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PRIMER SERIES

Office of Faciliti es Manageme nt

Standards Service

Department of Veterans Affairs

Facilit ies Quality Office

F i r s t D r a f t

April 1997

V A D E S I G N G U I D EVeterans Health Administration Washington, DC 20420

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VA DESIGN GUIDETuberculosis Primer

DRAFT

DEPARTMENT OF VETERANS

AFFAIRS VETERANS HEALTH

ADMINISTRATION FACILITIES

MANAGEMENT OFFICE

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VA DESIGN GUIDETUBERCULOSIS PRIMER FORWARD

Foreword

The material contained in the TuberculosisPrimer is the culmination of a partnering effort

by the Department of Veterans Affairs VeteransHealth Administration, and the Facilities QualityOffice. The goal of the Primer is to simplify thedesign process and to ensure the quality of VAfacilities while controlling construction andoperating costs.

This document is intended to be used as a guideand to supplement current technical manualsand other VA criteria in planning for theprevention of the spread of Tuberculosis. TheDesign Guide is not to be used as a standarddesign and use of the Design Guide does notpreclude the need for a functional and physicaldesign program for each specific project. It is theproject Architects and Engineers responsibility todevelop a complete and accurate project designthat best meets the users needs and applicablecode requirements.

_______________________________________

Lloyd H. Siegel, FAIADirector, Facilities Quality Office

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VA DESIGN GUIDETUBERCULOSIS PRIMER CONTENTS

Contents

Section 1 Foreword, Acknowledgments,

Abbreviations, and Legend Symbols

Introduction ...................................................1-1

Acknowledgments .........................................1-2

Abbreviations.................................................1-3

Legend of Symbols........................................1-4

Section 2 Narrative

Treatment of TB ............................................2-1

Section 3 Design Guide Plates and DesignStandards: Patient Care Areas

AFB Isolation Exam RoomEquipment & Utility Plan...........................3-1

Reflected Ceiling......................................3-1

Design Standards ....................................3-1

Equipment Guide List...............................3-1

AFB Isolation BedroomEquipment & Utility Plan...........................3-2



Equipment Guide List...............................3-2

Section 4 Enclosures

Program & Facility Guidance for TB...............4-1

Standard Technical Summaries .....................4-2

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VA DESIGN GUIDETUBERCULOSIS PRIMER CONTENTS - SECTION 1

Section 1

Introduction,

Acknowledgments,Abbreviations

Legend of Symbols

Page

Introduction ..................................................... 1-1

Acknowledgments........................................... 1-2

Abbreviations .................................................. 1-3

Legend of Symbols.......................................... 1-4

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VA DESIGN GUIDETUBERCULOSIS PRIMER PAGE 1 - 1

Introduction

The Tuberculosis Design Guide Primer isintended to be a graphic consolidation ofexisting Department of Veterans Affairsstandards and criteria. It contains data from the

following sources:

Master Construction Specifications PG-18-1

Construction Standards H-18-3

Standard Details PG-18-4

Equipment Guide List PG-7610

List of Equipment symbols PG-18-6

Space Planning Criteria PG-7610

Barrier-Free Design Handbook H-18-13

Room Finish and Door Hardware SchedulePG-18-14

Various Technical Criteria (Design Manuals)pertaining to Architectural, HVAC, Plumbing,and Electrical.

Ambulatory Care Program Division

Surgery Program Division

The Design Guide refers to the abovementioned sources when data is either toodetailed or too broad to be included in this guide.

The Design Guide for Tuberculosis DesignGuide Primer was developed as a design tool toassist the medical center staff and thecontracting officers in better understanding thechoices that designers ask them to make, and tohelp designers understand the functionalrequirements necessary for a proper approach

towards addressing Tuberculosis (TB) within ourVA facilities.

The Guide Plate contained in the TuberculosisDesign Guide Primer is intended as illustrationsof VA's furniture, equipment and personnelspace needs. It is not meant to limit design

opportunities.

This Design Guide Primer is not intended to beproject-specific. It is important to note that theguide plate contained in this TB Primer is ageneric graphic representation only.

Equipment manufacturers should be consultedfor actual dimensions and utility requirements.Use of this Design Guide Primer does notsupersede the project architect's and engineers'responsibilities to develop a complete andaccurate design that meets the user's needs and

the appropriate code requirements.

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AcknowledgmentsCredit is due to the following individuals whose guidance, advice, and effort made this publicationpossible:

FACILITIES MANAGEMENT OFFICE

C.V. Yarbrough Chief FacilitiesManagement Officer

Robert L. Neary, Jr. Deputy Chief FacilitiesManagement Officer

Lloyd H. Siegel, FAIA Director, FacilitiesQuality Office

Leo A. Phelan, AIA Director, StandardsService

Mark G. Hall Design GuideDeveloper, Architect

William J. Leahy Architect

Wesley C. Wheeler Jr. Architect

Frances C. Wells Secretary

Satish Sehgal Mechanical Engineer

Jeff Steplowski Consulting Support Office

Dan Colagrande Consulting Support Office

Richard A. Mc Crone Chief Network Office

Enclosure 1

VHA TB Planning Group Gary Roselle, MDChair

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Abbreviations

AFB Acid Fast BacilliA AmperesAC/HR Air Changes per HourADA Americans with Disabilities Act

AFF Above Finished FloorAI Acquisition and InstallationA&MM Acquisitions and Material ManagementAR As RequiredAT Acoustical Ceiling TileC Degrees CelsiusCC Contractor Furnished and Installed,

Construction FundsCF Construction Funds, VA Furnished,

Installed by VA or ContractorCFM Cubic Feet per MinuteCLG CeilingCMU Concrete Masonry Unit

CP Carpet (without cushion broadloom)CS Construction StandardCT Ceramic TileDISCSW Disconnect SwitchEASS Electronic Access Security SystemEtO Ethylene Oxide GasEXH ExhaustF Degrees FahrenheitFC Foot-candleFD Floor DrainFIXT FixtureFLUOR FluorescentFM Facilities Management Office

GB Grab BarGFI Ground Fault InterrupterGWBD Gypsum WallboardHAC Housekeeping Aids ClosetHEPA High Energy Particulate Air FilterHVAC Heating, Ventilation, and Air

ConditioningHP HorsepowerHR HourICU Intensive Care UnitK KelvinKW Kilowatt

LB Pound/PoundsLLTS Lounge, Lockers, Toilets, andShowers

MCS Master Construction SpecificationsMTD MountedNA Not Procured with Activation FundsNFPA National Fire Protection AssociationNSF Net Square FeetNSM Net Square Meters

OSD Open Site DrainPBPU Patient Bedside Power UnitPCP Portland Cement PlasterPH Phase

PL PlasterPREP PreparationPSIG Pounds per Square Inch GaugePT Paper Towel DispenserQT Quarry TileRB Resilient BaseSC Special Coating (High Build Glazed

Coating)SD Standard Detail / Soap DispenserSF Square Feet, Square FootS/KI Suspected or Known Infectious TBSPD Supply, Processing, and DistributionSOPC Satellite Outpatient Clinic

SS Stainless SteelTELEC TelecommunicationsUFAS Uniform Federal Accessibility

StandardsV VoltsVA Department of Veterans AffairsVACO Veterans Affairs Central OfficeVAMC Veterans Affairs Medical CenterVC VA Furnished and Contractor Installed

-- Medical Care Appropriation forEquipment and ConstructionAppropriations for Installation

VCT Vinyl Composition Tile

VHA Veterans Health AdministrationVV VA Furnished and Installed-VHA

AppropriationW WattsW/sf Watts per Square FootW/m

2Watts per square meter

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Section 2

Narrative

Page

Narrative -Tuberculosis ................................... 2-1

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VA DESIGN GUIDETUBERCULOSIS PRIMER PAGE 2-1

Narrative

Primer Package - Tuberculosis

During this decade the issue of

Tuberculosis has again gained

prominence in both medical literature andthe national press as a major threat to life

and health. The numbers of active cases

have increased nationwide, particularly

along the coastal areas of the United

States where there are dense

populations, but no area has been

spared, and sporadic cases have been

reported in allVA regions.

