C.2. Risk and Risk Assessments HCA 402
Risk and Community Risk Assessment: From the case below, complete the risk assessment with the available information provided in the case below regarding Duval County M. tuberculosis.
CDC, Notes from the Field: Tuberculosis Cluster Associated with Homelessness — Duval County, Florida, 2004–2012. Notes from the Field: Tuberculosis Cluster Associated with Homelessness — Duval County, Florida, 2004–2012. July 20, 2012 / 61(28); 539-540
This module you begin your second skills assessment, i.e., a community risk assessment. The next two pages of this document are a case study and then the assessment survey form makes up the remaining pages of the document. You will use the Duval Case and assume you are from Duval County, FL. There is a lot of information available from the TB surveillance and epidemiological field work completed in this county on the Internet. Assume your facility is the Golden Retreat Assisted-Living Facility and you are part of the risk management team that is responsible for performing the risk assessment surveys.
Example: In November 2008, the local health department discovered an outbreak of tuberculosis in a Jacksonville assisted-living facility, Golden Retreat. The CDC was called in to assist the health department and found 18 active cases of TB (Jacksonville.com, 2012).
A suggestion regarding work flow is to print out the two pages of the case, and use it and the supplemental links below to fill in the survey form. Know that you need to fill it out to the best of your ability based on the case information available. You may not have information for every box on the survey form. However, you may make some logical assumptions when filling it out based on what you find (in other words, abstract and report as the information found will allow). The goal here is to learn what type of information is in the various risk assessment surveys. If you need help finding Duval County, FL statistics, here are some links:
LINK: http://www.doh.state.fl.us/disease_ctrl/tb/Trends-Stats/trends.html LINK: Duvall County Epidemiology Comprehensive Surveillance Reports LINK: DCHD Tuberculosis Epi-Aid Investigation Update Article on Golden Retreat Assisted-Living Facility Palm Beach County. (2012). Center of TB outbreak often cited, rarely punished. http://www.palmbeachpost.com/news/news/state-regional/center-of-tb-outbreak-often-cited-rarely-punished/nPzxw/
Tuberculosis Cluster Associated with Homelessness — Duval County, Florida, 2004–2012
Despite a decrease in incidence of tuberculosis (TB) in Duval County, Florida, from 102 cases (11.2 per 100,000 population) in 2008 to 71 cases (8.2 per 100,000) in 2011,* analysis of Mycobacterium tuberculosis genotyping data revealed a substantial increase in the percentage of TB cases with the same genotype.† That percentage increased from 27% (10 of 37) of genotyped cases in 2008 to 51% (30 of 59) of genotyped cases in 2011 (Florida Department of Health, unpublished data, 2012). During this period, the percentage of patients with this genotype who were homeless or who abused substances also increased. Because of concern over potential ongoing TB transmission involving these hard-to-reach populations, the Duval County Health Department, Florida Department of Health, and CDC conducted an investigation during February 15–March 13, 2012. As of March 13, review of medical records and interviews with TB patients had identified 99 cases related to the cluster based on matching genotype results and epidemiologic links (48 cases), matching genotype only (22), epidemiologic links only (22), or common social risk factors for TB (e.g., homelessness, incarceration, or substance abuse within 1 year of TB diagnosis) and suspected epidemiologic links (seven). The first known case with a matching genotype occurred in 2004.
Among the 99 TB cases during 2004–2012, a total of 96 (97%) patients were U.S.-born; 78 (79%) were male; 76 (77%) were black; 78 (79%) had a history of homelessness, incarceration, or substance abuse (i.e., alcohol or illicit substances); and 43 (43%) had been homeless within 1 year of TB diagnosis. Three patients were children aged <5 years. Twenty patients had known human immunodeficiency virus infection; 13 patients, all with comorbidities, had died. Site visits and review of electronic databases that track use of Duval County homeless services and incarceration found that the TB patients had stayed in several different homeless shelters and in a local jail. In addition, social network analysis identified one particular shelter and an outpatient mental health facility that serves the homeless community as the sites of concern for TB transmission during 2010–2012.
Duval County Health Department organized the screening of approximately 2,300 persons; approximately 2,100 additional persons are considered a high priority for TB screening because of recent exposure in a congregate setting to a patient with sputum smear-positive TB (1). To control ongoing TB transmission and detect and treat additional cases of active TB disease or latent TB infection, Duval County public health workers are finding and evaluating high-priority contacts and conducting TB evaluations at sites with evidence of recent TB transmission. Long-term control measures at homeless shelters will include enhanced infection control programs involving TB education, respiratory hygiene, periodic systematic TB screening of clients and workers, and environmental controls.
