Self-Study Modules on Tuberculosis
Module 8: Tuberculosis Surveillance and Case Management in Hospitals
Answers To Study Questions
8.1. What are the three primary goals of TB prevention
The three primary goals of TB prevention and control
- Identify and treat persons who have active TB disease
- Identify and evaluate exposed contacts, offering appropriate
treatment as indicated
- Test populations at high risk for TB infection and disease
to detect infected persons, and provide treatment for latent
TB infection to prevent progression to active TB
To accomplish these goals, public health workers may be assigned
to make routine visits to hospitals or other institutional settings
(for example, nursing homes, correctional facilities, homeless
shelters) to gather information and interview TB patients and
plan for patients' follow-up care.
8.2. What are the four basic steps in the process for conducting
TB surveillance and providing case management in hospitals and institutions?
The four basic steps in the process for conducting TB surveillance
and providing case management in hospitals or institutions are
- Identify suspected or confirmed TB cases as soon as possible
and report them to the TB control program
- Collect information from the patient's medical record and
- Conduct an initial interview with every patient who has suspected
or confirmed TB
- Plan for each TB patient's follow-up care upon discharge from
the hospital or institution
8.3. What are the serious consequences of a lapse in communication
between patients and public health workers?
A lapse in communication can have serious consequences.
For example, poor communication can cause a patient to receive incomplete
or inadequate treatment and therefore remain ill or infectious.
Incomplete treatment is a serious failure for TB prevention and
- Additional persons may be exposed to TB
- Patients may be rehospitalized with serious complications
- Patients may develop multidrug-resistant TB
Effective communication, good surveillance procedures, and efficient
case management can help prevent such serious consequences.
8.4. Below is a list of several hospital or institution staff
with whom public health workers collaborate to conduct TB surveillance
and case management. Match the key staff with the type of help they
provide for conducting TB surveillance and case management.
|A. Infection control practitioner
||Mycobacteriology results, including smear and culture
|B. Laboratory staff
||Reporting of TB cases; infectiousness and isolation procedures
|C. Pharmacy staff
||Patient contacts; outbreak information
|D. Radiology staff
||Prescriptions; purchase records
|E. Hospital epidemiologists or employee health service
||X-rays; current or baseline films
|F. Discharge planners
||Patient records from prior hospitilizations or other health
|G. Medical records staff
||Patient locating information; plans for follow-up health
8.5. List four ways that public health workers support hospital
or institutional personnel. (page 12)
As liaisons with the TB program, public health workers
support hospital or institutional staff by
Providing important information on a patient's
Providing information on services available
through the TB program
Supplying educational materials for patients
and hospital or institutional staff
Helping to plan for follow-up care for TB patients
In addition, public health workers assigned to hospitals
and institutions support the TB program by conducting active case
finding, assisting with contact investigations, and monitoring
the progress of TB patients in the facility.
8.6. What are some of the roles of the health
department staff in the surveillance and case management of TB patients
in correctional facilities?
Health department staff should help develop programs
to train correctional facility staff to
Create TB control policies and procedures
Perform, read, and record tuberculin skin tests
Identify signs and symptoms of TB disease
Initiate and observe therapy
Monitor medication side effects
Collect diagnostic specimens
Maintain record systems
Provide tracking and patient record system
Ensure released inmates complete therapy
8.7. What can correctional facilities do to
help ensure completion of therapy for inmates released or referred
while being treated for TB infection or disease?
It may be necessary for correctional facility staff
to request health departments and receiving facilities to formally
notify them of the arrival of referred inmates on DOT who are
released or transferred into the jurisdiction. This is a very
important component of a good TB control program, since persons
who are lost to follow-up are at high risk of never completing
therapy, developing drug-resistant TB disease, and spreading TB
to others. Inmates on DOT for LTBI who are released or transferred
to other correctional facilities should also be referred for follow-up
8.8. Name three things that will increase
the suspicion of TB disease.
