UNIVERSITY OF CONNECTICUT HEALTH CENTER

TUBERCULOSIS (TB) RISK ASSESSMENT FOR THE

CONTROL OF OCCUPATIONAL EXPOSURE

TO TUBERCULOSIS

(May, 2006)

EXECUTIVE SUMMARY

The Occupational Safety and Health Administration withdrew the TB standard on Occupational Exposure to Tuberculosis (29CFR1910.139) on December 31, 2003.  As a result of this action, medical facilities wishing to issue respirators to staff for control of potential exposure to TB had to comply with the more stringent General Industry Respiratory Protection Standard (29 CFR 1910.134).  Ramifications of this action were significant, including the addition of requirements for annual fit testing, training and medical clearances.  Congressional action followed and on December 22, 2004, Congress passed the Consolidated Appropriations Act (FY 2005 Budget Bill) that forbid OSHA from utilizing any of its funding to enforce the annual fit testing requirement.  At this writing, it is not known if OSHA will enforce the Respiratory Standard in the future.  Therefore, this policy and the fit testing requirements have been developed to implement the new requirements if necessary.  Annual fit testing is voluntary at this time.  This policy has been expanded to include outpatient clinics and, although rare, potential exposures in research related activities.  It has also been written to allow for primary access by computer, with links to other appropriate documents.  This TB Control Program may be accessed through RESEARCH SAFETY WEB SITE.

The risk of exposure of Health Center staff to TB is low, based on recommendations of the Centers for Disease Control guidelines dated 2005 and data obtained by those writing this policy.  Target groups within the UCHC Health System have been identified that will require fit testing of respirators, training, tuberculosis skin testing (TST, formally known as PPD testing) using the PPD testing and medical evaluations.  Those not in these target groups are at very low risk for exposure to a potentially infectious TB patient, and will not be fitted with respirators.  The TB Exposure Control plan has been expanded to include outpatient clinics associated with the John Dempsey Hospital.   Individuals in non-target areas may enter the program on a voluntary basis by contacting the Department of Epidemiology and/or the Office of Research Safety.  Duties have been assigned to various UCHC functional areas for implementation of this policy.  Primary responsibility for compliance rests with immediate supervisors, who are assigned the task of ensuring none of their staff members are inappropriately exposed.  Staff is instructed not to enter a respiratory isolation area without appropriate respiratory protection.  This plan will be reviewed and updated as needed by the Office of Research Safety, the Department of Epidemiology and the Infection Control Committee.

The University of Connecticut Health Center continues to assign the highest priorities to occupational safety and health practices for staff while working in research and health care environments.  The potential exposure and subsequent transmission of tuberculosis is a recognized risk to health care workers, and to a lesser extent, to staff working in a research setting with potential for exposure.  This policy has been developed by representatives of the University Employee Health Service, the John Dempsey Infection Control Committee, the Office of Research Safety and the John Dempsey Department of Epidemiology.  The goal of this policy is to minimize the risk of the transmission of TB from potentially infectious patients to others and to prevent infection of research staff potentially exposed to TB while conducting research activities.    This policy also includes measures to verify the effectiveness of the program.  The program is risk based, and the Centers for Disease Control publication entitled “Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, 2005” was used as model approach in developing this policy.  Certain components of the earlier CDC guidance published in 1994 were retained.  Central to an effective policy is the early identification of potential risk sources.  Such sources would be potentially infected patients entering the Hospital, an outpatient facility or research proposals involving potential TB exposures.  Hospital staff has the main responsibility for recognizing high-risk potentially active TB patients at the John Dempsey Hospital, Nurses and Medical Assistants have the responsibility for recognizing potentially active TB patients visiting the outpatient clinics and the Institutional Biological Safety Committee and/or the Animal Care Committee would determine potential research risk through protocol reviews.   For control of TB transmission in the Health Care areas, the University of Connecticut’s “Infection Control Manual” is incorporated by reference.  This policy will be printed in a hard copy version with reference to hard copies of the John Dempsey Hospital’s Infection Control Manual and the UCHC’s Written Respirator Program for the Selection and Use of Respirators, it may best be utilized by computer reference.  Using this policy is more easily accomplished by entering the Research Safety Office website where sections of all policies are immediately available.

