Management of Patients with Known or Suspected ... · PDF fileHampshire Hospitals NHS Foundation Management of Patients with Known or Suspected Tuberculosis Policy HH ... the Nursing

Hampshire Hospitals NHS Foundation Management of Patients with Known or Suspected Tuberculosis Policy HH(1)/IC/632/16 Due for latest review June 2019. CHECK THE INTRANET FOR THE LATEST VERSION

Page 1 of 28

Management of Patients with Known or Suspected Tuberculosis Policy: Infection

Control Issues HH(1)/IC/632/16 Previous document(s) being replaced

Location Policy No Policy Name

HHFT HH(1)/IC/632/13 Management of Patients with Known or Suspected Tuberculosis Policy: Infection Control Issues

Document Summary

This is a clinical and infection control guidance document that outlines the management of patients or staff suspected or confirmed as having Mycobacterium Tuberculosis (M.TB) infection. It is based primarily on the National Institute for Health and Care Excellence (NICE) guideline (ng33). This policy does not cover treatment or prophylaxis treatment details. Each case must be individually reviewed, risk assessed and control measures implemented appropriately.

Ownership Author Lucy Picton‐Turbervill

Job Title Respiratory Clinical Nurse Specialist

Document Type Level Level 1 Trustwide

Related Documents Document Details Standard Precautions Policy (Incorporating Personal Protective Equipment) Care of Patients at Death policy Learning and Development policy Patient Information and Procedure policy

Relevant Standards CQC Outcome Outcome 8

Equality Impact Assessment

Completed by Lorraine Amos

Date Completed 10 November 2016

Final Document Approval Committee Policy Approval Group

Date Approved 26 September 2016

Other Specialist Approving Committee

Committee Infection Prevention and Control Committee

Date Approved 19 September 2016

Final Document Ratification

Committee Executive Committee

Date Ratified 29 September 2016

Authorisation Authoriser Mary Edwards

Job Title Chief Executive

Signature

Date Authorised 11 November 2016

Dissemination Target Audience All Trust Staff

Dissemination and Implementation Plan

Action Owner Due by

Publicise detail of new document via Intranet and Midweek message

IPCT and Communication Team

Within 1 week of publication

Communication to all Senior Managers to advise publication of policy

BNHH Healthcare Library On publication

The policy will be available on the intranet and web site BNHH Healthcare Library and Communication Team

Within 1 week of authorisation


Page 2 of 28

Review Expiry date 26 September 2019

Review date 26 June 2019


Page 3 of 28

Document Control – Document Amendments

Version No. Details Key amendments to note By whom Date

1 Review of BNHFT & WEHCT policies to produce harmonised HHFT policy

Updated NICE Pathways for screening household contacts or other close contacts of a person with active TB

Sarah Symonds and Hazel Gray

January 2013

2 Review of HHFT policy Introduction/purpose re‐written to reflect new guidance Explanation of terms expanded Notification/surveillance – responsibility of CNS role

Lucy Picton‐Turbervill

August 2016


Page 4 of 28

Contents

1. Introduction ........................................................................................................ 5 2. Purpose ............................................................................................................... 5 3. Scope .................................................................................................................. 5 4. Explanation of Terms .......................................................................................... 6 5. Duties ................................................................................................................. 8 6. Notification/Surveillance .................................................................................... 9 7. Management in hospital ..................................................................................... 9 8. Contacts of a hospital inpatient or staff member diagnosed with TB .............. 14 9. Operating Theatres/Radiology.......................................................................... 15 10. Outpatient department .................................................................................... 15 11. Staff .................................................................................................................. 15 12. Patient Information .......................................................................................... 15 13. Stakeholders Engaged During Consultation ...................................................... 16 14. Dissemination and Implementation Plan .......................................................... 16 15. Training ............................................................................................................. 16 16. Monitoring Compliance with the Document .................................................... 16 17. References ........................................................................................................ 17 18. Associated Documentation ............................................................................... 18 19. Contributors ..................................................................................................... 18 Appendix A – Equality Impact Assessment ................................................................. 19 Appendix B ‐ Risk Assessment of Patients with Suspected TB .................................... 21 Appendix C – NICE pathway: Tuberculosis management and infection control in hospital ....................................................................................................................... 22 Appendix D ‐ Assessment for TB in patients before starting biologic therapies ........ 23 Appendix E ‐ How to obtain a sputum sample ............................................................ 24 Appendix F ‐ Draft Letter for General Practitioners and Consultants ......................... 25 Appendix G ‐ Draft Letter for Patients Present on the Same Ward as a Case of Infectious TB ............................................................................................................... 26 Appendix H ‐ New NHS employees ............................................................................. 27


Page 5 of 28

1. Introduction It is essential that infection control is seen as an organisational responsibility and priority, that adequate isolation facilities and resources are provided, and that appropriate infection control staff and support services are available.

2. Purpose The purpose of this document is to identify risk and prevent spread of a notifiable infectious disease.

The 2015 Public Health England PHE report Tuberculosis in England states in the last three years there has been a year on year decline in the number and rate of TB cases in England, down to 6,520 cases in 2014, a rate of 12.0 per 100,000. However the rate of TB in England remains one of the highest in Western Europe.

