Ravneet Singh, M.D. Depinder Mann, M.D. Length of Hospital Stay in Patients admitted for Rule Out Tuberculosis at Riverside County Regional Medical Center

Background Tuberculosis epidemiology varies widely from place to place, however the number of “Rule out Tuberculosis” admissions have shown an increase in California compared to previous years. We have observed the same trends at Riverside County Regional Medical Center. This increase can be attributed mainly to the increase in immigrant population in California.

Rates of Reported TB Cases California and Riverside, 1990–2004 Background Rates of Reported TB Cases California and Riverside, 1990–2004 Cases per 100,000 population California Riverside Slide 10. TB Rates CA and Riverside TB rates dropped steadily through the 90’s and have reached a relative plateau in California and Riverside. Riverside’s 2005 numbers suggest further decreases are very possible. Year

Background Race/Ethnic Composition of Reported TB Cases* and County Population**, Riverside County * Years 2000-2005 **Year 2004 Estimate Slide 20. TB cases and the County Population breakdown by Race/Ethnicity From the year 2000 through 2005, Asian Pacific Islanders have accounted for 22% of reported Tb cases while comprising around 5% of the County’s population. Whites and Blacks account for a disproportionately small number of cases when compared to their population distributions in the county. Whites make up about 47% of the population in 2004 and account for 16% of the Tb cases. Meanwhile….Hispanics are about 40% of the county population and 57% of the TB cases during the time period.

Introduction This study was undertaken to determine the length of hospital stay for patients admitted with “Rule Out Tuberculosis” to RCRMC because we observed an extended utilization of scarce inpatient beds and hospital resources along with increased anxiety to patients and families.

Research Goals Determine length of stay for patients admitted to RCRMC for “Rule Out Tuberculosis”. Understand reasons for extended stay. Recommend protocols and processes to help reduce the extended stay.

Method - Study Design Retrospective chart review Consecutive Charts Reviewed: 325 Review Period: 2003 to 2006 Inclusion Criteria Patients over the age of 18 Primary admitting diagnosis of R/O TB Exclusion Criteria Patients under the age of 18 Secondary diagnosis and co-morbidities Positive tuberculosis cases Final number of charts reviewed for the study: 100

Results

Length of Stay Average Length of Stay 11.36 days Median 10 days Mode – Most patients are spending 8 days Range of patient stay days 4 – 28 days

Reasons for Extended Length of Stay

Length of Stay Metrics Patients  (Lacking AFB + Incomplete Public Health + Home Isolation + Prison Delays) Patients  (Lacking AFB + Incomplete Public Health + Home Isolation) 7 Patients  (Lacking AFB + Incomplete Public Health + Prison Delay) 5 Patients  (Lacking AFB + Incomplete Public Health) 49 Patients  (Lacking AFB + Home Isolation) 14 Patients  (Lacking AFB + Prison Delays) 4 Patients  ( Incomplete Public Health + Home Isolation) 10 Patients  (Public Health + Prison Delays)

Reason #1 for Extended Stay Inability to collect three consecutive sputum samples for AFB smears and cultures.

Reason #2 for Extended Stay Incomplete Public Health Form Incomplete information No official X-ray readings or no comparison from admission CXR with CXR at time of anticipated discharge Leads to inability to obtain timely public health clearance

Reason #3 for Extended Stay Home isolation regulations as provided by Public Health. Patients unable to adhere to home isolation regulations due to: Home isolation agreements not signed Children under the age of 4 years in the home Early post-partum women Geriatric family members Immunocompromised Includes autoimmune disorders, long-term steroid users

Reason #4 for Extended Stay Prison facilities delays Inadequate negative pressure isolation rooms in the prison system. CIM has only 2 and CRC has only 1 negative isolation pressure rooms.

Limitations of the Study Retrospective chart review. Small sample size. Specific to a county hospital setting.

Conclusion Majority of the patients spend at least 8 days or more in the hospital. Extended stay of R/O TB patient caused Over utilization of hospital resources. Increased health care costs.

Recommendations Standardization and implementation of an efficient TB protocol to implement upon admission. More emphasis on training the nurses and respiratory therapists (RT) for collecting sputum samples for AFB smear and culture tests. Mandate complete information on public health forms filled by the residents and students. Coordinate information with Infection Control Develop skilled nursing facility in Riverside County equipped to handle patients who require a negative pressure isolation room.

Recommended TB Protocol

Future Research Run a pilot project with the recommended TB protocol on 10 new admissions. Modify and implement the recommended TB protocol using the findings from the pilot project. Run the same study again on 100 new admissions and compare the length of hospital stay with current findings.

References Management of Tuberculosis in the 21st Century, Training Course, Presented by Francis J. Curry National Tuberculosis Center Diagnostic Standards and Classification of Tuberculosis in Adults and Children, American Thoracic Society (2000) www.nationaltbcenter.edu www.cdc.gov

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