RN, BSN, department head nurse for the ED at Eastern Maine Medical Center in Bangor:

— Have you had a cough for more than three weeks?

— Have you had recent weight loss?

— Have you had fever or chills?

— Have you had night sweats?

— Do you tire easily?

These questions usually are prompted by a chief complaint of cough or fatigue, says Clements. "If the patient answers yes’ to three or more of these identifiers, the patient is masked and placed in isolation in a negative-pressure room, the charge nurse is notified, and appropriate signage is placed outside of the room," she says.

Suspected or known TB positive patients should be placed in a negative-airflow room if at all possible, urges Platt Lopez. "It is good to remove a coughing patient as soon as possible from the general waiting room population," she says.

Be vigilant in identifying signs and symptoms that may indicate TB, especially if the patient is part of a high-risk group or has high-risk conditions, adds Platt Lopez. (See Tuberculosis Exposure Plan for Triage.)

• Use N-95 masks when you suspect TB.

"At triage, as soon as a patient appears to be coughing, the easiest thing to do is to put a mask on the patient," says Platt Lopez. "The nurse should don a N-95 mask just in case, if she suspects possible TB."

If the patient is not wearing a mask once in the room, the door should be shut with a sign for airborne precautions, and each time you enter the room, you should put on your mask, she says. "If the patient is going on a field trip in the hospital, then they must wear a simple mask until they return to their room," Platt Lopez adds.

• Remember that patients with unrelated complaints may have active TB.

You need an effective system to notify exposed staff when patients come to your ED with active TB that is undetected until a later date, says Platt Lopez. "We have had some instances where patients were found to have active TB who presented with an entirely different complaint and coincidentally had active TB as well," she says.

For instance, when an elderly man presented at the ED with an orthopedic injury, he was treated and released. Shortly after, he presented to the TB clinic for evaluation and was found to have active TB. In this case, the county health department contacted the facility’s infection control nurses, who in turn notified the ED staff, says Platt Lopez.

"All staff who charted on the patient’s chart were notified, and a general mailing was sent out asking nurses to contact the occupational health department if they had contact with the patient found to have active TB," she says.

Sources/Resource

For more information about reducing risks of tuberculosis patients in the ED, contact:

  • Karen Clements, RN, BSN, Eastern Maine Medical Center, 489 State St., Bangor, ME 04401. Telephone: (207) 973-8010. Fax: (207) 973-7985. E-mail: kfclements@emh.org.
  • Diana Platt Lopez, RN, BSN, Clinical Educator, Resource Clinician, Emergency Services, Carondelet St Mary’s Hospital, 1601 W. St Mary’s Road, Tucson, AZ 85745. Telephone: (520) 740-6193. Fax: (520) 872-6641. E-mail: dplopez@carondelet.org.

A Guideline for Establishing Effective Practices: Identifying Persons with Infectious TB in the Emergency Department (Publication WPT-02) helps ED staff establish effective TB control practices for early identification of patients with infectious tuberculosis and includes diagrams with instructions demonstrating how patients should cover their coughs in English and Spanish. The publication can be downloaded at no charge at www.nationaltbcenter.edu. Click on Products/Services," "Workplace Tools," "A Guideline for Establishing Effective Practices: Identifying Persons with Infectious TB in the Emergency Department," "Download now." Or, single printed copies are available free of charge. To order, contact:

Francis J. Curry National Tuberculosis Center, 3180 18th St., Suite 101, San Francisco, CA 94110-2028. Telephone: (415) 502-4600. Fax: (415) 502-4620. E-mail: tbcenter@national tbcenter.edu.