Tuberculosis Risk Assessment Worksheet

ADVERTISEMENT
128
MMWR
December 30, 2005
Appendix B. Tuberculosis (TB) risk assessment worksheet
This model worksheet should be considered for use in performing TB risk assessments for health-care settings and nontraditional facility-based settings.
Facilities with more than one type of setting will need to apply this table to each setting.
✓ or Y = Yes
Scoring:
X or N = No
NA = Not Applicable
1. Incidence of TB
Rate
a. What is the incidence of TB in your community (county or region served by the health-care
Community ___________________
setting), and how does it compare with the state and national average?
State ________________________
b. What is the incidence of TB in your facility and specific settings, and how do those rates
National ______________________
compare? (Incidence is the number of TB cases in your community during the previous year.
Facility _______________________
A rate of TB cases per 100,000 persons should be obtained for comparison.)* This information
Department 1 _________________
can be obtained from the state or local health department.
Department 2 _________________
Department 3 _________________
c. Are patients with suspected or confirmed TB disease encountered in your setting (inpatient and
outpatient)?
1) If yes, how many are treated in your health-care setting in 1 year? (Review laboratory data,
No. patients
infection-control records, and databases containing discharge diagnoses for this
Year
Suspected
Confirmed
information.)
1 year ago
_______
_______
2 years ago _______
_______
5 years ago _______
_______
2) If no, does your health-care setting have a plan for the triage of patients with suspected or
confirmed TB disease?
d. Currently, does your health-care setting have a cluster of persons with confirmed TB disease
that might be a result of ongoing transmission of Mycobacterium tuberculosis ?
2. Risk Classification
a. Inpatient settings
1)
How many inpatient beds are in your inpatient setting?
Quantity ______________________
2)
How many patients with TB disease are encountered in the inpatient setting in 1 year?
Previous year _________________
(Review laboratory data, infection-control records, and databases containing discharge
5 years ago ___________________
diagnoses.)
___ Low risk
3)
Depending on the number of beds and TB patients encountered in 1 year, what is the risk
___ Medium risk
classification for your inpatient setting?
___ Potential ongoing transmission
_______
4)
Does your health-care setting have a plan for triaging patients with suspected or confirmed
TB disease?
b. Outpatient settings
Previous year _________________
1)
How many TB patients are evaluated at your outpatient setting in 1 year? (Review
laboratory data, infection-control records, and databases containing discharge diagnoses
5 years ago ___________________
for this information.)
_______
2)
Is your health-care setting a TB clinic? (If yes, a classification of at least medium risk is
recommended.)
_______
3)
Does evidence exist that a high incidence of TB disease has been observed in the
community that the health-care setting serves?
_______
4)
Does evidence exist of person-to-person transmission in the health-care setting? (Use
information from case reports. Determine if any TST or blood assay for M. tuberculosis
[BAMT] conversions have occurred among health-care workers [HCWs].)
_______
5)
Does evidence exist that ongoing or unresolved health-care–associated transmission has
occurred in the health-care setting (based on case reports)?
_______
6)
Does a high incidence of immunocompromised patients or HCWs in the health-care setting exist?
_______
7)
Have patients with drug-resistant TB disease been encountered in your health-care setting
Year encountered ______________
within the previous 5 years?
Date of classification ____________
8)
When was the first time a risk classification was done for your health-care setting?
_______
9)
Considering the items above, would your health-care setting need a higher risk classification?
128
MMWR
December 30, 2005
Appendix B. Tuberculosis (TB) risk assessment worksheet
This model worksheet should be considered for use in performing TB risk assessments for health-care settings and nontraditional facility-based settings.
Facilities with more than one type of setting will need to apply this table to each setting.
✓ or Y = Yes
Scoring:
X or N = No
NA = Not Applicable
1. Incidence of TB
Rate
a. What is the incidence of TB in your community (county or region served by the health-care
Community ___________________
setting), and how does it compare with the state and national average?
State ________________________
b. What is the incidence of TB in your facility and specific settings, and how do those rates
National ______________________
compare? (Incidence is the number of TB cases in your community during the previous year.
Facility _______________________
A rate of TB cases per 100,000 persons should be obtained for comparison.)* This information
Department 1 _________________
can be obtained from the state or local health department.
Department 2 _________________
Department 3 _________________
c. Are patients with suspected or confirmed TB disease encountered in your setting (inpatient and
outpatient)?
1) If yes, how many are treated in your health-care setting in 1 year? (Review laboratory data,
No. patients
infection-control records, and databases containing discharge diagnoses for this
Year
Suspected
Confirmed
information.)
