NTNC: TB Program Core Competencies for PH Nurses 2008 and Future Challenges Kathleen Hursen, RN, MS MPD Division of TB Prevention and Control
TB Control Priorities by 2015 1. 93% complete treatment within 12 months 2. Case rate 0.7/100,000 3. Contacts Smear positive case will have at least 1 contact 93% of contacts will be evaluated 79% of new positive contacts will complete treatment 4. New case will start treatment within 7 days
1. TB Technical Expertise Airborne pathogen TB-control measures Public health systems and processes for controlling TB The epidemiology of TB disease and LTBI Regions around the world with a high incidence of TB and migration patterns Risk factors for acquisition of TB infection and progression of infection to TB disease The groups at high-risk for TB
1. TB Technical Expertise Diagnostic tests for TB and interpretation of test results Treatment regimens for TB and LTBI Public health goals for TB patient management including promptly initiating and completing effective treatment, stopping transmission, and preventing development of drug-resistant TB
1. TB Technical Expertise Reviews data on TB cases in order to monitor and evaluate Treatment regimen orders Treatment plans and adherence Treatment barriers and interventions Treatment completion Identification, screening, and medical evaluation of high-risk TB contacts
2. Oversight and Consultation Knowledge of state and national TB guidelines Ensure patients are on appropriate treatment, adhere to the treatment, monitor adverse events and drug side effects as needed, monitor response to treatment, and ensure treatment is completed on time Prevent development of drug-resistant TB
Case Management Definition Primary responsibility for coordination of patient care to ensure that the patient s medical and psychosocial needs are met through appropriate utilization of resources and the case: Completes a course of therapy Is educated about TB and its treatment Has documented culture conversion Has a contact investigation completed, if appropriate Contacts are evaluated and treated
Elements of a TB Control Program X-ray Inpatient care Non-TB medical services Home evaluation Housing Guidelines Targeted testing/ LTBI treatment Medical evaluation and follow-up Social services Interpreter/ translator services Case Management Isolation, detention National surveillance Coordination of medical care DOT Contact investigation Federal TB Control Program Technical assistance Training Funding Patient education Follow-up/treatment of contacts Consultation on difficult cases Clinical Services HIV testing and counseling Data collection Epidemiology and Surveillance Outbreak Data analysis Investigation Program evaluation & QA, QI for case planning management Data for national surveillance report State TB Control Program Funding State statutes, regulations, policies, guidelines Training Information for public Pharmacy Laboratory
Elements of a TB Control Program Inpatient care Clinical Services Non-TB medical services Home evaluation Housing Guidelines Interpreter/ translator services medical care DOT Epidemiology Contact investigation Case Management Isolation, detention Coordination of Federal TB Control Program National surveillance Patient education Follow-up/treatment of contacts Consultation on difficult cases and Surveillance Outbreak Investigation State TB Control Program State statutes, regulations, policies, guidelines Information for public
TB Case Management Home evaluation Isolation and detention Coordination of care Evaluation of treatment response Patient education DOT Contact Investigation Follow-up of contacts Outbreak investigation Inpatient care Non medical services Interpreter/translation services Information for public Data collection Referrals Housing
Initial steps: reported TB case or suspect A nurse CM should be assigned to every case All critical information is collected Before seeing patient gather as much info as possible Demographics Patient weight Diagnostic work-up to date Current treatment, if any Risk factors Other important facts Family/living situation Work place/school/social
Initial steps: reported TB case or suspect Clinical Setting NP Formulate recommendations about diagnostic and therapeutic options for patients suspected or known to have TB Employs and evaluates appropriate diagnostic and therapeutic interventions and regimens for patients infected with TB and social networks affected by TB, with attention to safety, cost, invasiveness, simplicity, acceptability and efficacy.
