Original ContributionsImplementation of an emergency department triage procedure for the detection and isolation of patients with active pulmonary tuberculosis☆
Introduction
Tuberculosis has resurfaced as a serious threat to public health and health care workers. In the mid-1980s, the number of tuberculosis cases in the United States began to rise, following a long trend of declining cases.1 Many nosocomial tuberculosis outbreaks have since been reported that have resulted in purified-protein derivative (PPD) skin test conversions and cases of active pulmonary tuberculosis among health care workers.2, 3, 4, 5 The emergence of multidrug-resistant tuberculosis has added to the difficulty in treating and controlling the spread of this disease, and these strains may be more likely to result in health care workers’ purified protein derivative (PPD) conversions.6, 7
Emergency department personnel are at significant risk of tuberculosis exposure, especially in urban health care facilities that care for many indigent patients. Patients at high risk for tuberculosis, including those with HIV infection, homeless, foreign-born, chronically ill, intravenous drug users, or who reside in nursing homes, are commonly treated in the nation’s EDs. The risk to ED personnel is further increased by delays in recognition and respiratory isolation of patients with active pulmonary tuberculosis.8, 9, 10 In a recent study of hospitalized patients with tuberculosis, the median interval from admission to initiation of antituberculous chemotherapy was 6 days, and 75% of patients had a delay of at least 24 hours.11
Tuberculosis is often not initially suspected because symptoms may be nonspecific, patients usually present to the ED for care without a known prior diagnosis of tuberculosis, and the clinical and radiographic presentation of tuberculosis can be misleading in HIV-infected patients.12, 13, 14, 15, 16 In a 1994 study at our institution, it was noted that 31% of ED personnel converted their PPD status to positive at some time during their ED employment, with risk of PPD-conversion increasing with duration of ED employment.17
Because of the resurgence of tuberculosis and the risk to health care workers, in 1994 the Centers for Disease Control and Prevention issued recommendations for tuberculosis infection control in health care facilities.18 This included the screening of patients at triage for signs and symptoms suggestive of tuberculosis. The ED is a potentially important site for the control of tuberculosis infection, because it serves as a point of entry for tuberculosis patients to the hospital and may allow for surveillance of tuberculosis in the community.
In response to the high PPD conversion rate seen at our institution, a triage screening protocol was developed for the rapid identification and isolation of patients at risk of active pulmonary tuberculosis. This study was undertaken to evaluate the ability of this protocol to identify and isolate patients seeking care in the ED who have unsuspected active pulmonary tuberculosis. Our secondary objective was to describe the ED triage presentation of patients with active pulmonary tuberculosis.
Section snippets
Materials and Methods
Harbor-UCLA Medical Center is an urban, university-affiliated hospital that serves a predominantly medically indigent population in Los Angeles County. The adult ED has an annual census of approximately 60,000 patients. A triage screening instrument was developed using tuberculosis risk factors and symptoms identified from the literature. This was known as the Rapid Isolation of Pulmonary Tuberculosis (RIPT) screen. Each risk factor and symptom was weighted by assigning a point value based on
Results
During the 4-month study period, 10,674 patients were screened using the RIPT screening instrument. Based on review of triage logs, this represents 91% of all patients seen in the ED during that period. Of the screened patients, 2,302 (22%) reported sufficient risk factors, symptoms, or both to warrant immediate respiratory isolation and chest radiography (Figure 1).
Discussion
Screening patients at ED triage for pulmonary tuberculosis is a difficult task. The ideal screening instrument would be easy to administer, have a high sensitivity and specificity, and therefore result in few unnecessary chest radiographs or isolation events. The RIPT screening instrument had a sensitivity of 63% in our study, which we view as disappointing. On the other hand, on average this protocol resulted in the respiratory isolation at triage of 1 patient per week with otherwise
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Cited by (18)
Pulmonary tuberculosis: An analysis of isolation practices and clinical risk factors in a tertiary hospital
2019, Indian Journal of TuberculosisCitation Excerpt :Only half of the subjects (52.0%) had at least 3 sputum samples analyzed, of which 24 (17%) were positive for AFBs. This is in contrast to guidelines which require three negative sputum samples in order to remove isolation precautions.15 With the 253 subjects for whom both isolation and de-isolation date was available, we found that most subjects spent 5 days in isolation.
A current review of infection control for childhood tuberculosis
2011, TuberculosisCitation Excerpt :Another variable to consider is the suboptimal specificity of some of these tools. One algorithm was considered positive in any patient with fever and cough34; given the preponderance of febrile viral respiratory tract infections seen in all pediatric EDs, the utility of this tool would be minimal, resulting in massive over-isolation of children in the ED. Given the low rates of childhood TB seen in many centers in industrialized nations, the limited transmissibility of most children, and the paucity of adequate screening tools to allow for timely implementation of interventions, one can question the degree to which TB infection control recommendations developed for adults have applicability in pediatric facilities.
Decision Instrument for the Isolation of Pneumonia Patients With Suspected Pulmonary Tuberculosis Admitted Through US Emergency Departments
2009, Annals of Emergency MedicineCitation Excerpt :Because of limited resources and the need to prioritize risks, some patients with pneumonia, for which pulmonary TB is a diagnostic possibility, may be admitted to nonisolation areas. There have been numerous prediction models published that attempt to assist clinicians with deciding which patients require TB isolation.18-22 Limitations of these previous studies include small numbers of patients with TB and retrospective design that fails to capture the information available in the ED.18-22
Communicable Respiratory Threats in the ED: Tuberculosis, Influenza, SARS, and Other Aerosolized Infections
2006, Emergency Medicine Clinics of North AmericaCitation Excerpt :Development of methods for rapid identification of cases of TB at ED triage has met with mixed results. One study that evaluated the use of a simple triage guideline found that the sensitivity and specificity of their screening tool was only 63% and 78%, respectively [30]. Explanations for the relatively low sensitivity of the tool included lack of consistent compliance with guideline implementation and failure of a subset of patients to report key risk factors and symptoms at ED triage (which were elicited later during the ED evaluation).
Contact investigation of a case of active tuberculosis
2004, American Journal of Infection Control
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Address for reprints: Peter E. Sokolove, MD, Division of,Emergency Medicine, UC Davis Medical Center, 2315 Stockton Boulevard, PSSB 2100, Sacramento, CA 95817; 916-734-1534,fax 916-734-7950; E-mail [email protected] .