First of all, don’t be discouraged that your tracking system is getting outdated for your growth. Our TB tracking system used to be a room full of index cards, one for each employee, with a series of 12 holes near the border representing each month. Your designated month for testing would be clipped out to the edge of the card. Once a month, we’d run a knitting needle through that month’s hole in a big stack of cards, give it a shake, and if your card fell to the floor it was time for your TB test! I am not making this up. (This was before I got here of course. I am much too young to even know what “index cards” are...)
Some tips on TB surveillance:
1. Be sure you are only doing annual TB testing for locations that are at medium risk per the CDC 2005 guidelines. In the US, most outpatient clinic settings are likely to be low risk. Unless of course it’s a TB clinic or a special population. So do a critical check – do you really need annual testing at all of these off site locations?
2. For those who need annual testing, we programmed our tracking system to set their next test due one year from their latest completed negative result. So it’s staggered throughout the year. Our system starts sending weekly reminder emails a month before their next service is due (not just TB, any test.) This is helpful because people can easily get off track – they have an exposure and need earlier testing, they might be out on leave through their normal testing month and get it when they return, etc. And people are hired year round.
3. We have a designee program. We train nurses to place TSTs, and to read a completely normal result (if there is erythema or induration they must see one of our staff for a final read.) We have over 500 of these designee nurses scattered across the system, so each site can have several who can do that. Also we allow MDs and NPs to read a completely normal result without going through our class. Again we still insist on seeing any erythema or induration. We feel we cannot trust that training is good enough to be reliable for that. Even if everyone could accurately measure 7mm of induration, we need to talk to the person to interpret that – are they immunosuppressed? Are they postexposure? Not questions a coworker should ask. We use REDCap for them to enter the reads, our staff review the data for QA purposes and enter them in our tracking system.
4. We have an outreach nurse position - she travels to the offsites for everything, not just TB, and coordinates a crew of PRN nurses to extend our reach.
5. To Wendy’s point, if IGRAs are dirt cheap and readily available where you are, you could switch to a system where employees can go to a lab to have it drawn with results sent to you. We aren’t able to do that here as it’s just too expensive. ($270 a pop, and even if we did our full volume the best price we could get is $50. Yes you can quote the SWITCH study to me until you’re blue in the face, but the “total costs” of people getting skin tests don’t hit my budget. Only the PPD and the syringe do!)
Hope it helps and good luck!
Melanie Swift, MD
Director, Vanderbilt Occupational Health Clinic
We are facing the challenges of providing employee health services to healthcare system that is growing a very rapid pace. New clinics, off-site locations, and departments are being added monthly, if not weekly. I have two questions for the group.
1. One of our greatest challenges is in administering our tuberculosis testing program. We currently place PPDs based upon the designated month for the employee’s department. It is becoming more and more difficult to manually update and maintain a list that is then tied to our electronic employee health record. How do you administer your TB program? Do you designate testing by department by month, by the employee’s birth date, etc.? What challenges or advantages have you seen with your particular program method?
2. If your healthcare system has gone through or is going through rapid growth, how have you managed providing fitness for duty testing and exposure management follow up to your off-site employees? Do you outsource, contract with other hospitals, travel, etc.?
Meredith R. Weaver, SHRM-CP
Manager, Employee Health
PO Box 8120
Morgantown, WV 26506-8120
Phone: 304-598-4000 ext. 77719
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