Initial steps: reported TB case or suspect Contact new cases/suspects within 3 days of initial report Consult with medical provider to gather additional information and treatment plan, if needed Conduct initial interview with patient Recommend first visit in hospital, if hospitalized Anyone else with symptoms Recommend home visit early in initial follow-up period Assess exposure sites for likelihood of transmission Home/work/school/social environments Space, ventilation, presence of high-risk persons
Initial steps: reported TB case or suspect Assessment of the treatment plan Re-calculate dosages Enough meds? Right meds? Assess for potential drug-drug/food/herbal interactions Apply knowledge of community and public health resources for prevention and treatment of TB to optimize health care for patients with TB and their social networks. Health director involvement/legal action
Initial steps to the reported TB case or suspect Initial patient education Disease vs. Infection Transmission, signs & symptoms, treatment and importance of completion, diagnostic procedures, monitoring and follow-up, meaning of test results. Role of patient in treatment plan, role of case manager, role of health department Treatment plan Direct Observed Therapy (DOT Agreement form) Handling side effects, change in symptoms Disease of public health significance Consequences for failure to follow treatment plan
Patient Education
Evaluation: Response to Therapy Improvement of TB symptoms Cultures convert to negative by end of initial phase; if not extend treatment Improvement in CXR or other diagnostic tests Treatment completion is based on number of doses ingested over a given time period
Potential for Treatment Failure Sign and Symptoms Is patient s treatment adequate Delay in sputum conversion Worsening clinical status or signs of improvement Lack of improvement on x-ray Drug side effects Poor absorption of drugs Complex case co-morbidity, side effects Drug resistance
Assessment Barriers to Adherence Minimum: Monthly Nursing Assessment Personal Social Cultural Spiritual Health Care System Individualized Nursing Care Plan Least restrictive Care Continuum Most restrictive Self administered DOT Voluntary or Compulsory Fixed dose comb pills Hospitalization
Assessment Barriers to Adherence Potential Triggers History of previous incomplete treatment Treatment failure or lapse in treatment Delay in sputum conversion Missed appointments Other medical conditions: substance abuse, mental illness Homeless or migrant populations Lack of access to health care Health/cultural beliefs
D.O.T. Is Right for Me!
Contact Investigations (CI) The need for a CI is based on transmission risk: Infectiousness of case Characteristics of the contact Environmental characteristics Initiate < 3 days Test high priority < 7 days Test medium priority < 14 days
Contact Investigations (CI) Assessment of infectiousness Sputum reports/collection positive smear more infectious Determination of period of infectiousness Length of time symptomatic Extent of disease Non-cavitary or cavitary disease Isolation instructions and agreement
Contact Investigations (CI) Priority of Contacts < 5 years Immune suppressed, i.e., HIV Window prophylaxis Length of exposure Start with closest contacts Home/work/school/social Expand when there is evidence of transmission and conversion» Secondary case» Positive TB test
Contact Investigations (CI) Characteristics of Exposure Is environment conducive to transmission Small, enclosed Length of exposure Home/work/school/social
Someone I Know has TB What do I do now?
2. Oversight and Consultation Provides educational programs to health professionals, students and the general public Case managers Health department Correctional facility nurses Other health care professionals caring for high risk populations, i.e., HIV, substance abuse, refugee programs
Interactive Web Presentation June 24, 2008 Noon Eliminating TB Case by Case A Case Series for Providers and Clinicians Nira Pollock, MD, PhD Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston TB testing using QuantiFeron Gold: What the provider needs to know Access the TB Case Series at www.mymeetings.com/nc/join.php?i=pg1678747&p=2006&t=c Toll free audio access: 888 552-9191 - Password = 2006 # Accreditation: CME, CNE, CHES
3. Advocacy and Leadership World TB Day Organizations Those that cannot remember the past are condemned to repeat it George Santayana T B E limination N eglect The Medical Advisory Committee for the Elimination of Tuberculosis (MACET) Thomas Garvey, M.D., J.D. garvey@mamacet.org John Bernardo, M.D. jbernardo@lung.bumc.bu.edu MACET website: www.mamacet.org
4. Policy Promotes a framework for quality care Interprets program policies and procedures to stakeholders Summarizes clear and concise performance skills and qualities, position descriptions, care plans, and critical pathways for public health nurses in TB who are case managers Articulates the fiscal, administrative, legal, social, and political implications of policies States the feasibility and expected outcomes of each policy option
4. Policy: Main Corrections Toolkit Tool Kit What Your Shelter Can Do to Prevent TB Assessing Your Shelter Guests Risk for TB Cough Alert Policy Think TB Materials Stop TB Poster Cover Your Cough Poster
5. Surveillance Data & Epidemiologic Profiles Important to know your high risk populations and case management challenges Knowledge of data collection methods, routine surveillance forms, and individual TB worksheets for completion of therapy Analyzes data for contributing factors Evaluates implementation of state and national guidelines Incorporates data for state and national objectives into written reports and case management strategies
6. Teaching, Education Materials, and Models Conducts assessments to determine the educational needs Prepares and disseminates TB educational materials in a variety of formats (written, video, web-based, instructor-led) Provides information classes to lay and professional groups (i.e., clinical staff and community groups)
7. Training for Monitoring Quality Improvement of Health Care Practice Cohort Reviews
8. Certification Courses for Building Workforce and Assuring Competency New England Consortium, RTMCC Integrate training, education and consultation
9. Reporting/Notification Quality Assurance and Improvement Massachusetts 4 TB Surveillance Nurse MAVEN system Contact investigation follow-up New Hampshire, Vermont, Maine TB Controller does it all + what is H1N1doing in my isolation room?
