Suspicious minds triage TB out of the ED
Though the dramatic resurgence of tuberculosis in the United States has slowed in recent years, emergency department (ED) personnel still face the daily threat that an undiagnosed case will walk through the doors and pose an airborne infection risk to staff and patients. But aggressive triaging efforts keyed by classic TB symptoms and a good general knowledge of your patient population can prevent both initial transmission in the ED and subsequent exposures in the hospital.
"There is a lot of concern about ER's because that’s where people hit the hospital," says Renee Ridzon, MD, medical epidemiologist in division of TB elimination at the Centers for Disease Control and Prevention. "[Clinicians] should be familiar with the epidemiology of TB in their particular area. That can guide their index of suspicion in forming a differential diagnosis."
To prevent TB exposures, incoming suspect TB cases must be identified promptly and placed under CDC infection control precautions.1 (See CDC recommendations, p. 14.)Yet a recent national survey of 446 facilities to determine existing infection control policies in EDs found that only 56% had triage criteria for screening TB patients and only 20% had TB isolation rooms meeting CDC criteria for negative pressure air exchanges.2 To spot incoming cases, the CDC recommends that a diagnosis of TB be considered for any patient who has a persistent cough lasting for three weeks or more. In particular, patients who present with a cough that has been persistent despite administration of antibiotics for suspected bacterial infections should be suspected for active TB, Ridzon notes.
In general, the resurgence of TB that began in the 1980s has been greatest among substance abusers, the homeless, people of low socioeconomic status, and those with HIV infection. More recently there has been an upsurge in cases among the foreign-born. An increasing proportion of cases in the United States are among individuals born in areas where TB is common, such as Asia, Africa, and Latin America.
"The TB rate in Vietnam, for example, is 30 times the rate in the United States," Ridzon says. "Right now about a third of the cases of TB reported in the U.S. are in foreign-born persons. So the risk of having TB if someone is foreign-born is much, much higher than the risk of having TB in someone who is born in the United States."
Other triage questions should focus on patient history, including whether the patient has been around someone who is known to have TB or to have a history of a positive TB skin test, she adds. Patients suspected of TB ideally should be placed in a TB isolation room until the diagnosis can be confirmed or ruled out, but they at least should be asked to wear standard surgical masks if they remain in common areas, the CDC recommends.
Implementing such programs can pay off. For example, an infection control professional at University Hospitals of Cleveland reviewed and improved ED triaging efforts as part of implementing an overall TB care path at the hospital. Under the new protocol, triage nurses assess risk factors that include cough and classic symptoms, history, medications, demographics, and living conditions. (See TB care path, inserted in this issue.)
"Luckily we didn’t have any nosocomial transmission, but we noticed our numbers [of admitted TB cases] going up," says Julia Wendt, RN, BSN, CIC, infection control nurse.
In reviewing TB controls at the hospital, Wendt found a lack of expedient identification and isolation of patients at risk for TB. In order to promote early and appropriate recognition of TB, Wendt and colleagues developed a multidisciplinary institution-wide collaborative care path for TB that began the front-line fight in the ED.
"About 75% of our TB patients that are admitted usually come through the emergency room," she says. "Now, what we are doing is the nurses triage [patients] before they are even registered. They ask some questions, and if they come in with any one of those complaints, then they are masked and sent off for X-ray. It’s kind of like an automatic standard of care now."
Improvements in TB control were reflected by a lack of TB skin test conversions in the ED and other high-risk areas, and prompt placement of admitted patients into isolation rooms. Diagnostic evaluation for TB also has improved with earlier submission of respiratory specimens and more rapid processing of specimens by the microbiology laboratory, Wendt says. In addition, these diagnostic improvements led to earlier discontinuation of isolation in patients when TB was excluded.
References
1. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities, 1994. MMWR 1994; 43:(No. RR-13)1-133.
2. Moran GJ, Fuchs MA, Jarvis WR, et al. Tuberculosis infection control practices in United States emergency departments. Ann Emerg Med 1995; 26:283-289.
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