Genotyping data, combined with epidemiologic investigation, enabled recognition of this cluster and subsequent understanding of chains of TB transmission. Newly available electronic data systems in Duval County that document use of homeless services, stays at homeless shelters, and incarceration at a local jail also were critical in identifying likely transmission sites. Although TB incidence continues to decline in Florida and nationwide, outbreaks still occur among homeless persons, requiring sustained and aggressive control measures (2,3). Prompt identification of TB patients through symptom screening, radiographic screening, and testing for TB infection, along with evaluation of contacts of TB patients, can be difficult in hard-to-reach populations but is crucial to achieving the national goal of TB elimination (4).
Reported by
Vincy Samuel, MPH, Cynthia Benjamin, Ozzie Renwick, Aaron Hilliard, PhD, Duval County Health Dept; Sherrie Arnwine, Debra Spike, Jose Zabala, MHSA, Kateesha McConnell, MPH, Max Salfinger, MD, Florida Dept of Health. Kiren Mitruka, MD, Tracie Gardner, PhD, Div of TB Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.Emma Johns, CDC Experience Fellow. Robert Luo, MD, Madsen Beau de Rochars, MD, Raymund Dantes, MD, EIS officers, CDC. Corresponding contributor: Max Salfinger, max_salfinger@doh.state.fl.us, 850-245-4350.
Acknowledgments
Robert Harmon, MD, Duval County Health Dept; Richard Hopkins, MD, Florida Dept of Health. Gail Burns-Grant, Dan Ruggiero, MPS, Jimmy Keller, DHSc, Div of TB Elimination, National Centers for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.
References
1. CDC. Guidelines for the investigation of contacts of persons with infectious tuberculosis: recommendations from the National Tuberculosis Controllers Association and CDC. MMWR 2005;54(No. RR-15):1–48.
2. CDC. Tuberculosis outbreak among homeless persons—King County, Washington, 2002–2003. MMWR 2003;52:1209–10.
3. CDC. Tuberculosis outbreak associated with a homeless shelter—Kane County, Illinois, 2007–2011. MMWR 2012;61:186–9.
4. CDC. Controlling tuberculosis in the United States: recommendations from the American Thoracic Society, CDC, and the Infectious Disease Society of America. MMWR 2005;54(No. RR-12).
* Additional information available at http://www.doh.state.fl.us/disease_ctrl/tb/trends-stats/trends.html
Centers for Disease Control and Prevention, Division of Tuberculosis Elimination, 2006
Appendix B. Tuberculosis (TB) risk assessment worksheet.
This model worksheet should be considered for use in performing TB risk assessments for health-care facilities and nontraditional facility-based settings. Facilities with more than one type of setting will need to apply this table to each setting.
Scoring √ or Y = Yes X or N = No NA = Not Applicable
1. Incidence of TB
What is the incidence of TB in your community (county or region served by the health-care setting), and how does it compare with the state and national average? What is the incidence of TB in your facility and specific settings and how do those rates compare? (Incidence is the number of TB cases in your community the previous year. A rate of TB cases per 100,000 persons should be obtained for comparison.)* This information can be obtained from the state or local health department.
Community rate_______
State rate ____________
National rate _________
Facility rate __________
Department 1 rate _______
Department 2 rate _______
Department 3 rate _______
Are patients with suspected or confirmed TB disease encountered in your setting (inpatient and outpatient)?
Yes No
If yes, how many patients with suspected and confirmed TB disease are treated in your health-care setting in 1 year (inpatient and outpatient)? Review laboratory data, infection-control records, and databases containing discharge diagnoses.
Year No. patients
Suspected Confirmed
1 year ago _____ _____
2 years ago _____ _____
5 years ago _____ _____
If no, does your health-care setting have a plan for the triage of patients with suspected or confirmed TB disease?
Yes No
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 within your setting (inpatient and outpatient)?
Yes No
2. Risk Classification
Inpatient settings
How many inpatient beds are in your inpatient setting?
How many patients with TB disease are encountered in the inpatient setting in 1 year? Review laboratory data, infection-control records, and databases containing discharge diagnoses.
Previous year ______
5 years ago ______
Depending on the number of beds and TB patients encountered in 1 year, what is the risk classification for your inpatient setting? (See Appendix C.)
( Low risk
( Medium risk
( Potential ongoing transmission
Does your health-care setting have a plan for the triage of patients with suspected or confirmed TB disease?