10. Program Evaluation Indicators: 2015 1. 93% complete treatment within 12 months 2. Case rate 0.7/100,000 3. Contacts Smear positive case will have at least 1 contact 93% of contacts will be evaluated 79% of new positive contacts will complete treatment 4. New case will start treatment within 7 days
11. Collaboration with Partners Program Collaboration and Service Integration (PCSI) TB HIV/AIDS STD Viral Hepatitis Some high risk populations are the same TB/HIV history
12. Interjurisdictional Referral Protocols and referrals on NTCA website http://tbcontrollers.org/ Maintain continuity of care throughout treatment Manages the transfer of (1) patient s treatment and care from one level/location to another for completion of medication doses within the designated period; (2) locating information for medical evaluation of named contacts
12. Interjurisdictional Referral No transmission across states in NE PCRType Spoligotype MIRU State Isolate file (Dec 2008) PCR00041 677777477413771 254326223432 CT 7 (5 in 2008) Indo-Oceanic Manila1 MA 6 251(3%) NH 4 ME 4 (3 in 2008) RI 3 (2 in 2008) PCR00091 000000000003771 223325153533 CT 2 East-Asian Beijing MA 2 152 (0.3%) NH 1 ME 1 RI 0 PCR00041 Indo-Oceanic Manila family. Mostly persons from Philippines and female. No connections of cases within the states or between states were identified. PCR00091 East-Asian Beijing family. The 2 cases in MA are MDR-TB. No connections of cases within the states or between states were identified
What s are the Future Challenges???? NTNC Survey Results 737 nurses filled out the survey between June 15 and July 30, 2008. NTNC/NTCA members: 69 (9% of respondents); 85% of the 81 nurse members Non-members: 664 (91% of respondents); denominator unknown
Completion of Treatment Challenges Lack of insurance or access to medical care 23% Difficulty providing DOT 20% Difficulty managing co-morbidity 20% Difficulty monitoring adherence & response to treatment Decreasing successful treatment outcomes, longer treatment or lapses in treatment 18% 16%
Completion of Treatment Challenges Legal issues 11% Lack of MD consultation support 11% Inadequate or inappropriate treatment 6% Delay in ability to obtain TB drugs 6% Diminished ability to develop an effective case management plan 6%
Completion of Treatment Challenges Changes Over Past 5 years Increase in social, language and cultural 45% barriers Increase in co-morbidities 34% Increase/change in ethnicity or country of 30% birth of cases Increase in number of cases 30% Increase in drug resistant TB 28%
Completion of Treatment Challenge Changes Over Past 5 years Increase in length of infectious period 23% > 2 weeks Increase in non-adherence 21% Increase in homelessness & migrants 19% Increased need for inpatient care for treatment complications or failure Increased need for inpatient care for isolation 14% 12%
Contact Investigation (CI) Difficulty conducting CI & ensuring contacts are evaluated and treated 30% Increase in complex social networks CI 28% Diminished ability to conduct home evaluations Increase in preventable cases among contacts 13% 7% Simmering outbreaks 6%
Treatment Initiation and Laboratory Reporting Challenges Increase in delayed diagnosis or misdiagnosis Difficulty getting suspects promptly evaluated and treated Diminished access to quality AFB smear & culture lab results 20% 14% 6%
Prevention Challenges Diminished ability to conduct targeted testing and treat high risk populations 20% Compromised surveillance and case finding 9% Delay in effective infection control measures 7%
Workforce/Capacity Nurses intending to leave TB in < 10 years 75% Increase in duties not related to TB 44% Decrease in nursing positions 44% Loss of TB related nursing expertise 31% Decrease in field/outreach staff 27%
Workforce/Capacity Increase in patients per nurse case manager 24% Loss of public health infrastructure 21% Loss of ongoing training and supervision 18% Loss of experienced staff, non nursing 18% Lack of MD or consultation support 11%
Now that s a Challenge
Major Concern TB pan sensitive MDR-TB - XDR-TB TDR-TB: Emergence of new forms of totally drug-resistant tuberculosis bacilli: super extensively drug-resistant tuberculosis or totally drug-resistant strains in Iran. 10% among 146 MDR=TB strains Spoligotyping revealed Haarlem (39.1%), Beijing (21.7%), EAI (21.7%), and CAS (17.3%) superfamilies of M tuberculosis. Velayati AA, Masjedi MR, Farnia P, Tabarsi P, Ghanavi J, Ziazarifi AH, Hoffner SE.. Emergence of new forms of totally drug-resistant tuberculosis bacilli: super extensively drug-resistant tuberculosis or totally drug-resistant strains in iran.
Questions.