The CDC recommends that a TB policy be developed that reflects the potential for exposure and then implementing appropriate procedures.  In addition, the policy should be reviewed and revised as necessary to reflect changes in the risk as determined by a case surveillance program and local demographics. 

The CDC has reported that the case rate of TB in the State of Connecticut from 1992 through 2003 has decreased from 4.8 cases/100,000 in 1992 to 3.0 cases/100,000 in 2002.  This represents a 37.5% rate reduction from 1992 to 2003.  In 1992, 156 cases were reported and in 2003 111 cases were reported.  The number of reported cases (provisional) for 2004 was 101 and 85 for 2005.  Observation of reported cases from 1998 through 2005 in the State of Connecticut indicates the following:

                                                                                 REPORTED TB CASES CONNECTICUT

Data for 2003 indicate that there were 3 reported cases in New Britain, 4 in Bristol and no cases reported in West Hartford, Avon, Farmington, Simsbury, Berlin, Plainville or Southington.  In addition to State data, the following table provides the number of confirmed respiratory TB cases identified for the Health Center. 

CONFIRMED TB CASES UCHC

It is concluded that there are TB patients in the State and local communities, and it is not likely that one of these patients would enter the John Dempsey Hospital.  However, the Health Center does receive patients from populations at greater risk for acquiring TB such as the Department of Corrections.  The John Dempsey Hospital would be notified prior to the admission of an active TB patient from the Department of Corrections.  There has been no evidence of person-to-person transmission and the Health Center has had no more than 2 patients admitted during ANY year.   The Health Center is therefore classified as a Low Risk facility based upon the CDC criteria (2005) of fewer than 6 or more patients per year entering a facility of 200 beds or more. 

 

The CDC recommended in the 1994 guidance document the following components of a TB infection control program based on a “low Risk” classification.  These components have been retained in this document.

                          *HCW, Health Care Worker

In addition to this policy, two UCHC publications are incorporated into this document by reference.  These documents are the"Infection Control Manual, 2003” and the University of Connecticut Health Center Written Program for the Selection and Use of Respirators, 2005.  Sections of these documents will be incorporated as needed, and the reader is referred to the document links provided.

The Infection Control Committee, the Employee Health Service and the Department of Epidemiology have designated the following areas as having a risk of exposure to TB within the UCONN Health System and research areas:

 Anatomic Pathology (Autopsy only)

Cardio/Pulmonary Service

Emergency Department

Intensive Care Unit

Infectious Disease Clinic

Psych 1

Med 4

Surg 5

Oncology 6

Surg 7

Geriatric Psych 3

Transportation Aids

Respiratory

Diagnostic Radiology

Correctional Health Care

Laboratory Medicine (Phlebotomists)

Facilities Management (EOC)

Housekeeping (Supervisors only)

Center for Laboratory Animal Care (At risk Staff)

Department heads, administrative and managerial staff in these designated areas must identify those individuals and procedures which could potentially expose staff to TB.  Procedures specifically identified include, but may not be limited to, diagnostic sputum induction, administration of aerosolized pentamidine, bronchoscopy, endotracheal intubation/suctioning or receiving patients that could potentially be infectious.  Individuals in designated areas must be specifically trained in TB control measures and must participate in the OSHA mandated UCHC Respirator Program for the Selection and Use of Respirators.  Individuals not specifically participating in the TB control program are not permitted to treat or be exposed to patients with suspected or confirmed cases of infectious TB.     

The outpatient clinics located at East Hartford, West Hartford and Simsbury and other above mentioned areas do not admit active or suspected tuberculosis patients.  The CDC guidance document, “Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, 2005”, recommends that procedures be in place to respond to a potential patient presenting at outpatient clinics.  The CDC classifies an outpatient clinic as low risk if 3 or less active TB patients are seen in a year.  Based on site data, these clinics are classified as low risk facilities.  As for the John Dempsey Hospital, target groups have been identified that require TB training, respirator fit-testing with appropriate medical clearance and TST tests on an annual basis.  These target groups are

Nurses

Medical Assistants

whose primary purpose is to immediately identify a potential TB patient and minimize the risk to other patients and staff until the patient can be transferred to the John Dempsey Hospital or other suitable facility.  A POTENTIALLY ACTIVE TB PATIENT SHALL NOT BE ADMITTED FOR MEDICAL EVALUATION at these clinics or outpatient service centers.