Nationally statistics demonstrate a reduction in the number of cases in the non UK born population, which is likely in part to reflect recent declines in the number of migrants from high TB burden countries however the demographics of the local area show a significant immigrant population who also contribute to the Trust workforce and TB rates for HHFT have increased with more than 130 cases since 2010. The majority of non‐UK born cases (86%) are now identified more than 2 years after entering the UK, and are likely due to reactivation of latent TB (LTBI). The NHS England Collaborative TB strategy 2015 ‐2020 and the newly established TB Control Boards have identified preventing the spread of the disease as a priority. There are new recommendations for the identification and treatment of LTBI.

Risk factors such as co‐infection with HIV and other blood born viruses, social conditions and lifestyle choices all contribute to a higher risk of TB activation/infection. Delayed diagnosis poses an infection risk to contacts and vulnerable people found in congregate settings such as hospitals. Advice should be sought early from Respiratory Team, Consultant Microbiologist or the Infection Control Team if you have any concerns.

3. Scope This policy and procedure will be applied fairly and consistently to all employees and service users regardless of their protected characteristics as defined by the Equality Act 2010 namely, age, disability, gender reassignment, race, religion or belief, gender, sexual orientation, marriage or civil partnership, pregnancy and maternity. For employees this policy also applies irrespective of length of service, whether full or part‐time or employed under a permanent or a fixed‐term contract, irrespective of job role or seniority within the organisation.

Where an employee or service user has difficulty in communicating, whether verbally or in writing, arrangements will be put in place as necessary to ensure that the processes to


Page 6 of 28

be followed are understood and that the individual is not disadvantaged during the application of this policy.

The application of this policy is completely clinically based and ensuring prompt testing/treatment would be the priority, however the Trust would endeavour to continue to meet patients’ individual needs as far as is practicable.

In line with the Equality Act 2010, the Trust will make reasonable adjustments to the processes to be followed where not doing so would disadvantage an individual with a disability during the application of this policy.

This policy complements professional and ethical guidelines and the Nursing and Midwifery Council (NMC) Code of Professional Conduct (NMC 2015).

4. Explanation of Terms This policy while primarily applying to infection with Mycobacterium tuberculosis, also applies to Mycobacterium africanum, Mycobacterium bovis, Mycobacterium mictroti and Mycobacterium caprae. There are many other atypical Mycobacterium that are not infectious and may not require treatment. Advice should be sought from the respiratory team or consultant microbiologist before starting medication.

Acid fast Bacilli (AFB) ‐ staining process to determine potential presence of TB (and other bacteria) on slide

BCG‐ Bacillus Calmette Guerin ‐ live vaccine against TB developed in 1921 from attenuated strain of M.Bovis.

Clinical diagnosis ‐ in the absence of culture confirmation these are cases that in the clinician’s judgement exhibit clinical or radiological signs and symptoms compatible with active TB.

Contact screening ‐ method of controlling the spread of TB by active screening. Planned and initiated by Respiratory Clinical Nurse Specialist. Culture Confirmation ‐ the gold standard of diagnosis enabling speciation and sensitivities to be examined. This is a key part of limiting inappropriate treatment leading to drug resistant TB. It can take up to 6‐8 weeks to pronounce culture negative. Interferon Gamma release assay IGRA ‐ blood test to ascertain if a person has been exposed to TB. The test will not distinguish between latent and active disease. It is a time sensitive test and can be requested on ICE (TB Assay) but discuss requirements with Consultant Microbiologist or Respiratory team. Latent tuberculosis infection (LTBI) ‐ a state of persistent immune response to stimulation by Mycobacterium tuberculosis antigens without evidence of clinically manifested active TB. 1/3 of the world’s population is estimated to have LTBI. The lifetime risk of reactivation for a person with documented LTBI is estimated to be 5–10%


Page 7 of 28

with the majority developing TB disease within the first five years after initial infection. However, the risk is considerably higher in the presence of predisposing factors.

Mycobacterium Tuberculosis (M.tb) ‐ slow growing highly infectious bacteria that causes Tuberculosis infection. It can occur in any part of the body, is spread by droplet/aerosol and symptoms are commonly cough, fevers, night sweats, weight loss, lethargy and lymphadenopathy. It can mimic many other diseases and can be hard to diagnose. Once diagnosed it is normally treatable with antibiotic therapy. MDR‐TB ‐ multi‐drug resistant TB is defined as resistance to at least isoniazid and rifampicin, with or without resistance to other first line drugs. MDR‐TB should not be treated at HHFT without advice from tertiary centre and transfer to negative pressure room at Southampton or Oxford if requiring admission for pulmonary symptoms. Non‐pulmonary TB ‐ Lower infectivity however pulmonary must be excluded by CXR +/‐ sputum. Notifiable disease ‐ there is a statutory duty to report any case of TB to Public Health England (PHE). All new tuberculosis (TB) cases, including cases diagnosed on post mortem, culture confirmed disease, with speciation confirming Mycobacterium tuberculosis complex (M. tuberculosis, M. bovis, M. africanum and M. microti). Clinically diagnosed cases in the absence of culture confirmation must also be notified. Microbiology department notify Public Health and TB nurses at HHFT complete this on ETS website. Personal protective equipment (PPE) ‐ aprons, gloves and a filtering face piece (FFP3) device meeting the 1992 Personal Protective Equipment (EC Directive) Regulations. It provides a high level of filtering capability and face fit. It can be supplied with an exhale valve so that it can be worn comfortably over a fairly long period of time. It will provide an effective barrier to both droplets and fine aerosols.) Quadruple therapy or Standard treatment ‐ 4 antibiotics, Rifampicin (R), Isoniazid (H), Pyrazinamide (P) and Ethambutol (E) for 2 months, then 4 months further of Rifampicin and Isoniazid. Smear positive TB ‐ Acid fast bacilli (AFB) seen immediately with a microscope. Highly infectious form of TB.