The U.S. Department of Health and

Human Services Public Health ServiceCenters for Disease Control and

Prevention (CDC) and VA's TB Guidelines

are major controls for current

recommendations to be followed by VA

Facilities. (Enclosure 1 of this Design

Guide.)The VA's Program & Facility

Planning Guidance for Tuberculosis

Programs of August 18, 1995 defines

characteristics of TB Programs by

discussing Responsibility, Risk

Assessment Characteristics, TB Plans,Periodic Reassessment Identification,

Evaluation and treatment of TB Patients,

Engineering Controls, Healthcare Worker

Training, Counseling & Screening and

Personnel Health. There is also a

bibliography of contemporary relevant

sources. This document has been added

to the HVAC Design Manual for Hospital

Projects as item A36 "TB Criteria" and

should apply to all future VA Projects.

VA Standards Service (I87C) has recently

completed a Technical Summary titled

HVAC Requirements in TB Isolation

Room Suite which defines mechanical

requirements for this most important

room. See Enclosure 2 and Guide Plates

3-1 and 3-2 provided in this document.

The U.S. Department of Health and

Human Services, Public Health Service

Centers for Disease Control andPrevention (CDC) has also in its Morbidity

and Mortality Weekly Recommendations

and Reports issued a Guidelines for

Preventing the Transmission of

Mycobacterium Tuberculosis in

Healthcare Facilities, dated Oct. 28, 1994.

Vol. 43, No. RR-13 This report is too

large to include in this Primer but contains

much useful reference material. The

Report covers many of the items

mentioned in the VA Program and FacilityPlanning Guidance Report but has more

detail on the many aspects of TB. The

CDC Report contains several

recommendations for isolation rooms:

1. An Ante Room may increase theeffectiveness of the isolation room by

minimizing the potentialescape of droplet

nuclei into the corridor when the bedroom

door is open.

2. HEPA Filters in the exhaust systemshould be considered whenever exhaust

air could possibly re-enter the exhaust

system. According to CDC, a regularly

scheduled maintenance and monitoring

program is required for HEPA filters. A

dioctal phthalate (DOP) penetration test

should be performed at the initial

installation and every time the filter is

changed or moved. The test should be

repeated every six months.

3. Emergency Power the medical centercould consider emergency power for fans

if it is determined to be practical.

These items are recommended, but not

mandatory and can be precluded by

budgetary restraints.

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Section 3

Design Guide Plates

and Data Sheets:Patient Care Areas

Guide Plate Series Plate Number

AFB Isolation Exam RoomEquipment & Utility Plan .......................... 3-1



Equipment Guide List ..............................3-1

AFB Isolation BedroomEquipment & Utility Plan .......................... 3-2



Equipment Guide List ..............................3-2

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Design Standards

AFB Isolation Exam RoomARCHITECTURALCeiling: Gypsum Wallboard

Ceiling Ht: 2400 mm (8'-0")

Wall Finish: Ante. Room & Bedroom: PaintToilet Room: Ceramic Tile

Wainscot: --

Base: Bedroom: Resilient Base

Toilet Room: Ceramic Tile

Floor Finish: Bedroom: Vinyl Composition Tile


Slab Depr: --

Notes: 1. 1500mm (3-6) wide doors

SPECIAL EQUIPMENT

None

LIGHTINGGeneral: Ante Room: 60 FC (2.5 W/sf)

Toilet Room: 40 FC (1.8 W/sf)

Exam room: 30 FC (1.2 W/sf)

Special: Exam room: 30 FC (1.2 W/sf)

Notes:1. 600mm x 1200mm (2x4) recessed

fluorescent light fixture, acrylic prismatic

lens, W/4-F32T8 lamps, 3500K, CRI=75

(Min.).

2. 1200mm (4) wall mounted fluorescent

bed light fixture, acrylic prismatic lens

W/4-F32T8 lamps, 3500K CRI=75 (Min.)with four (4) position pull cord switch (2

uplights & 2 downlights).

3. 600mm x 600mm (2x2) recessedfluorescent light fixtures, acrylic prismatic

lens W/2-F32T8/U lamps, 3500K,

CRI=75 (Min.) in Ante Room and Toilet.

POWERGeneral: 1200 W (receptacles)Emergency: 200 W (receptacles)

COMMUNICATIONS:

Radio: --

Telephone: Yes

Intercom: --

Public Address: --

MATV: --

Nurse Call: YesNotes: --

HEATING, VENTILATING AND AIRCONDITIONINGDry Bulb Temp Cooling: 24C( 76F)

Dry Bulb Temp Heating: 25C(78F)Minimum % Outside Air: See Note 1 Below

100% Exhaust Air: Yes (see note 2)

Noise Criteria: NC-35

Steam: --

Relative Humidity/Cooling: 50%Relative Humidity/Heating: 30%

Minimum Air Changes/Hr.: 12

Room Pressure: Negative

AC Load Lights: 26W/m2(2.4 W/sf)

AC Load Equipment:1 22W/m2(2.0 W/sf)

Number of People: 1

Special Exhaust: Yes (See Note 2 Below)

Notes:1. Minimum two (2) air changes per hourbut does not need to be provided directly

to room. It is normally provided at the airhandling unit for the building.

2. 100% exhaust to exterior of the building.

PLUMBING AND MEDICAL GASESCold Water: YesHot Water: Yes

Laboratory Air: --

Laboratory Vacuum: --

Sanitary Drain: Yes

Medical Air: --

Medical Vacuum: YesOxygen: Yes

Nitrogen Oxide: --

Nitrogen: --Anesthesia Evac: --

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Equipment Guide List

AFB Isolation Exam Room

ISOLATION EXAM ROOM1 VV STRETCHER, RECOVERY1 VV CHAIR, STACKING1 CC LIGHT, WALL MOUNTED ABOVE STRETCHER 2130mm (7) ABOVE

FLOOR (PG-18-1, MCS 16510)1 CC RECEPTACLE, ELECTRICAL, 120 VOLT, 20 AMP WITH

GROUND FAULT INTERRUPTER, ADJACENT TO LAVATORY(PG-18-1, MCS 16140: H-18-3, CS 801-3)

AR CC RECEPTACLE, ELECTRICAL, DUPLEX, 120 VOLT,(PG-18-1, MCS 16140: H-18-3, CS 801-3)

