Presentation on theme: "Diana Nilsen, MD Bureau of Tuberculosis Control"— Presentation transcript:
1Hospital Discharge of TB Patients: Collaborating with the Health Department Diana Nilsen, MDBureau of Tuberculosis ControlNYC Department of Health and Mental Hygiene
2Today’s Presentation Epidemiology of TB in NYC, 2011 Discuss the rationale for discharging infectious TB patients from the hospitalDescribe the new health code reporting requirementsSubmission of hospital discharge plansSubmission of treatment plansProvide an update on hospital discharge plan submissionsDiscuss common issues related to hospital discharges
3Reported TB Cases United States, 1982–2010* No. of Cases11,182 casesSlide 2. Reported TB Cases, United States, 1982–2010. The resurgence of TB in the mid-1980s was marked by several years of increasing case counts until its peak in Case counts began decreasing again in 1993, and 2010 marked the eighteenth year of decline in the total number of TB cases reported in the United States since the peak of the resurgence. From 1992 until 2002, the total number of TB cases decreased 5%–7% annually. From 2002 to 2003, however, the total number of TB cases decreased by only 1.4%. In 2010, a total of 11,182 cases were reported from the 50 states and the District of Columbia (DC). This represents a decline of 3.1% from 2009 and of approximately 58.1% from 1992.Year*Updated as of July 21, 2011
4Tuberculosis Cases and Rates New York City, 1982 – 2011 Tuberculosis Cases and Rates New York City, 1982 – 2011* 689 Cases in 2011Number of CasesRate/100,00051.121.48.5I’d like to start today by reviewing some trends in TB control. This slides shows TB control in NYC by graphing the numbers and case rates from 1980 to We had our highest rate in 1992 and have maintained a pretty steady decrease in incidence. In 2009 we have 760 TB cases in NYC which corresponds to an incidence of 9.1 per 100,000.*Rates based on official Census data and intercensal estimates prior to Rates for 2000 to 2006 are based on intercensal estimates, and for 2007 to 2011on American Community Survey.
5US* and Non-US-Born TB Cases† New York City, 1982-2011 3,132Number of CasesThis slide shows the trend in US vs Non-US-born cases from 1980 to 2009.The # of US born pts continued to go down, and the # of non-US born cases decreased by 14%.1,010*Puerto Rico and U.S. Virgin Islands are included as US-born†There was 1 case with unknown country of birth in 2011.
6Top 10 Countries of Birth of Foreign-born Persons, NYC TB Cases 2011N2010China104Mexico49Dominican Republic41Bangladesh33Ecuador313530HaitiPhilippines28India26Nepal192316Pakistan20Puerto Rico15Guyana
7Tuberculosis rates1 by United Hospital Fund (UHF) neighborhood, New York City, 2009-2011 The rates of TB in NYC are not uniform and reflect residential patterns of at risk populations.In 2011, there were 17 United Hospital Fund (UHF) neighborhoods with a TB rate that exceeded the 2011 NYC TB rate of 8.5 per 100,000 persons.
8Trend in HIV-Infection and TB New York City, 1992-2011 Decreasing trend in co-infected patients69 (9%) HIV-infected compared to 95 (11%) in 200829% missing HIV status (18% of whom refused testing)11% of cases aged years were HIV-infected
9HIV-Infected TB Patients BTBC Annual Slides, 2008Saturday, April 01, 2017HIV-Infected TB PatientsNew York City,The proportion of HIV infected patients decreased in 2003 compared to 2002, but HIV status is unknown for about 40% of cases.The proportion of cases w/ an HIV result should increase somewhat by the time data are finalized for the year.The number of TB cases with HIV co-infection declined from 68 in 2009 to 58 in 2011, a 15% decrease (Figure 9). The proportion of TB patients with HIV co-infection has declined over time, from 18% in 2000 to 8% in 2011.
