Asking the Right Questions. A Visual Guide to Tuberculosis Case Management for Nurses. Reference Guide

Asking the Right Questions A Visual Guide to Tuberculosis Case Management for Nurses Reference Guide

The Francis J. Curry National Tuberculosis Center is a joint project of the San Francisco Department of Public Health and the University of California, San Francisco, funded by the Centers for Disease Control and Prevention (CDC) under CDC Cooperative Agreement U52 CCU 900454. Permission is granted for nonprofit educational use and library duplication and distribution. Suggested citation: Francis J. Curry National Tuberculosis Center. Asking the Right Questions: Reference Guide. San Francisco, CA; 2010: [inclusive pages]. This publication is available on the Francis J. Curry National Tuberculosis Center website at www.nationaltbcenter.edu/arq/. Design: Edi Berton Design

Contents Contents... 1 Introduction... 2 About this Project... 2 Why Are Questions Important?... 2 Why Understand the Whole TB Case Management Process?... 3 The Right Questions Quick Reference List... 5 Throughout Case Management... 8 Understanding TB Case Management Goals and Tasks... 8 Ensuring that the Patient Understands TB... 10 Completing the Patient s Chart... 11 Taking Special Considerations into Account... 12 During Assessment... 13 Determining the Risk for TB... 13 Knowing When to Suspect TB... 14 Gathering Information to Evaluate the Patient s TB Disease... 19 Determining the Patient s Infectious Period... 25 Learning about the Patient s Culture and Beliefs... 27 Ensuring that the Patient s Basic Needs are Met... 29 During Treatment... 30 Ensuring Completion of Therapy... 30 Monitoring the Patient s Response to Treatment... 33 Monitoring for Adverse Reactions... 37 Determining When Treatment Is Completed... 38 Page 1 Asking the Right Questions: A Visual Guide to TB Case Management Reference Guide 2010

Introduction About this Project Purpose Use the Asking the Right Questions educational toolkit to Prompt your critical thinking about TB case management Find relevant basic national training materials Get an overview of the full TB case management timeline Online Educational Toolkit Go to the Asking the Right Questions Web Guide at www.nationaltbcenter.ucsf.edu/ arq/ to download the Asking the Right Questions Visual Guide to TB case management, usable as a poster or smaller reference sheet. While on the website, you also can interactively review the TB case management timeline, explore the right questions list, hyperlink directly to national training materials and guidelines, and access an online glossary. Why Are Questions Important? No Step-by-Step Procedures TB cannot be assessed or treated using a set of step-by-step procedures. Instead, to assess and treat TB requires applying guidelines to each patient s situation. To assess or diagnose TB, you can use several different sets of criteria depending upon the patient s situation. Each patient can present TB signs and symptoms differently, depending upon factors such as age, immune system status, coexisting diseases, area of the body affected, and severity of the TB disease. In assessment, for example, a standard test for pulmonary TB (acid-fast bacilli sputum smear microscopy) cannot detect the disease in its early stages, although the patient may have TB symptoms and be infectious. Sometimes a patient with TB disease may not have a cough if the immune system is suppressed or if they are under age 5, and HIV-positive patients with TB disease can have normal-appearing chest x-rays. Further, a patient can have culture-negative TB disease and be clinically diagnosed to have TB. In that case, a TB diagnosis requires starting empiric TB treatment and learning from the patient s response if he or she has TB. Multiple factors can affect the choice of a TB treatment regimen. When planning how to treat a TB patient and when monitoring the patient while on treatment, you need to consider many aspects of the patient s situation, such as: Page 2

Extent and site of the TB disease Drug resistance Other conditions, such as HIV, diabetes, arthritis Age Mental health and substance abuse Stability of residence Culture and beliefs about healthcare and TB Language These factors can impact the choice of treatment regimen, how it is delivered, and how you can help the patient to adhere to 6 to 12 months of treatment. Further, many of these factors can change during a patient s treatment. Critical Thinking Because a set of step-by-step procedures will not fit all patients, you need to gather and review the data for each patient s medical and psychosocial situation and work with your team to apply guidelines for assessment and treatment. This requires that you think critically and the key to critical thinking is asking yourself good questions. To recognize good questions, it helps to understand the TB case management process, be familiar with national guidelines (and local guidelines and protocols where available), and to carefully look at the data about your patient. Why Understand the Whole TB Case Management Process? Understanding the whole process of TB case management prompts you to ask the questions that you need to answer in order to meet TB case management goals and to understand the impact of your decisions and work throughout the TB case management process. TB Case Management Goals Asking good questions ensures make sure that you and the team meet TB case management goals for your patient: The patient is assessed, a medical evaluation is performed by a physician, and a treatment plan is established The patient is educated about TB and its treatment Treatment is promptly started with directly observed therapy and is continuous, safe, and completed Contacts are identified, screened, and evaluated and those who are eligible started on treatment for latent TB infection Page 3

The Impact of Your Work Your decisions will affect whether and when to suspect TB, the quality of assessment data collected, treatment planning and start date, the patient s understanding of TB, the patient s willingness and ability to adhere to treatment, and the safety and effectiveness of treatment. Page 4