1 CC NURSE, CALL STATION, WITH CORRIDOR SIGNAL LIGHT

(PG-18-1, MCS 16761)P-418 1 CC LAVATORY, SENSOR CONTROL (PG-18-1, MCS 15450; VOL. 3SD380)1 VV CABINET, INSTRUMENT, 760mm W x 405mm D x 1525mm H

(30 W x 16 D x 60H)

TOILET ROOMP-418 1 CC LAVATORY, SENSOR CONTROL

(PG-18-1, MCS 15450; VOL. 3SD380)1 VV DISPENSER, BI-FOLD PAPER TOWEL, SURFACE MOUNTED1 VV DISPENSER, SOAP, LIQUID, WALL MOUNTED1 CC MIRROR, 600mm x 910mm (24" x 36') OVER LAVATORY

(PG-1 8-1, MCS 10800; PG-1 8-4, SO 15)P-103 1 CC WATER CLOSET, WALL HUNG (PG-08-1, MCS 15450)

AR CC BAR, GRAB FOR WATER CLOSET(PG-18-1, MCS 10800; PG-18-4,SD 12)

1 CC DISPENSER, TOILET TISSUE, DOUBLE ROLL(PG-1 8-1, MCS 10800; PG-18-4, SD 12)

1 VV RECEPTACLE, WASTE 330mm (1 3') DIAMETER1 CC RECEPTACLE, ELECTRICAL, 120 VOLT, 20 AMP WITH


1 CC NURSE CALL, EMERGENCY STATION, WITH CORRIDOR SIGNAL LIGHT,PROVIDE PULL CORD BY WATER CLOSET (PG-18-1, MCS 16761)

1 CC RECEPTACLE, WASTE, STEP ON TYPE, APPROX.305MM(12)DIAMETER

ANTE ROOM2 VV HOOK, COAT, WALL MOUNTED

NOTE: CC DENOTES CONTRACTOR FURNISHED AND INSTALLED CONSTRUCTION FUNDS.

VV DENOTES VETERANS AFFAIRS FURNISHED AND INSTALLED, VHA APPROPRIATION

SYMBOL QTY AI DESCRIPTION

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Design Standards

AFB Isolation BedroomARCHITECTURALCeiling: Gypsum Wallboard

Ceiling Ht: 2400 mm (8'-0")

Wall Finish: Ante Room & Bedroom: PaintToilet Room: Ceramic Tile

Wainscot: --

Base: Bedroom: Resilient Base


Floor Finish: Bedroom: Vinyl Composition Tile


Slab Depr: --

Notes: 1. 1500mm (3-6) wide doors

SPECIAL EQUIPMENT

None

LIGHTING

General: Ante Room: 60 FC (2.5 W/sf)Toilet Room: 40 FC (1.8 W/sf)

Bedroom: 30 FC (1.2 W/sf)

Special: Bedroom: 30 FC (1.2 W/sf)

Notes:1. 600mm x 1200mm (2x4) recessed

fluorescent light fixture, acrylic prismatic

lens, W/4-F32T8 lamps, 3500K, CRI=75

(Min).2. 1200mm (4) wall mounted fluorescent

bed light fixture, acrylic prismatic lens

W/4-F32T8 lamps, 3500K, CRI=75

(Min.) with four (4) position pull cord

switch (2 uplights & 2 downlights)

3. 600mm x 600mm (2x2) recessedfluorescent light fixtures, acrylic prismatic

lens W/2-F32T8/U lamps, 3500K,

CRI=75 (Min.) in Ante Room and Toilet.

POWERGeneral: 1200 W (receptacles)Emergency: 200 W (receptacles)

Special: PBPU 600 W (receptacles)

Emergency: 400 W (receptacles)

Note 1. Provide ceiling mounted combination

power and signal outlet for ceilingmounted TV. Provide conduit to nurse

call outlet box in PBPU for remote control

of TV.

COMMUNICATIONSRadio: --

Telephone: Yes

Intercom: --Public Address: --

MATV: Yes

Nurse Call: Yes

Notes: --

HEATING, VENTILATING AND AIRCONDITIONINGDry Bulb Temp Cooling: 24C( 76F)

Dry Bulb Temp Heating: 25C(78F)

Minimum % Outside Air: Yes (see Note 1)

100% Exhaust Air: Yes

Noise Criteria: NC-35

Steam: --Relative Humidity/Cooling: 50%

Relative Humidity/Heating: 30%Minimum Air Changes/Hr.: 12

Room Pressure: Negative

AC Load Lights: 26W/m2(2.4 W/sf)

AC Load Equipment:1 22W/m2(2.0 W/sf)

Number of People: 1

Special Exhaust: Yes (See Note 2 Below)

Notes:1. Minimum two (2) air changes per hour

but does not need to be provided directly

to room. It is normally provided at the air

handling unit for the building.

2. 100% exhaust to exterior of the building.

PLUMBING AND MEDICAL GASESCold Water: Yes

Hot Water: YesLaboratory Air: --

Laboratory Vacuum: --

Sanitary Drain: Yes

Medical Air: --

Medical Vacuum: Yes

Oxygen: Yes

Nitrogen Oxide: --

Nitrogen: --

Anesthesia Evac: --

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AFB Isolation Bedroom

ISOLATION BEDROOM1 VV BED WITH MATTRESS, HOSPITAL PATIENT, HI-LO

455mm W x 94mm L (42W x 94L) WITH 75mm (3) dia. WHEELSAND TRAPEZE BAR

1 CC BUMPER GUARD, 50mm (2) DEEP, WALL MOUNTED OFFTHE FLOOR BEHIND HEAD OF BED (AVOID RETURN AIR GRILL)

1 VV TABLE, OVER BED, ADJUSTABLE HEIGHT840mm W x 355mm D (33W x 14D) ON CASTERS

1 VV CABINET, BEDSIDE, PORTABLE500mm W x 405mm D x 870mm H (20W x 16D x 34 H)

1 VV CHAIR, STACKING1 CC WARDROBE LOCKER, PATIENT, WITH PUSH BUTTON

SECURITY LOCK 915mm W x 650mm D x 1990mm H(36W x 25 D x 78H)(TOP SHELF FOR PILLOW ANDBLANKET STORAGE) WALL MOUNTED (PB-18-4)

1 CC OUTLET, MASTER TELEVISION ANTENNA(PG-18-1, MCS 16781, H-18-3, CS 864 1)

1 CC BRACKET FOR TELEVISION RECEIVER, CEILING MOUNTEDAT FOOT OF PATIENT BED (PG-18-1 MCS167811)

1 VV RECEIVER, TELEVISION, FULL SIZE1 CC RECEPTACLE, ELECTRICAL, CEILING MOUNTED, 120 VOLT,

20 AMP FOR CEILING MOUNTED TELEVISION1 CC LIGHT, BED (ON WALL OVER BED 2130mm (7) ABOVE

FLOOR (PG-18-1, MCS 16510)AR CC RECEPTACLE, ELECTRICAL, 120 VOLT, 20 AMP WITHGROUND FAULT INTERRUPTER, ADJACENT TO LAVATORY(PG-18-1, MCS 16140: H-18-3, CS 801-3)

1 CC RECEPTACLE, ELECTRICAL, DUPLEX, 120 VOLT,(PG-18-1, MCS 16140: H-18-3, CS 801-3)

1 CC NURSE, CALL STATION, WITH CORRIDOR SIGNAL LIGHT(PG-18-1, MCS 16761)

P-418 1 CC LAVATORY, SENSOR CONTROL (PG-18-1, MCS 15450; VOL. 3SD380)1 CC PREFABRICATED BEDSIDE PATIENT UNIT (PBPU) STYLE A1 ,

(PG-18-1, MCS 16685)


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AFB Isolation Bedroom (cont.)

