Quality Improvement Data Collection Tool
TB – Active Cases/Suspects
Facility
Sample
Size
Data Collector(s)
Date
DATA COLLECTED
#
1
1
Is date of incarceration listed/ documented?
2
Were there symptoms on admission to the facility?
3
4
Were the smear results positive?
6
Was NAAT/MTD test done?
7
Were the culture results positive?
8
Was the TST/IGRA positive?
9
Was the CXR result on chart?
10
Was the inmate placed on recommended 4-drug
therapy?
11
Were initial liver enzymes normal at baseline?
12
Was HIV counseling and testing done?
13
Were the results of the HIV and other lab tests on
the chart?
14
If positive smear/culture, were contacts identified?
16
17
2
3
4
5
6
7
8
9
10
THRESHOLDS
+
-
0
(yes)
(No)
(N/A)
COMMENTS
GOAL
ACTUAL
Was the inmate isolated in an Airborne Infection
Isolation (AII) room within 5 hours of the first
symptom?
Was the health department notified within the
appropriate timeframe of the suspect case?
5
15
TOTALS
INDICATOR
If positive smear/culture, were contacts
evaluated?
Was appropriate therapy initiated for LTBI
contacts?
Was initial contact information given to HD within
7 days?
PUT CHART IDENTIFYING INFORMATION HERE
SOUTHEASTERN NATIONAL TUBERCULOSIS CENTER (SNTC)
HTTP://SNTC.MEDICINE.UFL.EDU
888-265-7682
SNTC@MEDICINE.UFL.EDU
Instruction Tool
1.
Is the date of incarceration listed? This is a computergenerated date and can be obtained from Classifications or the
computer. The content of these cells will not be +/-, but should
identify the date the inmate came into the facility. NOTE: This
date will be important to identify potential teaching
opportunities during the intake process if the inmate is not
identified early into the incarceration.
2. Were there symptoms on admission to the facility? This can be
obtained from the intake sheet or a TB or cough questionnaire
the facility may have developed. NOTE: This information
indicates a potential for education that may be needed in the
Intake area or follow-through that may be needed.
3. Was the inmate isolated within five hours of the first
symptom? Check for documentation in the progress notes of
the chart or a date/time on a Sick Call Slip or Isolation log.
NOTE: This will assist in the event a contact investigation is
needed.
4. Was the health department notified within the appropriate
time frame of the suspect case? This can be identified from the
HD record as well as the facility record. Documentation can be
located within the progress notes of the record or a specific
area. The time frame is identified to meet local/state laws.
5. Were the smear results positive? This will assist in prioritizing
contact investigations, as well as identifying a need for focus
studies with regard to collection of the sputum.
NOTE: If any of the sputum is inadequate or overgrown, or not
cooled when transporting, this would indicate a need for
education for adequate collection of sputa.
6. Was NAAT/MTD test done? This should be done on all sputum
samples submitted initially. NOTE: This is an identification tool
that can facilitate early release from isolation. [NAAT = nucleic
acid amplification; MTD = mycobacterium tuberculosis direct]
7. Were the culture results positive? This is documented on the
lab slips. Note: this information will assist in identification of
prioritizing contact investigations, as well as identifying a need
for education of collection of sputa.
8. Was the TST/IGRA positive? The results of the tuberculin skin
test must be documented in millimeters. NOTE: Aids in
identifying issues with regards to TST (tuberculin skin testing) or
IGRA (immune gamma response assay) and education for
providers. The statement “negative” or “positive” is not
appropriate for TST. If TST is negative, it should be documented
as “0 mm”.
9. Was the CXR result in the chart? A copy of the results of the
recent chest x-ray should be located in the chart. NOTE: This is
a CXR form, not a notation in the progress record. This is a
“yes” or “no” in all cases, and would be “Not Applicable” only if
no CXR was ordered.
10. Was the inmate placed on recommended four-drug therapy?
This includes Isoniazid, Rifampin, Ethambutal and Pyrazinamide
(INH, RIF, ETH, and PZA). Other regimens require
documentation of consult with a TB expert. This information is
documented on a physician’s order. NOTE: If sensitivities were
returned with resistance to any of these, the inmate would be
changed to different TB medications. Special Note: If low level
resistance to INH, some MDs will keep INH in the regimen.
Consult with a TB expert.
SOUTHEASTERN NATIONAL TUBERCULOSIS CENTER (SNTC)
11. Were initial liver enzymes normal at baseline? This would be a
“yes” or “no” response. NOTE: The lab slip would indicate the
liver enzymes, such as SGOT, SGPT and Bilirubin and the range.
12. Was HIV counseling and testing done? There would be
documentation stating the client was offered counseling and
testing or a lab slip with refusal. NOTE: Documentation would
be on a form or a lab slip, a refusal or on a progress note (may
include signature). This would be Not Applicable if the facility
does not include HIV counseling and testing in their policy,
although it is recommended for every facility.
13. Were the results of the HIV and other lab tests on the chart? A
lab slip, indicating positive or negative, should be in the chart.
Include all other applicable lab tests, such as viral load, CD4
count. NOTE: The only time this would be “not applicable”
would be if no labs or HIV test was ordered.
14. If positive smear or culture, were contacts identified? There is
generally an indication in the chart’s progress note that a
contact investigation was initiated, and, if done, a sheet either
with the chart or a total number of contacts identified should
be included. This would be “not applicable” if the client was
extrapulmonary or documentation by HD staff no contact
investigation was needed. NOTE: A contact investigation should
be done for every pulmonary case of tuberculosis.
If positive smear or culture, were contacts evaluated? This can
be located on a contact evaluation sheet that would be
included with the inmate record, or in a separate file from
Infection Control. NOTE: This would be “not applicable” if the
client was extrapulmonary or documentation by HD staff no
contact investigation was needed. Contact evaluation is
important to ensure no new cases of tuberculosis are missed.
15. Was appropriate therapy initiated for LTBI contacts? A
physician’s order for INH or Rifampin therapy is documented in
the doctor’s orders. NOTE: This would be INH (Isoniazid) for
nine or six months, depending on the length of stay of the
inmate. Rifampin for four months should be used for inmates
staying at the facility for at least six months and only under the
guidance of a TB physician and directly observed treatment.
16. Was initial contact information given to the HD within seven
days? Documentation in the form of a Progress Note would
satisfy these criteria. NOTE: This would be “Not Applicable” if
the patient had extrapulmonary TB. This information is
essential to ensure appropriate follow-up and completion if the
client is released from the facility.
Put Chart Identifying Information Here
This area of the form is for documenting the initials or number of
the client’s chart for follow-up at a later date, if needed.
HTTP://SNTC.MEDICINE.UFL.EDU
888-265-7682
SNTC@MEDICINE.UFL.EDU