The Right Questions Quick Reference List Throughout Case Management? What are your goals and tasks to case manage this confirmed or suspected TB patient? What goals and tasks does your TB case management work involve? (Go to p.8) What is your role as a healthcare worker in TB treatment? (Go to p. 8)? After you provide information, has the patient explained back an accurate and complete understanding about TB and its treatment? What is missing or misunderstood? What is your process for educating this patient about TB? (Go to p.10)? Could someone pick up the patient s chart and know what s going on? Does the team regularly document all patient data and interventions? (Go to p. 11) Is the patient s treatment plan documented? (Go to p. 11)? Are there special considerations to take into account about your patient: HIV, pregnancy, breastfeeding, younger than 4 years old, extrapulmonary TB, diabetes, kidney dialysis, or any drug resistance? Where do you find information on conditions requiring special consideration? (Go to p. 12) During Assessment? How do you know that the patient is at risk for TB? What are the patient s risk factors for TB? (Go to p. 13) What are the risk factors for multidrug-resistant TB (MDR TB)? (Go to p. 13)? Why do you suspect that this patient has TB: TB symptoms? Abnormal chest x-ray? History? How is latent TB infection different from active TB disease? (Go to p. 14) How does latent infection progress to active disease? (Go to p. 15) Page 5 Asking the Right Questions: A Visual Guide to TB Case Management Reference Guide 2010

Does this patient have any history, signs, or symptoms associated with pulmonary TB disease? (Go to p. 16) Does this patient have any risk factors for multidrug-resistant TB (MDR TB)? (Go to p. 13) Does this patient have any characteristic or condition that may mask typical signs and symptoms of TB disease? (Go to p. 18) How do you prevent transmission if your patient is a TB suspect? (Go to p. 26)? How do you know that you can accurately describe the patient s TB disease? Was there a complete medical evaluation? (Go to p. 19) What information do you have about this patient s medical history? (Go to p. 19) What did the patient s physical examination reveal? (Go to p. 19) What tests were ordered to diagnose TB infection, and what test results were reported? (Go to p. 20) Were chest-x-rays ordered, and, if so, what did they show? (Go to p. 21) What bacteriologic tests were ordered to diagnose TB disease and what information did they provide? (Go to p. 22) Were rapid tests ordered for TB disease and multidrug-resistant TB (MDR TB)? (Go to p. 23) Where and when was the patient interviewed? (Go to p. 24) What questions was the patient asked? (Go to p. 24) What infection control precautions were taken for this patient? (Go to p. 26)? On what evidence did you determine the patient s infectious period? When did the patient s symptoms begin, and how reliable is your evidence for that date? (Go to p. 25) Who were the patient s contacts and where were potential transmission sites during the infectious period? (Go to p. 25)? How did the patient describe her/his culture and initial beliefs about TB? What cultural competency skills have you used with this patient? (Go to p. 27) Where did you find information on the patient s culture? (Go to p. 27) Have you used an appropriate interpreter, if needed? (Go to p. 28)? How do you know whether or not your patient can get food, shelter, clothing, transportation, and health care? What enabler(s) have you used with this patient? (Go to p. 29) What referrals to other services did you provide for this patient? (Go to p. 29) Page 6 Asking the Right Questions: A Visual Guide to TB Case Management Reference Guide 2010

During Treatment? Is DOT happening as mutually agreed upon? Has the patient been observed swallowing each dose of anti-tb medication? (Go to p. 30) What are the terms of the patient s DOT agreement? (Go to p. 30) What other strategies are you using to foster adherence to treatment? (Go to p. 31) Are you using them in order from least restrictive to more restrictive? (Go to p. 32)? How do you know whether or not the patient is responding to treatment? What clinical observations are made to check for response to treatment and how frequently? (Go to p. 33) What bacteriologic tests did you order and how frequently? (Go to p. 34) If ordered, what did the chest x-rays show? (Go to p. 35) What signs and symptoms do you check to know if the patient is not responding to treatment? (Go to p. 36)? How have you checked for signs and symptoms of adverse reactions or side effects? How do you check the patient for signs and symptoms of an adverse reaction to anti-tb medication? Have you documented the adverse reactions? (Go to p. 37) Have you educated the patient on what to do if there are symptoms of an adverse reaction? Have you documented this patient s education? (Go to p. 37) What is your plan of action if the patient shows signs and symptoms of an adverse reaction? Have you documented the plan of action? (Go to p. 38) Page 7 Asking the Right Questions: A Visual Guide to TB Case Management Reference Guide 2010

Throughout Case Management Throughout Case Management The case manager is assigned primary responsibility Understanding TB Case Management Goals and Tasks Role of the Healthcare Worker The responsibility for TB control and prevention in the United States rests with the public health system through federal, state, county, and local public health agencies. To ensure that patients complete TB treatment, public health agencies use a case management model in which a health department employee is assigned responsibility for the management of specific patients, including monitoring patients for adverse reactions to anti-tb medications. Healthcare workers outside of the public health department at community clinics, hospitals, private medical offices, correctional facilities, and skilled nursing facilities also play important roles. Often they are the first to detect a patient s TB signs and symptoms. Throughout assessment and treatment, they may be involved in caring for the patient, forming an important part of the case management team. Responsibilities of the TB Case Manager In case management, the health department employee designated as the case manager is assigned primary responsibility and is held accountable for ensuring that: The patient is assessed, a medical evaluation is performed by a physician, and a treatment plan is established The patient is educated about TB and its treatment Treatment is promptly started with directly observed therapy and is continuous, safe, and completed Contacts are identified, screened, and evaluated and those who are eligible started on treatment for latent TB infection Although one person is assigned primary responsibility, case management provides continuity of care by using a team of persons who work together to help each patient complete treatment. What Is the Role of the Public Health Worker in TB Treatment? (Module 4, p. 45) www.cdc.gov/tb/education/ssmodules/pdfs/module4.pdf What is Case Management? (Module 9, pp. 12-13) www.cdc.gov/tb/education/ssmodules/pdfs/9.pdf Page 8

