Big Bend Hospice TUBERCULOSIS EXPOSURE CONTROL PLAN

Big Bend Hospice TUBERCULOSIS EXPOSURE CONTROL PLAN Health Care Workers (HCWs) and CDC, OSHA or NIOSH representatives may review and make copies of this Tuberculosis Exposure at Big Bend Hospice (BBH), 1723 Mahan Center Boulevard, Tallahassee, Florida 32308, or at any of the Big Bend Hospice county offices. Outline: I. Purpose II. Objectives III. Tuberculosis Overview and Definitions IV. Program Management and Scope V. Environmental Risk Level VI. Individuals with Suspected or Confirmed Tuberculosis are not admitted to BBH VII. Recommendations and Required Documentation for Patient Transfer and Health Care Worker Safety VIII. Hierarchy of Control Measures IX. Cleaning and Disinfecting Patient-Care Equipment and Rooms X. Health Care Worker s Tuberculosis-related needs XI. Respiratory Protection Program XII. Post Exposure Protocol and Incident Evaluation I. Purpose: To provide HCWs a healthcare setting which is free from recognized hazards, such as Mycobacterium tuberculosis (TB), that cause, or are likely to cause, serious physical harm or death. II. Objectives: 1. To establish procedures to ensure the monitoring and control of TB. 2. To identify the environment s risk level for TB. 3. To educate and provide guidance to prevent, identify and address TB. 4. To define terms associated with TB and the screening process. 5. To provide guidance for Post Exposure Control 6. To provide a screening tool for early identification of individuals with suspected TB. III. Tuberculosis Overview and Definitions: Tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis. The bacteria generally attack the lungs, but may attack any part of the body such as the kidney, spine, and 1

brain. If not treated properly, it can be fatal. TB is carried in droplet nuclei which are generated when a person with active TB disease of the lungs or throat coughs, sneezes, speaks, or sings. People nearby may breathe in these bacteria and become infected. TB is not spread by shaking someone s hand; sharing food or drink; touching bed linens or toilet seats. Identifying and addressing active TB is exceedingly important. Early identification for new HCWs is verified by a TST result and, if needed, a Questionnaire and/or Chest X-ray per Tallahassee Memorial Hospital s (TMH) Employee Health Program. In the event a TST is contraindicated, the HCW will complete a Tuberculosis Symptom Screen (Questionnaire) at BBH. The TMH Employee Health Program is available to provide a Chest X-ray, if deemed necessary. The responsibilities of BBH and the TMH Employee Health Program is to maintain the HCW s confidentiality, while assuring that s/he receives appropriate TB therapy and is non-infectious before returning to duty. A patient is considered to have suspected TB (unless the individual s condition has been medically determined to result from a cause other than TB) if a BBH physician determines/learns that the patient has: a persistent cough lasting 3 or more weeks with 2 or more signs and symptoms of active infectious TB (see table below). Not everyone infected with TB bacteria develops the disease. As a result, two TB-related conditions exist: Latent TB Infection and active TB Disease. Latent TB Infection (LTBI) --TB bacteria can live inside the body without making the individual ill. In most people who breathe in TB bacteria and become infected, the body is able to fight the bacteria and stop its growth. People with latent TB infection do not feel ill and do not experience any symptoms. The only sign of TB infection is a positive reaction to the tuberculin skin test. People with latent TB infection are not infectious and cannot spread TB bacteria to others. However, if TB bacteria become active in the body and multiply, the person will get sick with TB disease. TB Disease--TB bacteria become active if the immune system cannot halt their growth. When TB bacteria multiply, it is called TB disease and makes the individual ill. People with TB disease may spread the bacteria to others. Many people who have latent TB infection never develop TB disease. While others, develop TB disease within weeks after becoming infected--before their immune system can fight the bacteria. Still others, may become ill years later, when their immune system becomes weak for another reason. For individuals with weak immune systems, especially those with HIV infection, the risk of developing TB disease is much higher than persons with typical immune systems. The Difference between Latent TB Infection and TB Disease A Person with Latent TB Infection Has no symptoms A Person with TB Disease Has symptoms that may include: - a bad cough that lasts 3 weeks or longer - pain in the chest - coughing up blood or sputum 2

