QAPI 24 - TB in the ED: Consequences of Delayed Recognition Active Pulmonary Tuberculosis Infection in the Emergency Department Waiting Room

Wednesday, June 28, 2023

1:21 PM – 1:40 PM

Location: W103 A/B; Orange County Convention Center

CE: 0.33

CNE Credits: 0.33
CME Credits: 0.33

Presenter(s)

Jorge P. Parada, MD, MPH, FACP, FIDSA, FSHEA

Medical Director Infection Prevention and Control
Loyola University Medical Center
Maywood, Illinois

Disclosure(s): Merck: Speaker/Honoraria (Ongoing); Shionogi, INC: Speaker/Honoraria (Ongoing)

PDF

Co-Author(s)

Louise Lie, MPH CIC (she/her/hers)

Infection prevention practitioner
Loyola university medical center
Elmhurst, Illinois
HP

Herminia Pua, RN, BSN, CIC

Infection Prevention Practitioner
Loyola University Chicago
Maywood, Illinois
TY

Tara Yurinich, MNA (she/her/hers)

Regional Director ED Services
Loyola University Medical Center
Lorriane Fearon, APRN (she/her/hers)

Employee Health
Loyola University
Maywood, Illinois
DS

David H. Slade, MD JD (he/him/his)

Associate Professor of Medicine - Associate Medical Director Infection Prevention & Control
Loyola University Chicago

Moderator(s)

Luz Caicedo, MPH, CPH, CIC, CRCST, VA-BC

Infection Prevention Manager
AdventHealth Celebration, Florida

Disclosure(s): No financial relationships to disclose

Co-Moderator(s)

Krista Doline, BS, MLS (ASCP), CIC, FAPIC

Infection Preventionist
Piedmont Healthcare
Fayetteville, Georgia

Disclosure(s): No financial relationships to disclose

Background: Early recognition of infectious tuberculosis (TB) cases and use of appropriate precautions are essential to infection prevention. In late 2021, a patient with active pulmonary TB presenting with an abnormal x-ray and productive cough went unrecognized for nearly 20 hours in our emergency department.

Methods: Logs of patients' registration times and charts-reviews were used to determine patient and staff exposures. All potentially exposed patients were contacted by telephone, regular and certified mail and asked to present for free baseline interferon gamma release assay testing, followed by a free second test 10-12 weeks later. Patients were asked to provide information about anyone who accompanied them to the ED (visitors). The employee health service followed-up staff.

Results: 70 persons were recognized as potentially having TB exposure; including 9 staff and 39 patients. 32 patients reached by phone identified 22 additional visitors. 2 staff wore N95s (considered not exposed). 5/7 (71.4%) staff, 17/39 (43.6%) patients and 13/22 (59.1%) visitors completed baseline post-exposure testing. 5/7 (71.4%) staff, 8/39 (20.5%) patients and 4/22 (18.2%) visitors completed follow-up testing. We estimate 17 additional visitors accompanied the patients never reached by phone.

Conclusions: A symptomatic smear-positive patient with active TB was not placed on appropriate precautions and ≥ 70 persons were potentially exposed to TB. No known TB conversions resulted from this event, but there was significant noncompliance with post-exposure testing, especially by non-staff. Hundreds of man-hours and thousands of resource dollars were spent on this investigation. Unnecessary staff exposures were identified, as only 2 staff used N95 respirators, although COVID-related precautions required N95 use by patient-facing staff. Non-staff reached directly by phone were more likely to come in for testing than those who only received mailings, underscoring the importance of personal direct communication. Names/contacts of all persons lost to follow up were provided to the department of public health.

Learning Objectives:

Upon completion the participant will recognize important consequences of inappropriate use of infection prevention precautions.
Upon completion the participant will understand elements required to conduct an TB post-exposure investigation.
Upon completion the participant will be able to identify the complexity of post-exposure investigations of major public health concern, like TB.