PATIENT TOILET/SHOWER ROOMP-418 1 CC LAVATORY, SENSOR CONTROL (PG-18-1, MCS 15450; VOL. 3SD380)

1 CC MIRROR, WHEELCHAIR 610mm x 914mm (24" x 36') OVER LAVATORY(PG-18-1, MCS 10800; PG-1 8-4, SD 15)

1 CC LIGHT, OVER LAVATORY (PG-18-1, MCS 16510; PG-18-4,SD 919)1 CC SHELF, STAINLESS STEEL, WALL HUNG, 152mm x 457mm (6 x 18)

(PG-1 8-1, MCS 10360; PG-18-4, SD 15)1 VV DISPENSER, BI-FOLD PAPER TOWEL, SURFACE MOUNTED1 VV DISPENSER, SOAP, LIQUID, WALL MOUNTED

P-103 1 CC WATER CLOSET, WALL HUNG (PG-18-1, MCS 15450)

AR CC BAR, GRAB FOR WATER CLOSET (PG-18-1, MCS 10800; PG-18-4,SD 12)1 CC DISPENSER, TOILET TISSUE, DOUBLE ROLL

(PG-1 8-1, MCS 10800; PG-18-4, SD 12)P-701 1 CC SHOWER, BATH FIXTURE, DETACHABLE, WALL MOUNTED, CONCEALED

SUPPLIES (PG-18-1, MCS 15450 PG-18-4,SD 13 & 382)1 CC STALL, SHOWER, 910mm x 910mm (36 x 36)

(PG-18-1, MCS 10170; PG-18-4, SD 13)1 CC ROD, FOR SHOWER CURTAIN (PG-18-1, MCS 10800; PG-18-4,SD 14)1 VV CURTAIN, SHOWERAR CC BAR, GRAB FOR SHOWER (PG-18-1, MCS 10800; PG-18-4,SD 13, 13.1)1 CC DISH, SOAP, RECESSED (PG-18-1, MCS 10800)1 CC BAR, TOWEL (PG-18-1, MCS 10800)2 CC HOOK, CLOTHES (PG-18-1, MCS 10800)1 VV RECEPTACLE, WASTE 330mm (1 3') DIAMETER1 CC RECEPTACLE, ELECTRICAL, 120 VOLT, 20 AMP WITH


1 CC NURSE CALL, EMERGENCY STATION, WITH CORRIDOR SIGNAL LIGHT,PROVIDE PULL CORD BY WATER CLOSET (PG-18-1, MCS 16761)

1 VV RECEPTACLE, WASTE, STEP ON TYPE, APPROX.,305 MM (12) DIAMETER

ANTE ROOM2 VV HOOK, COAT, WALL MOUNTED

NOTE: CC DENOTES CONTRACTOR FURNISHED AND INSTALLED, CONSTRUCTION FUNDSVV DENOTES VETERANS AFFAIRS FURNISHED AND INSTALLED,VHA APPROPRIATION


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Section 4

Enclosures

Enclosure Title

Program & Facility Planning Guidance for TBPrograms................................................ Encl 1

Standard Technical Summaries............... Encl 2

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Department of Veterans Affairs

Veterans Health Administration

Program and Facility Planning Guidance

for Tuberculosis ProgramsAugust 18, 1995

OVERVIEW

Over the last several years, the issue of tuberculosis (TB) has been prominent in both the medical

literature and the national press. This has been emphasized in the last year coincident with an increased

pubic awareness of emerging and re-emerging pathogens on the national and global level. Finally, andafter much work, the actual number of new cases of active tuberculosis disease is decreasing nationally

with the most notable decrease in the New York area. However, the TB epidemic continues particularly

along the coast of the United States. No section of the country has been completely spared, however, as

cases of tuberculosis have been identified in all VHA Regions.

To effectively plan and implement a tuberculosis program facilities must obtain information on current

and projected TB workload, evaluate and define missions related to TE, and develop integrated plans for

patient care, employee healtf4.and enhance facility controls. This TB program guidance will provide a

consistent framework for such VA TB program planning,

This planning document is organized in a format that prioritizes overall guidance for TB control based on

clinical and epidemiologic priorities. It specifies infection control practices and regulatory requirements,

while incorporating work practice controls, engineering, controls, and personal protective equipment intothe overall guidance. This is not designed to be a regulatory compliance document, but rather to

integrate the various components of tuberculosis control strategies into the medical facility culture.

CHARACTERISTICS OF A TB PROGRAM

I. Assign Responsibility

While all programs within VA Medical Centers are the ultimate responsibility of the Medical Center

Director, it is appropriate to assign the responsibility for the tuberculosis program to a specific qualified

person or group of people within the facility. Each facility is to have a coherent, practical and

implementable program. Then the program must be implemented, monitored, and evaluated. The

program will also ensure that a mechanism will be established to identify responsible parties. for

components of the program, establish the program structure, and define the hierarchy of responsibility

from TB program officials to the facility Director. Included in this group should be representation from

Infection Control, Medical Staff (Infectious Diseases and Pulmonary Medicine if available), Nursing,

Occupational Health, Safety/Industrial Hygiene, and Engineering, thus assuring the availability of

expertise in all areas of TB control as well as ownership of the program through a multidisciplinary input

process.

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II. Risk Assessment, Tuberculosis Plan and Periodic Reassessment

An initial facility risk assessment must be undertaken. This includes gathering data regarding the

following: tuberculosis in the community, tuberculosis within the facility, skin test conversions within the

facility, and other evidence, if any, of person-to-person transmission of TB within the local health care

setting. A specific level of risk can be assigned for purposes of planning and monitoring or evaluating

'intervention strategies to be incorporated into the written facility tuberculosis plan. The plan should

include all components of the tuberculosis control strategies for the facility in a format that is concise yet

comprehensive. It should be located in a single document or group of documents that are easily

accessible by hospital employees. Fragmentation of the tuberculosis control plan with multiple non-

centralized documents should be avoided.

This risk assessment will need to be redefined at intervals appropriate to the risk- of transmission of

tuberculosis as defined by disease/infection prevalence in the community and the facility. Specifically,

changes incase rates for the facility or the community, clusters of skin test conversions, or other evidencesuspicious for facility TB mission will necessitate immediate reevaluation of the facility risk. The repeat

risk assessment should also include evaluation of the effectiveness of the extant, local methodologies for

prevention of TB transmission.

III. Identification, Evaluation, and Treatment of Patients with Tuberculosis

The most important factors in preventing transmission of Mycobacterium tuberculosis are the early

identification of patients who may have infectious TB, prompt implementation of TB precautions for such

patients, and prompt initiation of effective treatment for those who are likely to have TB.