Does not feel sick Cannot spread TB bacteria to others Usually has a skin test or blood test result indicating TB infection Has a normal chest x-ray and a negative sputum smear Needs treatment for latent TB infection to prevent active TB disease - weakness or fatigue - weight loss - no appetite - chills - fever - sweating at night Usually feels sick May spread TB bacteria to others Usually has a skin test or blood test result indicating TB infection May have an abnormal chest x-ray, or positive sputum smear or culture Needs treatment to treat active TB disease AFB (Acid Fast Bacilli)- staining used primarily to identify Mycobacterium tuberculosis. The process includes staining the specimen and then trying to wash out that stain by applying an acid. If the acid does not wash out the color that was applied, then the bacterium is called "acid fast". BCG (bacille Calmette-Guerin)- a vaccine for TB disease that many foreign-born persons received in childhood. It was used in many countries that had a high prevalence of TB, in order to prevent childhood tuberculous meningitis and miliary disease. CDC (Centers for Disease Control and Prevention)- collaborates to create the expertise, information, and tools that people and communities need to protect their health through health promotion, prevention of disease, injury and disability, and preparedness for new health threats. HCW (health care worker)- includes all volunteers and employees (nursing staff, chaplains, social workers, music therapists, etc. and potentially clerical, dietary, maintenance, transport personnel, etc.) working in healthcare settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease. Healthcare setting- any connection in which HCWs might share air space with persons with TB or in which health care workers may come in contact with TB specimens. Airspace is not just in the same room, but anywhere in the same building or vehicle. It includes an enclosed space that has recently been occupied by a patient, even though the patient may no longer be physically present. NIOSH (National Institute for Occupational Safety and Health)- as part of the CDC, NIOSH is responsible for conducting research and making recommendations for the prevention of workrelated illnesses and injuries. OSHA (Occupational Safety and Health Administration)- with the Occupational Safety and Health Act of 1970, Congress created OSHA to assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, 3

education and assistance. OSHA is part of the United States Department of Labor. The administrator for OSHA is the Assistant Secretary of Labor for Occupational Safety and Health. OSHA's administrator answers to the Secretary of Labor who is a member of the cabinet of the President of the United States. TST-Tuberculin Skin Testing- is an intradermal injection of tuberculin antigen, with subsequent measurement of the induration by designated, trained personnel. The TST is completed at TMH s Employee Health Program. The required Two-step testing for new hires involves the application of the skin test and, then a return visit 48-72 hours later for reading (so far, two visits to employee health). Then, 1-3 weeks later, the new HCW will return to the Employee Health Program to repeat the procedure (for a total of 4 visits to employee health). TB skin tests, treatment evaluations and follow-up are offered at no cost, by BBH, to the HCW. Additionally, a HCW who develops symptoms of TB disease shall be immediately evaluated, and needs addressed, according to TMH s Employee Health Program, CDC and OSHA Guidelines. Tuberculosis Symptom Screen- evaluates for TB exposure in the past year. Symptoms of pulmonary TB may include productive prolonged cough (more than 3 weeks), hemoptysis (blood in sputum), and chest pain. Systemic symptoms may include fever, chills, night sweats, and unexplained loss of appetite or weight, and unexplained fatigue. The TB Symptom Screen is included in this document, must be completed annually and provided to Human Resources by the annual deadline. Classification of the Tuberculin Skin Test Reaction Skin test interpretation depends on two factors: 1. The induration s measurement in millimeters. 2. The person s risk of being infected with TB and of progression to disease if infected. An induration of 5 or more millimeters is considered positive in: -HIV-infected persons -A recent contact of a person with TB disease -Persons with fibrotic changes on chest x-ray consistent with prior TB -Patients with organ transplants An induration of 10 or more millimeters is considered positive in: -Recent immigrants (< 5 years) from high-prevalence countries -Injection drug users -Residents and employees of high-risk congregate settings -Mycobacteriology laboratory personnel An induration of 15 or more millimeters is considered positive in: -Any person, including persons with no known risk factors for TB. However, targeted skin testing programs should only be conducted among high-risk groups -Persons who are immunosuppressed for other reasons (e.g., taking the equivalent of >15 mg/day of -Persons with clinical conditions that place them at high risk -Children < 4 years of age 4

