Case Study Presentation

Airborne Isolation Management

Patient’s History

• Madam A- 55yrs old, Female. • Admitted for right eye ECCE + IOL insertion

surgery, under Dr.Mohammed.

• No drug/food allergy.

• Patient has HTN, DM, dyslipidemia and active PTB- on medication.

Medications patient is on:

Amlodipine , Omeprazole, Metformin, Glibenclamide, Insulin, Cozar, Rifadin, Pyrazinamide, Citalopram, Ethambutol.

Background of patient :

• PTB since year 2011, after 3 sputum smear positive.

• Started on Isoniazid & Rifampicin for 6 months and 2 additional antibiotics- Pyrazinamide & Ethambutol everyday for 1st 2 months.

• Patient stopped taking meds in year 2012 for 8 months and defaulted follow ups, due to personal reasons.

• Started back on TB meds in year 2013.• Last follow up with Dr.Thamer was on

12/1/14.• Chest x-ray last done on 26/2/14.• Still active PTB.

What is PTB?

• Pulmonary tuberculosis (PTB) is an infectious disease caused by slow- growing bacteria that resembles a fungus, Myobacterium tuberculosis, which is usually spread from person to person by droplet nuclei through the air.

• The lung is the usual infection site but the disease can occur elsewhere in the body, such as at the cervical lymph glands, bone, the renal system.

Incidence and Prevalence

of Tuberculosis in KSA

Table 1: Annual TB patient numbers and incidence rate/100,000 in Saudi Arabia

(1991-2010)

Epidemiology for more Incidence of TB occurrence in Saudi Arabia

According to WHO statistics review:

Huge number of expatriate worker force who are residents of this country,came from countries with a high burden of TB such as India, Pakistan, Bangladesh, Indonesia, and Yemen.

This probably has adversely affected TB control in the Kingdom.Relapse and default patients to moderate likelihood of MDR

Late diagnosis

• Pulmonary TB patients are often diagnosed many weeks after the onset of symptoms.

• This diagnostic delay allows for transmission of the disease to many contacts.

• Emphasis on timely contact tracing and treatment of those with active or latent disease is one of the most important aspects of TB control.

• Clinicians caring for TB patients need to be more vigilant in this particular area.

Pilgrims from various part of the world coming into KSA with background of unknown medical conditions.

• TB incidence for Saudis showed a clear variation in different regions. Makkah and Gizan regions showed the highest incidence rate that reached up to 29.5/100,000.

• The trend was rising significantly in Makkah over the last 20 years. The Central region had a significant rise in incidence climbing from 6.4 to 14.2/100,000.

• Other regions showed a much lower and stable incidence of 4-9/100,000.

Drug resistance

• One of the most dangerous forms of TB is multidrug-resistant TB (MDR-TB), defined as resistance to, at least, Isoniazid and Rifampin, the two most potent first-line anti-TB drugs. 

• Arises due to improper use of antibiotics in chemotherapy of drug-susceptible TB patients. 

AIRBORNE ISOLATION PRECAUTIONS

• Airborne infection isolation is based on the following hierarchy of control measures:

a) Administrative (work practice) controls

b) Environmental controls

c) Personal protective equipments (PPE)

Principles of Airborne Infectious Disease Management

a) Administrative (work practice) controls

Work practice controls include using infection control precautions while performing aerosol-generating procedures, closing doors to AIIRs, hand hygiene, and signage.

Written policies and protocols to ensure the rapid identification, Isolation, diagnostic evaluation, and treatment of persons likely to have an airborne infectious disease.

Internal Policies and Procedures (IPP) in NGHA

Airborne Isolation Precautions – ICM-III-03 Management of Suspected/Confirmed Cases of

Infectious Tuberculosis – ICM-V-03 Standard Precautions – ICM-II-03 Transporting Patients in Isolation Precautions –

ICM-III-09 Isolation System: A Quick Reference Guide – ICM-

III-06

b) Environmental controls

• Physical or mechanical measures (as opposed to administrative control measures) used to reduce the risk for transmission of airborne infectious diseases. Example :

• ventilation• filtration• AIIRs (Airborne Infection Isolation Rooms)• local exhaust• UVGI (Ultra-violet Germicidal Irradiation)

c) Personal Protective Equipment (PPE)

• Equipment worn by health care workers and others to reduce exposure to communicable diseases.

EXAMPLES:

Gowns Gloves Masks (N95) Respirators Eye protection

NURSING ASPECTS FOR PTB PATIENTS

Risk for Infection

• The goal is to reduce the risk of spreading tuberculosis and making sure the patient's tuberculosis is effectively treated.

Teach the patient about the infectious nature of tuberculosis and the need to prevent its spread.

Place the patient in a negative pressure room (AIIRs) or in a private room.

All nurses and visitors entering the patient's room should wear a N-95 mask.

Put a surgical mask on the patient during transportation to other departments. Refer to

ICM-III-09 Transporting Patients in Isolation Precautions.

Keep the door to the patient's room shut and place an isolation sign at a visible location near the door.

Use standard precautions when providing direct care to the patient. This includes wearing gloves, gowns, mask and effective hand washing.

Teach patient how to avoid spreading the disease by sneezing or coughing into doubly ply tissue instead of their bare hands, washing their hands after this and disposing of the tissue into a closed plastic bag.

• Airborne isolation precautions must be used together with standard precautions

–ICM-II-03

Standard precautions

ICM-II-03

• Treating all patients in the health care facility with the same basic level of "standard" precautions.

• It involves work practices that are essential to provide a high level of protection to patients, health care workers and visitors.

These include the following: • hand washing and antisepsis (hand hygiene); • use of personal protective equipment when

handling blood, body substances, excretions and secretions;

• appropriate handling of patient care equipment and soiled linen;

• prevention of needle stick/sharp injuries; • environmental cleaning and spills-

management; and appropriate handling of waste.

TB Patient Transportation

• THE PATIENT SHOULD WEAR A SURGICAL MASK IF TRANSPORT OUTSIDE OF THE ROOM AND IT IS ESSENTIAL.

• Surgical masks are designed to reduce the number of droplets being exhaled into the air by persons with infectious TB disease when they breathe, talk, cough, or sneeze.

• Respirators/N95 are designed to protect HCWs and other individuals from inhaling those droplet nuclei.

After discharge patient :

• KEEP DOORS CLOSED FOR AT LEAST 30 MINUTES AFTER AN AIRBORNE INFECTION ISOLATION PATIENT LEAVES THE ROOM.

• During that time the door should remain closed and respiratory protection is still required to enter the room.

• In a room with re-circulated air, if the patient has been in the room without a surgical mask on, the portable HEPA (High-efficiency Particulate Absorption) unit should be left running approximately 30 minutes after the patient leaves.

Discontinuation :

• Airborne precautions in a health-care or congregate setting may be discontinued when a patient has been on adequate therapy for 2 weeks or longer, symptoms improved, and there have been three consecutive, negative AFB (Acid-Fast Bacilli) sputum smear results.

References

• NGHA Infection Control Manual.

• Lippincott Manual of Nursing Practice"; Sandra M. Nettina ANP-BC.; 2013.

• World Health Organization:WHO Report 2013: Global Tuberculosis Control; 2013. 

• "Nursing care Plans: Nursing Diagnosis and Intervention"; NANDA; Meg Gulanick, PhD, APRN, FAAN., et. al.; 2012.