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 in case rates for the facility or the community, clusters of skin test conversions, or other evidence
suspicious 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 its
own 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 should
only 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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