prednisone for 1 month or longer, taking TNF (tumor necrosis factor) antagonists) - Infants, children, and adolescents exposed to adults in high-risk categories IV. Program Management and Scope: The Program Management s responsibility is addressed by BBH s Clinical Quality and Infection Control Specialist. Additional support includes: BBH s Infection Control Committee, Human Resource Department, Facilities Maintenance Department, Education, Physicians, HCWs, as well as TMH s Employee Health Program and other areas, as needed. The Clinical Quality and Infection Control Specialist, with assistance from HR and others, will annually monitor TB infection rates, review data, and make recommendations for modifications to the TB Exposure. V. Environmental Risk Level: BBH is classified as a Low-risk Tuberculosis environment. This means that one would not expect to come in contact with an individual diagnosed with TB, nor would one anticipate being exposed to a specimen containing M. tuberculosis this is because patients with suspected/confirmed TB are transferred to facilities which have the ability to provide the necessary care. Due to BBH s Low-risk classification, HCWs will receive a baseline, two-step TST upon hire, which tests for infection with M. tuberculosis. Additionally, HCWs will complete an annual Tuberculosis Symptom Screen to evaluate for TB exposure. The total number of BBH s confirmed TB cases, in the last 12 months, was zero. When considering the most recent TB incidence rates in the eight counties that BBH serves, six of the eight counties experienced only 0-1 TB cases, per county. Of the last two counties, the reported cases, per county population, were: 4 per 48,123; and 7 per 276,471. BBH s TB risk category will be reassessed annually, and more frequently if circumstances require thus, reflecting new or modified tasks; procedures and engineering controls; or, new or revised HCW positions. The reassessment will be completed by the Clinical Quality and Infection Control Specialist, with assistance, as needed, from other departments such as HR and Maintenance. If the risk category changes from low-risk to medium- or high-risk during the year, annual TB screening will be adjusted per TMH s Employee Health Program, CDC and OSHA guidelines. (As a noteworthy point, BBH does not perform high-hazard procedures such as bronchoscopy, pulmonary function testing, endoscopy or autopsy.) VI. Individuals with Suspected or Confirmed Tuberculosis are not admitted to BBH: 5