10Top 10 Medical Facilities First Evaluating Patients for TB- New York City, 2011 Facility Name# of cases% cases1. Elmhurst Hospital Center4162. New York Hospital Medical Center of Queens3553. Bellevue Hospital Center344. Maimonides Medical Center325. Lincoln Medical and Mental Health Center2436. Kings County Hospital Center237. Beth Israel, Queens Hospital Center218. Lutheran Medical Center139. Coney Island Hospital12210. Montefiore Medical Center, Bronx-Lebanon Medical Center1118. Lenox Hill Hospital10Montefiore north division only counted 2 cases for 2011
11TB Reporting Requirements Article 22 of the New York State Public Health Law and Articles 11 and 13 of the New York City Health Code require that suspected and confirmed cases of tuberculosis be reported to the local health authority, i.e., DOHMH, within 24 hoursReminder that reporting of patients suspected and confirmed of having TB is legally mandated by both NYC and NYS laws: Article 22 of the New York State Public Health Law and Articles 11 of the New York City Health Code require that TB be reported to the health department within 24 hours. Providers and laboratories should use fax, telephone or electronic means to ensure prompt reporting. Note: TB should be reported when suspected, do not wait for confirmation.11
12Reporting TB CasesSuspected or confirmed TB patients may be reported by telephone at (212) orA completed Universal Reporting Form (URF) must follow within 48 hours by faxing it to the Bureau of Tuberculosis Control at (212)The URF can also be completed online, by first creating an account on NYCMED atSupport for NYCMED is available by calling (888) NYCMED9(212)Original mailed to DOHMH at 125 Worth Street, Room 315, CN-6, New York, NY
13Reporting by Healthcare Providers Providers are required by law to report within 24 hours any case with:AFB+ smear from any siteNucleic Acid Amplification (NAA) test + for Mycobacterium tuberculosis (M. tb)Culture + for M. tb>=2 anti-TB medications for suspected or confirmed TBClinically suspected TBPathology findings consistent with TBChild < 5 years old with + TST(regardless of BCG)The NYC Health Code requires physicians and hospitals to report patients with TB and patients suspected of having TB to the DOH within 24 hours of detection. This include patients with positive smear, culture, NAA tests, patients placed on treatment or those suspected of having TB – because of pathologic, clinical or radiologic signs/symptoms of TB. NAA tests are FDA-approved for use in respiratory specimens (sputum, BAL, tracheal aspirates, bronchial aspirates), regardless of smear status. Any strong TB suspect is reportable, before the culture is back: whether the patient is suspected of having TB based on clinical symptoms or a chest X-ray.In addition, children < 5 with a positive TST are also reportable in NYC.The reporting form currently used, the URF, should be as complete as possible, no area should be left blank; if the information is unknown or some laboratory test results are not back yet, then mark “pending”.We are getting reporting forms from hospitals financial departments for reimbursement purpose. Sometimes, the only reporting form we receive is from the finance staff and only the demographic and hospital information is completed. Many of these patients never turn out to have TB and some do not even have smear and culture sent; in some cases we have investigated, the ICP does not know about the patients. It seems then that TB is brought up for some of these patients solely for reimbursement purposes: this is quite an unacceptable practice. I am urging you to educate and work with your hospital finance department to ensure that they report through you or the patient’s provider and that the required information is complete and the reporting is justified.13
14Reporting by Laboratories Laboratories are required by law* to report within 24 hours :AFB + smearsCultures + for M. tuberculosis (M. tb)Any culture result associated with an AFB+ smear (even if negative for M. tb)Rapid diagnostic (NAA) tests identifying M. tbResults of susceptibility tests on M. tb culturesPathology findings consistent w/ TB*Articles 11 and 13, Sections 11.03, and NYC Public Health CodeLaboratories are required to report by law AFB+ smears, Cultures + for M tuberculosis, rapid diagnostic (NAA) tests identifying M tb, results of susceptibility tests on M tb cultures, pathology findings consistent w/ TB. They should report each and every result that meets these criteria, even if the patient has previously been reported.This does not preclude providers from reporting: both laboratory and provider must report.If a patient has an AFB+ smear, laboratories are required to report the related culture, even if it is negative. All tests associated with a positive smear should be reported.14
