Hospital Discharge of TB Patients: Collaborating with the Health

Department

Diana Nilsen, MDBureau of Tuberculosis Control

NYC Department of Health and Mental Hygiene

Today’s Presentation Epidemiology of TB in NYC, 2011 Discuss the rationale for discharging infectious TB

patients from the hospital Describe the new health code reporting

requirements – Submission of hospital discharge plans– Submission of treatment plans

Provide an update on hospital discharge plan submissions

Discuss common issues related to hospital discharges

Reported TB Cases United States, 1982–2010*

*Updated as of July 21, 2011

11,182 cases

Tuberculosis Cases and Rates Tuberculosis Cases and Rates New York City, 1982 – 2011*New York City, 1982 – 2011*

689 Cases in 2011689 Cases in 2011

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11

Year

0

10

20

30

40

50

60Case Rate

# Cases51.1

8.5

Number of Cases Rate/100,000

21.4

*Rates based on official Census data and intercensal estimates prior to 2000. Rates for 2000 to 2006 are based on intercensal estimates, and for 2007 to 2011on 2008-2010 American Community Survey.

US* and Non-US-Born TB CasesUS* and Non-US-Born TB Cases† †

New York City, 1982-2011New York City, 1982-2011

*Puerto Rico and U.S. Virgin Islands are included as US-born†There was 1 case with unknown country of birth in 2011.

3,132

1,010

Nu

mb

er o

f C

ases

Top 10 Countries of Birth of Foreign-born Persons, NYC TB Cases

20112011 NN 20102010 NN

ChinaChina 104104 ChinaChina 104104

MexicoMexico 4949 Dominican RepublicDominican Republic 4141

BangladeshBangladesh 3333 EcuadorEcuador 4141

Dominican RepublicDominican Republic 3131 MexicoMexico 3535

EcuadorEcuador 3030 BangladeshBangladesh 3030

HaitiHaiti 3030 PhilippinesPhilippines 2828

IndiaIndia 3030 IndiaIndia 2626

NepalNepal 1919 HaitiHaiti 2323

PhilippinesPhilippines 1616 PakistanPakistan 2020

Puerto RicoPuerto Rico 1515 GuyanaGuyana 1616

6

Tuberculosis rates1 by United Hospital Fund (UHF) neighborhood,

New York City, 2009-2011

Trend in HIV-Infection and TBNew York City, 1992-2011

34 33 3331

26

22 22

1815

1816 16 15

13 1311

97 9

0

10

20

30

40

50

200

400

600

800

1,000

1,200

1,400

92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11

Year

% TB/HIV+

# TB/HIV+

% of TB/HIV Infected CasesNumber of Cases

8

HIV-Infected TB Patients New York City, 1992-2011

Top 10 Medical Facilities First Evaluating Patients for TB- New York City, 2011

Facility NameFacility Name # of cases# of cases % cases% cases1. Elmhurst Hospital Center1. Elmhurst Hospital Center 4141 66

2. New York Hospital Medical Center of Queens2. New York Hospital Medical Center of Queens 3535 55

3. Bellevue Hospital Center3. Bellevue Hospital Center 3434 55

4. Maimonides Medical Center4. Maimonides Medical Center 3232 55

5. Lincoln Medical and Mental Health Center5. Lincoln Medical and Mental Health Center 2424 33

6. Kings County Hospital Center6. Kings County Hospital Center 2323 33

7. Beth Israel, Queens Hospital Center7. Beth Israel, Queens Hospital Center 2121 33

8. Lutheran Medical Center8. Lutheran Medical Center 1313 33

9. Coney Island Hospital9. Coney Island Hospital 1212 22

10. Montefiore Medical Center, Bronx-Lebanon 10. Montefiore Medical Center, Bronx-Lebanon Medical CenterMedical Center

1111 22

18. Lenox Hill Hospital18. Lenox Hill Hospital 1010

Article 22 of the New York State Public Health Law and Articles 11 and 13 of the New York City Health Code require that suspected and confirmed cases of tuberculosis be reported to the local health authority, i.e., DOHMH, within 24 hours

TB Reporting Requirements

Reporting TB Cases

Suspected or confirmed TB patients may be reported by telephone at (212) 788-4162 or 347-396-7400– A completed Universal Reporting Form (URF) must follow

within 48 hours by faxing it to the Bureau of Tuberculosis Control at (212) 788-4179

The URF can also be completed online, by first creating an account on NYCMED at www.nyc.gov/health/nycmed – Support for NYCMED is available by calling (888) NYCMED9