Smear negative TB ‐ Bacilli grown on culture Sputum ‐ Pulmonary secretion. Send 3 samples for AFB. Highest bacterial load early in morning. Infectivity varies as to whether spontaneous, induced (nebuliser or physio) or Broncho‐aveolar lavage (BAL) at bronchoscopy. XDR‐TB ‐ resistance to first and second line drugs. Needs expert advice on management.


Page 8 of 28

5. Duties

5.1 Post‐holders with Duties

The Chief Executive (CE) has ultimate accountability for ensuring robust systems are in place to ensure the Trust continues to work to best practice and complies with all relevant legislation in regard to the management of patients and staff suspected or confirmed of having TB.

The Director of Infection Prevention and Control (DIPC) is the Trust Director responsible to the board for the delivery of IPC standards.

The Director of Nursing will ensure that the Divisional Directors take clinical ownership of the policy.

The Divisional Operational Directors will ensure that all health care workers comply with this policy and that all health care workers attend mandatory infection prevention and control training. They are responsible for ensuring adequate facilities and resources are available to adhere to this policy.

The Clinical Matrons will ensure that the current version of this policy is available in all of their areas. They will ensure that all health care workers comply with this policy and that all health care workers attend mandatory infection prevention and control training.

The Health and Safety Advisers will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and health care workers regarding the use of personal protective equipment. Nominated Chest Physician responsible for Mycobacterium infections will provide clinical advice. Each case should be risk assessed separately by the treating clinician with support from the IPCT. Control measures may have to be modified to allow for appropriate control. Respiratory Clinical Nurse Specialist is responsible for contact tracing and will monitor the implementation of this policy via audit within clinical areas and be responsible for regularly reviewing and updating it. All Trust employees will comply with this policy and inform the IPCT about any issues or concerns relating to the policy. All staff will attend mandatory Infection Prevention and Control training annually. Infection control is the responsibility of ALL staff associated with patient care. A high standard of infection control is required on ALL wards and units, although the level of risk may vary. It is an important part of total patient care. 5.2 Committees / Groups with Duties The Infection Prevention and Control Team (IPCT) will act as a resource for information and support. They will provide education in relation to this policy which includes mandatory training.


Page 9 of 28

The Health4Work department is responsible for staff screening and management and for ensuring departmental protocols reflect up to date local and national guidance. They will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and health care workers regarding the use of personal protective equipment. The Health and Safety Team will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and healthcare workers regarding the use of personal protective equipment. The Respiratory Team will act as resource for clinical information and support. Any confirmed case must be discussed with the Team. Advice on screening can also be sought if unclear by both Primary and Secondary Care. Public Health England ‐ Wessex team support in cases where wider or group screening is required.

6. Notification/Surveillance All forms of TB are compulsorily notifiable by the diagnosing physician to the national Enhanced TB Surveillance database (ETS). In practice this is completed by the Respiratory Nurse. Notification must be made for two reasons:

contact tracing can begin

provides surveillance data to detect outbreaks and monitor epidemiological trends The Infection Prevention and Control Team and the Respiratory Clinical Nurse Specialist must also be informed of all patients and staff with active TB (any site of disease) in the Trust. A decision to commence treatment (but not chemoprophylaxis) for TB of a patient indicates a level of suspicion that should trigger notification for all forms of tuberculosis.

7. Management in hospital Unless there is a clear clinical or socioeconomic need, such as homelessness, people with TB at any site of disease should not be admitted to hospital for diagnostic tests or for care. Risk Assessment If clinically necessary and the case requires admission please follow the infection control risk assessment in Appendix B to determine level of infection control measures required. If unclear seek advice from Infection Control or Respiratory Teams.