BBH does not admit or provide services to individuals with suspected/confirmed TB, nor does it currently have ample engineering controls for TB such as HEPA filters and isolation rooms. Instead, BBH transfers individuals with suspected/confirmed infectious TB to an acute care hospital, within 5 hours of identification of the suspected/confirmed TB status. In the event that a patient is admitted, and later found to have suspected/confirmed TB, the Team Manager, Interdisciplinary Team (IDT), Clinical Quality and Infection Control Specialist, Clinical Director and Facilities Maintenance Manager (who will notify any on-site contractors) will be notified immediately. Notification will occur via Voice Mail, Email and/or Text Messages, as well as Interdisciplinary Team Meetings and Shift Reports, as appropriate. Simultaneously, the IDT will immediately prepare to have the patient transferred to an acute care hospital which has the capacity and capability to provide care to TB patients. VII. Recommendations and Required Documentation for Patient Transfer and HCW Safety: While BBH does not admit patients with suspected/confirmed TB, it is beneficial to plan ahead-- against the unlikely time that the situation could arise. Therefore, this section will provide interventions to implement, while awaiting transfer of a patient with suspected/confirmed TB. The goal of this plan will be to provide safety and manage the patient s care, while minimizing HCWs exposure to the patient and his/her air space. Document the following, along with other pertinent patient-related information, in the medical record. 1. The name of the acute care hospital which has the capacity and capability to provide care to the TB patient; and has agreed to accept the patient. 2. Transportation plans including the patient wearing a surgical mask, as applicable. 3. If the patient is at the Hospice House, in suite 1,2,4,5,6,7,8,11 or 12: Make for certain that the door leading to the suite is closed, and the individual packaged terminal air conditioner (PTAC, a type of self-contained heating and air conditioning system), ceiling and bathroom fans are turned on. This will circulate the air to the bathroom, where it will be discharged to the outside. a. If the patient is at the Hospice House, in suite 3, 9 or 10, make for certain that the door leading to the suite is closed, and the air conditioning system, ceiling fan and bathroom fan are turned on. This will circulate the air to the bathroom, where it will be discharged to the outside. 4. If appropriate, while awaiting transport, instruct the patient to wear a surgical mask and remain alone in his/her room with the door securely closed to minimize the patient s air space from flowing into other areas of the building. 5. If possible, strive to address patient s communication needs via telephone, text or email to avoid entering the patient s room. 6

6. To the extent possible, strive to avoid entering the patient s air space, such as the home, Hospice House, vehicle, etc; or performing suctioning and/or aerosolized treatments for the patient. 7. When the task is essential, the nurse will don a N95 mask prior to entering the patient s air space. If the patient is able, the nurse will strive to have the patient wear a surgical mask, if s/he is not already. The number of HCWs entering the room will be minimized to one nurse, if possible; the nurse will combine as many tasks as possible into one entry; and the necessary service(s) will be provided inside the patient s room to minimize exposure to others. a. If the individual cannot wear a surgical mask, but is alert, provide tissues and instruct him/her to use them to cover his/her mouth anytime s/he sneezes, coughs, laughs, talks, etc. Additionally, teach the patient to discard the used tissue into a dirty tissue bag, secure the bag and throw it away. This will help minimize potential exposure. b. If the patient must leave the room, staff will instruct/escort the patient to use a door that is not typically used, as well as an unpopulated route to minimize TB exposure into commonly occupied areas. It is particularly important to keep the individual separated from other persons, especially those who are immunocompromised, very old, or very young. For individuals with weak immune systems, especially those with HIV infection, the risk of developing TB disease is much higher than persons with typical immune systems. 8. If the patient is located at the Hospice House, staff will place a sign on the patient s door and request that the patient remain inside his/her room. The sign MUST include a picture of a stop sign, have a red background with white lettering and say: No Admittance Without Wearing a N95 or More Protective Respirator. This will be documented in the medical record. 9. If a TB Skin Test Conversions/Exposure Incident occurs, then BBH MUST investigate the circumstances to determine the origin and needed interventions, in order to prevent an exposure from reoccurring. The investigation will be completed by the Clinical Quality and Infection Control Specialist, with assistance, as needed, from other departments such as HR, Maintenance, etc. Assistance may also be obtained from TMH s Employee Health Program. CDC and OSHA investigation guidelines will be followed. VIII. Hierarchy of Control Measures: The goal of TB exposure prevention is principally addressed through administrative measures, enhanced by the use of work practice controls and followed by respiratory personal protective equipment (PPE). Together, these reduce the HCW s risk of exposure to persons with suspected or confirmed TB while they await transfer to an acute care hospital. Administrative measures include: Assigning responsibility for TB infection control at BBH; Completing a TB risk assessment of the agency; Developing and instituting a written TB 7