Throughout Case Management CDC. MMWR: Controlling Tuberculosis in the United States: Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America www.cdc.gov/mmwr/pdf/rr/rr5412.pdf New Jersey Medical School Global Tuberculosis Institute. Tuberculosis Case Management for Nurses: Self-Study Modules: Overview of Public Health and Public Health Nursing (Module 1, pp. 1-19) www.umdnj.edu/globaltb/downloads/products/nursing%20module%201.pdf Fundamentals of Tuberculosis Case Management (Module 2, pp. 3-20) www.umdnj.edu/globaltb/downloads/products/nursing%20module%202.pdf Page 9

Throughout Case Management Ask the patient what has just been explained and what is understood Ensuring that the Patient Understands TB Patient Education Before you begin educating a patient about TB, find out how much the patient may already know about TB. To present new information, use effective communication techniques such as the following: Use simple, nonmedical terms Use the appropriate language level Limit the amount of information Discuss the most important topics first and last Repeat important information Listen to feedback and questions from the patient Use concrete examples Make the interaction with the patient a positive experience To be certain that a patient has an accurate understanding, ask the patient what has just been explained and what is understood. Do this with concern and care so that the patient does not feel threatened. Spend extra time reviewing important information. Examples of Open-Ended Questions for Patient Assessment (Module 9, p. 17) www.cdc.gov/tb/education/ssmodules/pdfs/9.pdf Effective Communication Techniques (Module 9, pp. 27-31) www.cdc.gov/tb/education/ssmodules/pdfs/9.pdf Cultural Competency topic (Go to p. 26) Professional Medical Interpreters topic (Go to p. 27) Page 10

Throughout Case Management Completing the Patient s Chart Recommended Documentation The nurse case manager must ensure that documentation is completed regularly by all members of the case management team. Document all interventions in a clear and concise manner to support continuation of appropriate care. A chart audit tool offers a way to check your documentation. Document all interventions in a clear and concise manner TB Treatment Plan For each patient with newly diagnosed TB, develop a specific treatment and monitoring plan within one week of the suspected diagnosis. If you work in a community clinic, hospital, or other setting outside of the local health department, collaborate with your local health department when developing the treatment plan. This plan should include: A description of the treatment regimen Methods of monitoring for adverse reactions Methods of assessing and ensuring adherence to the treatment Methods for evaluating treatment response New Jersey Medical School Global Tuberculosis Institute. Tuberculosis Case Management for Nurses: Self-Study Modules: Fundamentals of Tuberculosis Case Management: Documentation (Module 2, pp. 19-20) Plan Development and Appendix 4: Elements of a Treatment Plan for Patients with TB (Module 2, pp. 14, 26-27) www.umdnj.edu/globaltb/downloads/products/nursing%20module%202.pdf Treatment and Monitoring Plan (Module 4, p. 34) www.cdc.gov/tb/education/ssmodules/pdfs/module4.pdf Washington State Department of Health. Washington State Tuberculosis Services Manual: Tuberculosis Chart Audit Tool www.doh.wa.gov/cfh/tb/manual/forms/chartaudit.pdf Page 11

Throughout Case Management Taking Special Considerations into Account Special Considerations for TB Assessment and Treatment The situations listed below require additional or different testing and tasks during TB assessment and treatment: HIV Consult a TB expert and national guidelines Pregnancy Breastfeeding Age Under 4 Diabetes Kidney Dialysis Drug Resistance Extrapulmonary TB Consult a TB expert and the resources below to understand how best to assess and treat a patient with one or more of these conditions. CAUTION: HIV-positive patients should be referred to HIV/AIDS specialists and have their TB treatment administered in consultation with those specialists. Treatment Regimens (Module 4, pp. 29-31) www.cdc.gov/tb/education/ssmodules/pdfs/module4.pdf CDC. MMWR: Treatment of Tuberculosis (pp. 50-66) www.cdc.gov/mmwr/pdf/rr/rr5211.pdf Page 12

Assessment During Assessment Carefully consider information about your patient to assess risk for TB Determining the Risk for TB High-Risk Groups Information about a patient s medical condition, age, TB exposure, place of birth, travel and immigration, residence, workplace, socioeconomic situation, lifestyle, and substance abuse are important in assessing risk for TB. High-risk groups can be divided into two categories: People who are at high risk for becoming infected with Mycobacterium tuberculosis People who are at high risk for developing TB disease once infected with M. tuberculosis In the Self-Study Modules on Tuberculosis, the CDC lists these groups in Table 3.1: Groups at High Risk for LTBI and TB Disease. Refer to p. 7 of Module 3 online at www.cdc.gov/tb/education/ssmodules/pdfs/module3.pdf. Risk for Multidrug-Resistant TB (MDR TB) Drug resistance is more common in people who: Have had a previous episode of TB treatment Have had inadequate or improper current TB treatment (patient not taking medications regularly, breaks in treatment, wrong drugs prescribed, treatment duration too short) Are not responding to current TB treatment Have come from, or frequently travel to, areas of the world where drug-resistant TB is common Have spent time with someone known to have drug-resistant TB disease Order rapid molecular drug susceptibility testing on smears for patients from areas with endemic MDR TB or with past exposure to MDR TB. Groups at High Risk for LTBI and TB Disease (Module 3, pp. 6-7) www.cdc.gov/tb/education/-ssmodules/pdfs/module3.pdf CDC. Multidrug-Resistant Tuberculosis (MDR TB) Fact Sheet www.cdc.gov/tb/publications/factsheets/drtb/mdrtb.htm Francis J. Curry National Tuberculosis Center. Drug-Resistant Tuberculosis: A Survival Guide for Clinicians www.nationaltbcenter.ucsf.edu/products/product_details.cfm?productid=wpt-11cd World Health Organization. Multidrug and Extensively Drug-resistant TB (M/ XDR-TB): 2010 Global Report on Surveillance and Response http://whqlibdoc.who.int/publications/2010/9789241599191_eng.pdf See the Rapid Tests for TB Disease and Drug Resistance topic (Go to p. 22) Page 13

