hospital discharge of tb patients: collaborating with the health department
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Hospital Discharge of TB Patients: Collaborating with the Health Department. Diana Nilsen, MD Bureau of Tuberculosis Control NYC Department of Health and Mental Hygiene. Today’s Presentation. Epidemiology of TB in NYC, 2011 - PowerPoint PPT PresentationTRANSCRIPT
Hospital Discharge of TB Patients: Collaborating with the Health
Department
Diana Nilsen, MDBureau of Tuberculosis Control
NYC Department of Health and Mental Hygiene
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
Reported TB Cases United States, 1982–2010*
*Updated as of July 21, 2011
11,182 cases
Tuberculosis Cases and Rates Tuberculosis Cases and Rates New York City, 1982 – 2011*New York City, 1982 – 2011*
689 Cases in 2011689 Cases in 2011
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11
Year
0
10
20
30
40
50
60Case Rate
# Cases51.1
8.5
Number of Cases Rate/100,000
21.4
*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.
US* and Non-US-Born TB CasesUS* and Non-US-Born TB Cases† †
New York City, 1982-2011New York City, 1982-2011
*Puerto Rico and U.S. Virgin Islands are included as US-born†There was 1 case with unknown country of birth in 2011.
3,132
1,010
Nu
mb
er o
f C
ases
Top 10 Countries of Birth of Foreign-born Persons, NYC TB Cases
20112011 NN 20102010 NN
ChinaChina 104104 ChinaChina 104104
MexicoMexico 4949 Dominican RepublicDominican Republic 4141
BangladeshBangladesh 3333 EcuadorEcuador 4141
Dominican RepublicDominican Republic 3131 MexicoMexico 3535
EcuadorEcuador 3030 BangladeshBangladesh 3030
HaitiHaiti 3030 PhilippinesPhilippines 2828
IndiaIndia 3030 IndiaIndia 2626
NepalNepal 1919 HaitiHaiti 2323
PhilippinesPhilippines 1616 PakistanPakistan 2020
Puerto RicoPuerto Rico 1515 GuyanaGuyana 1616
6
Tuberculosis rates1 by United Hospital Fund (UHF) neighborhood,
New York City, 2009-2011
Trend in HIV-Infection and TBNew York City, 1992-2011
34 33 3331
26
22 22
1815
1816 16 15
13 1311
97 9
0
10
20
30
40
50
200
400
600
800
1,000
1,200
1,400
92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11
Year
% TB/HIV+
# TB/HIV+
% of TB/HIV Infected CasesNumber of Cases
8
HIV-Infected TB Patients New York City, 1992-2011
Top 10 Medical Facilities First Evaluating Patients for TB- New York City, 2011
Facility NameFacility Name # of cases# of cases % cases% cases1. Elmhurst Hospital Center1. Elmhurst Hospital Center 4141 66
2. New York Hospital Medical Center of Queens2. New York Hospital Medical Center of Queens 3535 55
3. Bellevue Hospital Center3. Bellevue Hospital Center 3434 55
4. Maimonides Medical Center4. Maimonides Medical Center 3232 55
5. Lincoln Medical and Mental Health Center5. Lincoln Medical and Mental Health Center 2424 33
6. Kings County Hospital Center6. Kings County Hospital Center 2323 33
7. Beth Israel, Queens Hospital Center7. Beth Israel, Queens Hospital Center 2121 33
8. Lutheran Medical Center8. Lutheran Medical Center 1313 33
9. Coney Island Hospital9. Coney Island Hospital 1212 22
10. Montefiore Medical Center, Bronx-Lebanon 10. Montefiore Medical Center, Bronx-Lebanon Medical CenterMedical Center
1111 22
18. Lenox Hill Hospital18. Lenox Hill Hospital 1010
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
TB Reporting Requirements
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
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)
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
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
Background- Discharge Planning
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)(Tuberculosis Chemotherapy Centre, Madras. Bull WHO 1959:21-144:51-339)
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 WHOTuberculosis Chemotherapy Centre, Madras. Bull WHO 1960, 23; 463-5101960, 23; 463-510
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!