Reporting byHealthcare Providers

Providers are required by law to report within 24 hours any case with:

• AFB+ smear from any site• Nucleic Acid Amplification (NAA) test + for

Mycobacterium tuberculosis (M. tb)• Culture + for M. tb• >=2 anti-TB medications for suspected or

confirmed TB• Clinically suspected TB• Pathology findings consistent with TB

– Child < 5 years old with + TST (regardless of BCG)

Reporting by Laboratories

Laboratories are required by law* to report within 24 hours :– AFB + smears– Cultures + for M. tuberculosis (M. tb)– Any culture result associated with an AFB+ smear

(even if negative for M. tb)– Rapid diagnostic (NAA) tests identifying M. tb– Results of susceptibility tests on M. tb cultures– Pathology findings consistent w/ TB

*Articles 11 and 13, Sections 11.03, 11.05 and 13.03 NYC Public Health Code

Pathology Findings Suggestive of TB

Presence of acid-fast bacilli (AFB) Caseating/non-caseating granuloma Tubercles Fibro-caseous lesions Necrotizing/non-necrotizing granuloma Langhans giant cells/multinucleated Langhans

cells Epithelioid cells/Epithelioid granuloma Necrotizing inflammation Chronic granulomatous lesions/chronic

inflammation with granuloma formation Giant cells

Background- Discharge Planning

Outpatient Treatment of TB TB patients could be treated successfully as

outpatients with the advent of modern chemotherapy No significant difference between hospital and

outpatient treatment – Cure rates– Spread of infection

Main determinant of cost of treatment is INPATIENT admission

(Tuberculosis Chemotherapy Centre, Madras. Bull WHO 1959:21-144:51-339)(Tuberculosis Chemotherapy Centre, Madras. Bull WHO 1959:21-144:51-339)

Treatment of TB in India

Tuberculosis Chemotherapy Centre, Madras, compared home treatment of TB with sanatorium – Treatment at home is satisfactory

Crowded living conditions, low nutritional standards, low income

Major risk to contacts lies in exposure to the infectious case BEFORE diagnosis

Tuberculosis Chemotherapy Centre, Madras. Bull WHOTuberculosis Chemotherapy Centre, Madras. Bull WHO 1960, 23; 463-5101960, 23; 463-510

Successful Treatment of TB

Requirements for successful treatment include: Prescription of the correct chemotherapy Compliance with medication doses

– Achieved as outpatient with DOT Completion of a minimum number of doses

All of which can be done as an outpatient!

Risks of Hospitalization

Nosocomial transmission to:– Health care workers– Vulnerable patients

Anxiety for the patient who is isolated– Feeling of isolation – Removal from social supports– Loss of control over one’s life

NYC Guidelines for Hospitalization and Discharge

Developed to ensure that only patients who need it are admitted and hospitalized

Infectious patients could be discharged in the appropriate circumstances – TB can be dangerous for other hospitalized patients– Patients should be treated as OUTPATIENTS unless they

meet certain criteria– Patients become noninfectious quickly once on

treatment

Criteria for Discharge

• Clinical improvement• Tolerating anti-TB meds• Patient must be reported to DOH (212-788-4162 or 347-396-

7400), but must be reported via URF as well• Electronic URF filled out within 24 hrs.• Patient should have sputa for AFB• CXR should be done• Involvement of DOHMH in discharge planning with submission

of discharge plan to DOHMH– Referral to DOH clinic and DOT

Instructions given to patient and household members if they were exposed to an infectious patient

Pg 128

NYC Health Code Amendment

Care of TB Patients in NYC

In 2009, 83% (255/308) of respiratory smear positive TB patients were hospitalized

In NYC, approximately 50% of TB cases are treated by a private provider

Collaboration between DOHMH and community health care providers removes barriers and fosters achievement of key public health objectives

NYC Health Code AmendmentNew York City Health Code Article 11 Section 21(4)

amended June 16, 2010

1. Hospitals/providers must obtain approval from health department at least 72 business hours before discharging infectious TB patients

2. Providers must submit proposed treatment plan to NYC Health Department within one month of treatment initiation for all persons newly diagnosed with active TB disease

New requirement communicated to hospital providers (June and November 2010)

Process for Submitting Hospital Discharge Plans

Discharge Plan Approval Process

Determination72 hrs before discharge Within 1 business day

Provider •discusses discharge plan issues with DOHMH •revises plan•informs DOHMH

Provider submits Hospital Discharge Approval Request Form to DOHMH via fax

DOHMH physician •reviews discharge plan •makes determination•communicates withhospital provider

