Hospital TB Exposure

1. Hospital TB Exposure Lessons Learned

2. A bit about PRMC • Owned by Essent Healthcare, located in Paris, Texas

3. Two campuses: North with Women’s and Children’s Services, Rehab, Senior Transitions, Pediatrics; space rented to Dubuis LTAC and a SNF South with Medical/Surgical Units, ICU, Orthopedics, and Oncology Area and Population Served: Northeast Texas and Southeast Oklahoma Average daily census: about 100

4. So my story begins 6/12/08 ran by micro to pick up lab reports on my way to the office.

5. Culture report from the state with culture positive Mycobacterium Tuberculosis on an employee, not just any employee, a RT.

6. Immediate Action • Called Vicki Harris at Region 5/6 – she was at day 2 of the seminar – left her a voice mail message. • Called Sandi Williams in Sulphur Springs – she was at day 2 of the seminar – left a voice mail message. • Faxed both of them – usual report form, rad reports, lab, anything I could find

7. Notified my boss • Notified Employee Health • Notified Human Resources

8. Who (of the wwww) • Baby Boomer age, Filipino Respiratory Therapist, became ill in the later part of 2007 with weight loss, a cough, fatigue, BUT had arthritis and chronic renal insufficiency. • Hospitalized in February and X-rays worrisome – for cancer. 28mm cavitary mass medially in the right apex. Dang. • Bronch as an outpatient in May – AFB smear negative.

9. What • Active TB in a person the doctor thought had lung cancer. • Fortunately the TB was not resistant.

10. Why • Why me? • Why this employee? • Because of BCG vaccination and a past positive attributed to the BCG vaccination, this employee had not gotten PPD testing for years. Annual CXRs were done until 2003, then we just got CXRs as indicated per symptom review. This employee denied symptoms. • This employee was on etanercept (Embrel) and Humira, which are TNF blockers (suppressing the immune system), and both have black box warnings about potential infections, including TB.

11. When • Determine exposure time period • Time symptoms began to time placed on medical leave (break in contact)

12. Where • This employee worked 7p to 7a shift on North campus • Was hospitalized on South Campus • Bronch lab is on South Campus • Main radiology department is on South Campus

13. First lesson learned • A person who is smear negative can be culture positive for TB. • Smear negative = less infectious, but these patients do contribute to TB transmission – about 13% to 17% • Lancet 1999 Feb 6; 353 (9151): 444-9 • Clin Infect Dis. 2008 Nov 1: 47 (9): 1135-42

14. Second lesson learned • Prior BCG vaccination does not mean the person doesn’t get a PPD test. • CDC Division of Tuberculosis Elimination Fact sheet BCG Vaccine, last reviewed 05/18/2008

15. Third lesson learned • Don’t let people make excuses on the symptom review.

16. Fourth lesson • Ask about immunosuppressent meds that employees may be on – build that into your TST questionnaire “Are you on any medications that can suppress the immune system, such as prednisone, Remicaid, Humira, or Enbrel?”

17. Planning • Conference call with the Region 6/24/08 • Discussed plan of action • Determining and testing hospital employee contacts • Testing all foreign born employees • Determining patient contacts

18. Investigation • Schedule • Time Card • Treatment sheets • Billing records • Code Blue sheets • Review of the Medical Records of all patients seen by RT during the contact time

19. Who were exposed during employee’s hospitalization? • Rad • ER and nursing unit • Physicians – ER, admitting, consulting • Lab phlebotomists • RTs • Diet clerk • ER • Housekeeping • Who were exposed when employee came in for bronch? • Other patients and their family members in the waiting room • Bronch lab staff • Rad • Registration staff and people in the registration office waiting to be registered • Co-workers exposed from November 2007 to June 2008 • Classes this employee attended (ACLS, Customer Service, etc)

20. Others for the State to consider • Family • Close Community contacts • Physician Office waiting room exposures

21. Second Conference Call 7/2/08 • Still pulling charts and reviewing them for exposure • Testing of employees hadn’t started yet – got in trouble • The urgency of getting all this done was well communicated to me • Reviewed airflow – we don’t re-circulate air, it is all vented outside

