Tuberculosis Control and Personal Respiratory Home Health Protection Program 

Implementing a Tuberculosis Control and Personal Respiratory Home Health Protection Program

PURPOSE

·       To provide home health agency guidelines for effective tuberculosis control program

·       To reduce the risk of transmission of M. tuberculosis (MTB)

RELATED PROCEDURES

·       Applying Principles of Standard Precautions: General Guidelines

·       Reporting and Managing an Exposure Incident

·       Tuberculin Skin Test (see Chapter 10)

GENERAL INFORMATION

OSHA supports the CDC guidelines for the prevention of MTB in health-care facilities.

·       Emphasis is placed on:

1.     administrative and engineering control and personal respiratory protection of health care workers;

2.     health-care facility risk assessment and development of a written MTB control plan;

3.     early detection and management of persons with MTB;

4.     purified protein derivative (PPD) skin testing programs; and

5.     health-care worker education, counseling, screening, and evaluation regarding MTB transmission, symptomology, prevention, and treatment. Be aware that OSHA guidelines regarding protection of health care workers from exposure to MTB were under review for revision at the time of this writing. See the OSHA Regulations in the procedure for Applying Principles of Standard Principles of Standard Precautions: General Guidelines.

M. tuberculosis is carried in airborne particles, known as droplet nuclei, that can be generated when persons with pulmonary or laryngeal MTB sneeze, cough, speak, or sing. The particles are estimated to be approximately 1 to 5 microns. Normal air currents keep the particles airborne and can spread them throughout a room or building.

PROCEDURE

1.     Institute the elements of the Personal Respiratory Protection and MTB Protection Program to include the following:

a.    Conduct a risk assessment to evaluate the risk of MTB transmission among staff and patients.

b.   Develop a written program based on the risk assessment, and periodically repeat the risk assessment to evaluate program effectiveness.

c.    Develop, enforce, maintain, and evaluate policies and protocols to ensure early detection and treatment of patients/staff who may have infectious MTB.

d.   Educate and train home health nurses and field staff about clinical manifestations of MTB, effective methods for prevention of MTB transmission, treatment modalities, and the benefits of a medical screening program.

e.    Promptly evaluate possible episodes of MTB transmission in the home health agency and coordinate activities with the local public health department, emphasizing reporting, adequate discharge follow-up, and ensuring continuation and completion of therapy.

f.    Perform an annual evaluation of the program. Based on outcomes, both written procedures and program administration should be modified as necessary. Elements of the program that should be evaluated include work practices and use of respirators.

2.     Perform two-step PPD testing of home health nurses and field staff at the time of their

a.    employment, with retesting done annually and as needed. Consult with the local health department and local OSHA representative each year to keep updated on guidelines.

3.     Provide respiratory protection devices. Appropriate respiratory protection must be worn by all staff potentially exposed to MTB in settings where administrative and engineering controls may not provide adequate protection. NIOSH requires the following criteria for respiratory devices used for MTB:

a.      Provide a respiratory protection device (respirator) able to filter particles of 1 micron with a filter efficiency of 95%, given flow rates of up to 50 L/minute (check manufacturer guidelines, and purchase certified respirators that meet or exceed NIOSH criteria).

b.     Provide a medical evaluation that determines the health care worker is physically able to perform the work and use the respirator.

c.      Provide a fit-test protocol whereby respirations are tested in a reliable way to obtain a face-seal leakage of no more than 10%.

4.     Ensure that all staff that provides direct patient care in the home are instructed and trained in the proper use of respirators and their limitations (the face-piece seal should be checked by staff each time they put the respirator on).

5.     Ensure that respirators are easily available for use and stored in a sanitary location. If used again, clean and disinfect the respirator, according to the manufacturer’s recommendations.

6.     Clean and replace equipment. Discard disposable items according to Standard Precautions.

NURSING CONSIDERATIONS

When visiting a patient with suspected or confirmed infectious MTB, offer the patient a surgical mask, and instruct the caregivers/family to cover their mouth and nose with a tissue when coughing or sneezing. Wear respiratory protection when entering the home or the patient’s room until the patient is no longer actively infectious.

Educate the patient/caregiver about the importance of the taking MTB medications as prescribed by the physician.

Cough-inducing procedures should be performed on patients with actively infectious MTB only if absolutely necessary. If cough-inducing procedures are necessary, perform them in a well-ventilated area of the home away from caregivers/family members.

Respirators should not be worn when conditions prevent a good seal. Such conditions may include the growth of a beard; sideburns; a skull cap that projects under the face piece; dentures; and in some cases, glasses. In addition, home health nurses and field staff who are severely immunosuppressed or pregnant should avoid exposure to MTB.

DOCUMENTATION GUIDELINES

Document Standard Precautions on the visit report. Any home health staff exposure shall be reported on the OSHA 200 form.