Risk assess each case individually including assessment of:


Page 10 of 28

Previous TB

Risk of MDR‐TB e.g. acquired abroad, contact with known case, previous TB

Known TB contact

Symptomatic

Immunosuppression whether through disease process such as HIV, hepatitis B or C, or medication such as chemotherapy, anti‐TNF treatment (Appendix B), anti‐ rejection therapy post transplantation

Under‐served populations including the homeless, drug users, alcohol users or prisoners

Unnecessary isolation/ PPE can be detrimental and stigmatising. It is still recognised in some situations as the most effective way of limiting spread of infection. Follow the infection control risk assessment in Appendix B and seek help if unclear from Infection Control or Respiratory team. Children with suspected TB should be treated as above and immediate advice be sought from Paediatric TB lead at BNHH (secretary 01256 824798). TB nurse must be informed before discharge and will arrange community support. Isolation All patients with pulmonary TB should be isolated in a side room if possible. Patients with smear positive TB must be isolated in a single room with en‐suite facilities and the door kept closed, until:

they have completed 2 weeks of the standard recommended treatment regime; or

they are discharged from hospital Depending on the risks of MDR‐TB and XDR‐TB some patients will require isolation in a negative pressure room. Such rooms are not available at HHFT and patients with smear positive TB and any of the above mentioned risk factors for MDR‐TB should be transferred to an infectious diseases unit with appropriate facilities e.g. Southampton or Oxford. While awaiting the results of microscopy of sputum from these ‘at risk’ patients it is reasonable for them to remain in a side room on a ward with no immune‐compromised patients.

Patients whose bronchial washings are microscopy positive for alcohol acid fast bacilli

(AFB) can be managed as non‐infectious unless:

the sputum is also positive or no good quality specimen obtained, or

they are on a ward with immune‐compromised patients, or

they are known or suspected of having MDR‐TB

If a patient has a TB wound site, that requires irrigation, or the care of which may generate aerosols, isolation in a side room is necessary. Aerosol‐generating procedures


Page 11 of 28

such as bronchoscopy, sputum induction or nebuliser treatment should be carried out in an appropriately engineered and ventilated area. Within paediatrics it is important to ensure that any child with active TB is nursed in a cubicle at the opposite end of the ward to any immune‐compromised children by a separate team or nurses. Visitors should be kept to a minimum, ideally with no new contacts but this should be discussed with the nurse in charge on a case by case basis. Visitors may be asked to wear a mask while visiting. Babies and young children are not advised to visit. People who are immune‐compromised themselves should be risk assessed before visiting. Any visitors to a child with TB in hospital should be screened as part of contract tracing, and kept separate from other patients until they have been excluded as the source of the infection.

See Appendix B risk assessment and Appendix C for NICE patient pathway.

Termination of Isolation This should be decided by the Consultant Physician caring for the patient and the Infection Prevention and Control Team. As a general rule, isolation is no longer required if:

an immune‐competent patient has completed 2 weeks of anti TB therapy including isoniazid and rifampicin

a patient suspected of having MDRTB who is smear negative has evidence from the reference laboratory that there is no rifampicin resistance on molecular testing, and has completed 2 weeks appropriate therapy guided by the chest physician

if HIV +ve and smear negative the following criteria in addition to the above also need to be met:

o completion of at least 2 weeks of appropriate multiple drug

therapy and o demonstrated tolerance to the prescribed treatment and an

ability; and agreement to adhere to treatment; and o either a complete resolution of cough or a definite clinical

improvement to treatment e.g. remaining afebrile for one week Specimens It is essential to obtain specimens to determine whether an individual is infectious as quickly as possible so that:

appropriate treatment can be commenced

isolation facilities can be used appropriately

appropriate contact tracing can be carried out


Page 12 of 28

To enhance yield of mycobacteria, three early morning sputum specimens should be collected and sent promptly to the laboratory. See Appendix C. Ideally this should be done on three consecutive days. However if there is a risk of MDR‐TB/XDR‐TB three specimens should ideally be collected and sent to the laboratory within 24 hours. This is to ensure the patient can be sent promptly to a facility with negative pressure rooms if the respiratory samples are smear positive. ‘Danger of infection’ should be labelled on specimens and identified on the ICE request. The ICE request should specify ‘microscopy and culture for AFB’ in addition to any other tests requested by the physicians. If AFBs are seen on microscopy of sputum the patient must be regarded as infectious. Patients are not regarded as infectious if AFBs are not seen on microscopy of good quality sputum samples, but cultures subsequently grow a mycobacterium species. Sometimes a patient is unable to produce a specimen of sputum themselves simply by coughing. Physiotherapy and/or sputum induction may be required to obtain a sample. This must not be carried out in an open ward area, and should only be attempted in a side room with the door closed, by staff wearing appropriate masks. If MDR‐TB is suspected, bronchoscopy, physiotherapy and/or sputum induction should only be performed in a negative pressure room i.e. after the patient is referred to another unit. IGRA Blood tests for TB will not distinguish between active and latent disease but can be a useful diagnostic tool. Masks Healthcare workers caring for people with TB should use masks, gowns and standard precautions unless discussed with the infection control team / respiratory nurse specialists. See Appendix B.

For patients with suspected MDR‐TB all visitors and healthcare workers must wear masks on entering the patient’s room.

The correct masks to wear when caring for patients with TB are FFP3 masks meeting the 1992 Personal Protective Equipment (EC Directive) Regulations. All staff and visitors must be instructed how to fit the mask correctly. Visitors should be shown this by the nurse looking after the TB patient.

When such equipment is used, the reason should be explained to the patient. It is the Trust’s responsibility to provide effective personal protection equipment including masks but it is the employee’s responsibility to wear it correctly and raise any issues with it. See Standard Precautions Policy (Incorporating Personal Protective Equipment).