For patients presenting to the health care facility for care, screening for signs and symptoms of TB should

be done in the initial triage locale. The detail and extent of this screening process should be determined

based on the facility risk category. An example of a suitable screening methodology would be

questioning the patient regarding cough lasting greater than three weeks, weight loss, night-sweats and

malaise. A facility should individualize its screening methodology in the most appropriate manner for itsown risk stratum based on perceived risk to other patients and employees. As patients present for care in

high or moderate risk areas, the issue of initial triage is extremely critical. Consideration should be given

to speed of triage, traffic patterns as patients move about in admissions area, clinic assignments, and risk

to employees performing administrative functions. Any triage system must be designed to prevent

patients with suspected or known infectious tuberculosis (S/KI TB) from moving about the facility in an

unprotected manner.

Tuberculin skin testing for high risk patients (methodology to meet most current CDC Guidelines) is

designed to identify patients who are infected with Mycobacterium tuberculosis before they develop

symptoms (cough, fever, sweats, weight loss) of active disease and become infectious.

For long-term care facilities, screening prior to admission should include PPD testing (following most

recent CDC and VA guidance) and/or chest x-ray as appropriate (routine screening chest x-rays shouldonly be implemented based on local risk assessment), and include a focused physical examina6on. In

high or moderate risk areas this should be done prior to admission to the long-term care facility. In

minimal or low risk areas, this screening may be completed within 72 hours of admission if adequate

triage is accomplished.

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A. Patient Masks

When any patients are identified as having S/KI TB, they should wear a surgical mask and be placed in

rooms meeting identified engineering controls 'or S/KI TE patients as noted later in this document.

B. Tuberculin Skin Test (TST) for High Risk Patients

Screening for high risk individuals must be a hospital-wide policy. This includes, but is not limited to,timely ongoing screening of HIV-positive patients, dialysis patients, the homeless, substance abuse

patients and patients in other high risk special programs such as Hospital Based Home Care (HBHC) and

others as identified by the facility. All these screening programs should use the most current CDC-

defined methodology for TST. If a patient has signs orsymptoms suggestive of tuberculosis disease, a

full evaluation must be conducted.

C. Laboratory Assessment

It is critical to expedite the evaluation and treatment of patients with S/KI TB. This includes access to

current laboratory technology for acid fast bacteria (AFB) smears, cultures, and susceptibility testing.

1. AFB smears, the following is necessary:

a. Available five days per week and reported within 24 hours of specimen receipt

b. Consideration should be given to seven days per week for areas with a high

incidence of TB

c. One sputum per patient per day should be sufficient

2. Cultures forMycobacterium tuberculosis, the following is needed:

a. Available five days per weekb. Rapid identification methodology

Smears and culture results should be reported immediately to designated person(s). This must include the

care provider and should be reported to the Infection control function.

3. Susceptibility testing forMycobacterium tuberculosis, the following, is appropriate:

a. First isolate

b. Additional isolates if:

(1) failure to convert cultures within three months of beginning therapy

(2) clinical evidence of failure to respond to therapy(3) other specific circumstances may dictate additional susceptibility testing.

It is not required that all of these activities be done on station. It is the facilitys responsibility to assure

that rapid, current diagnostic laboratory testing for Mycobacterium tuberculosis is readily available to

the clinicians. The guidance above should be used as a basis for individual station decision-making

regarding specific time frames and location for each of the studies noted above based on patient care

needs. These decisions should be documented in writing in the facility tuberculosis control plan to ensure

facility-wide consensus by the process stakeholders on these critical clinical testing issues.

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D. Patient Management

If the patient has been identified as having active tuberculosis disease, initiation of therapy should

be prompt using the most current CDC guidelines.

After a patient has been identified as having S/KI TB, the patient should be placed in a room meeting the

engineering control guidelines noted below in this document. Enablers may be necessary to assure that

the patient remains in this controlled environment, since patients cannot be allowed to wander about the

hospital in an unprotected manner. Enablers, such a-s television sets, telephones, bathing facilities, and

recreational activities may be important to maintain these precautionary measures. In order to maintain

proper directional air flow in the rooms, the doors must remain closed. If the patient must be out of the

room for clinical purposes, the patient should wear a surgical mask and administrative arrangements

made to expedite the return of the patient to the negative pressure room. Discharge and follow-up

planning should be initiated as soon as possible in order to assure seamless transition between the hospital

setting and outpatient care. This will likely involve the VHA outpatient clinic system and the

governmental health department from which the patient may receive follow-up. As part of this process,

immediate reporting of tuberculosis patients to the health department consistent with VA rules and

regulations is necessary.

E. Visitors

Visitors to patients who have S/KI TB should be given respirators to wear while in the isolation rooms,

and they should be given general instructions on how to use their respirators (CDC Guidelines MMWR,

October 28, 1994, Vol. 43, No.RR- 13, p28).

F. Discontinuation of AFB Precautions

The following criteria must be used for discontinuing precautions for patients in the Medical Center with

S/KI TB:

1. The patient is found not to have tuberculosisor

2. The patient is on appropriate therapy; (it should be noted that appropriate therapy

needs to be defined at the local level based on community incidence of multi-drug

resistant tuberculosis, tuberculosis susceptibility testing of facility isolates, and the

specific known susceptibilities of the patient's organism)and A positive clinical

response to therapyand Three consecutive negative A.FB smears collected on separate

days

IV. Engineering Controls

A. General Guidelines

The CDC guidelines are the minimum acceptable level, and should be increased where required to satisfy

other mandated criteria or engineering requirements. Where current VA criteria exceed the CDC

guidance, the use of VA criteria is recommended. However, if existing configuration or cost do not allow

compliance to more stringent VA criteria, then the CDC guidance is the minimum acceptable.

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1. Six total air changes per hour are likely to reduce the concentration of bacteria the room. For

the purposes of reducing the concentration of droplet nuclei, TB bedrooms and treatment rooms in

existing health care facilities should have an airflow of greater than or equal to six air changes per hour.

Where feasible, this airflow rate should be increased to greater than or equal to 12 air changes per hour.

New construction or renovation of existing health care facilities should be designed so that TB bedrooms

achieve an airflow of greater than or equal to 12 air changes per hour.

2. Air from TB bedrooms and treatment rooms for S@ TB patients should be exhausted to the

outside. The air should be exhausted in a manner and location so that it is not pulled into intake louvers

or windows without significant dilution. At a minimum, the exhaust shall be 25 feet from any air intake.

However, other factors, such as wind direction, wind velocity, stack effect, system sizes, and height of

buildings must be evaluated and location of intake and exhaust outlets adjusted as required. If, in some

instances, recirculation of air into the general ventilation system from such rooms is unavoidable, high-

efficiency particulate air (HEPA) filters should be installed in the exhaust leading from the room to the

general ventilation system. Air from TB bedrooms and treatment rooms in new or renovated facilities

should not be recirculated into the general ventilation system.

3. Exhaust air quantity must be 10% greater than the supply air. It is further recommended thatthe exhaust system should serve only the TB rooms and not be part of the general exhaust system. If this

is not practical, then use of the general exhaust system is acceptable provided appropriate precautions are

taken to assure that these systems are adequately designed, installed, balanced and maintained. These

requirements result in providing additional outside air through the air handling system which then impacts

heating and cooling capacities for both air side and primary equipment. In all applications, thermal load

calculations or occupancy of the space may require a higher air change rate.

4. Rooms should be under negative pressure with respect to adjacent areas when occupied by a

patient with SIKI TB.