Assessment Knowing When to Suspect TB Classification System for TB The current classification system is based on the pathogenesis of TB. Many healthcare providers use this system to describe patients. Be aware that a Class 3 patient should be receiving treatment for TB The current classification system is based on the pathogenesis of TB Note that a Class 5 patient may require treatment if the suspicion of TB is moderate or high Promptly report the case or suspected case on treatment to the local or state health department Classification System for TB Class Type Description 0 No TB exposure Not infected No history of TB exposure Negative result to a TST or IGRA 1 TB exposure No evidence of infection 2 TB infection No TB disease 3 TB, clinically active 4 Previous TB disease (not clinically active) History of TB exposure Negative result to a TST (given at least 10 weeks after exposure) or to an IGRA Positive result to a TST or to an IGRA Negative smears and cultures (if done) No clinical or x-ray evidence of active TB disease Positive culture (if done) for Mycobacterium tuberculosis Positive result to a TST or to an IGRA, and clinical, bacteriological, or x-ray evidence of TB disease Medical history of TB disease Abnormal but stable x-ray findings Positive result to a TST or to an IGRA Negative smears and cultures (if done) No clinical or x-ray evidence of current TB disease 5 TB suspected Signs and symptoms of TB disease, but evaluation not complete IGRA = interferon gamma release assay; TST = tuberculin skin test Page 14

Assessment Always Think TB Progression to TB Disease Progressing from TB infection to TB disease means that the body cannot fight the TB bacteria and they begin to multiply. Before there are enough TB bacteria in the lungs to confirm TB disease, the patient may feel unwell and may have symptoms such a cough, loss of weight, bloody sputum, and weakness. Often to relieve symptoms, the patient makes several visits to a doctor, clinic, or hospital. Healthcare workers in hospitals and community clinics as well as public health should always Think TB to prevent delays in diagnosis. Classification System for TB (Module 1, pp. 25-26) www.cdc.gov/tb/education/ssmodules/pdfs/module1.pdf Latent TB Infection (LTBI) and LTBI vs. TB Disease (Module 1, pp. 13-14) www.cdc.gov/tb/education/ssmodules/pdfs/module1.pdf Pathogenesis (Module 1, pp.12-21) www.cdc.gov/tb/education/ssmodules/pdfs/module1.pdf CDC and ATS. American Journal of Respiratory Critical Care Medicine: Diagnostic Standards / Classification of TB in Adults and Children (pp. 1377-78,1391-92) www.cdc.gov/tb/publications/pdf/1376.pdf Page 15

Assessment When to Suspect TB Disease [! ] Suspect TB in any patient who has a persistent cough for more than two to three weeks (and does not respond to over-the-counter medications), or who has other compatible signs and symptoms. Ask the patient to use a surgical mask or tissue to cover the mouth. Suspect TB in any patient who has a persistent cough for more than 2 to 3 weeks, or other compatible signs and symptoms [! ] Medically evaluate for TB disease anyone with symptoms of TB or anyone found to have a positive tuberculin skin test or interferon gamma release assay. When to Suspect Pulmonary TB in Adults Suspect pulmonary TB and start to assess a patient when the features, signs, symptoms, and findings listed below occur in an adult. Be aware that the clinical presentation of TB varies considerably as a result of the extent of the disease and the patient s response. Historic Features Exposure to a person with infectious TB Positive test result for Mycobacterium tuberculosis infection Presence of risk factors, such as immigration from a high-prevalence area, HIV infection, homelessness, or previous incarceration* Diagnosis of community-acquired pneumonia that has not improved after 7 days of treatment Previous treatment for latent TB infection or disease Signs and Symptoms Typical of TB Prolonged coughing ( 2 3 weeks) with or without production of sputum that might be bloody (hemoptysis) Chest pain Chills Fever Night sweats Loss of appetite Weight loss Chronic malaise and fatigue Chest Radiograph: Immunocompetent patients Classic findings of TB are upper-lobe opacities, frequently with evidence of contraction fibrosis and cavitation In patients with diabetes, atypical presentation is more common with exclusive lower lobe disease Chest Radiograph: Patients with advanced HIV infection Lower-lobe and multilobar opacities, hilar adenopathy, or interstitial opacities might indicate TB * See the High-Risk Groups topic. (Go to p. 13) Patients treated with levofloxacin or moxifloxacin may have a clinical response when TB is the cause of the pneumonia. Do not wait until sputum is bloody to consider a productive cough a symptom of TB. Sputum produced by coughing does not need to be bloody to be a symptom of TB. These features are not specific for TB, and, for every person in whom pulmonary TB is diagnosed, an estimated 10 100 persons are suspected on the basis of clinical criteria and must be evaluated. Information on patients with diabetes from Kawamura, LM. Diabetes and Tuberculosis: Converging Epidemics. Presentation at the National TB Conference. Atlanta, GA; June 24, 2010. Page 16

Assessment Diagnosis of TB Disease (Module 3, pp. 41-42) www.cdc.gov/tb/education/ssmodules/pdfs/module3.pdf CDC and ATS. American Journal of Respiratory Critical Care Medicine: Diagnostic Standards / Classification of TB in Adults and Children (pp. 1378-81) www.cdc.gov/tb/publications/pdf/1376.pdf Page 17