exposure control plan to ensure prompt detection, airborne precautions, and treatment of persons who have suspected/confirmed TB disease, including an annual Tuberculosis Symptom Screen completion by HCWs; Ensuring availability of the Employee Health Program to obtain recommended testing, laboratory processing, reporting of results to the ordering physician (and required governmental agency when the result is positive) and BBH s Infection Control Committee; Implementing effective work practices for management of patients with suspected/confirmed TB disease; Ensuring proper cleaning and disinfection of the environment; and Training and educating HCWs regarding TB, with a specific focus on prevention, transmission and symptoms. BBH is a low-risk environment, having only minimal work practice/engineering controls present in the Hospice House. Specifically, these are in-duct ultraviolet germicidal irradiation (UVGI) to minimize potential contamination; the original 1 MERV 6 standard filters have been upgraded to 4 MERV 8 media filters which capture additional airborne particles without reducing the HVAC static pressure; and diluting and removing contaminated air via general ventilation. Regarding the ventilation, there are 12 suites at the Hospice House, the differences between suites 3, 9, and 10 and the others are: they have sealed mini-split heat pumps rather than PTAC s; they have designated fresh air intakes rather than fresh air provided by the PTAC unit design; and the bathroom exhaust fans run 24/7. The N95 disposable respirator, after a proper fit testing, is provided by the employer to keep HCWs safe from those who may have TB. In the event that an individual is suspected of having TB disease, BBH volunteers would not be utilized in that air space. IX. Cleaning and Disinfecting Patient-Care Equipment and Rooms: Medical devices and equipment are divided into three general categories critical, semi-critical, and noncritical. They are based on the potential risk for infection if an item remains contaminated at the time of use. Note: Transmission of M. tuberculosis and pseudo-outbreaks (ex: contamination of clinical specimens) have been linked to inadequately disinfected bronchoscopes contaminated with M. tuberculosis. Critical medical instruments, such as needles, are introduced directly into the bloodstream, or other normally sterile areas of the body. BBH only utilizes single use only, sterile needles, which are discarded after use, into the required sharps container. Semi-critical medical instruments might come into contact with mucous membranes but do not ordinarily penetrate body surfaces (e.g., noninvasive flexible and rigid fiber optic endoscopes or bronchoscopes, endotracheal tubes, and anesthesia breathing circuits) are semi-critical medical instruments. BBH does not utilize these types of instruments. Noncritical medical instruments or devices either do not ordinarily touch the patient or touch only the patient's intact skin (e.g., crutches, bed boards, and blood pressure cuffs) are noncritical medical instruments. These items are not associated with transmission of M. tuberculosis. When 8