5. Anterooms are not necessary for SIKI TB patient bedrooms.

6. The direction of the air-flow for TB rooms shall be monitored daily when an S/KI TB patient

is occupying the room. When not in use by S/KI TB patients, the directional allow will be checked

monthly. The method of testing for directional airflow in the S/KI TB rooms is at the discretion of the

facility, but must be of an acceptable standard. This would include such methodologies as smoke tube

testing or an airflow gauge.

7. The number of air changes per hour in these rooms should be checked yearly at a

minimum. This may need to be more frequent based on facility risk assessment and recommendations of

the Environmental and Infection Control Committee. In addition, the number of air chances per hour

should be checked after any maintenance to the airflow system.

8. In rooms where patient turnover is expected, use CDC guidelines (MMWR, October28,

1994,Vol.43,No.RR-13) for airchanges per hour to determine time required for removal of airborne

contaminants before the next patient occupies the room vacated by a patient with S/KI TB.

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9. When in use by SIKI TB patients, doors in negative pressure rooms must remain closed,

except for entering or exiting the room. Proper airflow and pressure differentials between areas are

difficult to control because of open doors, movement of patients and staff, temperature, and the effect of

vertical openings. Air pressure differentials can only be maintained in completely closed rooms. An open

door reduces or eliminates the desired effect of negative pressure rooms. Whether windows are needed in

doors to S/KI TB patient bedrooms is a local decision.

10. Medical Centers and outpatient clinics should consider providing emergency power to

exhaust systems serving inpatient TB rooms and to some of the ambulatory care rooms designated for

management of S/KI TB patients. The potential risks to patients and staff, available emergency power

system capacity, and relative priority of other functions covered by emergency power should be carefully

evaluated when considering costly emergency power system emergency expansion.

B. Medical, Surgical, and Neurological (MS&M) Nursing Acute Care Units

To determine the number- of TB rooms, use the following formulae to determine number of patient

bedrooms for cases of S/KI TB:

1. Current need: (Identify the maximum number of patients requiring respiratory precautions

for S/KI TB at any one time within the past 12 months,) x (change in incidence of TB in community over

the past year).

2. Projected Need: Using the estimated change in the population in the facility, Distributed

Population Planning Base (DPPB) for any Future year, calculate future needs based on current estimate

as determined above multiplied by this population change ratio.

EXAMPLE 1 - All specific numbers are for illustrative purposes only.

15.0 - Maximum number of patients requiring AFB precautions at one time (e.g., 15)

x 1. 05 - Change in community incidence (this represents a 5% increase in community

incidence)

15.75 - Need for TB beds based on changes inTB incidence in community

x 10.85 - Correct for future anticipated changes in veteran population (this represents a 15%

decrease in expected veteran population)

13.38 - Projected no. of AFB precaution beds needed corrected for calculated changes in

veteran population and community incidence

C. Nursing Unit Organization

1. High Incidence Area or Referral Center:

Medical Centers with sufficient workload or those assigned the mission of referral center may choose to

concentrate all TB bedrooms on an existing MS&N nursing unit designated for TB inpatient care. Or,

they may designate bedrooms to be used for TB care throughout their facility. In establishing groups of

TB bedrooms on an MS&N nursing unit, a Medical Center should renovate a contiguous sub-set of the

bedrooms on the unit to meet HVAC and bathroom requirements; not necessarily the entire ward. The

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number of bedrooms included in the sub-set would be based on anticipated workload determined for that

facility. The following facility requirements must be met:

a. All one-bed rooms designated for TB must meet CDC guidelines for S/KI TB

b. Each one-bed room must have a private bathroom and should have a shower where

possible. Safe shower facilities are to be available, however, if the bedroom for S/KI TB . patients does

not offer these facilities

c. Anterooms are not required for the negative pressure rooms designated for S/KI TB

d. For S/KI TB patients, examination/treatment rooms and any other special treatment

rooms where sputum induction, aerosol treatments and/or cough or aerosol-generating procedures are

performed should meet CDC requirements for infectious TB with the additional requirement of 12 or

greater air changes per hour. Ultraviolet germicidal irradiation (UVGI) may be used as an enhancement

to the recommended engineering controls.

2. Low Incidence Areas

For those facilities anticipating a low S/KI TB workload, little or no chance to existing nursing units-may

be required. Existing VA space planning criteria for MS&N nursing units (see Planning Criteria for VA

Facilities, Handbook 7610 Chapter 100.04) requires two isolation suites per nursing unit. These rooms

will be capable of providing negative or positive pressure and have an anteroom and attached private

bathroom. Minimum air changes are 8 per hour with 100% outside exhaust through a HEPA filter. If

these rooms are not currently provided or if additional rooms are needed for S/KI TB patients then these

additional rooms must meet CDC guidance for S/KI TB and have a private bathroom. An existing 2-bed

room which has appropriate ventilation airflow and bathroom facilities meeting, at a minimum, current

CDC guidance for S/KI TB, may be scheduled for use by a single TB patient as a low cost alternative to

constructing or renovating an additional 1-bed room.

Sputum induction, aerosol treatments and/or cough or aerosol-generating procedures should be performed

either in TB bedrooms or other rooms that meet CDC guidance for S/KI T'B.

D. MH&BS Nursing Units (Mental Health and Behavioral Sciences)

In general, no rooms should be required for S/KI TB patients as they should be transferred to an

appropriate MS&N nursing unit for diagnosis and treatment as needed until they are no longer infectious.

E. Intensive Care Units (ICUs)

1. Existing ICUs should meet cur-rent VHA space planning criteria (see Planning Criteria forVA Facilities, Handbook 7610 Chapter 102.05) for the number of isolation suites and at a minimum meet

CDC criteria for ventilation for S/KI TB.

2. All ICUs which utilize return air systems shall have the return air HEPA filtered.

Installation of ultraviolet (UV) lamps may be considered in ICUs which there is a high risk for TB

transmission. All ICU rooms housing S/KI TB patients must, at a minimum, meet the current CDC

guidance for S/KI TB.

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F. Post Anesthesia Recovery Units (PARUs)

Medical Centers should have at le one recovery room within the PARU meeting at a minimum CDC

ventilation criteria for S/KI TB. As an option, especially in low-incidence areas, Medical Centers may

recover surgical patients with S/KI TB in an ICU isolation suite or room that meets CDC guidance for

S/KI TB.

G. Surgical Suite (SeeMMWR, October 28, 1994, Vol. 43, No. RR- 13, p. 50-51 for details)

1. Existing VHA facility criteria (see HVAC Design Manual) and standards for surgery are

appropriate for surgical care of S/KI TB patients. Current VHA criteria exceed the CDC guidelines.

Typically, no changes will be required unless return air is used in the OR. VA criteria have not

sanctioned the use of return air in ORs for many years.

2. Traffic patterns should be designed to reduce unnecessary movement throughout the

surgical suite, hallways and other associated areas when surgery on a patient with S/KI TB is performed.

3. Appropriate scheduling and other controls are necessary for surgery on S/KI TB patientssince positive pressure allow is used in operating rooms.

H. Long Term Care

In general, no rooms are required for S/KI TB patients as they should be transferred to an appropriate

MS&N nursing unit for diagnosis and treatment as needed until they are no longer infectious.