Assessment Conditions that Mask TB Signs and Symptoms A patient with TB disease may or may not have symptoms People with TB disease may or may not have symptoms. In many patients, TB is associated with other medical and social conditions such as HIV infection, diabetes mellitus, kidney failure, cancer, homelessness, alcohol or drug abuse, malnourishment, and diseases that require immunosuppressive drugs. The signs and symptoms of these conditions and their complications can easily mask those of TB and result in considerable delays in diagnosis, especially in patients with HIV infection. Factors that Influence the Clinical Features of TB Host (Patient) Factors Age Immune status Specific immunodeficiency states Malnutrition Genetic factors (not yet defined) Coexisting diseases Immunization with bacillus Calmette-Guérin (BCG) Microbial (TB Strain) Factors Virulence of the organism Predilection (tropism) for specific tissues Host (Patient) Microbe (TB Strain) Interaction Sites of involvement Severity of disease TB should still be considered a diagnosis in asymptomatic patients who have risk factors for TB and abnormal chest x-rays compatible with TB. If a patient is symptomatic, do not be fooled by a negative TB test. A negative tuberculin skin test or interferon gamma release assay never rules out active TB or TB disease. Active TB itself or other immunocompromising conditions often cause falsely negative tests because TB tests require a healthy immune system to react. Extrapulmonary TB should be considered if there are risk factors and general symptoms of TB (such as weight loss, fever, or night sweats) and no pulmonary symptoms. The symptoms of extrapulmonary TB depend on the part of the body that is affected by the disease. CDC and ATS. American Journal of Respiratory Critical Care Medicine: Diagnostic Standards / Classification of TB in Adults and Children (pp. 1378-81) www.cdc.gov/tb/publications/pdf/1376.pdf CDC. MMWR: Tuberculosis Associated with Blocking Agents Against Tumor Necrosis Factor- Alpha California, 2002 2003 www.cdc.gov/mmwr/pdf/wk/mm5330.pdf Page 18

Assessment A complete medical evaluation includes five components Gathering Information to Evaluate the Patient s TB Disease Medical Evaluation A complete medical evaluation for diagnosing TB disease includes: Medical history Physical examination Testing for TB infection Chest x-rays Bacteriologic examination and culture (may include molecular testing) Medical History To document medical history, ask whether the patient has: Any symptoms of TB disease Been exposed to a person with infectious TB or has risk factors for exposure to TB Risk factors for developing TB disease Had latent TB infection or prior TB disease Any previous treatment for latent TB infection or TB disease Suspect TB disease in patients with any of these factors. Physical Examination A physical examination can provide valuable information about the patient s overall condition and factors that may affect how TB disease is treated, if diagnosed. However, a physical examination cannot confirm or rule out TB disease. At a minimum, a physical examination should include: Temperature and weight Overall assessment of nutritional status (pale conjunctiva may indicate anemia of chronic disease) Lymph node palpation Heart and lung examination Extremity examination looking for signs of chronic lung disease such as blue fingers or clubbing of the fingernails Diagnosis of TB Disease (Module 3, pp. 40-43) www.cdc.gov/tb/education/ssmodules/pdfs/module3.pdf CDC and ATS. American Journal of Respiratory Critical Care Medicine: Diagnostic Standards / Classification of TB in Adults and Children (pp. 1376-95) www.cdc.gov/tb/publications/pdf/1376.pdf Patient Interviews topic (Go to p. 23) Page 19

Assessment Testing for TB Infection Two types of tests are available to test for TB infection: the TB skin test (TST) and blood tests. Tuberculin Skin Test (TST) Two types of tests are available to test for TB infection You can use a Mantoux (TST) to determine if a person is infected with Mycobacterium tuberculosis. In this test, you inject tuberculin (also known as purified protein derivative, or PPD) into the skin. Interferon Gamma Release Assays (IGRAs) IGRAs are blood tests that measure a person s immune reactivity to M. tuberculosis. Currently available IGRAs include QuantiFERON -TB Gold (QFT-G), QuantiFERON - TB Gold In-Tube (QFT-GIT), and T-SPOT.TB (T-Spot) tests. Targeted Testing and the Diagnosis of Latent Tuberculosis Infection and Tuberculosis Disease (Module 3, pp. 8-39) www.cdc.gov/tb/education/ssmodules/pdfs/module3.pdf CDC. MMWR: Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection (pp. 1-51) www.cdc.gov/mmwr/pdf/rr/rr4906.pdf CDC. MMWR: Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium tuberculosis Infection United States, 2010 (pp. 1-25) www.cdc.gov/mmwr/pdf/rr/rr5905.pdf Page 20

Assessment Chest X-Rays for Assessment During assessment, chest x-rays (CXRs) are used to: Chest x-rays help rule out pulmonary TB disease and check for lung abnormalities Help rule out the possibility of pulmonary TB disease in a person who has a positive tuberculin skin test (TST) or a positive QuantiFERON -TB Gold (QFT-G), QuantiFERON -TB Gold In-Tube (QFT-GIT) or a T-SPOT.TB (T-Spot) result Check for lung abnormalities in people who have symptoms of TB disease Sometimes an abnormal chest x-ray provides the first clue that your patient has pulmonary TB. In this situation, get a full TB symptom and medical history, administer a TST or interferon gamma release assay (IGRA), and collect three sputum specimens for acid-fast bacilli (AFB) sputum smear microscopy and culture. Sputum specimens are the best means to promptly test for pulmonary TB. Collect the sputum specimens 8 to 24 hours apart, with at least one being an early morning specimen. On all firsttime sputum specimens, obtain a rapid molecular detection test called a nucleic acid amplification test (NAAT) or use a molecular detection of drug resistance test. The results of a chest x-ray, however, cannot confirm that a person has TB disease. A variety of illnesses may produce abnormalities whose appearance on a chest x-ray resembles TB. In persons living with HIV, pulmonary TB disease may have an unusual appearance on the chest x-ray. The chest x-ray may even appear entirely normal. Diagnosis of TB Disease: The Chest X-Ray (Module 3, pp. 46-47) www.cdc.gov/tb/education/ssmodules/pdfs/module3.pdf Francis J. Curry National Tuberculosis Center. Radiographic Manifestations of Tuberculosis: A Primer for Clinicians www.nationaltbcenter.ucsf.edu/products/product_details.cfm?productid=edp-04 CDC and ATS. American Journal of Respiratory Critical Care Medicine: Diagnostic Standards / Classification of TB in Adults and Children (pp. 1378-79) www.cdc.gov/tb/publications/pdf/1376.pdf Page 21