noncritical instruments or equipment become contaminated with blood or body substances, they should be cleaned and then disinfected with a hospital-grade, Environmental Protection Agency (EPA)-registered germicide disinfectant with a label claim for tuberculocidal activity (i.e., an intermediate-level disinfectant). Tuberculocidal activity is not necessary for cleaning agents or low-level disinfectants that are used to clean or disinfect minimally soiled, noncritical items and environmental surfaces (e.g., floors, walls, tabletops, and surfaces with minimal hand contact). Per, http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm., the rationale for use of a disinfectant with tuberculocidal activity is to ensure that other potential pathogens with less intrinsic resistance than that of mycobacteria are killed. A common misconception in the use of surface disinfectants in health care relates to the underlying purpose of products labeled as tuberculocidal germicides. Such products will not interrupt and prevent transmission of M. tuberculosis in health-care settings, because TB is not acquired from environmental surfaces. The tuberculocidal claim is used as a benchmark to measure germicidal potency. Because mycobacteria have the highest intrinsic level of resistance among the vegetative bacteria, viruses, and fungi, any germicide with a tuberculocidal claim on the label (i.e., an intermediate-level disinfectant) is considered capable of inactivating many pathogens, including much less resistant organisms such as the bloodborne pathogens (e.g., hepatitis B virus, hepatitis C virus, and HIV). Rather than the product's specific potency against mycobacteria, a germicide that can inactivate many pathogens is the basis for protocols and regulations indicating the appropriateness of tuberculocidal chemicals for surface disinfection. There are two points to be mindful of when terminally cleaning a suite at the Hospice House, which lodged a suspected/confirmed TB patient: 1) the amount of time required to wait prior to entering the suite, without a N95 respirator; and 2) the cleaning agent must be a Tuberculocidal (an intermediate level disinfectant). If the patient was in suite 1, 2, 4, 5, 6, 7, 8, 11 or 12, the ventilation system is not pooled with the building s overall air flow. Therefore, the PTAC (a self-contained heating and air conditioning system) ceiling fan and bathroom fan need to remain on to assist air circulation to the bathroom, so it can be released to the outside, via the vent. Once outside, the bacterial concentration will diminish when mixed (diluted) with common air particles, making it improbable for a person to be effected by the bacteria. Due to multiple factors associated with these suites, the Air Changes per Hour (ACH) is indeterminable. Therefore, the least amount of ACH 1, will be designated, indicating that the suite will need to remain vacant, with the door closed, the PTAC/and both fans running for no less than 414 minutes (6.9hrs) before it is deemed safe for an individual to enter without wearing a N95 mask. If the patient was in suite 3, 9 or 10, the ACH is 6. The 6 ACH indicates that these suites need to remain vacant, with the door closed and the air conditioning system, ceiling fan and bathroom fan turned on for no less than 69 minutes before it is deemed safe for an individual to enter without wearing a N95 mask. 9

Please see the chart below and note line #7, which indicates 6 ACH, requiring 69 minutes for the air system to remove 99.9% of airborne contaminates from the room. While 69 minutes is essential waiting period, it is acceptable to wait longer, if circumstances allow. Per, http://wonder.cdc.gov/wonder/prevguid/m0035909/m0035909.asp#table_s31, Table S3-1. Air changes per hour (ACH) and time in minutes for required removal efficiencies of 90%, 99%, and 99.9% of airborne contaminates. Minutes required for a removal efficiency of: --------------------------------------------- ACH 90% 99% 99.9% ---------------------------------------------------------------- 1. 1 138 276 414 2. 2 69 138 207 3. 3 46 92 138 4. 4 35 69 104 5. 5 28 55 83 6. 7. 6 23 46 69 8. 7 20 39 59 9. 8 17 35 52 10. 9 15 31 46 11. 10 14 28 41 12. 13. 11 13 25 38 14. 12 12 23 35 15. 13 11 21 32 16. 14 10 20 30 17. 15 9 18 28 18. X. HCW s TB-related needs: BBH has contracted with TMH s Employee Health Program to address all BBH HCWs, TB needs. These needs include, but are not limited to: physical, laboratory, and radiographic evaluations, as needed. New BBH HCWs producing documentation of a negative TST result completed within the previous 12 months, or those who had received the BCG vaccine in childhood, will review the situation with the Employee Health Program to assure that the most current guidelines are implemented and finalized. After the baseline two-step TST, annual TST of HCWs is not required since duties do not include probable contact with patients diagnosed with TB, or contact with possible TB specimens. However, completion of the Tuberculosis Symptom Screen is required annually. This form is attached. HCWs with a baseline positive, or newly positive test result, for M. tuberculosis infection, or documentation of previous treatment for LTBI or TB disease will receive recommendations, treatment and/or follow up care, as needed, through TMH s Employee Health Program. 10