Department Heads:     

Department Heads, Deans, administrative and managerial staff are responsible for compliance with this TB Exposure Control Plan.  Their primary responsibilities include identification of possible TB exposure mechanisms in their areas of responsibility, ensuring that staff is familiar with this policy, ensuring that their staff complies with this policy and providing updated information to the Department of Epidemiology and/or the office of Research Safety on newly identified TB risk factors in their respective areas.  Department heads, administrative and managerial staff must ensure that all staff (including residents, fellows, students, volunteers) working in designated areas (see Item IV) and who may be exposed to TB comply with all aspects of this plan. 

Health Care Workers, Employees, Fellows, Residents, Students, Volunteers:

Individuals in this category shall not be exposed to TB unless prior approval is obtained by supervisory staff and proper training, medical clearance and respirator fit testing is obtained.   Minors and volunteers shall not be exposed.

Infection Control Committee:    

The Infection Control Committee is responsible for periodic TB risk assessment and review of this plan.  As recommended by the CDC this shall be done at least yearly for the UCHC’s low risk classification, and if needed, make revisions to this policy to reflect increased risk levels.

UCHS Safety and Emergency Preparedness Committee:

The Safety and Emergency Preparedness Committee shall ensure that all medical staff are aware of this TB policy and provide recommendations for improvements and compliance with the JCAHO.

Institutional Biological Safety Committee:

The Institutional Biological Safety Committee shall review experimental protocols involving biological agents.  Protocols shall be developed to ensure research staff is not exposed to infectious TB.  This Committee also reviews all protocols involving biological agents used in humans, and works in conjunction with the IRB to approve such protocols. 

Office of Research Safety:

The Office of Research Safety shall be responsible for administering the respiratory protection program, including training of HCW’s, training of designated area “Trainers” and fit testing.  The “Written Program for the Selection and Use of Respirators” can found on the Research Safety website.  The Office of Research Safety shall maintain a database of all those individuals fit tested for respirator use and shall determine the appropriate respirator to be used in each exposure condition.  It should be noted that all health care workers will not be fitted with respirators, and emergency fits will be done by the Office of Research Safety as needed by HCW’s or other individuals qualified as “Trainers” to perform routine fit testing and training. 

            Department of Epidemiology:

The responsibility for Infection Control in the Health Care system is with the Department of Epidemiology, and rests with the Hospital Epidemiologist and the Nurse Epidemiologist (x4376).  Day to day inquiries should be directed to the Nurse Epidemiologist for TB control issues.  For potential exposures to TB while involved in research activities the Office of Research Safety should be contacted, and specifically, the Biological Safety Officer (x2723).  Exposures in the Research area are rare.  All protocols involving animals and biological safety level II or greater agents are reviewed by the Biological Safety Officer and approved by the Institutional Biological Safety Committee, and if appropriate, the Animal Care Committee.

The Department of Epidemiology (4376) is responsible for maintaining and updating the Infection Control Manual as needed.  Members of this Department work with the Office of Research Safety in providing TB training and fit testing of respirators.   The Department of Epidemiology shall determine, with the assistance of the Employee Health Services Medical Director and the Infection Control Committee, the TB risk level at the UCHC and determine if a change in policy is warranted.  This shall be done at least annually. 

The Department of Epidemiology is responsible for reporting confirmed TB cases to the Connecticut Department of Public Health.  Procedures for reporting communicable diseases to the DPH may be found in the Infection Control Manual, Section 4.2, “List of Reportable Communicable Diseases in Connecticut–2003”.