Page 13 of 28

Patients with smear‐positive respiratory TB should be asked (with explanation) to wear a respiratory mask whenever they leave their room until they have had two week medication and permission given by the respiratory consultant and discussed with the infection control team.

Cleaning Protocols

Linen, crockery and cutlery ‐ no special precautions are needed

Daily cleaning of the room ‐ it is important to clean the room twice a day (using standard cleaning protocols) paying particular attention to any horizontal surfaces that may become contaminated with microscopic droplets from either coughing, or following irrigation of a wound draining TB. The room should be aired twice a day, by opening the window though the door should remain shut.

Terminal Cleaning ‐ terminal cleaning of the isolation room using a chlorine releasing agent at 1000ppm available chlorine must be carried out if the patient is discharged or transferred. Curtains should be changed. Fumigation of rooms that have housed patients with TB is unnecessary.

Transport Arrangements

All staff in close contact with a patient who is to be transferred to a negative pressure room at a tertiary referral centre, because of smear positive disease where MDR or XDR‐TB is suspected, must wear appropriate filter masks e.g. FFP3.

When a patient is in isolation with known or suspected pulmonary TB they should not be transferred to other hospitals or departments unless this is essential for their care e.g. transfer to ITU, emergency investigations.

If a patient has TB in a wound/drain site etc this should be covered with an occlusive

dressing.

Last Offices

The risk of infection from the deceased individual with TB is small however appropriate infection control measures should be taken. The deceased infected individual should be placed in a cadaver bag and a ‘Danger of Infection’ sticker attached for transfer to the mortuary. Mortuary staff must be informed of this risk. If performing last offices for a patient with incompletely treated smear positive TB or suspected MDR TB it is still necessary to wear FFP3 masks. The deceased should also wear a face mask as air will escape from the body during the last offices. Family should be made aware of this risk with sensitivity


Page 14 of 28

See Care of Patients at Death policy.

8. Contacts of a hospital inpatient or staff member diagnosed with TB A risk assessment to be performed including:

Degree of infectivity of the index case

Duration and proximity of contact

Susceptibility of other patients

Contact tracing and testing will only be performed following risk assessment carried out by the respiratory team together with the infection control team and Health4Work.

Risk assessed patients will be managed as a household contacts if they were exposed to a patient with sputum smear positive TB for long enough to be equivalent, or are particularly susceptible to infection.

A significant contact in the hospital setting is defined as any patient in the same bay as a patient with a cough and smear positive TB, who has been exposed for a period of 8 hours or more, this could be a cumulative period. Patients elsewhere on the ward should be regarded as significant contacts if they are immunocompromised and the exposure was for more than 48 hours. Transmission in this situation is uncommon but some patients may be at increased risk. If the patient had MDR‐TB, or exposed patients are HIV positive, contact trace in line with NICE guidelines:

HIV‐ related tuberculosis

Drug‐resistant including multiple drug resistant, tuberculosis. London: Department of Health. Available from www.dh.gov.uk The Infection Prevention and Control Team together with the ward manager will draw up a list of contacts.

The Infection Prevention and Control Team will then liaise with the Consultants responsible for the patients who are contacts to ensure appropriate follow up. Action will be discussed with Public Health England and when appropriate, a letter will be sent to the contact, their consultant and GP informing them of the exposure. See Appendices F and G.

Staff are not considered significant contacts unless they have:

performed mouth to mouth resuscitation

undertaken prolonged care of a high dependency patient i.e. 1:1 care for a shift, without wearing a mask

carried out repeated chest physiotherapy without wearing a mask

immunocompromised themselves


Page 15 of 28

greater than 8 hours of exposure, this could be a cumulative period, to a case of infectious TB e.g. cavitary (chest x‐ray/CT evidence of communication of a cavity to an airway) or open TB

9. Operating Theatres/Radiology Patients with infectious pulmonary TB who require an operative procedure/radiology must be kept separate from other patients. They must be recovered in a separate area. Patients with TB in a closed body site do not need to be separated from other patients. Ward staff must ensure that theatre/radiology staff are made aware if a patient with infectious pulmonary TB is to attend theatres/radiology, so that necessary infection control precautions can be arranged before the patient arrives in the department.

10. Outpatient department If possible attendance of a patient with infectious pulmonary TB to the outpatient department should be delayed until the patient is no longer infectious unless the appointment is urgent. The risk of transmission in this setting is low as the exposure time of a patient to an infected individual is unlikely to be prolonged, but contact with other patients must be minimised including during ambulance journeys. If the patient has TB in a wound/drain site this should be covered with an occlusive dressing. If further advice is required please contact Infection Prevention and Control.

11. Staff All staff must have their TB status checked on employment by Health4Work.

The above advice also pertains to bank and agency staff. The ward co‐ordinator must seek assurance from any bank or locum staff that BCG status has been checked, before allocating them to care for a patient with infectious TB.

Screening for staff should be according to NICE 33 Guidance section 1.1.4. Health4Work should advise the individual regarding the precautions when caring for patients with infectious pulmonary TB. See Appendix F.