I. Ambulatory Care

1. Determining the Number of TB Rooms:

Determining the number of TB rooms 'in the Ambulatory Care setting should be in alignment with thefacility risk assessment. Specifically, facilities in the lowest risk assessment category may not need

rooms with specific tuberculosis engineering controls at all, but rather a written plan for dealing with the

possible event of a S/KI TB patient reaching the facility. For facilities above the minimal risk category,

the following is a suggested method for determining the number of exam/treatment or special treatment

rooms designated for S/KI TB patients in unscheduled ambulatory care areas (hospital-based, satellite,

and independent OPCs):

a. Obtain the estimated eligible veteran population for the facility from DPPB for any

specified future year and the current eligible veteran population for the facility.

b. Each facility should generate the estimated number of potential unscheduled S/KI TBpatient visits per year.

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c. Calculate the projected number of potential unscheduled S/KI TB Patient visits per

year using the following formula:

A = Estimated eligible veteran population for the facility from the DPPB for any specified

future year

B = Current eligible veteran population for the facility from DPPB

C = Current number of potential unscheduled S/KI TB patient visits

D = Projected potential unscheduled S/KI TB patient visits per year

(A B)x C = D

EXAMPLE 2 - All specific numbers are for illustrative purposes only.

(A)400,000 - Estimated population for a future year (e.g., 400,000 for the year 2000)

(B)

450,000 - Current veteran population )e.g., 450,000)

0.88 - Result of A B

(C)

480 = Current number of unscheduled S/KI TB patient visits per year (e.g., year 2000)

(D)

422.4 - Results of A B x C which is the estimated number of unscheduled visits of S/KI

TB patients for future year (e.g., year 2000)

d. Provide the number of designated TB exam/treatment or special procedure rooms as

determined below using the potential SIM TB patient visit estimated generated in 1. I.c. above.

CALCULATED POTENTIAL UINSCHEDULED

S/KI TB PATIENTS VISITS (PER YEAR)

DESIGNATED TB EXAM/TREATMENT

ROOMS

500 OR LESS Use emergency area isolation room

501-1000 One additional TB room

Each additional 1000 One additional room

Designated TB rooms determined above may be located in the walk-in clinic module and/or in other

modules to meet local operating procedures and needs.

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2. Facility/air:

a. Meet at a minimum current CDC guidelines for unscheduled areas and high risk

clinics.

b. Meet a minimum current CDC guidelines for ventilation and airflow for S/KI TB:

(1) Emergency area Isolation room(s) (anteroom not required)

(2) ENT room(s)

(3) Aerosolized pentamidine room(s)

(4) Designated exam/treatment/procedure room(s)

3. Unscheduled areas

All unscheduled ambulatory care areas and associated waiting- areas should have ventilation designed

and maintained to reduce the risk of tuberculosis transmission. Germicidal UV lamps and/or HEPA

filters may provide additional benefit when used to supplement ventilation, particularly in facilitieslocated in areas of high incidence for TB.

4. Scheduled areas (clinics)

All scheduled areas serving patients who are at high risk for TB transmission should be designed to

reduce the risk of TB transmission. Air from clinics serving patients at high risk for TB should not be re-

circulated unless it is first passed through an effective high-efficiency filtration system (HEPA filters are

currently the effective high-efficiency filtration system available).

5. Designated exam/treatment rooms for S/KI TB

VHA ambulatory care programs in Medical Centers and in satellite/independent outpatient clinic must

have some facilities that are adequate to deal with S/KI TB patients. These TB rooms can be

exam/treatment rooms and/or special procedures rooms that are designated for use with S/KI TB patients.

These rooms should meet CDC guidance for S/KI TB with the additional requirement that a minimum of

12 air changes per hour must be exhausted (See IV.A.2). These rooms would normally be located 'm or

near the walk-in clinic module.

J. High Risk Areas

1. Potential Aerosol Producing Procedure Areas:

a. The pulmonary function laboratory (including spirometry and exercise rooms),bronchoscopy area(s), pulmonary function treatment rooms, and sputum induction areas and any other

special procedure room (e.g., ENT) in which cough inducing procedures are done on patients who may

have infectious TB must meet CDC guidelines for S/KI TB with the additional requirement that a

minimum of 12 air changes per hour must be exhausted. Additionally, airflow rates should be calculated

on expected patient turnover in these treatment areas based on the most recent CDC guidance.

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b. Any room (e.g. examination/treatment room procedure room) in the health care facility

in which aerosolized pentamidine (AP) procedures are performed on patients who may have infectious TB

must meet CDC guidelines for infectious TE with the additional requirement that a minimum of 12 air

changes per hour must be exhausted (See IV .A-2). Additionally, airflow rates should be calculated on

expected patient turnover in these treatment areas based on the most recent CDC guidance. If a booth or

other containment entity is used for any potential aerosol producing procedure, booth airflow and exhaust

should meet CDC guidelines.

K. Radiology

At least one radiology room with chest x-ray capabilities should meet CDC guidance for S/KI TB. Both

ambulatory care and in-patient programs can share this negative pressure radiology room if feasible.

This specialized room with these engineering controls may not be necessary in facilities in the minimal

risk category.

L. Anatomic Pathology:

The morgue must meet at a minimum CDC guidance for infectious TB and follow current VA criteriawith a minimum of 12 air changes per hour with 100% exhaust to the outside through a HEPA filter.

M. Dental

At referral centers and at facilities in which emergency dental care is provided, at least one dental

operators should meet CDC guidance for S/KI TB. Other health care Facilities may send S/KI TB

patients for dental. care to referral centers based on workload and travel distance.

N. HIV-related Issues

No, specific heating, ventilation and air conditioning (HVAC) considerations are necessary for patients

with HIV infection.

O. Dialysis Program

A room which meets at a minimum current CDC ventilation and airflow guidelines for S/KI TB must be

available for dialysis of S/KI TB patients. The location of this area is at the discretion of the facility.

Based on local need this area may be in the dialysis unit or ICU, or other area in the Medical Center

based on patient need and efficient use of resources.

V. Respiratory Protection

A. General Criteria

Performance criteria for respiratory protective devices as outlined in the most recent CDC guidance are to

be met. This requires a respiratory protection program that follows the regulatory requirements of the

Occupational Safety and Health Administration (OSHA) as well as American National Standards

Institute (AINSI) Standards.

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B. Respiratory Protective Devices

Respiratory protection is required for persons entering rooms in which patients with S/KI TB are being

housed, for persons present during cough-inducing, aerosol-generating procedures performed on such

patients, and for persons in other settings where administrative and engineering controls are not likely toprotect them from inhaling, infectious airborne droplet nuclei. These other settings include transporting

patients who may have S/KI TB in emergency transport vehicles, and providing urgent surgical or dental

care to pa6ents who have S/KI TB before determination has been made that the patient is non-infectious.

These settings may also include home based health care programs, where patients with S/KI TB are being

seen inthe home setting.In the Mycobacteriology Laboratory, routine use of respiratory protective devices should not be

necessary. However, if the laboratorian is working with significantly amplified Mycobacteriurn

tuberculosis cultures in liquid media, or performing specific procedures where aerosolization is expected,

the use of respiratory protective equipment, gloves and gowns may be appropriate. The most recent

standards for laboratory practices should be followed.

