Rangel PDSA TB Didactic

TB or not TB?

AIM Statement

• In order to improve care at the Charles Rangel Clinic, we will implement a tuberculosis screening protocol in order to identify high risk patients aged 1-11 years old who require PPD placement according to the guidelines set forth by the AAP Committee on Infectious Disease.

AIM Statement

• Our goal – ≥95% of our patients will have documented

screening for tuberculosis risk factors at least yearly

– ≥95% of patients with documented risk factors will have a PPD placed AND read

– follow those in whom treatment is warranted   

Why pediatric TB is important:

• 30% of global TB cases; 7% in U.S. • Age 0-4 more likely to develop active TB

once infected and more vulnerable to disseminated TB

• Public Health Standpoint:Pediatric TB = Sentinel Event

• Worldwide, 500,000 children die annually from TB

Tuberculosis rates by neighborhood

2005

Routine pediatric care: No more universal testing

• Not cost-effective to routinely skin test healthy children without risk

• Up to 85% of positive results will be FALSE positives in areas of low TB prevalence

• Preferred strategy: “targeted testing”– Focuses testing children with risk factors– Screen all children for risk factor(s)– Test only if > 1 risk factor(s) present

PDSA Cycle 1:TB screening questions

• To be asked once yearly at well child visits in children between the ages of 1 and 10:

– Was your child or any household member born outside the United States?

– Has your child or any household member traveled outside the United States?

– Has your child been exposed to anyone with TB disease or a positive PPD?

– Does your child spend time with anyone who has been in jail (or prison) or a shelter, uses illegal drugs, or has HIV?

Cutoff PPD values• 5mm is positive when

– close contact with known or suspected contagious tuberculosis– suspicion of disease based on clinical factors, or radiologic

abnormalities• 10 mm is positive when

– risk for dissemination, including those younger than 4 years or those having medical conditions such as HIV diabetes renal failure or solid tumors

– increased exposure such as frequent exposure to HIV infected persons, drug users, incarcerated persons, or nursing home residents

– areas endemic for TB and those who have contact with adults from those areas (Asia, Middle East, Africa, Latin America)

• 15 mm is positive when– 4 years of age and over without any risk factors

PDSA Cycle 2:Baseline Measures

• Chart review of all well child visits on 2 consecutive Tuesdays

• 19 patients were screened for tuberculosis risk factors• 8 (42%) of the patients screened had at least one risk

factor– 3/8 (38%) did not have PPD placed– 2/8 (25%) had PPD placed: 1 patient did not return for the

reading. 1 patient had positive read and was referred for CXR and started on INH

– 1/8 (13%) had a documented negative PPD in the chart and was not retested

– 2/8 (25%) could not be followed due to missing charts

All the screening questions, in one nice neat little box – oh the joys of modern medicine!!

PDSA Cycle 3:

Old Projects revisited

PDSA Cycle 4:

PDSA Cycle 5

• Assessed return rate for PPD readings in January– 15 PPDs placed– 12 (80%) returned for reading in the

appropriate amount of time All 12 were read as negative

– 1 (7%) did not return – 2 (13%) still pending at the end of the cycle

The Rangel Clinic’s state of the art Mead Composition Book has a 0% “system shut down from 1-3am” rate!

page from 7/2007

page from 4/2008

Over the course of the year – increased messiness possibly correlating with increased activity!

PDSA Cycle 5:Keeping Track of PPD Placement

• Implemented a “PPD placement note” into Eclipsys– Started by the nurse at the time of placement and kept

“incomplete”– Note completed when the patient returned for PPD

read

• Unfortunately, this did not completely solve the issues:– Unable to filter PPD notes in Eclipsys– Difficult to keep track of outstanding PPD and results

PDSA Cycle 6:Improving Tracking

• Organized with the nurses that PPD notes in Eclipsys should include the ordering MD as a co-signer for the note.– MD and nurse share the responsibility of following

up on results

• Talked to Eclipsys administrators to create a filter for patients who have PPDs placed in a given time

PDSA Cycle 6:Reviewing Positive PPDs

• Review of positive PPDs over 3 years (2005-2008)

• 6 patients with positive PPDs documented

• 4 of these patients had charts available for review

• 2/4 (50%) had documented CXR and INH treatment

PDSA Cycle 7:Progress of PPD Tracking

• Chart review January 30-February 17

• 94% of PPDs placed had a PPD placement note in Eclipsys

• 70% returned for PPD read, 100% negative

• 17% of these were co-signed to a physician– When a note is updated in Eclipsys, all co-sign data

gets erased and must be reassigned– Our head nurse reminded staff to reassign a co-signer

each time the note was accessed

PDSA Cycle 7Reassess TB Screening

• Chart review of patients presenting on 1 day of clinic

• 75% of the charts had documentation of TB screening during a WCC over the past year

• 100% who screened positive had PPDs placed

• 100% of the patients who returned for their read were read as negative

PDSA Cycle 8:Positive PPD requirements

• 100% of PPDs placed were read as negative

• Induration >10mm was always read as postive.

• Unclear what to do with induration >5mm.

• Nurses and physicians re-educated about definition of positive PPD

• Red Bood guidelines posted in nursing office

PPD Placement, Return and % show rates

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The Future of TB at Rangel

• TB screening is sustainable, as there is a prompt within the Eclipsys ambulatory note

• Once screened, placing a PPD is also simple• Issues still lie with improving return rate for

PPD reads– Reminder phone calls to families regarding visit– Implementation of Televox system

PDSA Cycle 3:Old Projects Revisited

• 25 charts (8/07-9/07) coded “WCC” for ages 6 months to 4 years were reviewed for documentation of dental screening and and lead risk.

• 5/25 had documentation of dental screening (20%)• 8/25 had documentation of lead risk factors (32%) • 3/25 had documentation of both (12%)

PDSA Cycle 3:Old Projects Revisited

• A presentation reviewing our previous projects was given on each clinic day

• To improve documentation rates utilized Eclipsys: – “Dental” check box should be added to the

Eclypsis note with a free text box– The lead risk factors check box, which existed

in the “Social” portion of the note should be in its own separate drop box.