1 year ago
_______
_______
2 years ago _______
_______
5 years ago _______
_______
2) If no, does your health-care setting have a plan for the triage of patients with suspected or
confirmed TB disease?
d. Currently, does your health-care setting have a cluster of persons with confirmed TB disease
that might be a result of ongoing transmission of Mycobacterium tuberculosis ?
2. Risk Classification
a. Inpatient settings
1)
How many inpatient beds are in your inpatient setting?
Quantity ______________________
2)
How many patients with TB disease are encountered in the inpatient setting in 1 year?
Previous year _________________
(Review laboratory data, infection-control records, and databases containing discharge
5 years ago ___________________
diagnoses.)
___ Low risk
3)
Depending on the number of beds and TB patients encountered in 1 year, what is the risk
___ Medium risk
classification for your inpatient setting?
___ Potential ongoing transmission
_______
4)
Does your health-care setting have a plan for triaging patients with suspected or confirmed
TB disease?
b. Outpatient settings
Previous year _________________
1)
How many TB patients are evaluated at your outpatient setting in 1 year? (Review
laboratory data, infection-control records, and databases containing discharge diagnoses
5 years ago ___________________
for this information.)
_______
2)
Is your health-care setting a TB clinic? (If yes, a classification of at least medium risk is
recommended.)
_______
3)
Does evidence exist that a high incidence of TB disease has been observed in the
community that the health-care setting serves?
_______
4)
Does evidence exist of person-to-person transmission in the health-care setting? (Use
information from case reports. Determine if any TST or blood assay for M. tuberculosis
[BAMT] conversions have occurred among health-care workers [HCWs].)
_______
5)
Does evidence exist that ongoing or unresolved health-care–associated transmission has
occurred in the health-care setting (based on case reports)?
_______
6)
Does a high incidence of immunocompromised patients or HCWs in the health-care setting exist?
_______
7)
Have patients with drug-resistant TB disease been encountered in your health-care setting
Year encountered ______________
within the previous 5 years?
Date of classification ____________
8)
When was the first time a risk classification was done for your health-care setting?
_______
9)
Considering the items above, would your health-care setting need a higher risk classification?
Vol. 54 / RR-17
Recommendations and Reports
129
Appendix B. ( Continued )Tuberculosis (TB) risk assessment worksheet
_______
10) Depending on the number of TB patients evaluated in 1 year, what is the risk classification
___ Low risk
for your outpatient setting (see Appendix C)?
___ Medium risk
___ Potential ongoing transmission
_______
11) Does your health-care setting have a plan for the triage of patients with suspected or
confirmed TB disease?
c. Nontraditional facility-based settings
1)
How many TB patients are encountered at your setting in 1 year?
Previous year _________________
5 years ago ___________________
_______
2)
Does evidence exist that a high incidence of TB disease has been observed in the
community that the setting serves?
_______
3)
Does evidence exist of person-to-person transmission in the setting?
_______
4)
Have any recent TST or BAMT conversions occurred among staff or clients?
_______
5)
Is there a high incidence or prevalence of immunocompromised patients or HCWs in the setting?
Year encountered ______________
_______
6)
Have patients with drug-resistant TB disease been encountered in your health-care setting
within the previous 5 years?
Date of classification ____________
7)
When was the first time a risk classification was done for your setting?
_______
8)
Considering the items above, would your setting require a higher risk classification?
_______
9)
Does your setting have a plan for the triage of patients with suspected or confirmed TB
disease?
___ Low risk
_______
10) Depending on the number of patients with TB disease who are encountered in a nontraditional
___ Medium risk
setting in 1 year, what is the risk classification for your setting (see Appendix C)?
___ Potential ongoing transmission
3. Screening of HCWs for M. tuberculosis Infection
_______
a. Does the health-care setting have a TB screening program for HCWs?
If yes, which HCWs are included in the TB screening program? (check all that apply)
___ Physicians
___ Service workers
___ Mid-level practitioners
___ Janitorial staff
(nurse practitioners [NP] and
___ Maintenance or engineering staff
physician’s assistants [PA])
___ Transportation staff
___ Nurses
___ Dietary staff
___ Administrators
___ Receptionists
___ Laboratory workers
___ Trainees and students
___ Respiratory therapists
___ Volunteers
___ Physical therapists
___ Others ________________________
___ Contract staff
___ Construction or renovation workers
_______
b. Is baseline skin testing performed with two-step TST for HCWs?