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
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
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
Pg 128
NYC Health Code Amendment
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
NYC Health Code AmendmentNew York City Health Code Article 11 Section 21(4)
amended June 16, 2010
1. Hospitals/providers must obtain approval from health department at least 72 business hours before discharging infectious TB patients
2. Providers must submit proposed treatment plan to NYC Health Department within one month of treatment initiation for all persons newly diagnosed with active TB disease
New requirement communicated to hospital providers (June and November 2010)
Process for Submitting Hospital Discharge Plans
Discharge Plan Approval Process
Determination72 hrs before discharge Within 1 business day
Provider •discusses discharge plan issues with DOHMH •revises plan•informs DOHMH
Provider submits Hospital Discharge Approval Request Form to DOHMH via fax
DOHMH physician •reviews discharge plan •makes determination•communicates withhospital provider
Approved
Not applicable
Disapproved
Outcomes of Discharges
Approved: criteria for discharge metNot approved: additional actions or
information needed Not applicable: extrapulmonary TB cases,
noninfectious cases, atypical mycobacterium (NTM)
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
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
What Does the DOHMH Need to Do Prior to Discharge?
Field staff need to interview patient to elicit contacts
Home assessment should be donePatient to agree to home isolation and DOT
– Sign agreements for bothFollow up appointment is made
Update on Hospital Discharge Plan Submissions
November 1- March 1, 2011
Acid Fast Bacilli Sputum Smear Positive TB Patients
Sputum smear positive TB patients *
97
*Suspected and confirmed
Discharged smear positive48 (50%)
Still in hospital33 (34%)
Plan submitted22 (46%)
No plan submitted26 (54%)
Discharged smear negative16 (17%)
Plan submitted
9 (56%)
No plan submitted
7 (44%)
Plan submitted10 (27%)
No plan submitted23 (73%)
Patients Discharged While Acid Fast Bacilli Sputum Smear Positive (n=48)
0
1
2
3
4
5
6
H1
H2
H3
H4
H5
H6
H7
H8
H9
H10
H11
H12
H13
H14
H15
H16
H17
H18
H19
H20
H21
H22
H23
H24
H25
H26
H27
Hospital
Nu
mb
er
of
pa
tie
nts No plan submitted Plan submitted
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 dateMedian number of days for DOHMH
physician to respond to treating MD was 0 days (range: <1-3)
Initial Approval Status of Discharge Plan Submissions
Approved52%
Disapproved41%
Pending2%
Not Applicable
5%
Reasons For Initial Disapproval*
# %
Home assessment not complete 6 27
Discharge plan form incomplete 5 23
DOT not offered/agreed 4 18
Discharged to congregate setting/unstable residence
3 14
Inadequate treatment regimen 2 9
Children <5 in house not evaluated 2 9
*Discharge plans may be disapproved for more than one reason
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
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
Process for Submitting Treatment Plans
Treatment Plan Approval ProcessWithin 1 month of
treatment start date
Treating provider •discusses treatment plan issues with DOHMH •revises plan•informs DOHMH
DOHMH case manager •contacts treating provider • obtains completed treatment plan form
DOHMH physician •reviews treatment plan •makes determination•communicates with provider
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)
Future Considerations
• Continue collaboration with hospitals/providers
• Monitor submission of hospital discharge/treatment plans
• Outreach to hospitals/providers experiencing issues with plans
• Continue to evaluate impact of initiative
Conclusion
Submit discharge plans for infectious TB patients within 72 business hours of planned discharge
Submit treatment plans within one month of treatment initiation
Ensure forms are complete/accurateRefer to NYC DOHMH guidelines & resourcesCall 311 to consult with DOHMH TB experts
Acknowledgements
NYC DOHMH Bureau of TB Control Provider Outreach Project Working Group
NYC DOHMH Bureau of TB Control StaffNYC Infection Control Nurses and
Practitioners
For Consultation call:311 DOHMH TB Hotline 212-788-4162www.nyc.gov/health/tb