Assessment Bacteriologic Examination for Assessment Clinical specimens (for example, sputum or urine) are examined and cultured (grown) in the laboratory for the bacteriologic examination. TB bacteriologic examination is done in a laboratory that specifically deals with Mycobacterium tuberculosis and other mycobacteria. Collect three sputum specimens 8 to 24 hours apart, with at least one being an early morning specimen The bacteriologic examination has five parts: 1. Specimen collection 2. Direct smear for examination acid-fast bacilli (AFB) 3. Nucleic acid amplification test (NAAT) for direct identification of M. tuberculosis from the first sputum specimen 4. Culture and identification 5. Drug susceptibility testing Collect three sputum specimens for AFB sputum smear microscopy and culture 8 to 24 hours apart, with at least one being an early morning specimen. On all first-time sputum specimens, obtain the rapid molecular detection NAAT. If the first culture results are positive, order drug susceptibility tests. If susceptibility testing shows isoniazid and rifampin resistance, order testing on susceptibility to second-line drugs. If a patient comes from an area with endemic multidrug-resistant TB or has past exposure to multidrug-resistant (MDR TB), order rapid molecular drug susceptibility testing on smears on the first positive culture. Diagnosis of TB Disease: The Bacteriologic Examination (Module 3, pp. 48-64) www.cdc.gov/tb/education/ssmodules/pdfs/module3.pdf CDC. MMWR: Updated Guidelines for the Use of Nucleic Acid Amplification Tests in the Diagnosis of Tuberculosis www.cdc.gov/mmwr/pdf/wk/mm5801.pdf CDC and ATS. American Journal of Respiratory Critical Care Medicine: Diagnostic Standards / Classification of TB in Adults and Children (pp. 1381-87) www.cdc.gov/tb/publications/pdf/1376.pdf Page 22

Assessment Rapid Tests for TB Disease and Drug Resistance Nucleic Acid Amplification Test (NAAT) A NAAT can be used for directly identifying Mycobacterium tuberculosis from sputum specimens, avoiding the delay in waiting for a culture result. A NAAT avoids the delay in waiting for a culture result If a patient has a positive NAAT or an acid-fast bacilli (AFB)-positive smear, the patient can be presumed to have TB. If a patient has a negative NAAT with an AFB-positive smear, the patient may have a nontuberculous mycobacteria infection. NAAT results can help guide the clinician s decisions for treatment and isolation; however, they do not replace the need for AFB smear, culture, or clinical judgment. Molecular Drug Susceptibility Testing If a patient comes from an area with endemic multidrug-resistant TB (MDR TB), has had prior TB treatment, or has past exposure to MDR TB, order rapid molecular drug susceptibility testing on smears of the first positive culture. Rapid drug resistance testing may be available from the CDC if your patient is at high risk of MDR TB. The CDC s Molecular Detection of Drug Resistance (MDDR) test allows rapid confirmation of resistance to the first-line drugs rifampin (RIF) and isoniazid (INH). It also can confirm resistance to the most effective second-line drugs: fluoroquinolones (FQ) and the injectables amakacin (AMK), kanamycin (KAN), and capreomycin (CAP). MDDR is a presumptive test and needs to be confirmed by traditional susceptibility testing. CDC performs confirmation for the first-line drugs (up to 14 days from the receipt of the specimen) and second-line drugs (28 days from the receipt of the specimen). MDDR results are available within three to four business days from the receipt of specimen at the CDC laboratory. Diagnosis of TB Disease: The Bacteriologic Examination (Module 3, p. 58) www.cdc.gov/tb/education/ssmodules/pdfs/module3.pdf CDC. MMWR: Updated Guidelines for the Use of Nucleic Acid Amplification Tests in the Diagnosis of Tuberculosis www.cdc.gov/mmwr/pdf/wk/mm5801.pdf CDC. Report of Expert Consultations on Rapid Molecular Testing to Detect Drug-Resistant Tuberculosis in the United States; 2010 www.cdc.gov/tb/topic/laboratory/rapidmoleculartesting/default.htm CDC. Laboratory User Guide: Molecular Detection of Drug Resistance (MDDR) in Mycobacterium tuberculosis Complex by DNA Sequencing www.cdc.gov/tb/topic/laboratory/guide.htm CDC. Use of the MDDR Service by Submitters [web page] www.cdc.gov/tb/topic/laboratory/userguide/submitters.htm Washington State Department of Health. Washington State TB Services Manual: Chapter 4: Diagnosis of Tuberculosis Disease (p. 4.20) www.doh.wa.gov/cfh/tb/manual/sections/section4.pdf Page 23