If a health care worker is suspected or confirmed of having TB, Health4Work, Consultant in Communicable Disease (CCDC) for Public Health England and IPCT should be informed promptly to allow for risk assessment and contact tracing to be undertaken.

12. Patient Information In accordance with the Trust Patient Information Policy the Macmillan Health Information Manager will ensure information is made available in alternative formats and languages, as and when requested.


Page 16 of 28

A Patient Information leaflet will be available on the intranet.

13. Stakeholders Engaged During Consultation

14. Dissemination and Implementation Plan

Action(s) Owner Publicise detail of new document via Intranet and Midweek message

IPCT and Communication Team

Communication to all Senior Managers to advise publication of policy

BNHH Healthcare Library

The policy will be available on the intranet and web site BNHH Healthcare Library and Communication Team

15. Training

Individuals in the Trust should receive annual infection prevention and control training to ensure they are aware of their responsibilities. Education and Training will be provided in accordance with the Trust Training Needs Analysis (Learning and Development Policy).

16. Monitoring Compliance with the Document

NHSLA Minimum

Requirement Reviewed by

Method of Monitoring

Frequency of Review

Committee where

Stakeholder Date of Consultation

Infection Prevention and Control (Lead Infection Prevention & Control Nurse)

19/08/2016

Health and Safety (Health and Safety Advisor) 19/08/2016

Safeguarding (Trust Safeguarding Lead) 19/08/2016

Information Governance (Information Governance Manager) 19/08/2016

Assistant Risk and Compliance Manager (Risk and Compliance) 19/08/2016

Divisional Directors and Divisional Directors (Operational) 19/08/2016

Equality and Diversity Lead (Equality & Diversity) 19/08/2016

Head of Health4Work 19/08/2016

Infection Prevention and Control Committee 19/08/2016

Consultant Microbiologists 19/08/2016

Clinical Matrons/Clinical Service Leads 19/08/2016

Operational Service Managers 19/08/2016

Respiratory Team 19/08/2016


Page 17 of 28

requirements Monitoring is Reported to

A. Effectiveness of policy

Respiratory Clinical Nurse Specialist

Audit of notification and management of each case

Each case Respiratory team meeting

17. References Health and Safety Executive (1992) Personal Protective Equipment at Work Regulations (online) http://www.hse.gov.uk/pUbns/priced/l25.pdf [Accessed 22 August 2016] National Institute for Health and Care Excellence (2016) Tuberculosis NICE guidelines [NG33] (online) https://www.nice.org.uk/guidance/ng33 ][Accessed 22 August 2016] National Institute for Health and Care Excellence (2016) Tuberculosis NICE pathway (online) http://pathways.nice.org.uk/pathways/tuberculosis ][Accessed 22 August 2016] National Institute for Health and Care Excellence (2016) Tuberculosis: management and infection control in hospital NICE pathway (online) http://pathways.nice.org.uk/pathways/tuberculosis#content=view-index&path=view%3A/pathways/tuberculosis/tuberculosis-management-and-infection-control-in-hospital.xml ][Accessed 22 August 2016]

NHS England (2015) Tuberculosis (TB): collaborative strategy for England (online) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/403231/Collaborative_TB_Strategy_for_England_2015_2020_.pdf [Accessed 22 August 2016] Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives (online) https://www.nmc.org.uk/globalassets/sitedocuments/nmc‐publications/nmc‐code.pdf [Accessed 22 August 2016] Public Health England (2015) Tuberculosis in England 2015 Report (online) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/492431/TB_Annual_Report_v2.6_07012016.pdf [Accessed 22 August 2016] Public Health England (2016) Tuberculosis (TB) and other mycobacterial diseases: diagnosis, screening, management and data (online) https://www.gov.uk/government/collections/tuberculosis‐and‐other‐mycobacterial‐diseases‐diagnosis‐screening‐management‐and‐data [Accessed 22 August 2016]


Page 18 of 28

18. Associated Documentation

Standard Precautions Policy (Incorporating Personal Protective Equipment) Care of Patients at Death policy Learning and Development policy Patient Information and Procedure policy

19. Contributors

Contributor Job Title Contributor Name

Lead Infection Prevention and Control Nurse Hazel Gray


Page 19 of 28

Appendix A – Equality Impact Assessment

To be completed by the Policy Author at the development stage of the policy and before consultation. Part 1 should be forwarded to an Equality Analysis Lead (list available on the Document Control Trust Intranet page) for sign off and any comments from them considered and addressed before seeking final approval of the policy.

Document Title: Management of Patients with Known or Suspected Tuberculosis Policy: Infection Control Issues

PART 1 – Policy Author to complete and forward on to an EA Lead for sign off

1. Could the application of this document have a

detrimental equality impact on individuals with any of

the following protected characteristics? (See Note 1)

Yes/No

/NA

Summarise the equality and

diversity related elements

within the policy

a Age N

b Disability N

c Gender reassignment N

d Race N

e Religion or belief N

f Sex N

g Sexual orientation N

h Marriage & civil partnership N

i Pregnancy and maternity N

2. If ‘Yes’ to question 1, do you consider the detrimental

impact to be valid, justifiable and lawful? If so, please

explain your reasoning.