UCHC Division of Occupational and Environmental Medicine, Employee Health Service:

The Employee Health Service (EHS) is responsible for all respirator medical examinations and tuberculosis skin tests (TST tests).  Prior to issuing and fit testing an individual for a respirator, the OSHA “Respirator Medical Evaluation Questionairre” must be completed  The information on this questionnaire is confidential and must only be reviewed by the Medical Director, EHS, or an individual delegated by the Medical Director.  For routine, non-emergency respirator assignments, the questionnaire must be returned directly to Dr. Marcia Trapé-Cardoso, Medical Director, Employee Health Service, MC6210.  Respirators will not be issued without a signed medical clearance from the Employee Health Service.

If an employee requires a fit test during off hour periods, page Dr. Trapé-Cardoso or the physician on call for Occupational Medicine after completing the medical questionnaire.  Dr. Trapé-Cardoso or the physician on call will provide medical clearance after reviewing the information on the questionnaire.  Dr. Trapé-Cardoso or the physician on call will authorize the individual performing the fit test to issue the respirator, or if not authorized, directed to use a PAPR.  The clearance form will be sent to the Office of Research Safety the next working day. 

The EHS will maintain required medical records and recall employees at prescribed frequencies for reevaluation.  Based on the “Low Risk” classification at the time of this writing, Health Care Workers identified as potentially exposed must obtain a TST test at a minimum of once per year.  The Medical Director shall determine if an individual is medically qualified to don a respirator and perform medical reevaluations at least annually (If required by OSHA and/or if the employee requests it).  The Medical Director shall determine how annual medical reevaluations will be accomplished, and may designate qualified UCHC staff to assist in such evaluations.    The Medical Director shall monitor the number and locations of TB cases and number of positive TST conversions, and in conjunction with the Infection Control Committee and the Department of Epidemiology, determine if a reassessment of the “risk level” is in order.  This shall be done at least annually.  All health care workers with a TST conversion will receive a medical evaluation at the Employee Health Service which will include a chest radiograph to exclude active disease.  Newly converted workers will be offered treatment for latent TB infection (LTBI) according to Employee Health Service policy and procedures for the management of LTBI.

Facilities Management:

Facilities Management shall ensure that all TB isolation rooms are maintained at a negative pressure relative to the entryways shall maintain the portable HEPA filtering units and shall ensure that Facilities staff that may be potentially exposed to a suspected TB patient are adequately trained in the use and care of Powered Air Purifying Respirators (PAPR’s).  The Facilities Management Environmental Operations Center shall maintain the Powered Air Purifying Respirators (PAPR’s) stored in their area.

The Occupational Safety and Health Administration (OSHA) have withdrawn its standard on Occupational Exposure to Tuberculosis, 29 CFR 1910.139.  However, Congress has temporarily prohibited OSHA from enforcing the full respirator standard.  Individuals wearing respirators for TB protection may, in the future,  have to comply with OSHA’s standard on Respiratory Protection, 29 CFR 1910.134.  This standard requires annual fit testing, training and medical clearances for all those issued respirators.  At present, the UCHC is not requiring annual fit testing.  The designated areas (identified in Items IV and V) are considered areas where HCW’s could receive patients that may have symptoms suggestive of TB.  Individuals working in these areas must comply with the UCHC’s  “Written Respirator Program for the Selection and Use of Respirators” Supervisory staff in these areas shall identify potentially exposed individuals and these individuals must:

Receive TB Specific Training and Refreshers as Needed

Receive Training in the Policy for Control of TB

Be Medically Qualified to Don a Respirator

Be Trained in the Use of Respirators

Be Fit Tested With an Appropriate Respirator

Obtain a TST at least Annually

HCWs that are not members of the designated areas or who have not been issued a respirator shall not enter a TB isolation room, handle or treat a potentially infectious TB patient.  Refer to Section 3.9 of the Infection Control Manual “Respirator Use for Protection Against Tuberculosis” Respirator Use for Protection Against Tuberculosis.

A.                  Early Identification of Potentially Infectious Patients or Research Related Exposures

The HCW is the first point of contact for a potentially infectious patient and staff in designated areas needs to be trained and act quickly for effective TB control.  The John Dempsey Hospital Infection Control Manual, Section 2.19 Tuberculosis Protocol: Assessment for Initiating Respiratory (STOP SIGN) Isolation for Tuberculosis, is incorporated by reference into this procedure.  No individual may enter an isolation room posted with a STOP SIGN without training, respirator fit testing and medical clearance.  A companion procedure from the Infection Control Manual, Section 3.2, “Admission Screening for Communicable Airborne Disease” is also applicable.

