Case Study of a Non-compliant TB Patient DENEEN GALLAGHER RN, BSN INGHAM COUNTY HEALTH DEPARTMENT MDCH TB NURSE CERTIFICATION COURSE JULY 24, 2014 Case History 21 year old male from Honduras Known exposure to an active TB case Presented to the local hospital 3/2012 with complaint of cough, fever/chills, and unintentional weight loss Chest x-ray revealed infiltrates in the right upper lobe, and cavitary lesion in the right lung suggestive of an abscess AFB positive on smear and culture for M.TB Case History 8 additional sputum specimens were collected (1 induced). All were negative on smear & 1 additional specimen was culture positive for M.TB Initial phase of treatment (7x/week) started 3/27/12 (INH, RIF, PZA, EMB, B6). Pan-sensitive to all 4 drugs Continuation phase started 7/9/12 Completed treatment on 4/1/13 (1 year). Treatment was extended due to cavitation, and missed/unwitnessed doses throughout treatment 1
Case History The case was a resident of another county at his diagnosis and start of treatment Other county did the initial investigation for contacts He had been in the Ingham County jail during his infectious period Ingham CD office worked with the jail, and with contacting Ingham county residents for follow up screening Client moved to Ingham County in May 2012 Psychosocial History Arrived in the USA at age 15 with refugee status Placed in the foster care system until aging out at 18 At the time of diagnosis, he was living with his girlfriend s family. She was 15 years old and pregnant. Did not have a great relationship with her parents and was eventually asked to move out His mother and sister live in Honduras, and he maintained contact with them by phone. No real or consistent local support system in place Psychosocial History Housing was transit MC(1 Did not complete high school Did not have reliable transportation History of petty crimes and incarceration at local MC(2 county jails prior to the diagnosis Arrested during treatment d/t non-related TB issue 2
Slide 6 MC(1 MC(2 Did you mean transient? Transit as a noun describes a system of pasing through or conveyance, such as "there is a problem with our urban transit system." As a verb, it is the action of moving or passing such as "once you transit three blocks, you will make it to the store." Transient means not lasting long in one place, or staying only a short time before moving on to something else. McNulty, Cassandra (DCH), 7/9/2014 I deleted many periods because of two reasons: 1. slides are not typically intended for full sentences 2. you are using fragmented statements, so you do not need punctuation at the ends McNulty, Cassandra (DCH), 7/9/2014
Issues Poor compliance with DOTs, and follow-up exams Inconsistent access to phone (no minutes/no income) Unreliable transportation Transient housing Lack of local support system Legal/court issues Lack of education Inconsistent employment Slight language barrier Drug use 3 case mangers/ingham County Jail Addressing Issues Multiple meetings with CD supervisor Had to call daily/weekly for location of DOT DOTs changed to 5x a week Interpreters used to assure client understood directions Multiple verbal warnings, followed by written warning Court was petitioned twice due to ongoing noncompliance Court Orders Be available for all DOTs and follow up with any tests ordered by the Health Department Keep all scheduled medical appointments Give 24 hour notice if leaving Lansing for work purpose/s Maintain communication with the Health Department for any issues related to DOTs Incarceration if non-compliance continued 3
Addressing Issues Provided bus tokens for transportation Transported to medical appointments and to court hearing/s as needed Provided calendar with dates of DOTs If unable to present to the HD would attempt to meet the client at location of his choice Flexibility with DOTs during continuation phase Provided incentives Provided support, and problem solved Other Issues Discovered that his friend visiting from another county was also an active TB case (contact) Friend decided to move to Lansing, so the case was transferred to Ingham County Both were required to come to the Health Department for their DOTs Other Legal Issues HD was notified that both clients were arrested for a non TB related crime Initially the local jail was dispensing the TB medication. Jail medical staff assessed the clients, reported any problems to the Health Department, and Communicable Disease. Nurse would visit every 2 weeks Both clients reported that they had missed some doses CDN presented to the jail 2x weekly to assess the clients and dispense the medication through the end of treatment (~2 months) Arrangements made through the jail for the client to be transported by a Deputy to the TB clinic 4
Conclusion Treated for 1 year The final chest x-ray was stable but the cavitation was still present. A repeat exam was recommended 6 months after completing treatment Ingham County unable to arrange the repeat chest x-ray due to the client being transferred to the Department of Corrections The chest x-ray done by the Department of Correction 9/2013 was negative 5