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. Today’s 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, 1982–2010* 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

7. Tuberculosis rates1 by United Hospital Fund (UHF) neighborhood, New York City, 2009-2011

8. Trend in HIV-Infection and TBNew 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

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 byHealthcare 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 >=2 anti-TB medications for suspected or confirmed TB Clinically suspected TB Pathology findings consistent with TB Child < 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 1959:21-144:51-339)

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 WHO1960, 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 one’s 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

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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 TBdisease New requirement communicated to hospital providers (June and November 2010)

27. Process for Submitting Hospital Discharge Plans

28. Approved Provider submits Hospital Discharge Approval Request Form to DOHMH via fax • DOHMH physician • reviews discharge plan • makes determination • communicates with • hospital provider Not applicable Disapproved • Provider • discusses discharge • plan issues with DOHMH • revises plan • informs DOHMH Discharge Plan Approval Process 72 hrs before discharge Within 1 business day Determination

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 Department’s website: www.nyc.gov/health/tb

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 SubmissionsNovember 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 (n=48)

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: <1-3)

44. Initial Approval Status of Discharge Plan Submissions

45. Reasons For Initial Disapproval* *Discharge plans may be disapproved for more than one reason

46. Discharge of Non-NYC Residents • NYC DOHMH will communicate discharge plans with patient’s 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. DOHMH case manager • contacts treating • provider • obtains completed • treatment plan form • DOHMH physician • reviews treatment plan • makes determination • communicates with • provider • Treating provider • discusses treatment • plan issues with • DOHMH • revises plan • informs DOHMH 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)