More education needed to stop nosocomial TB
Physicians in training should be targeted
A new study of health care worker compliance with the Centers for Disease Control and Prevention’s (CDC) guidelines for preventing tuberculosis transmission in health care facilities shows that educational efforts need improvement, particularly among physicians in training.1,2
The observational study was conducted at the University of California-San Diego (UCSD) Medical Center, an urban teaching hospital that admits 25 to 30 cases of active TB per year. The institution has been successful in rapidly identifying and isolating potentially infectious TB cases.3
Over a 14-week period, a trained research assistant observed occupied adult respiratory isolation rooms for one- to two-hour periods. The observer did not reveal the observation’s purpose and tried to remain inconspicuous.
Most observations took place on the day shift. Information was recorded for each HCW observed, including job title, whether a mask was worn entering and leaving the room, the type of mask worn (N95 masks are the only type permitted at UCSD), whether it was worn properly, and whether the door was closed immediately after entering and leaving the room.
A total of 541 HCW observations in 115 observation sessions involving 52 patients in isolation took place during the study period. Some HCWs were observed more than once. Most of the HCWs were aides or transports (166), followed by registered or licensed practical nurses (135), dietary workers (49), residents or fellows (47), medical students (46), phlebotomists (42), attending physicians (12), jail guards (10), skin-test technicians (9), housekeepers (8), nursing students (4), social workers (3), respiratory therapists (3), EKG technicians (3), security (3), and an X-ray technician (1).
Sixty-four total violations were observed, with 36 involving failing to maintain respiratory isolation (such as leaving the door open upon entry or exit) and 28 involving failure to use masks properly (masks not worn, masks worn improperly, or wrong type of mask worn).
Most importantly, the number of violations per observation differed significantly by employee job category. The highest rates were among physicians in training (residents, fellows, and medical students), housekeepers, and jail guards, with physicians in training by far the highest. They committed 45% of all violations but accounted for only 17.2% of total observations made.
While noting that the 29 violations committed by this group included at least eight technical violations that were not considered clinically important (orders to discontinue isolation were written either just before or after the observation), the study authors emphasize that educational efforts directed at physicians in training need improvement.
Although compliance with the CDC’s guidelines seems "reasonably good," the researchers advocate continued and improved education of all HCWs regarding the importance of TB protection and complying with control measures.
References
1. Centers for Disease Control and Prevention. Guide lines for preventing the transmission of Mycobacterium tuberculosis in health care facilities, 1994. MMWR 1994; 43 (No. RR-13):1-133.
2. LoBue P, Catanzaro A. Healthcare worker compliance with nosocomial tuberculosis control policies. Infect Control Hosp Epidemiol 1999; 20:623-624.
3. LoBue PA, Catanzaro A. Effectiveness of a nosocomial tuberculosis program at an urban teaching hospital. Chest 1998; 113:1,184-1,189.
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