Assessment Patient Interviews Interview a patient both during the initial assessment and during ongoing assessments throughout treatment. The patient interviews collect data to: Make decisions for the patient s treatment and care Interview a patient both during the initial and ongoing assessments throughout treatment Identify areas where the patient requires education about TB Identify adverse reactions to medications Guide the contact investigation Conduct the initial assessment during the patient s hospitalization, at the first clinic visit, or during a home visit. During treatment, conduct an ongoing assessment monthly. Additional assessments may be needed if the patient has problems with treatment or is nonadherent to directly observed therapy or follow-up appointments. The case manager needs all medical records in order to provide case management and recommend a case management plan. Prior to the visit with the patient, ensure that a copy of all of the patient s medical records (from hospitals, clinics, and other healthcare providers) and chest radiographs are available to the treating physician. Learn about the differences between a patient s beliefs and your beliefs by asking several open-ended questions. An open-ended question begins with a word that demands an explanation so that it cannot be answered with a simple yes or no. Getting to Know the Patient (Module 9, pp. 14-24) www.cdc.gov/tb/education/ssmodules/module6/ss6recordreview.htm#interview Patient Interview (Module 6, pp. 28-36) www.cdc.gov/tb/education/ssmodules/pdfs/6.pdf Strategies for Conducting Effective Interviews (Module 6, pp. 36-43) www.cdc.gov/tb/education/ssmodules/pdfs/6.pdf Open-Ended Questions (Module 9, pp. 16-24; Module 6, p. 45) www.cdc.gov/tb/education/ssmodules/pdfs/9.pdf www.cdc.gov/tb/education/ssmodules/pdfs/6.pdf New Jersey Medical School Global Tuberculosis Institute. Tuberculosis Case Management for Nurses: Self-Study Modules Assessment (Module 2, pp. 8-11) www.umdnj.edu/globaltb/products/tbcasemgmtmodules.htm Professional Medical Interpreters topic (Go to p. 27) CDC. Effective TB Interviewing for Contact Investigation: Self-Study Modules www.cdc.gov/tb/publications/guidestoolkits/interviewing/default.htm Page 24

Assessment Determining the infectious period helps to focus the contact investigation efforts Determining the Patient s Infectious Period Infectious Period and Contact Investigation The infectious period is the time period during which a person with TB disease is capable of transmitting Mycobacterium tuberculosis. Determining the infectious period helps to focus the contact investigation efforts on those persons who were exposed while the patient was infectious. After a complete assessment of the information available, clinical and supervisory staff should estimate the infectious period. There is no universal, well established method to determine the infectious period, but the beginning of the infectious period is usually estimated by determining the date of onset of the patient s symptoms (especially coughing). Sometimes when it is difficult to obtain a reliable history from the patient about the onset of symptoms, the beginning of the infectious period is estimated to be earlier than the onset of symptoms. For guidance in determining when a patient has become noninfectious, see the topic on Bacteriologic Examination of Response to Treatment (p. 36). Use the guidelines below to determine whether to conduct a contact investigation. If it is decided to pursue a contact investigation, use interviews with the patient and contacts and field investigations to collect data on contacts and transmission sites. Identify, screen, and evaluate contacts. Start those eligible on treatment for latent TB infection. The Period of Infectiousness (Module 6, pp. 25-27) www.cdc.gov/tb/education/ssmodules/pdfs/6.pdf Contact Investigations for Tuberculosis (Module 6, pp. 1-103) www.cdc.gov/tb/education/ssmodules/pdfs/6.pdf CDC. MMWR: Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosis: Recommendations from the National Tuberculosis Controllers Association and CDC www.cdc.gov/mmwr/pdf/rr/rr5415.pdf Page 25

Assessment Infection Control Precautions Use of infection control precautions usually are part of a broader infection control program. The main goal of an infection control program is to detect TB disease early and to promptly isolate and treat people who have TB disease. The infection control programs include three types of controls: administrative controls, engineering controls, and personal respiratory protection. Infection control programs include administrative controls, engineering controls, and personal respiratory protection For guidance in determining when a patient has become noninfectious, see the topic on Bacteriologic Examination of Response to Treatment (p. 36). Francis J. Curry National Tuberculosis Center. Practical Solutions for TB Infection Control: Infectiousness and Isolation [online course] www.nationaltbcenter.ucsf.edu/courses/course_details.cfm?productid=onl-13 Infectiousness and Infection Control (Module 5, pp. 1-53) www.cdc.gov/tb/education/ssmodules/pdfs/module5.pdf CDC. MMWR: Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-care Settings, 2005 www.cdc.gov/mmwr/pdf/rr/rr5417.pdf Francis J. Curry National Tuberculosis Center. Tuberculosis Infection Control. A Practical Manual for Preventing TB www.nationaltbcenter.ucsf.edu/products/product_details.cfm?productid=wpt-12 Do Not Board Order Ask the TB patient if he or she has any plans to travel in the near future. If the patient has travel plans, be ready to issue a Do Not Board order. A Do Not Board order alerts airports and airlines not to allow the patient to board an aircraft. This order is coordinated by the Department of Homeland Security and the Division of Global Migration and Quarantine and is for air travel only. Washington State Department of Health: Do Not Board (DNB) Protocol www.doh.wa.gov/cfh/tb/manual/forms/dnbprotocol.pdf Do Not Board (DNB) Questionnaire www.doh.wa.gov/cfh/tb/manual/forms/dnbquestions.pdf Division of Global Migration and Quarantine [website] www.cdc.gov/ncpdcid/dgmq/ Page 26

Assessment Learning about the Patient s Culture and Beliefs Cultural Competency Culture is shaped by experiences and life events that contribute to a person s beliefs, values, attitudes, and behaviors. Culture can affect the ways in which a person communicates, both verbally and nonverbally, and understands information. Be aware of the cultural diversity of TB patients, contacts, and healthcare workers and how cultural factors may affect assessment and treatment of your TB patient. Be aware of how cultural factors may affect assessment and treatment of your TB patient Cultural competency is the sensitivity to and awareness of the various factors that shape a person s identity. It is the ability to work with and care for diverse persons to meet their cultural needs without compromising their health or that of the public. CDC. Effective TB Interviewing for Contact Investigation: Self-Study Modules Module 3: Cultural Competency www.cdc.gov/tb/publications/guidestoolkits/interviewing/selfstudy/module3/toc.htm Washington State Department of Health. Cultural Competency in Health Services and Care: A Guide for Health Care Providers www.doh.wa.gov/hsqa/professions/publications/documents/culturalcomp.pdf Resources on Specific Countries and Ethnic Groups Consult the following resources to research more about your patient s culture: Harborview Medical Center, University of Washington. Ethnomed [Website] http://ethnomed.org/ CDC. Ethnographic Guides for China, Laos (Hmong), Mexico, Somalia, and Vietnam www.cdc.gov/tb/publications/guidestoolkits/ethnographicguides/default.htm Southeastern National Tuberculosis Center. Quick Reference Guides Country-Specific Guides for Health Professionals Working with Foreign-Born Clients https://sntc.medicine.ufl.edu/products.aspx Page 27