Yes No
Outpatient settings
How many TB patients are evaluated at your outpatient setting in 1 year? Review laboratory data, infection-control records, and databases containing discharge diagnoses.
Previous year ______
5 years ago ______
Is your health-care setting a TB clinic?
(If yes, a classification of at least medium risk is recommended.)
Yes No
Does evidence exist that a high incidence of TB disease has been observed in the community that the health-care setting serves?
Yes No
Does evidence exist of person-to-person transmission of M. tuberculosis in the health-care setting? (Use information from case reports. Determine if any tuberculin skin test [TST] or blood assay for M. tuberculosis [BAMT] conversions have occurred among health-care workers [HCWs]).
Yes No
Does evidence exist that ongoing or unresolved health-care–associated transmission has occurred in the health-care setting (based on case reports)?
Yes No
Is there a high incidence of immunocompromised patients or HCWs in the health-care setting?
Yes No
Have patients with drug-resistant TB disease been encountered in your health-care setting within the previous 5 years?
Yes No
Year ________
When was the first time a risk classification was done for your health-care setting?
__________________
Considering the items above, would your health-care setting need a higher risk classification?
Yes No
Depending on the number of TB patients evaluated in 1 year, what is the risk classification for your outpatient setting? (See Appendix C)
( Low risk
( Medium risk
( Potential ongoing transmission
Does your health-care setting have a plan for the triage of patients with suspected or confirmed TB disease?
Yes No
Nontraditional facility-based settings
How many TB patients are encountered at your setting in 1 year?
Previous year ______
5 years ago ______
Does evidence exist that a high incidence of TB disease has been observed in the community that the setting serves?
Yes No
Does evidence exist of person-to-person transmission of M. tuberculosis in the setting?
Yes No
Have any recent TST or BAMT conversions occurred among staff or clients?
Yes No
Is there a high incidence of immunocompromised patients or HCWs in the setting?
Yes No
Have patients with drug-resistant TB disease been encountered in your health-care setting within the previous 5 years?
Yes No
Year ________
When was the first time a risk classification was done for your setting?
Considering the items above, would your setting require a higher risk classification?
Yes No
Does your setting have a plan for the triage of patients with suspected or confirmed TB disease?
Yes No
Depending on the number of patients with TB disease who are encountered in a nontraditional setting in 1 year, what is the risk classification for your setting? (See Appendix C)
( Low risk
( Medium risk
( Potential ongoing transmission
3. Screening of HCWs for M. tuberculosis Infection
Does the health-care setting have a TB screening program for HCWs?
Yes No
If yes, which HCWs are included in the TB screening program? (Check all that apply.)
( Physicians
( Mid-level practitioners (nurse practitioners [NP] and physician’s assistants [PA])
( Nurses
( Administrators
( Laboratory workers
( Respiratory therapists
( Physical therapists
( Contract staff
( Construction or renovation workers
( Service workers
( Janitorial staff
( Maintenance or engineering staff
( Transportation staff
( Dietary staff
( Receptionists
( Trainees and students
( Volunteers
( Others_________________
Is baseline skin testing performed with two-step TST for HCWs?
Yes No
Is baseline testing performed with QFT or other BAMT for HCWs?
Yes No
How frequently are HCWs tested for M. tuberculosis infection?
Are the M. tuberculosis infection test records maintained for HCWs?
Yes No
Where are the M. tuberculosis infection test records for HCWs maintained? Who maintains the records?
If the setting has a serial TB screening program for HCWs to test for M. tuberculosis infection, what are the conversion rates for the previous years? †
1 year ago _________________ 4 years ago _________________
2 years ago _________________ 5 years ago _________________
3 years ago _________________
Has the test conversion rate for M. tuberculosis infection been increasing or decreasing, or has it remained the same over the previous 5 years? (check one)
( Increasing
( Decreasing
( No change
Do any areas of the health-care setting (e.g., waiting rooms or clinics) or any group of HCWs (e.g., lab 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?
Yes No
If yes, list _________________________
_________________________________
_________________________________
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 (LTBI) treatment with the local health department or their primary physician?
Yes No Not applicable
4. TB Infection-Control Program
Does the health-care setting have a written TB infection-control plan?
Yes No
Who is responsible for the infection-control program?
When was the TB infection-control plan first written?
When was the TB infection-control plan last reviewed or updated?
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)?
Yes No
Does the health-care setting have an infection-control committee (or another committee with infection control responsibilities)?
Yes No
If yes, which groups are represented on the infection-control committee? (Check all that apply.)