Potential exposure in a Research setting will be determined well in advance through the protocol review process.  The Medial Director, Employee Health Service, the Institutional Biological Safety Committee, the Animal Care Committee and the Office of Research Safety will establish proper protocols to ensure minimal risk of TB infection of research staff.

B.                  Isolating Suspected TB Patients

A potentially infectious TB patient must be placed in respiratory isolation as soon as is practical.  Prior to placement of a patient into a negative pressure isolation room measures should be taken to prevent airborne contamination, such as placing a surgical mask on the patient if this does not pose a risk to the patient’s medical condition.  Section 2.1 of the Infection Control Manual, “Placing and Maintaining a Patient on Respiratory (STOP SIGN) Isolation”, describes the policy in detail.

C.                  Establishing and Maintaining Isolation

A potentially infectious TB patient may be placed into a designated negative pressure room or a room equipped with a portable HEPA air filtering unit.  The policy for maintaining isolation for designated negative pressure rooms is provided in Section 3.1 of the Infection Control Manual, “Tuberculosis Protocol: Isolation Rooms, Monitoring of Negative Pressure”.  The policy for maintaining isolation in a situation where a patient is not placed in a designated isolation room is provided in Section 2.22, “Tuberculosis Control:  Air Filtration Unit, Use of Portable HEPA Filtration Unit”.  It should be noted that placement of a portable HEPA unit is done by the Facilities Environmental Operations Center (EOC) staff.  As described in the Facilities Assignment of Responsibilities, training and use of respirators with medical clearance are required prior to entry into an isolation room.  Alternatively, PAPR’s can be used provided proper training is done.

D.                  Confirming An Infectious TB Case

After placement of a suspected infectious TB patient into an isolation room, sputum samples must be collected to rule out infectious TB.  A patient shall not be removed from respiratory isolation unless TB is ruled out.  The Infection Control Manual, Section 2.23, “Tuberculosis Control: Sputum Collection for Rule Out Tuberculosis” shall be followed prior to releasing a patient from TB isolation.  An important corollary procedure, Section 2.9, “Laboratory Specimens”, must be implemented for all laboratory specimens.

E.                  Discontinuing TB Isolation

TB isolation shall only be discontinued if TB is ruled out when 1) three negative consecutive sputum specimens are negative for acid fast bacilli or 2) Sputum culture report is mycobacterium other than tuberculosis.  The length of time required for therapy to render a TB patient non-infectious is variable.  A patient must not be removed from isolation until the patient has started on a minimum of three drug therapy and has definite clinical improvement.  HCWs are encouraged to contact the Department of Epidemiology and/or refer to the Infection Control Manual for any questions.  Prior to discharge, arrangements must be made to ensure continued therapy.  An infectious patient should only be discharged to a facility that has isolation capability or to their homes.  Due consideration must be made, if discharge to their home, of other family members exposure.  The Infection Control Manual, Section 2.20, “Tuberculosis Protocol:  Discontinuing Respiratory (STOP-SIGN) Isolation” shall be followed.  If an infectious TB patient requires transport to another facility or area of the Health Center, it is important to minimize the potential for staff exposure.  Section 2.6 of the Infection Control Manual, “Transporting Infected or Colonized Patients” shall be followed.  All potentially infectious TB patients must don a surgical mask while being transported.

F.                  Releasing a Room After Use for TB Isolation

Once a room is designated for isolation, the STOP-SIGN shall not be removed until the room is properly sanitized.  Section 2.21 of the Infection Control Manual, “Tuberculosis Protocol: Airing of Rooms Used for Respiratory (STOP-SIGN) Isolation”, provides the policy for restoring an isolation room back to “normal”.   Entry is not permitted by unauthorized individuals until the STOP-SIGN is removed.  The CDC has recommended the following wait times for entering an isolation room:

Room Ventilation                     Wait Time, m               Wait Time, m

Air Changes/Hour                    99% Removal               99.9% Removal

              2                                       138                                  207

              4                                         69                                  104

              6                                         46                                    69

            12                                          23                                    35

G.                  Cough Inducing Procedures

Cough inducing procedures are those that result in the instrumentation of the lower respiratory tract or induction of cough and include:  endotracheal intubation and suctioning, diagnostic sputum induction, aerosol treatments (including pentamidine therapy) and bronchoscopy.  The following guidelines must be followed for patients that may have infectious TB, and procedures that produce aerosols should be avoided in such patients. 