Assessment If the patient understands very little of the conversation, it is time to engage an interpreter Professional Medical Interpreters The interviewer must gauge when an interpreter is needed. In some cases this is obvious, while in others it is not. The patient s medical record may mention a language barrier, so an interpreter can be arranged prior to meeting the patient. A patient may demonstrate language comprehension by nodding his or her head affirmatively or verbally indicate understanding by saying yes or no when answering questions. However, despite some proficiency, the patient may not have an adequate understanding of the interviewing messages. The responses to open-ended questions require more than a word or two, so they can help the interviewer to judge how much is understood by the answer given. Despite simplifying the language used and basing questions on the patient s level of understanding, if the patient understands very little of the conversation, it is time to engage an interpreter. CDC. Effective TB Interviewing for Contact Investigation: Self-Study Modules: Working with Interpreters www.cdc.gov/tb/publications/guidestoolkits/interviewing/selfstudy/module2/2_6.htm Interpretation Services (Module 9, pp. 32-35) www.cdc.gov/tb/education/ssmodules/pdfs/9.pdf Francis J. Curry National Tuberculosis Center Making the Connection: An Introduction to Interpretation Skills for TB Control www.nationaltbcenter.ucsf.edu/products/product_details.cfm?productid=edp-09 Page 28

Assessment Case management uses a combination of patientfocused services Ensuring that the Patient s Basic Needs Are Met Enablers Enablers are provisions that make it possible or easier for the patients to receive treatment by overcoming barriers such as transportation difficulties. Referrals for Other Services Case management uses a combination of patient-focused services in which the case management team performs tasks that include providing patients with needed health or social services or making referrals to other appropriate service agencies. These referrals are a form of enabler used to improve adherence. New Jersey Medical School Global Tuberculosis Institute. Tuberculosis Case Management for Nurses: Self-Study Modules: Assessment and Implementation (Module 2, pp. 10, 11, 15-16) www.umdnj.edu/globaltb/downloads/products/nursing%20module%202.pdf Using Incentives and Enablers to Improve Adherence (Module 9, pp. 54-57) www.cdc.gov/tb/education/ssmodules/pdfs/9.pdf Problem Solving (Module 9, p. 65) www.cdc.gov/tb/education/ssmodules/pdfs/9.pdf Page 29

Treatment During Treatment DOT is the most effective strategy for making sure that patients take their medicines Ensuring Completion of Therapy Directly Observed Therapy (DOT) A component of case management that helps to ensure that patients adhere to treatment is directly observed therapy (DOT). DOT, the most effective strategy for making sure that patients take their medicines, means that a healthcare worker or other designated person watches the patient swallow every dose of the prescribed drugs. DOT should be considered for all patients because it is difficult to reliably predict which patients will be adherent. Using DOT to Improve Adherence (Module 9, pp. 38-53) www.cdc.gov/tb/education/ssmodules/pdfs/9.pdf Washington State Department of Health Agreement for Directly Observed Therapy (DOT) www.doh.wa.gov/cfh/tb/manual/forms/dotagree%28king%29.pdf Virginia Department of Health Directly Observed Therapy Agreement www.doh.wa.gov/cfh/tb/manual/forms/dotagree%28king%29.pdf Page 30 Asking the Right Questions: A Visual Guide to TB Case Management Handbook, 2010

Treatment Adherence Strategies Adherence to treatment means that a patient follows the recommended course of treatment by taking all the prescribed medications for the entire length of time necessary. Adherence is important because TB is nearly always curable if patients adhere to their TB treatment regimen. Adherence strategies include case management, patient assessment, patient education, working with an interpreter, directly observed therapy, incentives, and enablers. TB is nearly always curable if patients adhere to their TB treatment regimen Patient Adherence to Tuberculosis Treatment (Module 9, pp. 6-62) www.cdc.gov/tb/education/ssmodules/pdfs/9.pdf What is Adherence? and Reasons for Nonadherence (Module 9: pp. 6-11) www.cdc.gov/tb/education/ssmodules/pdfs/9.pdf Patient Assessment (Module 9:, pp. 16-24) www.cdc.gov/tb/education/ssmodules/pdfs/9.pdf Using Incentives and Enablers to Improve Adherence (Module 9: pp. 54-59.) www.cdc.gov/tb/education/ssmodules/pdfs/9.pdf New Jersey Medical School Global Tuberculosis Institute. Tuberculosis Case Management for Nurses: Self-Study Modules: Assessment and Implementation (Module 2, pp. 8-17) www.umdnj.edu/globaltb/downloads/products/nursing%20module%202.pdf Patient Education topic (Go to p. 10) Krueger K, Ruby D, Cooley P, Montoya B, Exarchos A, Djojonegoro BM, Field K. The International Journal Against TB and Lung Disease: Videophone Utilization as an Alternative to Directly Observed Therapy for Tuberculosis www.ingentaconnect.com/content/iuatld/ijtld/2010/00000014/00000006/art00019 Directly Observed Therapy (DOT) topic (Go to p. 29) Page 31 Asking the Right Questions: A Visual Guide to TB Case Management Handbook, 2010