( Physicians
( Nurses
( Epidemiologists
( Engineers
( Pharmacists
( Laboratory personnel
( Health and safety staff
( Administrator
( Risk assessment
( Quality control (QC)
( Others (specify)_________
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
Has a person been designated to be responsible for implementing an infection-control plan in your health-care setting? If yes, list the name: _________________________
Yes No
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) _____
Through what means (e.g., review of TST or BAMT conversion rates, patient medical records, and time analysis) are lapses in infection control recognized?
What mechanisms are in place to correct lapses in infection control?
Based on measurement in routine QC exercises, is the infection-control plan being properly implemented?
Yes No
Is ongoing training and education regarding TB infection-control practices provided for HCWs?
Yes No
6. Laboratory Processing of TB-Related Specimens, Tests, and Results Based on Laboratory Review
Which of the following tests are either conducted in-house at your health-care setting’s laboratory or sent out to a reference laboratory?
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 (NAA) testing
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 ___________
Other (specify) ___________
NAA testing ___________
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?
Yes No
______________________
______________________
7. Environmental Controls
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]) ___________________________________________________________
What are the actual air changes per hour (ACH) and design for various rooms in the setting?
Room ACH Design
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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
What general ventilation systems are used in your health-care setting? (Check all that apply)
( Single-pass system
( Variable air volume (VAV)
( Constant air volume (CAV)
( Recirculation system
( Other____________________
What air-cleaning methods are used in your health-care setting? (Check all that apply)
HEPA filtration
( Fixed room-air recirculation systems
( Portable room-air recirculation systems
UVGI
( Duct irradiation
( Upper-air irradiation
( Portable room-air cleaners
How many AII rooms are in the health-care setting?
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) _________________
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?
Yes No
Are environmental controls regularly checked and maintained with results recorded in maintenance logs?
Yes No
Are AII rooms checked daily for negative pressure when in use?
Yes No
Is the directional airflow in AII rooms checked daily when in use with smoke tubes or visual checks?
Yes No
Are these results readily available?
Yes No
What procedures are in place if the AII room pressure is not negative?
______________________________________
Do AII rooms meet the recommended pressure differential of 0.01-inch water column negative to surrounding structures?
Yes No
8. Respiratory-Protection Program
Does your health-care setting have a written respiratory-protection program?
Yes No
Which HCWs are included in the respiratory protection program? (Check all that apply)
( Physicians
( Mid-level practitioners (NPs and PAs)
( Nurses
( Administrators
( Laboratory personnel
( Contract staff
( Construction or renovation staff
( Service personnel
( Janitorial staff
( Maintenance or engineering staff
( Transportation staff
( Dietary staff
( Students
( Others (specify)_________________
_______________________________
_______________________________
_______________________________
_______________________________
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
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________
Is annual respiratory-protection training for HCWs performed by a person with advanced training in respiratory protection?
Yes No
Does your health-care setting provide initial fit testing for HCWs?
If yes, when is it conducted? ____________________________
Yes No
Does your health-care setting provide periodic fit testing for HCWs?
If yes, when and how frequently is it conducted? ____________________________
Yes No
What method of fit testing is used? Describe.
____________________________________________________________________________________________________________________________________________________________________________
Is qualitative fit testing used?
Yes No
Is quantitative fit testing used?
Yes No
9. Reassessment of TB risk
How frequently is the TB risk assessment conducted or updated in the health-care setting?
When was the last TB risk assessment conducted?
What problems were identified during the previous TB risk assessment?
1) __________________________________________________________________________________________________________________________________________________________
2) _____________________________________________________________________________ _____________________________________________________________________________
3) _____________________________________________________________________________ _____________________________________________________________________________
4) _____________________________________________________________________________ _____________________________________________________________________________
5) _____________________________________________________________________________ _____________________________________________________________________________
What actions were taken to address the problems identified during the previous TB risk assessment?
1) __________________________________________________________________________________________________________________________________________________________
2) _____________________________________________________________________________ _____________________________________________________________________________
3) _____________________________________________________________________________ _____________________________________________________________________________
4) _____________________________________________________________________________ _____________________________________________________________________________
5) _____________________________________________________________________________ _____________________________________________________________________________
Did the risk classification need to be revised as a result of the last TB risk assessment?
Yes No
* If the population served by the health-care facility is not representative of the community in which the facility is located, an alternate comparison population might be appropriate.
† Test conversion rate is calculated by dividing the number of conversions among HCWs by the number of HCWs who were tested and had prior negative results during a certain period (see Supplement, Surveillance and Detection of M. tuberculosis infections in Health-Care Settings).
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