Return to work requirements for LTBI or TB disease will be considered in accordance with the Employee Health Program, CDC and OSHA s current standards. In the event that BBH s Low-risk status is upgraded to Medium- or High-Risk, the above recommendations will be modified with guidance from TMH s Employee Health Program, CDC and OSHA guidelines. XI. Respiratory Protection Program: The Respiratory Protection Program includes assignment of responsibility, training, and fit testing. Assignment of Responsibility: BBH s Clinical Quality and Infection Control Specialist, with support from the Infection Control Committee, HR Department and TMH s Employee Health Program, manages all aspects of the Respiratory Protection Program. The Clinical Quality and Infection Control Specialist reports to BBH s Director of Organizational Excellence and Corporate Compliance. All HCWs who use respirators for protection against M. tuberculosis are included in the Respiratory Protection Program and are educated regarding rationale and guidance for the proper selection, use, and care of respirators. HCW training is provided annually, on multiple topics: All health care workers will receive initial employment and annual education regarding TB, as it is appropriate to their job category. The following is an educational framework for initial hire and annual education: The basic concepts of TB transmission, cause/development/effects, and diagnosis, including the difference between latent TB infection and active TB disease, the signs and symptoms of TB, and the possibility of a false positive in the person with a positive TST. The potential for occupational exposure to patients with infectious TB, including the prevalence of TB in the community and nationwide, situations with increased risk of exposure to TB and working with people reported to have high risk for TB. The principles and practices of infection control that reduce the risk of TB transmission, including the hierarchy of TB infection control measures, the TB Exposure Control Plan, Respiratory/Airborne Precautions, transportation of TB patients, and required personal protective equipment. The purpose of the TST, the significance of a positive result and compliance with follow up/treatment, as necessary. 11

The importance of HCWs participating in preventive therapy for latent TB infection. The responsibility of the HCW to seek medical attention promptly if TB-like symptoms develop, or if a TST conversion occurs, so appropriate evaluation/therapy may ensue and prevent transmission. The treatment for active TB including: the medication regimen and direct observed therapy in the hospital and community. The possibility of the HCW requesting a voluntary work reassignment, if s/he is immunocompromised. The nature, extent, and hazards of TB disease in the health-care setting including: The risk assessment process and how it relates to the respirator program; Signs and symbols used to demonstrate that respirators are required in an area; Administrative and Environmental controls used to prevent the spread and reduce the concentration of infectious droplet nuclei; Reasons for selecting the N95 NIOSH respirator for potential TB concerns; Operation, capabilities, and limitations of respirators; Respirator care; Cautions regarding facial hair and respirator use; Regulations regarding respirators use. HCWs are provided opportunities to handle and wear a respirator until they are proficient. This occurs during the initial/annual fit testing. HCWs are educated regarding potential respiratory hazards that they may be exposed to during routine and emergency situations; Procedures for regularly evaluating the effectiveness of the respirator program; and The cost of respirators, training, and medical evaluations are provided by BBH. Additionally, HCWs shall be trained to recognize, and report any individuals with symptoms suggestive of infectious TB to Fran Folsom RN, Clinical Quality and Infection Control Specialist. HCWs will be instructed regarding: OSHA requirements for the respiratory protection program; and the basis for selecting respirators, such as potential workplace respiratory hazards and user dynamics that affect respirator performance and reliability. HCWs will receive instruction on the TB Post Exposure Protocol which requires HCWs to complete an Incident Report and to immediately seek Medical Evaluation and Follow Up at TMH s Employee Health Program. Fit Testing: HCWs are not assigned a task requiring use of respirators unless they are physically able to perform job duties while wearing the respirator. Upon hire and annually, HCWs who might need to use a respirator are screened by a licensed health-care professional for relevant medical 12