®
_______
c. Is baseline testing performed with QuantiFERON
-TB or other BAMT for HCWs?
d. How frequently are HCWs tested for M. tuberculosis infection?
Frequency ____________________
_______
e. Are M. tuberculosis infection test records maintained for HCWs?
Location _____________________
_______
f. Where are test records for HCWs maintained?
_______
g. Who maintains the records?
Name _______________________
h. If the setting has a serial TB screening program for HCWs to test for M. tuberculosis infection,
1 year ago ____________________
what are the conversion rates for the previous years?
2 years ago ___________________
3 years ago ___________________
4 years ago ___________________
5 years ago ___________________
i. Has the test conversion rate for M. tuberculosis infection been increasing or decreasing, or has
___ Increasing
it remained the same over the previous 5 years? (check one)
___ Decreasing
___ No change in previous 5 years
130
MMWR
December 30, 2005
Appendix B. ( Continued )Tuberculosis (TB) risk assessment worksheet
_______
j. Do any areas of the health-care setting (e.g., waiting rooms or clinics) or any group of HCWs
Rate ________________________
(e.g., laboratory workers, emergency department staff, respiratory therapists, and HCWs who
attend bronchoscopies) have a test conversion rate for M. tuberculosis infection that exceeds
the health-care setting’s annual average? If yes, list.
___ Not applicable
k. For HCWs who have positive test results for M. tuberculosis infection and who leave
_______
employment at the health setting, are efforts made to communicate test results and recommend
follow-up of latent TB infection treatment with the local health department or their primary
physician?
4. TB Infection-Control Program
_______
a. Does the health-care setting have a written TB infection-control plan?
Name _______________________
b. Who is responsible for the infection-control program?
Date ________________________
c. When was the TB infection-control plan first written?
Date ________________________
d. When was the TB infection-control plan last reviewed or updated?
_______
e. Does the written infection-control plan need to be updated based on the timing of the previous
update (i.e., >1 year, changing TB epidemiology of the community or setting, the occurrence of
a TB outbreak, change in state or local TB policy, or other factors related to a change in risk for
transmission of M. tuberculosis )?
_______
f. Does the health-care setting have an infection-control committee (or another committee with
infection-control responsibilities)?
1)
If yes, which groups are represented on the infection-control committee? (check all that apply)
___ Physicians
___ Health and safety staff
___ Nurses
___ Administrator
___ Epidemiologists
___ Risk assessment
___ Engineers
___ Quality control
___ Pharmacists
___ Others (specify)
___ Laboratory personnel
Committee ____________________
2)
If no, what committee is responsible for infection control in the setting?
5. Implementation of TB Infection-Control Plan Based on Review by Infection-Control
Committee
_______
a. Has a person been designated to be responsible for implementing an infection-control plan in
Name _______________________
your health-care setting? If yes, list the name.
b. Based on a review of the medical records, what is the average number of days for the following:
____ Presentation of patient until collection of specimen.
____ Specimen collection until receipt by laboratory.
____ Receipt of specimen by laboratory until smear results are provided to health-care provider.
____ Diagnosis until initiation of standard antituberculosis treatment.
____ Receipt of specimen by laboratory until culture results are provided to health-care provider.
____ Receipt of specimen by laboratory until drug-susceptibility results are provided to health-
care provider.
____ Receipt of drug-susceptibility results until adjustment of antituberculosis treatment, if
indicated.
____ Admission of patient to hospital until placement in airborne infection isolation (AII).
c. Through what means (e.g., review of TST or BAMT conversion rates, patient medical records,
Means _______________________
and time analysis) are lapses in infection control recognized?
Mechanisms __________________
d. What mechanisms are in place to correct lapses in infection control?
_______
e. Based on measurement in routine QC exercises, is the infection-control plan being properly
implemented?
_______
f. Is ongoing training and education regarding TB infection-control practices provided for HCWs?
Vol. 54 / RR-17
Recommendations and Reports
131
Appendix B. ( Continued )Tuberculosis (TB) risk assessment worksheet
6. Laboratory Processing of TB-Related Specimens, Tests, and Results Based on Laboratory
Review
a. Which of the following tests are either conducted in-house at your health-care setting’s
laboratory or sent out to a reference laboratory? (check all that apply)
In-house
Sent out
____
____
Acid-fast bacilli (AFB) smears
____
____
Culture using liquid media (e.g., Bactec and MB-BacT)
____
____
Culture using solid media
____
____
Drug-susceptibility testing
____
____
Nucleic acid amplification testing
b. What is the usual transport time for specimens to reach the laboratory for the following tests?
