Performance Improvement Project to Identify Factors that Led to Employee Exposure to Mycobacterium Tuberculosis
Nya Ebama, M.D., Aman Dalal, M.D., Janice Burns, R.N., Ed Mangini, R.N., Kathy DiBenedetto, R.N., Teresa Abreu, R.N., Wehbeh Wehbeh, M.D., and James Rahal, M.D.
Background: The New York Hospital Queens, Department of Infection Control Tuberculosis (TB) Policy aims to provide appropriate treatment for patients, offer prophylaxis to infected staff members, and prevent nosocomial transmission to patients and staff. It describes procedures to identify patients with active TB by clinical and laboratory means, report cases of TB to the New York City Department of Health, and isolate patients with confirmed or suspected infectious TB. It emphasizes having an alternate diagnosis and the involvement of an Infection Control practioner when removing a patient from respiratory isolation is considered. Despite having such a policy, there are still situations in which isolation is discontinued prematurely leading to unwarranted, direct, prolonged contact to a patient with active, symptomatic TB.
Objective: To identify the factors that led to patient and hospital staff exposure to Mycobacterium tuberculosis.
Methods: A retrospective study of TB exposures at New York Hospital Queens between January 2003 and December 2007 was conducted. It was approved by the IRB. The Infection Control Department tracks and records all TB cases and all hospital exposures to TB. A review of this data determined that 27 patients with positive TB cultures were sources of subsequent exposures. A retrospective chart review was conducted for these patients to determine compliance of hospital staff with the TB policy.
Results: There were 165 TB cases documented in this period. In 27 of these 165 cases, the hospital policy was not followed. This led to the exposure of 1,368 patients and staff to TB. Most of the exposures (440/1,368) were in 2007. Among the 27 patients, 14 were male and 13 female, one was less than the age of 30 years old, eight between 30-50, five between 51-70, 12 between 70-90, and one greater than 90. Ten were immunocompromised and three had a history of tuberculosis. There were 13 with cough, 14 with fever, and eight with cough and fever. There were 16 with an upper lobe finding on CXR, and five of these 16 had cough. Ten out of 16 patients who had a CT scan of the lungs had an upper lobe finding. In eight cases, tuberculosis isolation was initiated appropriately upon admission but was incorrectly discontinued. Five of these eight patients were still symptomatic when isolation removed. Furthermore, correct adherence to the policy would have led to initiating isolation for the additional 19 cases. Eleven of these 19 patients were isolated during their hospitalization.
Conclusions: Our study shows that poor compliance with the hospital’s TB policy was the main factor that led to unnecessary exposures. Adherence to this policy must be encouraged to prevent these exposures. This can be done through increased education to nursing staff, residents, and attendings and instituting a protocol for initiating and discontinuing TB isolation.