15Pathology Findings Suggestive of TB Presence of acid-fast bacilli (AFB)Caseating/non-caseating granulomaTuberclesFibro-caseous lesionsNecrotizing/non-necrotizing granulomaLanghans giant cells/multinucleated Langhans cellsEpithelioid cells/Epithelioid granulomaNecrotizing inflammationChronic granulomatous lesions/chronic inflammation with granuloma formationGiant cellsTB can also be suspected or diagnosed based on findings on a biopsy or surgical specimens. Findings c/w M tb disease include: of course, presence of acid-fast bacilli (AFB), but also, caseating/non-caseating granuloma, tubercles, fibro-caseous lesions, necrotizing/non-necrotizing granulomas, Langhans giant cells/multinucleated Langhans cells, epithelioid cells/pithelioid granuloma, necrotizing inflammation, chronic granulomatous lesions/chronic inflammation with granuloma formation, and giant cellsThe presence of these findings is reportable w/in 24 hours also.1515
17Outpatient Treatment of TB TB patients could be treated successfully as outpatients with the advent of modern chemotherapyNo significant difference between hospital and outpatient treatmentCure ratesSpread of infectionMain determinant of cost of treatment is INPATIENT admission(Tuberculosis Chemotherapy Centre, Madras. Bull WHO 1959:21-144:51-339)We have known since 1959 that TB can be treated as outpatient, not requiring hospitalization.17
18Treatment of TB in India Tuberculosis Chemotherapy Centre, Madras, compared home treatment of TB with sanatoriumTreatment at home is satisfactoryCrowded living conditions, low nutritional standards, low incomeMajor risk to contacts lies in exposure to the infectious case BEFORE diagnosisTuberculosis Chemotherapy Centre, Madras. Bull WHO 1960, 23;18
19Successful Treatment of TB Requirements for successful treatment include:Prescription of the correct chemotherapyCompliance with medication dosesAchieved as outpatient with DOTCompletion of a minimum number of dosesAll of which can be done as an outpatient!Successful Treatment of TBOut patient therapy is more cost-effective and achieves cure rates comparable to inpatient care, and is not associated with an increase in TB transmission in the community. Also outpatient treatment is less disruptive for a patient.Work-up and treatment of TB can be done as an outpatient for most individuals. Requirements for successful treatment include:Prescription of the correct chemotherapyCompliance with medication doses.Achieved as outpatient with DOTCompletion of a minimum number of doses.19
20Risks of Hospitalization Nosocomial transmission to:Health care workersVulnerable patientsAnxiety for the patient who is isolatedFeeling of isolationRemoval from social supportsLoss of control over one’s lifeRisk of Hospitalization20
21NYC Guidelines for Hospitalization and Discharge Developed to ensure that only patients who need it are admitted and hospitalizedInfectious patients could be discharged in the appropriate circumstancesTB can be dangerous for other hospitalized patientsPatients should be treated as OUTPATIENTS unless they meet certain criteriaPatients become noninfectious quickly once on treatment21
22Criteria for Discharge Clinical improvementTolerating anti-TB medsPatient must be reported to DOH ( or ), but must be reported via URF as wellElectronic URF filled out within 24 hrs.Patient should have sputa for AFBCXR should be doneInvolvement of DOHMH in discharge planning with submission of discharge plan to DOHMHReferral to DOH clinic and DOTInstructions given to patient and household members if they were exposed to an infectious patient
25Care of TB Patients in NYC In 2009, 83% (255/308) of respiratory smear positive TB patients were hospitalizedIn NYC, approximately 50% of TB cases are treated by a private providerCollaboration between DOHMH and community health care providers removes barriers and fosters achievement of key public health objectivesNo significant decline in hospitalization rates despite medical
26NYC Health Code Amendment New York City Health Code Article 11 Section 21(4) amended June 16, 2010Hospitals/providers must obtain approval from health department at least 72 business hours before discharging infectious TB patientsProviders must submit proposed treatment plan to NYC Health Department within one month of treatment initiation for all persons newly diagnosed with active TB diseaseNew requirement communicated to hospital providers (June and November 2010)On June 16, 2010 the Board of Health approved amendments to Article 11 of the New York City Health Code to require hospitals/providers to:1. Obtain approval from the health department before discharging infectious TB patients2. Submit to the health department a written TB treatment plan within one month of starting treatment for newly diagnosed TB patients.Two components of the health code72 hours1 business dayThe physician who attends a case of infectious tuberculosis in a hospital or the person in charge of a hospital or other health care facility where such case has been admitted shall notify the Department in writing on a form provided or approved by the Department and shall consult with the Department at least 72 hours before planned discharge of such case from in-patient care, and shall discharge such patients only after the Department has determined that discharge of such person will not endanger the public health. The Department shall make its discharge determination and respond to the attending physician or the person in charge of a hospital or other health care facility within one business day from the date of the consultation.