All cough inducing procedures should be performed using local exhaust ventilation devices (booths or special enclosures), or in an isolation room that meets the requirements for an isolation STOP-SIGN

All HCWs must be qualified to enter the room.  A properly fitted respirator must be worn. Training, medical qualification and fit testing must also be current.  PAPR use is also approved provided proper training in its use is documented.

After completion of cough-inducing procedures, suspect patients should remain in isolation until coughing subsides, and isolation controls kept in place.

Refer questions to the Department of Epidemiology (4376).  The following Sections of the Infection Control Manual should be consulted:  Section 2.1 “Placing and Maintaining a Patient on Respiratory Isolation(STOP-SIGN) Isolation”, Section 3.1 “Tuberculosis Protocol: Isolation Rooms, Monitoring of Negative Pressure”, Section 2.22 “Tuberculosis Control: Air Filtration Unit, Use of Portable HEPA Filtration Unit”, Section 2.20 “Tuberculosis Control: Discontinuing Respiratory(STOP-SIGN) Isolation”, Section 2.6 “Transporting Infected or Colonized Patients” and Section 2.21 “Tuberculosis Control: Airing of Rooms Used for Respiratory (STOP-SIGN) Isolation”.  Many of the other procedures referenced in this policy should be used as needed.

H.                  Health Care Worker (HCW) Monitoring

Maintaining a safe working environment for HCWs is of primary concern and requires an ongoing effort to maintain an effective TB control program.  HCWs that have been designated to care for patients potentially positive for TB must be, prior to ANY exposure to a potentially infectious TB patient:

 Attended Training

Obtain TST’s At Least Annually

Be Medically Qualified to Wear a Respirator

Be Fit Tested With an N95 Respirator

If Using a PAPR, Trained In Its Use

The HCWs immediate supervisor is responsible for ensuring compliance with these initial and annual requirements.  The HCW shall not be exposed if these requirements are not met.  The Medical Director, Employee Health Services, shall determine the method used for annual medical evaluations of HCWs.  Section 3.6 of the Infection Control Manual, “Tuberculosis Skin Testing (PPD)” should be consulted for specific requirements.

Staff working in Research who may be exposed will have specific protocols developed for their work.  The Medical Director, Employee Health Services, the Institutional Biological Safety Committee, the Animal Care Committee and the Office of Research Safety shall jointly develop TB control and monitoring requirements prior to the initiation of any such research.

I.                  HCW Work Restrictions

The Department of Epidemiology shall determine any work restrictions needed should a HCW develop active TB or has a TST conversion.  The Infection Control Committee may be consulted.  All information relating to the patient’s identification will be kept confidential. Section 3.4 of the Infection Control Manual, “Employee Work Restrictions Because of Communicable Diseases Or Special Conditions” shall be consulted.

J.                  Post-Mortem Handling of Bodies

Standard universal precautions are usually sufficient.  Section 2.7 of the Infection Control Manual, “Post-Mortem Handling of Bodies” shall be followed.

K.                  UCHC Written Program for Use of Respirators

Health Care Workers potentially exposed to TB must be fitted with appropriate respiratory protection equipment.  If a HCW is unable to be fitted, instruction must be given on the use and how to obtain a PAPR.  The UCHC’s Written Respirator Program is available on the Research Safety Web site, or by clicking on “Written Respirator Program for Selection and Use of Respirators”.  Any questions should be directed to the Office of Research Safety (x2723).  This TB exposure control policy includes the OSHA requirements.

A.      SUSPECT TB PATIENT ADMISSION POLICY

Suspect or confirmed TB patients SHALL NOT be admitted into these facilities for medical examination or treatment.