conditions. The form that is used is the OSHA Respirator Medical Evaluation Questionnaire, and is different from the TB questionnaire or the TST. Its purpose is to identify HCWs who need further medical evaluation prior to completing a Fit Test with a N95 respirator. The OSHA Respirator Medical Evaluation Questionnaire is provided to the HCW, and reviewed, by either BBH s Clinical Quality and Infection Control Specialist, a Team Manager, or designee, who is a licensed health-care professional, with additional training in Fit Testing procedures. After the Questionnaire is completed, the N95 Fit Testing procedure will also be completed, unless contradicted by the findings based on the Questionnaire. The finalized Questionnaire and ensuing Respiratory Issuance and Training Certification/Form (providing the N95 Fit Testing is completed), are forwarded to the HR department to be maintained by the Director of Human Resources. A current copy of the Certification form will also be kept in the Clinical Quality and Infection Control Specialist s office. Long term storage will not be kept in the Clinical Quality and Infection Control Specialist s office. The fit test is used to determine which respirator fits the user adequately and to ensure that the user knows when the respirator fits properly. Fit testing occurs: upon hire and annually. Fit testing may also occur periodically if there are changes with the HCW such as weight loss/gain of 10 lbs or more, significant oral surgery, etc that changes the form of the face; increased risk for transmission of M. tuberculosis; if a medical condition arises that affects the HCW s respiratory function/respiratory system; or a change in the model or size of the assigned respirator. Additional The results of such fit testing are maintained in a retrievable aggregate database. Employee training in the proper use of the N95 respirator will include: donning and removal; correct description and demonstration of the fit testing procedures for tight-fitting respirators; limitations on their use, any reasonably foreseeable emergency situations; and procedures for storing, inspecting, discarding, and otherwise maintaining the respirator. XII. Post Exposure Protocol and Incident Evaluation The TB Post Exposure Protocol requires the HCW to complete an Incident Report, submit it to his/her supervisor and to immediately seek Medical Evaluation and Follow Up at TMH s Employee Health Program. The Incident Evaluation will focus on the cause of the exposure, necessary interventions and goals. It will be completed with input from the involved HCW(s), TMH s Employee Health Program, Clinical Quality and Infection Control Specialist/Committee, Team Manager and other involved parties. References: http://www.cdc.gov/niosh/celintro.html http://www.cdc.gov/niosh/npptl/topics/respirators/disp_part http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm., http://wonder.cdc.gov/wonder/prevguid/m0035909/m0035909.asp#table_s31 13

BIG BEND HOSPICE, INC. Tuberculosis Symptom Screen As part of environmental monitoring for Tuberculosis, BBH employees and volunteers (HCWs) will complete this form annually and will return it to Fran Folsom, RN, BBH s Clinical Quality and Infection Control Specialist. Instructions: 1. Please complete the following questionnaire by checking YES, NO, N/A or Uncertain; filling in the Years and/or Months; or circling 1, 2, 3 or 4+. 2. If the answers indicate that Tuberculosis exposure may have occurred, you will be instructed to go to Tallahassee Memorial Hospital s Employee Health Program for further evaluation and, if necessary, treatment. QUESTIONS: YES NO N/A Uncertain 1. Have you lost more than 10 lbs in the last 2 months, without trying to? 2. Do you have night sweats (need to change the sheets or your clothes because they are wet)? 3. Have you noticed increased tiredness/weakness? 4. Have you lost your appetite? Aren t hungry? 5. Have you had occasional or unexplained fever? 6. Do you have a cough that has lasted longer than 3 weeks? 7. Do you cough up blood or mucous? 8. Have you recently had the mucous you coughed up tested for TB? 8a. If yes, were you told it was positive? 9. Have you ever had an abnormal chest x-ray? If yes, how long ago? Years Months 10. Have you been in the USA less than five years? 11. Have you been out of the USA for a prolonged length of stay in an area of high TB prevalence? 12. Do you live with, or have you been in close contact with, someone who was recently diagnosed with TB? (ex: shelter roommate, close friend, relative) 13. Have you ever had a positive TB skin test? 14. Have you ever been told that you have active Tuberculous? 14a. If yes, how long ago? Years Months 15. Have you ever been treated with medication for active TB? 15a. If yes, how many medications? Circle your answer: 1 2 3 4+ 16. Are you still taking TB medication? 17. Did you take all the TB medicine until the health care professional told you that you were finished? Employee/Volunteer Name (print) (signature) Date Employee # BBH Department Initial Annual Exposure F/U Exposure 14

RN Evaluator s Signature/Any Comments 15