Data Collection Quality Improvement

Quality Improvement Data Collection Tool TB – Active Cases/Suspects Sample Facility Size

Data Collector(s) Date

DATA COLLECTED TOTALS THRESHOLDS # INDICATOR COMMENTS 1 2 3 4 5 6 7 8 9 10 + - 0 GOAL ACTUAL (yes) (No) (N/A) 1 Is date of incarceration listed/ documented?

2 Were there symptoms on admission to the facility? Was the inmate isolated in an Airborne Infection 3 Isolation (AII) room within 5 hours of the first symptom? Was the health department notified within the 4 appropriate timeframe of the suspect case? 5 Were the smear results positive?

6 Was NAAT/MTD test done?

7 Were the culture results positive?

8 Was the TST/IGRA positive?

9 Was the CXR result on chart? Was the inmate placed on recommended 4-drug 10 therapy? 11 Were initial liver enzymes normal at baseline?

12 Was HIV counseling and testing done? Were the results of the HIV and other lab tests on 13 the chart? 14 If positive smear/culture, were contacts identified? If positive smear/culture, were contacts 15 evaluated? Was appropriate therapy initiated for LTBI 16 contacts? Was initial contact information given to HD within 17 7 days? PUT CHART IDENTIFYING INFORMATION HERE

SOUTHEASTERN NATIONAL TUBERCULOSIS CENTER (SNTC)  HTTP://SNTC.MEDICINE.UFL.EDU  888-265-7682  [email protected] Instruction Tool 1. Is the date of incarceration listed? This is a computer- 11. Were initial liver enzymes normal at baseline? This would be a generated date and can be obtained from Classifications or the “yes” or “no” response. NOTE: The lab slip would indicate the computer. The content of these cells will not be +/-, but should liver enzymes, such as SGOT, SGPT and Bilirubin and the range. identify the date the inmate came into the facility. NOTE: This 12. Was HIV counseling and testing done? There would be date will be important to identify potential teaching documentation stating the client was offered counseling and opportunities during the intake process if the inmate is not testing or a lab slip with refusal. NOTE: Documentation would identified early into the incarceration. be on a form or a lab slip, a refusal or on a progress note (may 2. Were there symptoms on admission to the facility? This can be include signature). This would be Not Applicable if the facility obtained from the intake sheet or a TB or cough questionnaire does not include HIV counseling and testing in their policy, the facility may have developed. NOTE: This information although it is recommended for every facility. indicates a potential for education that may be needed in the 13. Were the results of the HIV and other lab tests on the chart? A Intake area or follow-through that may be needed. lab slip, indicating positive or negative, should be in the chart. 3. Was the inmate isolated within five hours of the first Include all other applicable lab tests, such as viral load, CD4 symptom? Check for documentation in the progress notes of count. NOTE: The only time this would be “not applicable” the chart or a date/time on a Sick Call Slip or Isolation log. would be if no labs or HIV test was ordered. NOTE: This will assist in the event a contact investigation is 14. If positive smear or culture, were contacts identified? There is needed. generally an indication in the chart’s progress note that a 4. Was the health department notified within the appropriate contact investigation was initiated, and, if done, a sheet either time frame of the suspect case? This can be identified from the with the chart or a total number of contacts identified should HD record as well as the facility record. Documentation can be be included. This would be “not applicable” if the client was located within the progress notes of the record or a specific extrapulmonary or documentation by HD staff no contact area. The time frame is identified to meet local/state laws. investigation was needed. NOTE: A contact investigation should 5. Were the smear results positive? This will assist in prioritizing be done for every pulmonary case of tuberculosis. contact investigations, as well as identifying a need for focus If positive smear or culture, were contacts evaluated? This can studies with regard to collection of the sputum. be located on a contact evaluation sheet that would be NOTE: If any of the sputum is inadequate or overgrown, or not included with the inmate record, or in a separate file from cooled when transporting, this would indicate a need for Infection Control. NOTE: This would be “not applicable” if the education for adequate collection of sputa. client was extrapulmonary or documentation by HD staff no 6. Was NAAT/MTD test done? This should be done on all sputum contact investigation was needed. Contact evaluation is samples submitted initially. NOTE: This is an identification tool important to ensure no new cases of tuberculosis are missed. that can facilitate early release from isolation. [NAAT = nucleic 15. Was appropriate therapy initiated for LTBI contacts? A acid amplification; MTD = mycobacterium tuberculosis direct] physician’s order for INH or Rifampin therapy is documented in 7. Were the culture results positive? This is documented on the the doctor’s orders. NOTE: This would be INH (Isoniazid) for lab slips. Note: this information will assist in identification of nine or six months, depending on the length of stay of the prioritizing contact investigations, as well as identifying a need inmate. Rifampin for four months should be used for inmates for education of collection of sputa. staying at the facility for at least six months and only under the 8. Was the TST/IGRA positive? The results of the tuberculin skin guidance of a TB physician and directly observed treatment. test must be documented in millimeters. NOTE: Aids in 16. Was initial contact information given to the HD within seven identifying issues with regards to TST (tuberculin skin testing) or days? Documentation in the form of a Progress Note would IGRA (immune gamma response assay) and education for satisfy these criteria. NOTE: This would be “Not Applicable” if providers. The statement “negative” or “positive” is not the patient had extrapulmonary TB. This information is appropriate for TST. If TST is negative, it should be documented essential to ensure appropriate follow-up and completion if the as “0 mm”. client is released from the facility. 9. Was the CXR result in the chart? A copy of the results of the Put Chart Identifying Information Here recent chest x-ray should be located in the chart. NOTE: This is This area of the form is for documenting the initials or number of a CXR form, not a notation in the progress record. This is a the client’s chart for follow-up at a later date, if needed. “yes” or “no” in all cases, and would be “Not Applicable” only if no CXR was ordered. 10. Was the inmate placed on recommended four-drug therapy? This includes Isoniazid, Rifampin, Ethambutal and Pyrazinamide (INH, RIF, ETH, and PZA). Other regimens require documentation of consult with a TB expert. This information is documented on a physician’s order. NOTE: If sensitivities were returned with resistance to any of these, the inmate would be changed to different TB medications. Special Note: If low level resistance to INH, some MDs will keep INH in the regimen. Consult with a TB expert.

SOUTHEASTERN NATIONAL TUBERCULOSIS CENTER (SNTC)  HTTP://SNTC.MEDICINE.UFL.EDU  888-265-7682  [email protected]