It is recognised that isolation may have an adverse psychological impact on a person and may affect their freedom of liberty. However isolation is still considered the most effective measure in limiting the spread of infectious diseases/ organisms and is therefore considered a necessary intervention

3. Specify with which, if any, individuals and groups you have consulted in reaching your decision.

PART 2 – Equality Analysis Lead to complete and forward back to the Policy Author

Provide a brief summary of the potential impact of the policy and whether sufficient consideration has

been given to the Equality Duty.


Page 20 of 28

Document Title: Management of Patients with Known or Suspected Tuberculosis Policy: Infection Control Issues

The application of this policy for the management of patients with known or suspected tuberculosis is clinically based and ensuring the appropriate infection control measures are applied would be the priority, however the Trust would endeavour to continue to meet patients and employees individual needs as far as is practicable.

1. Is this document recommended for publication? Y If ‘yes’ go to question 3 if ‘No’ complete number 2 below.

2. This document is not recommended for publication because:

A Amendments are suggested as follows:

B A more detailed equality analysis should be undertaken as follows:

C Other (please specify)

3. Specify with which, if any, individuals and groups you have consulted in reaching your decision.

Name: Lorraine Amos Job Title: Pathology Business Manager Date: 10.11.2106

PART 3 – Policy Author to complete on receipt of part 2 and before forwarding for final policy

approval

1. I have reviewed the Part 2 assessment and have made the necessary amendments to the policy.

• If you have answered ‘no’, please explain why not – None required

Name: Lucy Picton‐Turbervill Job Title: Respiratory Clinical Nurse Specialist Date: 10.11.2106

Note 1 Under the terms of the Equality Act 2010’s public sector Equality Duty, the Trust has a legal responsibility to think about the following three aims of the Equality Duty as part of our decision making and policy development.

Eliminate unlawful discrimination, harassment and victimisation;

Advance equality of opportunity between people who share a protected characteristic and people who do not share it; and

Foster good relations between people who share a protected characteristic and people who do not share it.


Page 21 of 28

Appendix B – Risk Assessment of Patients with Suspected TB

PATIENT WITH SUSPECTED PULMONARY TB

Inform consultant TB physician if not already caring for patient

Inform IPCT if pulmonary TB suspected

Non‐pulmonary ‘closed’ site TB

Is there a possibility of aerosol creating procedures i.e. abscess/wound irrigation? *

*Contact IPCT for advice if required

Isolation requiredFollow pathway for pulmonary suspected TB

Isolation not required

If pulmonary TB suspected, does the patient have any of the following risk factors for MDR‐TB?

HIV infection

Known contact of MDR‐TB case

Previous drug treatment for TB

Failure to respond to current drug therapy i.e. microscopy positive at 4 months or culture positive at 5 months

Admit/transfer to ward within side room with door closed. If possible, ward should have no immunocompromised patients. Send 3 x sputa (or other appropriate specimens) for AFB microscopy

Microscopy:AFB positive

Microscopy:AFB negative

Admit/transfer to ward with side room with door closed. FFP3 masks to be worn at all times within room. Send 3 x sputa (or other appropriate specimens) for AFB microscopy

Microscopy: AFB positive

Microscopy:AFB negative

Transfer patient to negative pressure room in ITU

Maintain isolation in side room, with no immunocompromised patients on ward PPE including FFP3 masks to be worn at all times within the room

Maintain isolation until the patient has received at least 2 weeks of anti‐TB therapy including rifampicin and Isoniazid.

Discontinue isolation only on advice of Consultant Physician in charge of patient and IPCT

Patient is not infectious.Isolation not required

YES

YES

NO

NO


Page 22 of 28

Appendix C – NICE pathway: Tuberculosis management and infection control in hospital

https://pathways.nice.org.uk/pathways/tuberculosis#path=view%3A/pathways/tuberculosis/tuberculosis‐management‐and‐infection‐control‐in‐hospital.xml&content=view‐index


Page 23 of 28

Appendix D – Assessment for TB in patients before starting biologic therapies

Prior to any patients starting biologic therapies NICE TB guidance 2016 has been updated to advise that all patients should be grouped as immune‐compromised: These patients should be assessed by clinical assessment to include:

Previous diagnosis of TB

Country of birth/overseas work for more than 3 months

Risk factors for TB

Symptoms of TB

Family history of TB

IGRA blood test. If IGRA positive perform Chest x‐ray and refer to Respiratory Team prior to starting Biologic. If IGRA is borderline repeat test.

Do not start biologic therapy on a patient who is IGRA positive until Respiratory Team have assessed https://pathways.nice.org.uk/pathways/tuberculosis ‐ path=view%3A/pathways/tuberculosis/tuberculosis‐in‐high‐risk‐groups.xml&content=view‐node%3Anodes‐people‐who‐are‐immunocompromised


Page 24 of 28

Appendix E – How to obtain a sputum sample

If assisting the patient with this procedure wear PPE.

Emphasise the need for sputum rather than saliva.