Approved

Not applicable

Disapproved

Outcomes of Discharges

Approved: criteria for discharge metNot approved: additional actions or

information needed Not applicable: extrapulmonary TB cases,

noninfectious cases, atypical mycobacterium (NTM)

Hospital Discharge Form

Hospital Discharge Approval Request Form (TB 354) and Instructions

Hospital Discharge Planning Checklist for Tuberculosis Patients

Available on NYC Health Department’s website: www.nyc.gov/health/tb

What the DOHMH Would Like From Providers

Complete and legible forms Expected date of discharge Appropriate contact information for the treating

physician/attending MD Notification of any issues with medications, side effects or

abnormal lab values Specialized nursing needs : PICC lines, injections Discharge to congregate settings or home care agency

referrals Discharges to other jurisdictions requiring interstate

notification How many days of medication provided to patient Follow-up appointment date –should be close to date of

discharge

What Does the DOHMH Need to Do Prior to Discharge?

Field staff need to interview patient to elicit contacts

Home assessment should be donePatient to agree to home isolation and DOT

– Sign agreements for bothFollow up appointment is made

Update on Hospital Discharge Plan Submissions

November 1- March 1, 2011

Acid Fast Bacilli Sputum Smear Positive TB Patients

Sputum smear positive TB patients *

97

*Suspected and confirmed

Discharged smear positive48 (50%)

Still in hospital33 (34%)

Plan submitted22 (46%)

No plan submitted26 (54%)

Discharged smear negative16 (17%)

Plan submitted

9 (56%)

No plan submitted

7 (44%)

Plan submitted10 (27%)

No plan submitted23 (73%)

Patients Discharged While Acid Fast Bacilli Sputum Smear Positive (n=48)

0

1

2

3

4

5

6

H1

H2

H3

H4

H5

H6

H7

H8

H9

H10

H11

H12

H13

H14

H15

H16

H17

H18

H19

H20

H21

H22

H23

H24

H25

H26

H27

Hospital

Nu

mb

er

of

pa

tie

nts No plan submitted Plan submitted

Compliance With Health Code Time Requirements

Median days from discharge plan submission to planned discharge was 1 day (range: -4 to 5)– 23% (9/41) of plans submitted did not have a

planned discharge dateMedian number of days for DOHMH

physician to respond to treating MD was 0 days (range: <1-3)

Initial Approval Status of Discharge Plan Submissions

Approved52%

Disapproved41%

Pending2%

Not Applicable

5%

Reasons For Initial Disapproval*

# %

Home assessment not complete 6 27

Discharge plan form incomplete 5 23

DOT not offered/agreed 4 18

Discharged to congregate setting/unstable residence

3 14

Inadequate treatment regimen 2 9

Children <5 in house not evaluated 2 9

*Discharge plans may be disapproved for more than one reason

Discharge of Non-NYC Residents

NYC DOHMH will communicate discharge plans with patient’s local health department prior to discharge/transfer

Infectious TB patient will be discharged only upon approval of local health department

If a patient is being discharged to a verifiable NYC address, a discharge plan must be submitted

Discharge of NYC Residents from Non-NYC Hospital

•NYC DOHMH will work with discharging hospital &/or the local public health authorities to ensure discharge plans conform to NYC standards

Process for Submitting Treatment Plans

Treatment Plan Approval ProcessWithin 1 month of

treatment start date

Treating provider •discusses treatment plan issues with DOHMH •revises plan•informs DOHMH

DOHMH case manager •contacts treating provider • obtains completed treatment plan form

DOHMH physician •reviews treatment plan •makes determination•communicates with provider

TB Treatment Plan Form

NYC Health Department case manager will provide the treatment plan form to treating physician for completion

Treatment plan form does not replace Report of Patient Services Form (TB 65)

Future Considerations

• Continue collaboration with hospitals/providers

• Monitor submission of hospital discharge/treatment plans

• Outreach to hospitals/providers experiencing issues with plans

• Continue to evaluate impact of initiative

Conclusion

Submit discharge plans for infectious TB patients within 72 business hours of planned discharge

Submit treatment plans within one month of treatment initiation

Ensure forms are complete/accurateRefer to NYC DOHMH guidelines & resourcesCall 311 to consult with DOHMH TB experts

Acknowledgements

NYC DOHMH Bureau of TB Control Provider Outreach Project Working Group

NYC DOHMH Bureau of TB Control StaffNYC Infection Control Nurses and

Practitioners

For Consultation call:311 DOHMH TB Hotline 212-788-4162www.nyc.gov/health/tb