The presence of any of the following will increase
the suspicion of TB disease:
8.9. Under the classification system for TB,
give the class (0-5) for each type listed.
5 TB suspected
3 Current TB disease
1 Exposure to TB, no evidence of
4 Previous TB disease (not current)
0 No exposure to TB, not infected
2 TB infection, no disease
8.10. Explain the two basic methods for identifying
suspected or confirmed TB cases, and how they are put into practice.
The two basic methods for identifying suspected
or confirmed TB cases are
Routine case reporting
Active case finding
Routine case reporting is the required reporting
of suspected or confirmed TB cases to a public health authority.
In routine case reporting, physicians and other persons (for example,
infection control practitioners, pharmacists, laboratory staff)
submit reports of suspected or confirmed TB cases, as they are
detected, to a public health authority that collects and analyzes
the information. In active case finding, the TB program identifies
unreported cases of disease by actively searching for TB cases
through, for example, laboratory and pharmacy audits; active case
finding can be designed and implemented in several ways, depending
on local needs and practices. In addition to the public health
worker's responsibilities with cases routinely reported to the
TB program, he or she may also be doing active case finding to
identify suspected or confirmed TB cases that have not been reported.
8.11. How can public health workers use the
information found in laboratories and pharmacies?
Public health workers may make routine visits to
the pharmacies and to the mycobacteriology and pathology laboratories
used by the facilities to which they are assigned for TB surveillance.
With the collaboration of laboratory or pharmacy staff, public
health workers can use the information found there to
Actively search for unreported TB cases
Confirm suspected TB cases once the medical
evaluation is completed
Monitor the progress of reported TB patients
(for example, through sputum and culture conversion or prescription
Collect information on possible drug resistance
and the adequacy of the current regimen
8.12. What drugs are the focus of pharmacy
In most areas of the country, the initial regimen
for treating TB disease should include four first-line TB drugs:
The focus of pharmacy surveillance is the identification
of patients who are placed on two or more first-line TB drugs.
The reason for specifying two or more drugs is because patients
who may be on isoniazid (INH) therapy only are most likely on
a regimen for treatment for LTBI and not a regimen for the treatment
of TB disease.
8.13. How should a public health worker locate
a patient in a facility and where would he or she find patient addresses?
To locate a hospitalized patient or an institutional
resident, the public health worker should call the central information
number, if available, or check with the information desk receptionist.
He or she should ask for the patient's current room number and
ward or building location, as well as a phone number, if available.
If necessary, the public health worker may need to go to the admissions
or administrative office. Because patients are often transferred
from ward to ward or from room to room, it is important to get
current locating information. If a patient with suspected or confirmed
TB disease has left the facility or has died, record any available
patient addresses (for example, home address, next of kin, receiving
facility) from the medical record and report this immediately
to the TB program.
8.14. Where can smear and culture results
for a reported TB case be found?
A hospital's mycobacteriology laboratory has a
logbook or database containing AFB smear results, culture results,
and drug susceptibility patterns. The pathology laboratory will
have the results of AFB smears done on any tissue specimens submitted.
Although a computer database or the patient's medical record will
also have much of this information, it may not be complete or
accurate; laboratory reports are the definitive source for laboratory
results and should always be reviewed or obtained.
8.15. Describe seven main sections of the
patient's medical record.
The main sections of the patient's medical record
are as follows:
Identification data, including
the patient's name, address, social security number, date
of birth, and other demographic information (may be a separate
Progress notes, in which all
physicians and other specialists continuously record patient
information during a patient's hospital stay; they are an
important resource for information and may include nurses'
notes and notes from other ancillary staff
Nurses' notes, in which the
nurses who directly care for the patient continuously record
information, including the patient's symptoms, medications
given, and scheduled procedures or activities, and may be
included in the progress notes section
Physician's orders, in which
the physician(s) prescribes medications, orders laboratory
tests or procedures (for example, bronchoscopy or gastric
aspiration), and delivers other patient-care instructions
to staff. Medication orders specify date, name of medication,
dosage, and duration of treatment (in days or in number of
Medication record, an information
sheet on which the nurses record the date, time, and amount
of prescribed medications given to the patient during hospitalization
or care in a facility; may not be included in patient's medical
record (for example, may be kept in a separate medication
Laboratory results, records
presenting the results of every laboratory test that has been
done on the patient, such as AFB smear examinations, cultures,
and drug susceptibility tests performed in a laboratory
Radiology reports, reports
summarizing all radiology procedures performed on the patient
(for example, chest radiographs or CT scans)
8.16. Why is it important to gather information
on the patient's potential adherence?