28Discharge Plan Approval Process 72 hrs before dischargeWithin 1 business dayDeterminationProviderdiscusses dischargeplan issues with DOHMHrevises planinforms DOHMHProvider submitsHospital DischargeApproval Request Formto DOHMHvia faxDOHMH physicianreviews discharge planmakes determinationcommunicates withhospital providerApprovedNot applicableDisapproved
29Outcomes of Discharges Approved: criteria for discharge metNot approved: additional actions or information neededNot applicable: extrapulmonary TB cases, noninfectious cases, atypical mycobacterium (NTM)
30Hospital Discharge Form Hospital Discharge Approval Request Form (TB 354) and InstructionsHospital Discharge Planning Checklist for Tuberculosis PatientsAvailable on NYC Health Department’s website:
31TB forms located on the Bureau of TB Control’s website: www. nyc TB forms located on the Bureau of TB Control’s website:For providers-Guidelines and Forms --Bottom circle takes to 19 and then 20; Top circle takes to 20
32Guidelines and Forms-Hospital Discharge Approval Request and Treatment Plans
37Weekend and holiday discharges need to be planned and discussed in advance
38What the DOHMH Would Like From Providers Complete and legible formsExpected date of dischargeAppropriate contact information for the treating physician/attending MDNotification of any issues with medications, side effects or abnormal lab valuesSpecialized nursing needs : PICC lines, injectionsDischarge to congregate settings or home care agency referralsDischarges to other jurisdictions requiring interstate notificationHow many days of medication provided to patientFollow-up appointment date –should be close to date of dischargeDischarges to other jurisdictions require a discussion with health agencies
39What Does the DOHMH Need to Do Prior to Discharge? Field staff need to interview patient to elicit contactsHome assessment should be donePatient to agree to home isolation and DOTSign agreements for bothFollow up appointment is made
40Update on Hospital Discharge Plan Submissions November 1- March 1, 2011
41Acid Fast Bacilli Sputum Smear Positive TB Patients 97Discharged smear negative16 (17%)Discharged smear positive48 (50%)Still in hospital33 (34%)97 AFB sputum smear positive TB patients reported to the health department during Nov 1-March 1Main point 54% of smear positive patients discharged from hospitals had no hospital discharge plans submittedPlan submitted22 (46%)No plan submitted26 (54%)Plan submitted9 (56%)No plan submitted7 (44%)Plan submitted10 (27%)No plan submitted23 (73%)*Suspected and confirmed
42Patients Discharged While Acid Fast Bacilli Sputum Smear Positive (n=48) 27 hospitals that discharged 48 smear positive patients12 of the hospitals have not submitted discharge plansHigh admitters are not submitting plans27 hospitals that discharged 48 smear positive patients from the prior slide2 that had most number of discharges did not consistently submit plans.-High admitters are not submitting plans upon dischargeHosp 1-maimodiesHosp 2-columbia
43Compliance With Health Code Time Requirements Median days from discharge plan submission to planned discharge was 1 day (range: -4 to 5)23% (9/41) of plans submitted did not have a planned discharge dateMedian number of days for DOHMH physician to respond to treating MD was 0 days (range: <1-3)Plans are not submitted as required by law4 days after discharge to 5 days prior to discharge. Median is one day prior to discharge which is on day of discharge.For DOHMH physician response, 3 days means we could not get in touch with physicians/or holiday/.
44Initial Approval Status of Discharge Plan Submissions
45Reasons For Initial Disapproval* #%Home assessment not complete627Discharge plan form incomplete523DOT not offered/agreed418Discharged to congregate setting/unstable residence314Inadequate treatment regimen29Children <5 in house not evaluatedHome assessment not done” d/c plan submitted on day of discharge, couldn’t gain entry into house. D/cing patients on Friday.Reason that home assessment was not complete was due to discharge plans being submitted on the day of discharge, or entrance to the home was not available*Discharge plans may be disapproved for more than one reason
46Discharge of Non-NYC Residents Non-NYC residents (i.e., patients with a non-NYC address as their place of residence) admitted to a NYC hospitalAn approval for discharge will not be granted if the plan is to discharge to an address outside of NYC until the patient has become non-infectious i.e., unless public health officials in the receiving jurisdiction give explicit approval for the discharge of an infectious patient. DOHMH staff, through the Interstate Desk, will communicate all out-of-jurisdiction discharge plans with TB control in the jurisdiction to which patient is to be transferred/discharged to seek further guidance.Patient can only be approved for discharge if the local health department gives explicit approvalIf a non-NYC resident who is admitted to a NYC hospital is being discharged to a verifiable New York City address, DOHMH staff will treat this patient like a NYC resident.NYC DOHMH will communicate discharge plans with patient’s local health department prior to discharge/transferInfectious TB patient will be discharged only upon approval of local health departmentIf a patient is being discharged to a verifiable NYC address, a discharge plan must be submitted
47Discharge of NYC Residents from Non-NYC Hospital NYC DOHMH will work with discharging hospital &/or the local public health authorities to ensure discharge plans conform to NYC standardsNYC residents admitted to a hospital outside of NYCThe section of the Health Code that mandate discharge approvals only applies to facilities in New York City. Facilities outside New York City are not bound by this requirement. Those facilities will have to adhere to local public health laws and regulations. Therefore, NYC DOHMH staff have no authority in approving or denying requests from facilities outside the five boroughs. We will however work with local public health authorities to ensure that discharge plans conform to minimum standards.