VI. Healthcare Worker Training

All health care workers are to receive periodic TB education appropriate for their work responsibilities

and duties and should include epiderniology of TB in the facility, mode of transmission, pathogenesis,

diagnosis, and occupational risk for tuberculosis. The training should also describe work practices that

reduce the likelihood of transmitting Mycobacteriumtuberculosis in the healthcare setting. The training

must be given to all those who work at the VA Medical Center who are at risk for the transmission of

tuberculosis. All training is to follow the latest written regulatory requirements of valid oversight bodies

such as OSHA.

VII. Healthcare Worker Counseling And Screening

All healthcare workers should be counseled regarding tuberculosis disease and tuberculosis infection.This should include information about the increased risk to immunocompromised persons for developing

active tuberculosis disease.

VIU. Personnel Health

A. TB Screening using most current CDC methodology

1. Prior to employment, TST results are required for covered employees who work in the

VHA- For any TST done outside the Personnel Health Unit on station, appropriate written documentation

must be provided as detained by the Personnel Health Physician.

2. Interval TST screening as detained by risk assessment as outlined in the most recent CDC

guidance should be conducted.

3. TST is recommended at the time of separation for all employees

4. Follow all pertinent VACO Directives and Manual references related to TB screening

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B. Record keeping

1. Record keeping is critical for the long term needs of the employee, station, and regulatory

compliance

2. Record keeping to comply with VHA directives, manuals, and valid regulatory agencies'

requirements

C. Return to work clearance for health care workers with S/KI TB

1. At a minimum, return to work clearance should follow current CDC guidelines

2. Employees must be monitored for lack of infectiousness

D. Healthcare Worker TST Conversions

The facility must track and evaluate TST conversions in order to document possible episodes of

transmission of tuberculosis in the healthcare setting, to define the facility risk assessment category and toidentify facility TST conversion rates.

IX. Coordination with Health Department

It is critical that VA facilities coordinate all phases of tuberculosis control with appropriate health

department authorities. Prompt reporting to public health authorities is a critical component of TB

control. It is most critical that the discharge planning for individual patients be done in close alignment

with community health officials.

X. Child Day Care

For facilities with child day care facilities state and local guidelines regarding tuberculosis screeningand/or tuberculosis control programs should be followed.

XI. References

1. VHA Directive 10-93 -094, Supplement No. 1. TB (Tuberculosis) Control Responsibilities of

VA (Department of Veterans Affairs) Facilities. July 25, 1994.

2. VHA Directive 10-94-104. Administration of Aerosolized Pentamidine to Human

Immunodeficiency (HIV) Positive Patients. October 17, 1994.

3. MP-5, Part I, Chapter 792, Change 7, Health Services. June 30, 1990.

4. M-1, Pan III, Chapter 4. Services and Benefits Available to Volunteers. October 24, 1934.

5. M-2, Part I, Chapter 23, Change 1, Formed Consent. February 21, 1991.

6. M-1, Part 1, Chapter 9, Release of Medical Information. November 30, 1990.

7. 5 United States Code, Section 552A, Privacy Act.

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8. Title 38, United States Code, Committees on Veterans Affairs - Patient Rights January 31,

1992.

9. Title 38, United States Code, Committees on Veterans Affairs - Records. January 31, 1992.

10.VA Regulations, Title 38 Codeof Federal Regulations, Part 1, General Trans. Sheet 177,

Safeguarding personal Information in VA Records. May 9, 1986.

11. Handbook 7610, Planning Criteria for VA Facilities. Chapter 1, 100, 102, 212, 240, 262, 276,

and 316.

12. HVAC Design Manual for Hospital Projects. February, 1997.

13. M-5, Part IV. Geriatrics & Extended Care, Domiciliary Care. December 6, 1990.

14. CDC. Core Curriculum on Tuberculosis. Third Edition, 1994.

15.CDC. Typhoid immunization recommendations of the immunization practices advisorycommittee (ACIP) and prevention and control of tuberculosis in facilities providing long-term

care to the elderly. Recommendations of the Advisory Committee for Elimination of

Tuberculosis.MMWR, May 18, 1990, Vol. 39, No. RR-10).

16.Prevention and control of tuberculosis in U.S. communities with at-risk minority populations

and prevention and control of tuberculosis among homeless persons. Recommendations of the

Advisory Council for the Elimination of tuberculosis. MMWR, .April 17, 1992, Vol. 41,

No.RR-5).

17.CDC. Screening for tuberculosis and tuberculosis infection in high-risk populations and the

use of prevention therapy for tuberculosis infection in the United States. Recommendations of

the Advisory Committee for Elimination of Tuberculosis.MMWR, May 18, 1990, Vol. 39,No. RR-8.

18. CDC. Guidelines for preventing the transmission ofMycobacterium tuberculosisin healthcare

facilities. MMWR, October 28, 1994, Vol. 43, No.RR-13.

19.M-2, Part IV, Chapter 6, Infectious Diseases. April 29, 1994.

20. American Thoracic Society. Treatment of Tuberculosis and Tuberculosis Infection in Adults

and Children.Am J Resp Crit Care Med1994; 149:1359-1374.

21.CDC/National Institutes of Health. Agent:Mycobacterium tuberculosis, M. bovis. In:Biosafety in microbiological and biomedical laboratories. Atlanta: US Department of Health

and Human Services, Public Health Service, 1993:95, EDHHCS publication no. (CDC) 93-

8395.

22- Shinnick, TM and Good. RC. Tuberculosis commentary. CID, 1995; 21:291-9.

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HVAC REQUIREMENTS IN TB ISOLATION ROOM SUITE(NEW CONSTRUCTION)

SEE VA PRIMER OF MAY,1997, FOR GRAPHIC INFORMATION

1. Indoor Design Conditions:

Area Summer

Degree C (Degree F)

Winter

Degree C (Degree F)

HVAC Design

Manual Ref.

Bed Room 24 (76) - 50%RH 25 (78) - 30% RH Application. A36

Ante Room (If provided) 25 (78) -50% RH 22 (72) - 30% RH

Bathroom & Toilet 25 (78) 22 (72)

2. Minimum Air Changes per Hour:

Area Air Changes HVAC Design Manual

Ref.

Bed Room 12 Application. A36

Ante Room (If provided) 12

Bathroom & Toilet 10 (No supply) Para. 3.5

3. The use of Ante room is not mandatory, however, its need should be

discussed with the facility.

Application. A36

4. All air from bed room, ante room (if provided), bathroom & toilet should be

exhausted to outside through a dedicated exhaust system.

5. Maintain negative pressure in bed room with respect to ante room. Maintain

negative pressure in ante room with respect to corridor. Maintain negative

pressure in bath room & toilet with respect to bed room.

6. The supply air to the bed room and ante room shall be constant volume with

terminal reheat.

7. Provide an individual air flow control valve in each individual space exhaust

branch for control reason. See VA standard detail 15900-7 and 7A, but

controls should be set up for isolation room Mode 1 only, and NOT MODE 2

FOR REVERSE ISOLATION.

8. The use of HEPA filters in the 100% exhaust from the TB isolation suite is

not necessary, but its use should be considered wherever exhaust air could

possibly reenter the system.

CDC Guidelines

9. Negative pressure in the bed room should be monitored daily while the room

is occupied.

Application A36

10. Exhaust fan for TB isolation suite is not required to be on emergency power.

Consult facility staff..

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