First thing in the morning brush teeth and rinse mouth but do not eat or drink anything.

Encourage good cough hygiene by standing by an open window if possible (this helps protect others from possible bacteria when coughing) or outside. Have tissues to hand.

Take a deep breath and hold it for 5 seconds, slowly breath out, take another deep breath and cough hard until some sputum is in the mouth.

Spit into the pot.

Repeat until approximately a teaspoon of sputum is obtained if possible.

Dispose of any tissues and wash hands.

Write name, date of birth, date and time of specimen on pot or print ICE label and seal in bag.

Ask patient if possible to deliver to GP or hospital on same day, if not store in fridge until able to bring all 3 samples to hospital.

Early morning sputum has the highest bacterial load so best chance of getting a diagnosis.

Can do 3 sputum samples 8 hours apart if high degree of suspicion and ask Micro department to run a Nucleic Acid Amplification Test NAAT which will give an answer within 24 ‐48 hours.

If unable to get a sputum sample try a saline nebuliser before expectoration or ask physiotherapist for assistance.

For patients who have chest x‐ray changes but are non‐productive then a broncho alveolar lavage (BAL) completed as an outpatient is indicated. Brief Bronchoscopy suite that there is a risk of TB.


Page 25 of 28

Appendix F – Draft Letter for General Practitioners and Consultants

Dear X

Your patient Y was an inpatient at Hampshire Hospitals NHS Foundation Trust at the same time as another patient with potentially infectious tuberculosis. We do not think it is likely that your patient is at significant risk of infection, and no specific action need be taken unless you are aware that they are unusually susceptible to infectious diseases. In the very unlikely event of your patient consulting you in the future with persistent symptoms which are consistent with a diagnosis of tuberculosis, then you will wish to keep this possible exposure to the disease in mind. The patient has been advised of the exposure. Yours sincerely


Page 26 of 28

Appendix G – Draft Letter for Patients Present on the Same Ward as a Case of Infectious TB

Dear X During a recent stay in hospital there was a patient on xxxxx ward who was diagnosed as having Tuberculosis (TB). It is routine procedure for us to inform individuals who may have potentially come into contact with a person with TB. This information has also been passed to your GP. We do not believe that you are at significant risk and no further action needs to be taken. The signs and symptoms of TB infection include a persistent cough, fevers, night sweats, enlarged lymph nodes and tiredness so if you do have any particular concerns or believe yourself to be at particular risk of infection please make an appointment to discuss this with your doctor. Yours sincerely


Page 27 of 28

Appendix H – New NHS employees

In summary: All new employees should have Health4Work (H4W) screening for TB before starting work unless they can produce evidence of this happening in previous 12 months. Assessment is performed taking a risk based approach, taking into account the nature of work due to be performed within HHFT, personal and family history with respect to TB, any foreign travel for periods of > 4weeks within last 5 years to regions with high incidence of TB (>40/100,000 cases) and evidence of BCG and provision of TB symptom advisory information. The assessment: Low risk employee in low risk work environment (ie low probability of acquiring TB in workplace and not routinely caring for highly vulnerable patients)

TB questionnaire and act upon results

Evidence of BCG documented (examination or documentary evidence)

TB symptom advisory information at commencement of post and at 1 year following commencement of post

Low risk employee in high risk work environment (ie increased probability of acquiring TB in workplace and/or routinely caring for highly vulnerable patients)


Evidence of BCG (examination or documentary evidence)

If no/uncertain history of BCG and no evidence of BCG scar proceed to TST or IGRA (depending on local resources) and act upon results

TB symptom advisory information at commencement of post and at 1 year following commencement of post

Low risk employee who is known to be immunocompromised – treat as for high risk individual New employees (or transferring within the NHS) originally from a high incidence region (>40/100 000 cases) and who has resided within the UK for less than 5 years or anyone who has visited a high TB incidence area for more than 4 weeks (in any one visit) during last 5 years should provide the following evidence:

Written documentation of an adequate TB health screen within the previous 12 months and completion of current TB questionnaire with no evidence of new significant symptoms suggestive of TB or

TB health screen within health4work:


Evidence of BCG (examination or documentary evidence)


Page 28 of 28

IGRA and act upon results; if positive perform chest X ray and refer to chest physician if any abnormality on chest X ray to rule out active TB. If active disease is ruled, out diagnose latent TB and employee may start work and be seen in chest clinic for consideration of LTBI medication

TB symptom information provided at commencement of employment and at 1 year following commencement of employment.

Health for work contact details: Email: [email protected] Tel: 01962 824326

NICE 33 TB guidance section 1.1.4 https://www.nice.org.uk/guidance/ng33/chapter/recommendations#preventing‐infection‐in‐specific‐settings and section 1.2.1.5 https://www.nice.org.uk/guidance/ng33/chapter/recommendations#diagnosing‐latent‐tb‐in‐adults/ Guidance is also available from NICE 33 quick pathway https://pathways.nice.org.uk/pathways/tuberculosis#path=view%3A/pathways/tuberculosis/tuberculosis‐services‐staff‐vaccination‐and‐screening.xml&content=view‐node%3Anodes‐screening‐for‐new‐staff