It is important to collect information on the patient's
potential adherence in order to plan for and arrange the patient's
care both during and after hospitalization or stay in an institution.
Information about potential adherence problems may come from the
patient's medical record, social worker, nursing staff and physicians,
and family members or other visitors.
To help evaluate the patient's potential adherence
to therapy, it is important to note pertinent social history.
The public health worker should find out if the patient is foreign-born
or speaks a language other than English; if so, the public health
worker will need a translator for the patient interview and subsequent
care. The public health worker should look for and note a history
of residence in a congregate setting such as a prison, nursing
home, hospital, or shelter. Also note any history of drug or alcohol
abuse, homelessness, mental health problems, or previous nonadherence.
8.17. What should the initial patient interview
be used to do? Name four primary objectives.
The initial patient interview is very important
and should be used to
Establish the foundation for a good relationship
with the patient based on mutual trust and understanding
Confirm what the patient's address will be after
discharge and gather information on contacts who may have
been infected with M. tuberculosis
Begin an assessment of the patient's knowledge,
feelings, and beliefs about TB
Discuss the importance of adherence to the TB
In addition, the initial interview is a good opportunity
for the public health worker to
Get to know the patient
Educate the patient about TB
Look for factors that may affect the patient's
adherence to treatment
Arrange a follow-up visit with the patient
8.18. List four things that are necessary
for a successful initial interview between the public health worker
and the patient.
The initial interview marks the beginning of the
public health worker's relationship with a patient and therefore
requires a certain amount of planning. For the initial interview
to be successful, a public health worker should
Have a clear understanding of the interview's
Plan the interview so that each objective is
given adequate time
Listen to the patient's concerns about TB and
Share information freely with the patient
8.19. Under what conditions should the initial
interview take place? List four conditions that encourage effective
Because it is important to make the patient as comfortable
as possible, the public health worker should ensure that the interview
takes place under conditions that encourage effective communication.
These conditions include
Arranging for privacy and maintaining confidentiality
and assuring the patient all sensitive information will be
Creating an environment relatively free of distractions
and interruptions (for example, after physician or nursing
Listening attentively and respectfully to the
patient (for example, sit down near the patient and use open,
relaxed body language)
Being objective and nonjudgmental (for example,
be patient, not accusatory, and never show frustration)
8.20. List the three main objectives of a
contact investigation that should be kept in mind during the initial
The contact investigation should be started during
the initial patient interview, with three main objectives in mind:
Find out more about the patient's symptoms to
help determine the period of infectiousness
Find out places where the patient spent time
while he or she was infectious
Identify the patient's contacts, get the contacts'
addresses (if available) or other locating information, and
find out how long the contacts were exposed to the patient
while he or she was infectious
8.21. List seven things that the public health
worker will need to learn about his or her patient in order to assess
potential adherence problems
The public health worker will need to learn as much
as possible about his or her patient in order to assess potential
adherence problems. The public health worker will need to learn
about the patient's
Medical history and current health problems
Ethnic background and primary language(s)
Knowledge and beliefs about TB
Ability to take responsibility for following
their TB treatment plan or DOT arrangement
Resources (for example, family, other social
support, finances, interpretive services)
Barriers to treatment (for example, mental or
psychological problems, substance abuse, homelessness)
History of adherence to previous TB regimens
or other medication regimens
8.22. Describe the responsibility of the TB
program to every suspected or confirmed TB case.
