Hospital Discharge of TB Patients: Collaborating with the Health Department - PowerPoint PPT Presentation

Loading...

PPT – Hospital Discharge of TB Patients: Collaborating with the Health Department PowerPoint presentation | free to download - id: 593768-OTM4Y



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Hospital Discharge of TB Patients: Collaborating with the Health Department

Description:

Title: PowerPoint Presentation Author: Felicia Dworkin Last modified by: Jessica St. John Created Date: 9/4/2012 5:52:34 PM Document presentation format – PowerPoint PPT presentation

Number of Views:66
Avg rating:3.0/5.0
Slides: 56
Provided by: Felicia88
Learn more at: http://www.apicnyc.org
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Hospital Discharge of TB Patients: Collaborating with the Health Department


1
Hospital Discharge of TB Patients Collaborating
with the Health Department
  • Diana Nilsen, MD
  • Bureau of Tuberculosis Control
  • NYC Department of Health and Mental Hygiene

2
Todays Presentation
  • Epidemiology of TB in NYC, 2011
  • Discuss the rationale for discharging infectious
    TB patients from the hospital
  • Describe the new health code reporting
    requirements
  • Submission of hospital discharge plans
  • Submission of treatment plans
  • Provide an update on hospital discharge plan
    submissions
  • Discuss common issues related to hospital
    discharges

3
Reported TB Cases United States, 19822010
No. of Cases
11,182 cases
Year
  • Updated as of July 21, 2011

4
Tuberculosis Cases and Rates New York City, 1982
2011 689 Cases in 2011
Number of Cases
Rate/100,000
51.1
21.4
8.5
Rates based on official Census data and
intercensal estimates prior to 2000. Rates for
2000 to 2006 are based on intercensal estimates,
and for 2007 to 2011on 2008-2010 American
Community Survey.
5
US and Non-US-Born TB Cases New York City,
1982-2011
3,132
Number of Cases
1,010
Puerto Rico and U.S. Virgin Islands are included
as US-born There was 1 case with unknown country
of birth in 2011.
6
Top 10 Countries of Birth of Foreign-born
Persons, NYC TB Cases
2011 N 2010 N
China 104 China 104
Mexico 49 Dominican Republic 41
Bangladesh 33 Ecuador 41
Dominican Republic 31 Mexico 35
Ecuador 30 Bangladesh 30
Haiti 30 Philippines 28
India 30 India 26
Nepal 19 Haiti 23
Philippines 16 Pakistan 20
Puerto Rico 15 Guyana 16
7
Tuberculosis rates1 by United Hospital Fund (UHF)
neighborhood, New York City, 2009-2011
8
Trend in HIV-Infection and TB New York City,
1992-2011
9
HIV-Infected TB Patients New York City, 1992-2011
10
Top 10 Medical Facilities First Evaluating
Patients for TB- New York City, 2011
Facility Name of cases cases
1. Elmhurst Hospital Center 41 6
2. New York Hospital Medical Center of Queens 35 5
3. Bellevue Hospital Center 34 5
4. Maimonides Medical Center 32 5
5. Lincoln Medical and Mental Health Center 24 3
6. Kings County Hospital Center 23 3
7. Beth Israel, Queens Hospital Center 21 3
8. Lutheran Medical Center 13 3
9. Coney Island Hospital 12 2
10. Montefiore Medical Center, Bronx-Lebanon Medical Center 11 2
18. Lenox Hill Hospital 10
11
TB Reporting Requirements
Article 22 of the New York State Public Health
Law and Articles 11 and 13 of the New York City
Health Code require that suspected and confirmed
cases of tuberculosis be reported to the local
health authority, i.e., DOHMH, within 24 hours
12
Reporting TB Cases
  • Suspected or confirmed TB patients may be
    reported by telephone at (212) 788-4162 or
    347-396-7400
  • A completed Universal Reporting Form (URF) must
    follow within 48 hours by faxing it to the Bureau
    of Tuberculosis Control at (212) 788-4179
  • The URF can also be completed online, by first
    creating an account on NYCMED at
    www.nyc.gov/health/nycmed
  • Support for NYCMED is available by calling (888)
    NYCMED9

13
Reporting by Healthcare Providers
  • Providers are required by law to report within 24
    hours any case with
  • AFB smear from any site
  • Nucleic Acid Amplification (NAA) test for
    Mycobacterium tuberculosis (M. tb)
  • Culture for M. tb
  • gt2 anti-TB medications for suspected or
    confirmed TB
  • Clinically suspected TB
  • Pathology findings consistent with TB
  • Child lt 5 years old with TST
  • (regardless of BCG)

14
Reporting by Laboratories
  • Laboratories are required by law to report
    within 24 hours
  • AFB smears
  • Cultures for M. tuberculosis (M. tb)
  • Any culture result associated with an AFB smear
    (even if negative for M. tb)
  • Rapid diagnostic (NAA) tests identifying M. tb
  • Results of susceptibility tests on M. tb cultures
  • Pathology findings consistent w/ TB
  • Articles 11 and 13, Sections 11.03, 11.05 and
    13.03 NYC Public Health Code