B.      PROCEDURE FOR IDENTIFYING AND REROUTING SUSPECT TB OUTPATIENTS

1.       Characteristics of a potentially infectious TB patient include presence of a persistent cough, fever, anorexia and weight loss.  Any patient with pulmonary disease of undiagnosed etiology must be suspect. 

2.       Once an individual is identified as a potentially active TB patient, measures must be taken immediately to protect yourself, other patients and staff.  Ask the individual to cover their mouth when coughing and provide them a surgical mask. If you will come in close contact with the patient, put on your respirator. Do not give the patient a respirator!  Obtain patient’s name and other information that would be helpful in locating the patient in the future.  As is practical, obtain a list of patients and staff that may have been exposed and forward to Department of Epidemiology (4376).

3.       Isolate the patient in a room and place a red “STOP” sign on the door.

4.       Call an ambulance service for transport to the John Dempsey Hospital emergency room.  Notify ambulance service that the patient is a potentially infectious TB patient.  

5.       Notify the Infection Control Epidemiologist (679-4376) at the John Dempsey Hospital that a potentially infectious TB patient will be transported to the ED. Notify the Emergency Department (679-2588) also.   

6.       If the patient refuses transport to JDH, contact the Infection Control Specialist at 679-4376.  Ask patient to leave the facility.

7.       Keep the door to the room used for isolation closed and posted for one hour after the patient leaves. 

The Infection Control Epidemiologist will inform you if the patient was later found to be infectious.  If so, you must contact the Employee Health Service (679-2893) for medical follow up.        

Early identification by front line staff is critical for timely containment and minimization of risk to staff and caregivers.

If a patient or visitor exhibits signs or symptoms of TB (chronic productive cough, night sweats, etc.) staff should immediately contact a faculty member for further analysis.  If the faculty member determines that this individual is a potential TB case and requires a rule out the following steps must be taken as soon as possible.

-          Immediately provide the patient or visitor with a surgical mask (do not give them a respirator mask) or tissues to cough into.

-          Isolate the individual in a vacant patient room with a door and close the door. Post an isolation “STOP” sign on the door. An inventory of patients and staff who may have come in contact with the suspect individual should be maintained incase follow-up procedures are necessary and forward the list to the Department of Epidemiology.

-          Contact the Infection Control Practitioner X-4376 and the Manager of Dental Clinic Support Services X3161 or beeper 825-9922.

-          Movement of the patient must be coordinated through the Hospital Transportation Department at X1948.  You must convey your concerns about the suspect individual and inform the Transportation Department representative that respiratory precautions are necessary.  Only employees who have been trained medically qualified to wear a respirator and who have completed their fit testing may wear a respirator.

-          The patient may then be transported to the negative pressure room located in DC#5 room #16 or directly to the Emergency Department. 

-          Advanced notice to all receiving areas is mandatory to allow for preparation of the isolation room and to provide time for staff to don personal protective equipment (respirators).  If the suspect patient is to be placed in the DC#5 negative pressure room and PRIOR TO MOVING THE PATIENT, instruct DC#5 staff to turn on the HEPA unit, post the respiratory isolation “STOP” sign and visually verify the room is negative by the “ball in the wall” indicator.  If negative pressure is not achieved by the HEPA unit, reroute suspect patient to the Emergency Department and Radiology if necessary.  (Contact facilities regarding negative pressure room)

-          If the assigned patient caregiver is not certified to wear a N95 respirator, notify the Research Safety Office for training, medical evaluation and fit testing or obtain a PAPR (positive air pressure respirator) by contacting Facilities Management – ECC at X-2338.

Nights, weekend or holiday emergency patient visits must be seen in the Emergency Department.  The Emergency Department is trained to receive potentially infectious TB patients.

