Special Considerations and Frequently Asked Questions in a Contact Investigation Jessica Quintero, BAAS September 24, 2015 TB Nurse Case Management September 22 24, 2015 San Antonio, Texas EXCELLENCE EXPERTISE INNOVATION Jessica Quintero, BAAS has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity 1
Where Do We Begin? Systematic Approach to Contact Investigation Identified by CDC as best approach to CI Actual sequence varies Follow programs policy and guidance All steps comprise effective CI Systematic Approach to Contact Investigation; Steps 1 5 1. Review existing information 2. Determine an initial estimate for the infectious period and estimate the degree of infectiousness 3. Interview the case 4. Review information and develop a plan for the investigation 5. Refine the infectious period and degree of infectiousness 2
Systematic Approach to Contact Investigation; Steps 6 10 6. Prioritize Contacts 7. Conduct field visits 8. Conduct contact assessment 9. Determine whether to expand or conclude an investigation 10. Evaluate the contact investigation actives Conducting an Interview Information exchange Interviewing skills Contact info 3
What Factors Affect Information Exchange?? Cultural factors Language Using interpreters Communication Skills Cross Cultural Communication 1. Awareness of one s own cultural values Are you attentive to your own preconceived notions of other cultural groups? 2. Awareness and acceptance of cultural differences Do you look for opportunities to meet and interact with individuals who are from cultures other than your own? 3. Development of cultural knowledge Are you familiar with the worldviews of cultural groups other than your own? 4. Ability to adapt practice skills to fit the cultural context of the case Do you have the know how to navigate cross cultural case interactions? 4
61.8 Million People in the United States Speak a Language Other Than English at Home Less likely to receive care Less likely to understand care Increased risk of medical errors Reduced quality of care Center for Immigration Studies: http://cis.org/record one in five us residents speaks languageother than english at home Increased risk of unethical care Less satisfied with care Understanding the Interpretation Process The interview should be conducted in the primary language of the interviewee What is the role of the interpreter? Who should interpret? Interpreter etiquette 5
Communication Interviewing Techniques Use of open ended questions Active listening Tone of voice Assertive/Passive/Aggressive Questions to avoid What Is an Open Ended Question? Open ended Who else lives in the home with you? This is! Close Ended Do you live alone? How do you spend your free time? Do you go bowling, or to church? What number can you best be reached at? Do you have a cell phone? 6
How Can I Show That I am Actively Listening? Verbal Paraphrasing and summarizing What I m hearing is Reflection Nonverbal It seems to me that you might be feeling Silence Body language Tone of Voice Tone involves volume you use level and type of emotion communicated Emphasis that you place on the words that you choose The tone of your message can drastically change your meaning Tell me a little bit more about Susan 7
Assertive/Passive/Aggressive Assertive: To maintain one s rights without compromising the rights of others Tell me more about Susan Passive: To relinquish one s rights in deference of others Can you please tell me more about Susan Aggressive: To demand one s rights at the expense of others You need to tell me more about Susan Avoid jargon CI AII DOT Mask Contacts Give Information Simply Reputable resources Pictures for reference 8
What are Exposure Grading Settings By Size? "1" being the size of a vehicle or car "2" the size of a bedroom "3" the size of a house "4" a size larger than a house What Are Some Interviewing Pitfalls? Leading questions You Know What a Leading Question is Right? Asking several questions at once Who lives with you, are you married, how many kids do you have, tell me about visitors Interrupting Putting the person on the spot Not providing enough time to answer 9
What Do We Do with the Information? Post Interview Assigning priorities to contacts Investigation plan Follow up Data Reporting What are the Factors for Assigning Priorities to Contacts? Characteristics of the index patient Characteristics of contacts Age Immune status Other medical conditions Prioritization identified as high, medium, or low based on: Likelihood of infection Potential hazard to the individual contact if infected. 10
Evaluating Identified Contacts Evaluation Symptoms review Face to face assessment TST or IGRA HIV testing recommended FAQ: What if the contact received BCG? Interpreting Skin Test Reaction 5 mm induration is positive for any contact Do not use two step testing A positive BIC TST should be classified as recently infected FAQ: Can an expectant mother be tested? 11
Evaluation and Follow up of Children <5 Years Always assigned a high priority Full diagnostic medical evaluation If TST <5 mm of induration and last exposure <8 weeks, Window Period Prophylaxis recommended Second TST 8 10 weeks after exposure; decision to treat is reconsidered Negative TST treatment discontinued Positive TST treatment continued Data Collection Management of care and follow up Epidemiologic analysis Program evaluation Collected on standardized forms Electronic storage recommended 12
When Should We Expand an Investigation? Unexpected large positivity rate. >10% community rate Evidence of secondary transmission Program objectives achieved Expand to low priority contacts 8 10 weeks after last exposure. What is TB Genotyping? TB Genotyping or fingerprinting : is a laboratory based method that can determine the genetic pattern of the strain of M. tuberculosis that caused TB disease in a person. Identify unsuspected relationships between patients Locate unusual transmission settings Uncover transmission between jurisdictions Evaluate completeness of contact investigation Promptly identify false positive cultures Detect and investigate outbreaks sooner 13
Congregate Settings Correctional Facilities Shelters Work places Health Care Facilities Schools Congregate Settings Incomplete information Confidentiality Collaboration Legal implications Media coverage Worried well 14
When Can We Stop? All contacts have been evaluated Contacts on LTBI treatment have completed or are near completion No additional cases were found 15