15
Pathology Findings Suggestive of TB
  • Presence of acid-fast bacilli (AFB)
  • Caseating/non-caseating granuloma
  • Tubercles
  • Fibro-caseous lesions
  • Necrotizing/non-necrotizing granuloma
  • Langhans giant cells/multinucleated Langhans
    cells
  • Epithelioid cells/Epithelioid granuloma
  • Necrotizing inflammation
  • Chronic granulomatous lesions/chronic
    inflammation with granuloma formation
  • Giant cells

16
Background- Discharge Planning
17
Outpatient Treatment of TB
  • TB patients could be treated successfully as
    outpatients with the advent of modern
    chemotherapy
  • No significant difference between hospital and
    outpatient treatment
  • Cure rates
  • Spread of infection
  • Main determinant of cost of treatment is
    INPATIENT admission
  • (Tuberculosis Chemotherapy Centre, Madras. Bull
    WHO 195921-14451-339)

18
Treatment of TB in India
  • Tuberculosis Chemotherapy Centre, Madras,
    compared home treatment of TB with sanatorium
  • Treatment at home is satisfactory
  • Crowded living conditions, low nutritional
    standards, low income
  • Major risk to contacts lies in exposure to the
    infectious case BEFORE diagnosis

Tuberculosis Chemotherapy Centre, Madras. Bull
WHO 1960, 23 463-510
19
Successful Treatment of TB
  • Requirements for successful treatment include
  • Prescription of the correct chemotherapy
  • Compliance with medication doses
  • Achieved as outpatient with DOT
  • Completion of a minimum number of doses
  • All of which can be done as an outpatient!

20
Risks of Hospitalization
  • Nosocomial transmission to
  • Health care workers
  • Vulnerable patients
  • Anxiety for the patient who is isolated
  • Feeling of isolation
  • Removal from social supports
  • Loss of control over ones life

21
NYC Guidelines for Hospitalization and Discharge
  • Developed to ensure that only patients who need
    it are admitted and hospitalized
  • Infectious patients could be discharged in the
    appropriate circumstances
  • TB can be dangerous for other hospitalized
    patients
  • Patients should be treated as OUTPATIENTS unless
    they meet certain criteria
  • Patients become noninfectious quickly once on
    treatment

22
Criteria for Discharge
  • Clinical improvement
  • Tolerating anti-TB meds
  • Patient must be reported to DOH (212-788-4162 or
    347-396-7400), but must be reported via URF as
    well
  • Electronic URF filled out within 24 hrs.
  • Patient should have sputa for AFB
  • CXR should be done
  • Involvement of DOHMH in discharge planning with
    submission of discharge plan to DOHMH
  • Referral to DOH clinic and DOT
  • Instructions given to patient and household
    members if they were exposed to an infectious
    patient

23
Pg 128
24
NYC Health Code Amendment
25
Care of TB Patients in NYC
  • In 2009, 83 (255/308) of respiratory smear
    positive TB patients were hospitalized
  • In NYC, approximately 50 of TB cases are treated
    by a private provider
  • Collaboration between DOHMH and community health
    care providers removes barriers and fosters
    achievement of key public health objectives

26
NYC Health Code Amendment
  • New York City Health Code Article 11 Section
    21(4) amended June 16, 2010
  • Hospitals/providers must obtain approval from
    health department at least 72 business hours
    before discharging infectious TB patients
  • Providers must submit proposed treatment plan to
    NYC Health Department within one month of
    treatment initiation for all persons newly
    diagnosed with active TB disease
  • New requirement communicated to hospital
    providers (June and November 2010)

27
Process for Submitting Hospital Discharge Plans
28
Discharge Plan Approval Process
Determination
72 hrs before discharge
Within 1 business day
29
Outcomes of Discharges
  • Approved criteria for discharge met
  • Not approved additional actions or information
    needed
  • Not applicable extrapulmonary TB cases,
    noninfectious cases, atypical mycobacterium (NTM)

30
Hospital Discharge Form
  • Hospital Discharge Approval Request Form (TB 354)
    and Instructions
  • Hospital Discharge Planning Checklist for
    Tuberculosis Patients
  • Available on NYC Health Departments website
    www.nyc.gov/health/tb

31
(No Transcript)
32
(No Transcript)
33
(No Transcript)
34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
(No Transcript)
38
What the DOHMH Would Like From Providers
  • Complete and legible forms
  • Expected date of discharge
  • Appropriate contact information for the treating
    physician/attending MD
  • Notification of any issues with medications, side
    effects or abnormal lab values
  • Specialized nursing needs PICC lines,
    injections
  • Discharge to congregate settings or home care
    agency referrals
  • Discharges to other jurisdictions requiring
    interstate notification
  • How many days of medication provided to patient
  • Follow-up appointment date should be close to
    date of discharge

39
What Does the DOHMH Need to Do Prior to Discharge?
  • Field staff need to interview patient to elicit
    contacts
  • Home assessment should be done
  • Patient to agree to home isolation and DOT
  • Sign agreements for both
  • Follow up appointment is made