22. Planning for community testing July 17, 2008 Re: Possible Tuberculosis (TB) exposure during your hospital stay Dear Patitent: Your health is our first priority – both while you are in our hospital and when you go home. That is why we write to inform you that, during your recent stay, you may have been exposed to tuberculosis – commonly known as “TB.” TB is a treatable disease that affects the lungs and can be passed from an infected individual through the air. To determine if you have been infected, we are asking patients who may have been exposed to TB at the hospital between November 2007 and June 2008 to get a simple, free skin test. Even if you do not experience any symptoms, we encourage you to come take the test so that we can identify if you are infected and begin any necessary treatment. We are offering this test jointly with the Texas Department of State Health Services out of an abundance of caution and so that we follow guidelines and best practices to ensure our patients receive the medical attention they need. The testing schedule is as follows: Dates/Times: July 22nd, 23rd, and 25th, 2008; drop-in hours from 9:00 a.m. – 4:00 p.m. daily Location: Conference Room A& B at the PRMC South Campus (See enclosed map for directions) What to bring: If you have tested positive in the past, and have the test result, please bring that document with you. Cost: Free About the test: This simple test injects a small amount of testing fluid underneath your skin on your forearm. Within 48-72 hours, you will need to return to the testing site so that a medical professional can check for any reaction to the test, which may signal infection. Enclosed is a fact sheet about TB, how it is spread and what the symptoms are. If you have any questions, please feel free to call Danielle Mead with the Texas Department of State Health Services Tuberculosis Elimination Division, at 903-737-0268. Sincerely, Christopher W. Dux Mary Fitzwater, RN, BSN Chief Executive Officer Infection Prevention and Control

23. Fifth lesson learned • The state eats lunch

24. Publicity • Local and regional newspapers, radio, TV • Local blogs The-Paris-site Essent Healthcare, Inc., the owner of the hospital, didn’t like what was being ... the newspapers are having such a hard time: Yesterday's news printed today. ..... About Me. fac_p: Paris, TX, United States. View my complete profile ...the-paris-site.blogspot.com/ - 142k - Cached - Similar pages TB: PRMC tests for patient exposure - Topix Read full story from Paris Texas. Read All 6 Comments .... We take news from over 60000 sources and categorize those stories to over 40600 locations and ...www.topix.com/county/lamar-tx/2008/07/tb-prmc-tests-for-patient-exposure - 56k - Cached - Similar pages

25. Sixth lesson learned • Tell the hospital switchboard where to send calls • Plan for millions of phone calls and have a script of what to say • Understand that some callers will be angry

26. Clinic Planning • Large space • Plenty of seating • Cookies, bottled water, soft drinks, juice • Coloring books and crayons • Literature about TB in English and Spanish • Signage • Parking • Accessibility for the handicapped

27. Seventh lesson learned • Anticipate the need for interpreters

28. Clinic • Sign in sheets • Tuberculosis contact Screening Form • http://www.dshs.state.tx.us/idcu/disease/tb/forms/#reporting

30. First Clinic Attendance • 627 came in for TSTs • 416 returned for reading • Those that didn’t return were sent letters to return for the second round of TSTs planned for October • 7 previous positives, none agreed to start preventive medication • 3 converts and all agreed to start on preventive medication • 2 children started on window treatment

31. Eighth lesson learned • TB meds taste like swamp water • High-risk contacts (including children under 4 years of age) with a negative skin test reaction less than 10 to 12 weeks after their exposure should start treatment for LTBI and be retested after the window period ends. This is called window period prophylaxis. If the second skin test reaction is negative, treatment for LTBI is usually stopped. If the second skin test reaction is positive, they should continue taking treatment for LTBI. http://www.cdc.gov/tb/pubs/ssmodules/default.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5412a1.htm

32. Ninth lesson learned • Contract with the state for the hospital to do chest x-rays

33. Tenth lesson learned • Plan for those people who didn’t make it to the clinic, but need to be tested or want to be tested

34. Second Clinic in October • The state sent letters to 250 people who needed a second TST • 120 returned • Both of the children tested 0 mm at the second test, and window treatment was stopped Yea!

35. New Employee Health policies PPD unless known positive is documented – don’t take employee word for it PPD regardless of BCG vaccination Employees converting to positive get referred to the health department

36. http://www.cdc.gov/tb/pubs/Posters/Mantoux.htm