AFB smears _______
Culture using liquid media (e.g., Bactec, MB-BacT) _______
Culture using solid media _______
Drug-susceptibility testing _______
Nucleic acid amplification testing _______
Other (specify) _______
_______
c. Does the laboratory at your health-care setting or the reference laboratory used by your health-
care setting report AFB smear results for all patients within 24 hours of receipt of specimen?
What is the procedure for weekends?
_________________________________________________________________________
7. Environmental Controls
a. Which environmental controls are in place in your health-care setting? (check all that apply and
describe)
Environmental control
Description
____ AII rooms
____________________________
____ Local exhaust ventilation (enclosing devices
____________________________
and exterior devices)
____________________________
____ General ventilation (e.g., single-pass system,
____________________________
recirculation system)
____________________________
____ Air-cleaning methods (e.g., high efficiency
____________________________
particulate air [HEPA] filtration and ultraviolet
____________________________
germicidal irradiation [UVGI])
____________________________
b. What are the actual air changes per hour (ACH) and design for various rooms in the setting?
Room
ACH
Design
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
c. Which of the following local exterior or enclosing devices such as exhaust ventilation devices
are used in your health-care setting? (check all that apply)
___ Laboratory hoods
___ Booths for sputum induction
___ Tents or hoods for enclosing patient or procedure
d. What general ventilation systems are used in your health-care setting? (check all that apply)
___ Single-pass system
___ Variable air volume
___ Constant air volume
___ Recirculation system
___ Other _________________________________________________________________
e. What air-cleaning methods are used in your health-care setting? (check all that apply)
HEPA filtration
UVGI
___ Fixed room-air recirculation systems
___ Duct irradiation
___ Portable room-air recirculation systems
___ Upper-air irradiation
___ Portable room-air cleaners
132
MMWR
December 30, 2005
Appendix B. ( Continued )Tuberculosis (TB) risk assessment worksheet
f. How many AII rooms are in the health-care setting?
Quantity ______________________
g. What ventilation methods are used for AII rooms? (check all that apply)
Primary: (general ventilation)
___ Single-pass heating, ventilating, and air conditioning (HVAC)
___ Recirculating HVAC systems
Secondary (methods to increase equivalent ACH):
___ Fixed room recirculating units
___ HEPA filtration
___ UVGI
___ Other
(specify)____________________________________________________________
_______
h. Does your health-care setting employ, have access to, or collaborate with an environmental
engineer (e.g., professional engineer) or other professional with appropriate expertise (e.g.,
certified industrial hygienist) for consultation on design specifications, installation,
maintenance, and evaluation of environmental controls?
_______
i. Are environmental controls regularly checked and maintained with results recorded in
maintenance logs?
_______
j. Is the directional airflow in AII rooms checked daily when in use with smoke tubes or visual
checks?
_______
k. Are these results readily available?
l. What procedures are in place if the AII room pressure is not negative?
___________________________________________________________________________
_______
m. Do AII rooms meet the recommended pressure differential of 0.01-inch water column negative
to surrounding structures?
8. Respiratory-Protection Program
_______
a. Does your health-care setting have a written respiratory-protection program?
b. Which HCWs are included in the respiratory-protection program? (check all that apply)
___ Janitorial staff
___ Physicians
___ Maintenance or engineering staff
___ Mid-level practitioners (NPs and PAs)
___ Transportation staff
___ Nurses
___ Dietary staff
___ Administrators
___ Students
___ Laboratory personnel
___ Others (specify) ___________________
___ Contract staff
___ Construction or renovation staff
___ Service personnel
c. Are respirators used in this setting for HCWs working with TB patients? If yes, include
manufacturer, model, and specific application (e.g., ABC model 1234 for bronchoscopy and
DEF model 5678 for routine contact with infectious TB patients).
Manufacturer
Model
Specific application
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_______
d. Is annual respiratory-protection training for HCWs performed by a person with advanced
training in respiratory protection?
Date ________________________
_______
e. Does your health-care setting provide initial fit testing for HCWs? If yes, when is it conducted?
Date ________________________
_______
f. Does your health-care setting provide periodic fit testing for HCWs? If yes, when and how
frequently is it conducted?
Frequency ____________________
Method ______________________
g. What method of fit testing is used?
_______
h. Is qualitative fit testing used?
_______
i. Is quantitative fit testing used?

Download Tuberculosis Risk Assessment Worksheet

120 times
Rate
4.6(4.6 / 5) 7 votes
ADVERTISEMENT
Page of 6