40
Update on Hospital Discharge Plan Submissions
November 1- March 1, 2011
41
Acid Fast Bacilli Sputum Smear Positive TB
Patients
Sputum smear positive TB patients 97
Discharged smear negative 16 (17)
Still in hospital 33 (34)
Discharged smear positive 48 (50)
Plan submitted 22 (46)
No plan submitted 26 (54)
Plan submitted 9 (56)
No plan submitted 7 (44)
Plan submitted 10 (27)
No plan submitted 23 (73)
Suspected and confirmed
42
Patients Discharged While Acid Fast Bacilli
Sputum Smear Positive (n48)
43
Compliance With Health Code Time Requirements
  • Median days from discharge plan submission to
    planned discharge was 1 day (range -4 to 5)
  • 23 (9/41) of plans submitted did not have a
    planned discharge date
  • Median number of days for DOHMH physician to
    respond to treating MD was 0 days (range lt1-3)

44
Initial Approval Status of Discharge Plan
Submissions
45
Reasons For Initial Disapproval

Home assessment not complete 6 27
Discharge plan form incomplete 5 23
DOT not offered/agreed 4 18
Discharged to congregate setting/unstable residence 3 14
Inadequate treatment regimen 2 9
Children lt5 in house not evaluated 2 9
Discharge plans may be disapproved for more than
one reason
46
Discharge of Non-NYC Residents
  • NYC DOHMH will communicate discharge plans with
    patients local health department prior to
    discharge/transfer
  • Infectious TB patient will be discharged only
    upon approval of local health department
  • If a patient is being discharged to a verifiable
    NYC address, a discharge plan must be submitted

47
Discharge of NYC Residents from Non-NYC Hospital
  • NYC DOHMH will work with discharging hospital
    /or the local public health authorities to
    ensure discharge plans conform to NYC standards

48
Process for Submitting Treatment Plans
49
Treatment Plan Approval Process
Within 1 month of treatment start date
50
TB Treatment Plan Form
  • NYC Health Department case manager will provide
    the treatment plan form to treating physician for
    completion
  • Treatment plan form does not replace Report of
    Patient Services Form (TB 65)

51
(No Transcript)
52
Future Considerations
  • Continue collaboration with hospitals/providers
  • Monitor submission of hospital discharge/treatment
    plans
  • Outreach to hospitals/providers experiencing
    issues with plans
  • Continue to evaluate impact of initiative

53
Conclusion
  • Submit discharge plans for infectious TB patients
    within 72 business hours of planned discharge
  • Submit treatment plans within one month of
    treatment initiation
  • Ensure forms are complete/accurate
  • Refer to NYC DOHMH guidelines resources
  • Call 311 to consult with DOHMH TB experts

54
Acknowledgements
  • NYC DOHMH Bureau of TB Control Provider Outreach
    Project Working Group
  • NYC DOHMH Bureau of TB Control Staff
  • NYC Infection Control Nurses and Practitioners

55
For Consultation call 311 DOHMH TB Hotline
212-788-4162 www.nyc.gov/health/tb
56
Hospital Discharge Policy

57
Amendments to Tuberculosis (TB) Reporting
Requirements in New York City -1
  • Section 11.21 of the New York City Health Code
  • Physicians and/or persons in charge of hospitals
    who report infectious TB cases must obtain
    consultation with and consent of the Department
    at least 72 hours prior to discharging such cases
    from inpatient care.
  • Patients will only be discharged after the
    department has determined that discharge will not
    endanger the public health.
  • The department will respond to the attending
    physician within one business day of the
    consultation.

58
(No Transcript)
59
Amendments to Tuberculosis (TB) Reporting
Requirements in New York City -2
  • Providers who assume the care of newly diagnosed
    cases of TB should submit within one month of
    treatment initiation a proposed treatment plan to
    the Department for review
  • Include name of medical provider who is
    responsible for treatment, names and duration of
    prescribed anti-TB drugs, anticipated date of
    treatment completion and a plan for promoting
    adherence to prescribed treatment.
  • Form will be provided by the Bureau

60
(No Transcript)
61
(No Transcript)
62
TB Laboratory Case Definition
  • Isolation by culture of M. tuberculosis complex
    from a clinical specimen
  • OR
  • Demonstration of M. tuberculosis from a clinical
    specimen by nucleic acid amplification (NAA) test
    (when used in accordance with FDA approved
    product labeling) OR
  • Demonstration of acid-fast bacilli (AFB) in a
    clinical specimen when a culture has not been or
    cannot be obtained

62
63
TB Clinical Case Definition
  • Evidence of TB infection based on a positive
    tuberculin skin test or FDA approved blood test
  • AND
  • One of the following
  •  Findings compatible with current TB disease,
    such as an abnormal, unstable (worsening or
    improving) chest radiograph, or
  • Clinical evidence of current disease (e.g..
    fever, night sweats, cough, weight loss,
    hemoptysis)
  • AND
  • Improvement on current treatment with two or more
    anti-TB medications

63
About PowerShow.com