It is the responsibility of the TB program to ensure
that every suspected or confirmed TB case that is reported receives
A complete diagnostic evaluation
An adequate regimen of TB medications
Appropriate measures to promote adherence and
completion of therapy
Public health workers assigned to hospitals and
institutions can play a key role in carrying out these responsibilities;
however, practices will vary from facility to facility and often
the infection control practitioner, hospital epidemiologist, or
employee health department will be primarily responsible for quality
assurance. Public health workers should collaborate with a facility's
staff to monitor the patient's care throughout the hospital or
institutional stay. This means assessing the patient's care periodically,
after a case has been reported and the initial patient interview
has taken place, and reporting any problems to the TB program.
8.23. Explain the purpose of discharge planning
and briefly describe the public health worker's role in discharge
planning for a TB patient.
For patients who leave a hospital or institution,
discharge planning is necessary to ensure continuity of treatment
and quality care. Discharge planning for TB patients should begin
soon after a suspected or confirmed TB case is reported. It is
usually a team effort, led by a nurse or a facility's discharge
planner. In some cases, a case manager assigned by the public
health department may be in charge of planning for a patient's
discharge. Team members often include at least two or more of
The discharge planner or case manager
Nurses or therapists involved in the patient's
A social worker
The patient's physician
Expert consultants, if required
DOT outreach worker
An institution-based public health worker can also
provide input and share responsibility for ensuring that the TB
patient is appropriately managed after discharge.
The discharge planning team should meet while the
patient is in the facility to review the patient's treatment plan
and develop an adherence plan. An adherence plan is a written
plan that is based on the patient's understanding and acceptance
of the TB diagnosis, that addresses barriers to adherence, and
that details the method chosen to deliver treatment and monitor
adherence for that specific patient. If possible, the patient
should be included in this meeting to aid in decision-making.
The treatment plan includes the details of the medical regimen
as ordered by the physician, as well as plans for monitoring for
adverse reactions and other follow-up care.
8.24. Explain how to find information on a
patient who has been discharged, left the facility, or died.
The public health worker may need to review the
medical record of a patient who has been discharged, has left
the facility against medical advice, or has died. In addition,
it is sometimes important to review the medical record from a
patient's prior hospitalization or stay in an institution. When
a patient is no longer in the facility, the patient's medical
record is sent to the medical records department. To access these
records, the public health worker will usually complete a medical
record request form, providing the patient's name and either a
medical record number or the patient's date of birth. Each facility
has a specific procedure for requesting patient records; the public
health worker should become familiar with the procedure used in
the facility or facilities in which he or she works. If a patient
has died while in the facility, there will usually be a death
report and a pathology report in the medical record. These reports
should be reviewed along with the rest of the medical record for
information relevant to the contact investigation.
8.25. Explain the procedures for sending patient
information from one health jurisdiction to another.
When a patient leaves a health jurisdiction before
completing TB therapy, patient information should be sent to the
patient's destination health jurisdiction. The following procedures
should be followed:
Patients who are on antituberculosis treatment
or treatment for LTBI should be given records they can take
with them to indicate their current treatment and diagnostic
status. Special care should be taken to instruct such persons
on how to take their medications and how and where to get
additional medication and medical care at the destination
All relevant medical information should be forwarded
to the destination jurisdiction. Some jurisdictions use a
standard form when referring patients between health jurisdictions.
The state health department TB control officers
should be contacted and apprised of the need for follow-up
and the next possible destination of the patient.
Although sharing necessary information between
health departments is encouraged to ensure continuity of care,
as well as protect the public, measures should be taken to
All information received on the TB patient,
including TB laboratory reports, after the TB patient departs
for another area should be immediately telephoned, faxed,
or expeditiously mailed to the receiving jurisdiction following
procedures to maintain patient confidentiality.
Out-of-state communications regarding TB care
should be routed through state health departments to ensure
that the information is transmitted and that necessary follow-up
The referring jurisdiction should follow up
and maintain communication as needed until the patient is
located in the destination jurisdiction.