49Treatment Plan Approval Process Within 1 month oftreatment start dateTreating providerdiscusses treatmentplan issues withDOHMHrevises planinforms DOHMHDOHMH case managercontacts treatingproviderobtains completedtreatment plan formDOHMH physicianreviews treatment planmakes determinationcommunicates with
50TB Treatment Plan FormNYC Health Department case manager will provide the treatment plan form to treating physician for completionTreatment plan form does not replace Report of Patient Services Form (TB 65)This form does not replace the Report of Patient Services form (TB 65) which mustalso be submitted to the Health Department for every monthly visit of patients with activetuberculosis
52Future Considerations Continue collaboration with hospitals/providersMonitor submission of hospital discharge/treatment plansOutreach to hospitals/providers experiencing issues with plansContinue to evaluate impact of initiative
53ConclusionSubmit discharge plans for infectious TB patients within 72 business hours of planned dischargeSubmit treatment plans within one month of treatment initiationEnsure forms are complete/accurateRefer to NYC DOHMH guidelines & resourcesCall 311 to consult with DOHMH TB expertsSubmit discharge plans for infectious TB pts within 72 hours of planned dischargeSubmit completed forms (Treating MD contact numbers at the facility ie; pagers, phone number)Treating MD contact numbers at the facility ie; pagers, phone numberCan not discharge until discharge plan approved and approval letter sent???Discharge plans that do not meet the criteria for submissionPlans will still be reviewed by BTBC provider and feedback provided
54AcknowledgementsNYC DOHMH Bureau of TB Control Provider Outreach Project Working GroupNYC DOHMH Bureau of TB Control StaffNYC Infection Control Nurses and Practitioners
57Amendments to Tuberculosis (TB) Reporting Requirements in New York City -1 Section of the New York City Health CodePhysicians and/or persons in charge of hospitals who report infectious TB cases must obtain consultation with and consent of the Department at least 72 hours prior to discharging such cases from inpatient care.Patients will only be discharged after the department has determined that discharge will not endanger the public health.The department will respond to the attending physician within one business day of the consultation.
59Amendments to Tuberculosis (TB) Reporting Requirements in New York City -2 Providers who assume the care of newly diagnosed cases of TB should submit within one month of treatment initiation a proposed treatment plan to the Department for reviewInclude name of medical provider who is responsible for treatment, names and duration of prescribed anti-TB drugs, anticipated date of treatment completion and a plan for promoting adherence to prescribed treatment.Form will be provided by the Bureau
61Light yellow <= national rate Orange <= NYC rateDark red > NYC rate
62TB Laboratory Case Definition Isolation by culture of M. tuberculosis complex from a clinical specimenORDemonstration of M. tuberculosis from a clinical specimen by nucleic acid amplification (NAA) test (when used in accordance with FDA approved product labeling) ORDemonstration of acid-fast bacilli (AFB) in a clinical specimen when a culture has not been or cannot be obtainedTB is confirmed by laboratory techniques but can be diagnosed clinically. The following 2 slides will go over the CDC TB case definitions. The TB laboratory definition is via Isolation by culture of M. tuberculosis complex from a clinical specimen OR Demonstration of M. tuberculosis from a clinical specimen by nucleic acid amplification (NAA) test (when used in accordance with FDA approved product labeling) OR Demonstration of acid-fast bacilli (AFB) in a clinical specimen when a culture has not been or cannot be obtainedNAA test should be used as per FDA approval: only in respiratory specimen and in patients who have been treated for TB 7 days or less (or more than 1 year ago)Although not included in this definition, patients with pathologic specimens c/w TB are also reportable, as described later626262
63TB Clinical Case Definition Evidence of TB infection based on a positive tuberculin skin test or FDA approved blood testANDOne of the following: Findings compatible with current TB disease, such as an abnormal, unstable (worsening or improving) chest radiograph, orClinical evidence of current disease (e.g.. fever, night sweats, cough, weight loss, hemoptysis)Improvement on current treatment with two or more anti-TB medicationsThe clinical definition for TB include all the following criteria:Evidence of TB infection based on a positive tuberculin skin test ANDOne of the following:(1) Findings compatible with current TB disease, such as an abnormal, unstable (worsening or improving) chest radiograph, or(2) Clinical evidence of current disease (e.g.. fever, night sweats, cough, weight loss, hemoptysis) ANDImprovement on current treatment with two or more anti-TB medicationsWhat is a TB suspect: anyone with signs or symptoms/radiological findings c/w TB and the right epidemiology is a TB suspect. A suspect is as per the treating physician: if a providers think TB and order tests to show that the patient has TB, the patients is a suspect and should be reported. If the patient is stared on Rx even with negative smear/culture, that is a definite reason for reporting – promptly.636363