Additional information (UCHC TB Policy) and subsequent procedures that must be adhered to are contained on the Office of Research Safety home page and the Hospital Infection Control Manual.  This information may be obtained by going to the UCHC Home page, clicking on Research Administration, then on Office of Research Safety.  The Infection Control Manual may also be obtained within the Dental School and on the Infection Control shared folder

Richard A. Garibaldi, MD                        Hospital Epidemiologist             679-2715 (w)

                                                            Page, 2626

Nancy Dupont, BSN, RN                        Nurse Epidemiologist                 679-4376 (w)

                                                                                                            Page, 2626

Marcia Trapé-Cardoso, MD                     Medical Director,                        679-2893 (w)

                                                            Employee Health Service            Page, 2626

Kenneth Price, MPH, CHP                      Director, Office of Research        679-2723 (w)

                                                            Safety                                       205-6446 (c)

Steven Jacobs                                       Assistant Director, Office            679-2723 (w)

                                                            Of Research Safety                    825-3938 (p)

Ronald Wallace, Ph.D, CIH                     Biological Safety, Office              679-2723 (w)

                                                            Of Research Safety                    202-7802 (c)

JDH Emergency Department                   Emergency Services                  679-2588

Environmental Ops Center                      Facilities Management               679-2338 (24h)

___________________________                         _____________________________

Kenneth W. Price, MPH, CHP                            Marcia Trapé-Cardoso, M.D.

Director, Office Research Safety                          Director, Employee Health Service

___________________________                         _____________________________

Richard A. Garibaldi, M.D.                                  Steven Strongwater, M.D.

Hospital Epidemiologist                                      Associate Dean Clinical Operations

                                                                        Director, Clinical Operations

                                                                        Director, John Dempsey Hospital

UCHC  JOHN DEMPSEY HOSPITAL INFECTION CONTROL MANUAL

UCHC WRITTEN PROGRAM FOR THE SELECTION AND USE OF RESPIRATORS 2004

INFECTION CONTROL MANUAL-SECTION 4.2-LIST OF REPORTABLE COMMUNICABLE DISEASES IN CONNECTICUT

INFECTION CONTROL MANUAL-SECTION 3.9-RESPIRATOR USE FOR PROTECTION AGAINST TUBERCULOSIS

INFECTION CONTROL MANUAL-SECTION 2.19-TUBERCULOSIS CONTROL: ADMISSION ASSESSMENT FOR INITIATING RESPIRATORY (STOP-SIGN) ISOLATION

INFECTION CONTROL MANUAL-SECTION 3.2-ADMISSION SCREENING FOR COMMUNICABLE AIRBORNE DISEASE

INFECTION CONTROL MANUAL-SECTION 2.1-PLACING A PATIENT ON RESPIRATORY (STOP-SIGN) ISOLATION

INFECTION CONTROL MANUAL-SECTION 3.1-TUBERCULOSIS PROTOCOL: ISOLATION ROOMS: MONITORING OF NEGATIVE PRESSURE

INFECTION CONTROL MANUAL-SECTION 2.22-TUBERCULOSIS PROTOCOL: AIR FILTRATION HEPA UNIT, USE OF PORTABLE

INFECTION CONTROL MANUAL-SECTION 2.23-TUBERCULOSIS PROTOCOL: SPUTUM COLLECTION FOR RULE OUT TUBERCULOSIS

INFECTION CONTROL MANUAL-SECTION 2.9- LABORATORY SPECIMENS

INFECTION CONTROL MANUAL-SECTION 2.20-TSUBERCULOSIS PROTOCOL: DISCONTINUING RESPIRATORY (STOP-SIGN) ISOLATION

INFECTION CONTROL MANUAL-SECTION 2.6-TRANSPORTING INFECTED OR COLONIZED PATIENTS

INFECTION CONTROL MANUAL-SECTION 2.21-TUBERCULOSIS PROTOCOL: TERMINAL AIRING OF ROOMS USED FOR RESPIRATORY (STOP-SIGN) ISOLATION

INFECTION CONTROL MANUAL-SECTION 3.6-TUBERCULOSIS SKIN TESTING

INFECTION CONTROL MANUAL-SECTION 3.4-EMPLOYEE WORK RESTRICTIONS DUE TO COMMUNICABLE DISEASES OR SPECIAL CONDITIONS

INFECTION CONTROL MANUAL-SECTION 2.7-POST-MORTEM HANDLING OF BODIES

OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE