1. Hospital Discharge of TB Patients: Collaborating with the Health Department
Diana Nilsen, MD
Bureau of Tuberculosis Control
NYC Department of Health and Mental Hygiene

2. Today’s Presentation Epidemiology of TB in NYC, 2011
Discuss the rationale for discharging infectious TB patients from the hospital
Describe the new health code reporting requirements
Submission of hospital discharge plans
Submission of treatment plans
Provide an update on hospital discharge plan submissions
Discuss common issues related to hospital discharges

3. Reported TB Cases United States, 1982–2010*
No. of Cases
11,182 cases
Slide 2. Reported TB Cases, United States, 1982–2010. The resurgence of TB in the mid-1980s was marked by several years of increasing case counts until its peak in Case counts began decreasing again in 1993, and 2010 marked the eighteenth year of decline in the total number of TB cases reported in the United States since the peak of the resurgence. From 1992 until 2002, the total number of TB cases decreased 5%–7% annually. From 2002 to 2003, however, the total number of TB cases decreased by only 1.4%. In 2010, a total of 11,182 cases were reported from the 50 states and the District of Columbia (DC). This represents a decline of 3.1% from 2009 and of approximately 58.1% from 1992.
Year
*Updated as of July 21, 2011

4. Tuberculosis Cases and Rates New York City, 1982 – 2011
Tuberculosis Cases and Rates New York City, 1982 – 2011* 689 Cases in 2011
Number of Cases
Rate/100,000
51.1
21.4
8.5
I’d like to start today by reviewing some trends in TB control. This slides shows TB control in NYC by graphing the numbers and case rates from 1980 to We had our highest rate in 1992 and have maintained a pretty steady decrease in incidence. In 2009 we have 760 TB cases in NYC which corresponds to an incidence of 9.1 per 100,000.
*Rates based on official Census data and intercensal estimates prior to Rates for 2000 to 2006 are based on intercensal estimates, and for 2007 to 2011on American Community Survey.

5. US* and Non-US-Born TB Cases† New York City, 1982-2011
3,132
Number of Cases
This slide shows the trend in US vs Non-US-born cases from 1980 to 2009.
The # of US born pts continued to go down, and the # of non-US born cases decreased by 14%.
1,010
*Puerto Rico and U.S. Virgin Islands are included as US-born
†There was 1 case with unknown country of birth in 2011.

6. Top 10 Countries of Birth of Foreign-born Persons, NYC TB Cases
2011 N
2010
China
104
Mexico 49
Dominican Republic 41
Bangladesh 33
Ecuador 31 35 30
Haiti
Philippines 28
India 26
Nepal 19 23 16
Pakistan 20
Puerto Rico 15
Guyana

7. Tuberculosis rates1 by United Hospital Fund (UHF) neighborhood, New York City, 2009-2011
The rates of TB in NYC are not uniform and reflect residential patterns of at risk populations.
In 2011, there were 17 United Hospital Fund (UHF) neighborhoods with a TB rate that exceeded the 2011 NYC TB rate of 8.5 per 100,000 persons.

8. Trend in HIV-Infection and TB New York City, 1992-2011
Decreasing trend in co-infected patients
69 (9%) HIV-infected compared to 95 (11%) in 2008
29% missing HIV status (18% of whom refused testing)
11% of cases aged years were HIV-infected

9. HIV-Infected TB Patients
BTBC Annual Slides, 2008
Saturday, April 01, 2017
HIV-Infected TB Patients
New York City,
The proportion of HIV infected patients decreased in 2003 compared to 2002, but HIV status is unknown for about 40% of cases.
The proportion of cases w/ an HIV result should increase somewhat by the time data are finalized for the year.
The number of TB cases with HIV co-infection declined from 68 in 2009 to 58 in 2011, a 15% decrease (Figure 9). The proportion of TB patients with HIV co-infection has declined over time, from 18% in 2000 to 8% in 2011.

10. Top 10 Medical Facilities First Evaluating Patients for TB- New York City, 2011
Facility Name
# of cases
% cases
1. Elmhurst Hospital Center 41 6
2. New York Hospital Medical Center of Queens 35 5
3. Bellevue Hospital Center 34
4. Maimonides Medical Center 32
5. Lincoln Medical and Mental Health Center 24 3
6. Kings County Hospital Center 23
7. Beth Israel, Queens Hospital Center 21
8. Lutheran Medical Center 13
9. Coney Island Hospital 12 2
10. Montefiore Medical Center, Bronx-Lebanon Medical Center 11
18. Lenox Hill Hospital 10
Montefiore north division only counted 2 cases for 2011

11. TB Reporting Requirements
Article 22 of the New York State Public Health Law and Articles 11 and 13 of the New York City Health Code require that suspected and confirmed cases of tuberculosis be reported to the local health authority, i.e., DOHMH, within 24 hours
Reminder that reporting of patients suspected and confirmed of having TB is legally mandated by both NYC and NYS laws: Article 22 of the New York State Public Health Law and Articles 11 of the New York City Health Code require that TB be reported to the health department within 24 hours. Providers and laboratories should use fax, telephone or electronic means to ensure prompt reporting. Note: TB should be reported when suspected, do not wait for confirmation. 11

12. Reporting TB Cases
Suspected or confirmed TB patients may be reported by telephone at (212) or
A completed Universal Reporting Form (URF) must follow within 48 hours by faxing it to the Bureau of Tuberculosis Control at (212)
The URF can also be completed online, by first creating an account on NYCMED at
Support for NYCMED is available by calling (888) NYCMED9
(212)
Original mailed to DOHMH at 125 Worth Street, Room 315, CN-6, New York, NY  

13. Reporting by Healthcare Providers
Providers are required by law to report within 24 hours any case with:
AFB+ smear from any site
Nucleic Acid Amplification (NAA) test + for Mycobacterium tuberculosis (M. tb)
Culture + for M. tb
>=2 anti-TB medications for suspected or confirmed TB
Clinically suspected TB
Pathology findings consistent with TB
Child < 5 years old with + TST
(regardless of BCG)
The NYC Health Code requires physicians and hospitals to report patients with TB and patients suspected of having TB to the DOH within 24 hours of detection. This include patients with positive smear, culture, NAA tests, patients placed on treatment or those suspected of having TB – because of pathologic, clinical or radiologic signs/symptoms of TB. NAA tests are FDA-approved for use in respiratory specimens (sputum, BAL, tracheal aspirates, bronchial aspirates), regardless of smear status. Any strong TB suspect is reportable, before the culture is back: whether the patient is suspected of having TB based on clinical symptoms or a chest X-ray.
In addition, children < 5 with a positive TST are also reportable in NYC.
The reporting form currently used, the URF, should be as complete as possible, no area should be left blank; if the information is unknown or some laboratory test results are not back yet, then mark “pending”.
We are getting reporting forms from hospitals financial departments for reimbursement purpose. Sometimes, the only reporting form we receive is from the finance staff and only the demographic and hospital information is completed. Many of these patients never turn out to have TB and some do not even have smear and culture sent; in some cases we have investigated, the ICP does not know about the patients. It seems then that TB is brought up for some of these patients solely for reimbursement purposes: this is quite an unacceptable practice. I am urging you to educate and work with your hospital finance department to ensure that they report through you or the patient’s provider and that the required information is complete and the reporting is justified. 13

14. Reporting by Laboratories
Laboratories are required by law* to report within 24 hours :
AFB + smears
Cultures + for M. tuberculosis (M. tb)
Any culture result associated with an AFB+ smear (even if negative for M. tb)
Rapid diagnostic (NAA) tests identifying M. tb
Results of susceptibility tests on M. tb cultures
Pathology findings consistent w/ TB
*Articles 11 and 13, Sections 11.03, and NYC Public Health Code
Laboratories are required to report by law AFB+ smears, Cultures + for M tuberculosis, rapid diagnostic (NAA) tests identifying M tb, results of susceptibility tests on M tb cultures, pathology findings consistent w/ TB. They should report each and every result that meets these criteria, even if the patient has previously been reported.
This does not preclude providers from reporting: both laboratory and provider must report.
If a patient has an AFB+ smear, laboratories are required to report the related culture, even if it is negative. All tests associated with a positive smear should be reported. 14

15. Pathology Findings Suggestive of TB
Presence of acid-fast bacilli (AFB)
Caseating/non-caseating granuloma
Tubercles
Fibro-caseous lesions
Necrotizing/non-necrotizing granuloma
Langhans giant cells/multinucleated Langhans cells
Epithelioid cells/Epithelioid granuloma
Necrotizing inflammation
Chronic granulomatous lesions/chronic inflammation with granuloma formation
Giant cells
TB can also be suspected or diagnosed based on findings on a biopsy or surgical specimens. Findings c/w M tb disease include: of course, presence of acid-fast bacilli (AFB), but also, caseating/non-caseating granuloma, tubercles, fibro-caseous lesions, necrotizing/non-necrotizing granulomas, Langhans giant cells/multinucleated Langhans cells, epithelioid cells/pithelioid granuloma, necrotizing inflammation, chronic granulomatous lesions/chronic inflammation with granuloma formation, and giant cells
The presence of these findings is reportable w/in 24 hours also. 15 15

16. Background- Discharge Planning

17. Outpatient Treatment of TB
TB patients could be treated successfully as outpatients with the advent of modern chemotherapy
No significant difference between hospital and outpatient treatment
Cure rates
Spread of infection
Main determinant of cost of treatment is INPATIENT admission
(Tuberculosis Chemotherapy Centre, Madras. Bull WHO 1959:21-144:51-339)
We have known since 1959 that TB can be treated as outpatient, not requiring hospitalization. 17

18. Treatment of TB in India
Tuberculosis Chemotherapy Centre, Madras, compared home treatment of TB with sanatorium
Treatment at home is satisfactory
Crowded living conditions, low nutritional standards, low income
Major risk to contacts lies in exposure to the infectious case BEFORE diagnosis
Tuberculosis Chemotherapy Centre, Madras. Bull WHO 1960, 23; 18

19. Successful Treatment of TB
Requirements for successful treatment include:
Prescription of the correct chemotherapy
Compliance with medication doses
Achieved as outpatient with DOT
Completion of a minimum number of doses
All of which can be done as an outpatient!
Successful Treatment of TB
Out patient therapy is more cost-effective and achieves cure rates comparable to inpatient care, and is not associated with an increase in TB transmission in the community. Also outpatient treatment is less disruptive for a patient.
Work-up and treatment of TB can be done as an outpatient for most individuals. Requirements for successful treatment include:
Prescription of the correct chemotherapy
Compliance with medication doses.
Achieved as outpatient with DOT
Completion of a minimum number of doses. 19

20. Risks of Hospitalization
Nosocomial transmission to:
Health care workers
Vulnerable patients
Anxiety for the patient who is isolated
Feeling of isolation
Removal from social supports
Loss of control over one’s life
Risk of Hospitalization 20

21. NYC Guidelines for Hospitalization and Discharge
Developed to ensure that only patients who need it are admitted and hospitalized
Infectious patients could be discharged in the appropriate circumstances
TB can be dangerous for other hospitalized patients
Patients should be treated as OUTPATIENTS unless they meet certain criteria
Patients become noninfectious quickly once on treatment 21

22. Criteria for Discharge
Clinical improvement
Tolerating anti-TB meds
Patient must be reported to DOH ( or ), but must be reported via URF as well
Electronic URF filled out within 24 hrs.
Patient should have sputa for AFB
CXR should be done
Involvement of DOHMH in discharge planning with submission of discharge plan to DOHMH
Referral to DOH clinic and DOT
Instructions given to patient and household members if they were exposed to an infectious patient

23. Pg 128

24. NYC Health Code Amendment

25. Care of TB Patients in NYC
In 2009, 83% (255/308) of respiratory smear positive TB patients were hospitalized
In NYC, approximately 50% of TB cases are treated by a private provider
Collaboration between DOHMH and community health care providers removes barriers and fosters achievement of key public health objectives
No significant decline in hospitalization rates despite medical

26. NYC Health Code Amendment
New York City Health Code Article 11 Section 21(4) amended June 16, 2010
Hospitals/providers must obtain approval from health department at least 72 business hours before discharging infectious TB patients
Providers must submit proposed treatment plan to NYC Health Department within one month of treatment initiation for all persons newly diagnosed with active TB disease
New requirement communicated to hospital providers (June and November 2010)
On June 16, 2010 the Board of Health approved amendments to Article 11 of the New York City Health Code to require hospitals/providers to:
1. Obtain approval from the health department before discharging infectious TB patients
2. Submit to the health department a written TB treatment plan within one month of starting treatment for newly diagnosed TB patients.
Two components of the health code
72 hours
1 business day
The physician who attends a case of infectious tuberculosis in a hospital or the person in charge of a hospital or other health care facility where such case has been admitted shall notify the Department in writing on a form provided or approved by the Department and shall consult with the Department at least 72 hours before planned discharge of such case from in-patient care, and shall discharge such patients only after the Department has determined that discharge of such person will not endanger the public health. The Department shall make its discharge determination and respond to the attending physician or the person in charge of a hospital or other health care facility within one business day from the date of the consultation.

27. Process for Submitting Hospital Discharge Plans

28. Discharge Plan Approval Process
72 hrs before discharge
Within 1 business day
Determination
Provider
discusses discharge
plan issues with DOHMH
revises plan
informs DOHMH
Provider submits
Hospital Discharge
Approval Request Form
to DOHMH
via fax
DOHMH physician
reviews discharge plan
makes determination
communicates with
hospital provider
Approved
Not applicable
Disapproved

29. Outcomes of Discharges
Approved: criteria for discharge met
Not approved: additional actions or information needed
Not applicable: extrapulmonary TB cases, noninfectious cases, atypical mycobacterium (NTM)

30. Hospital Discharge Form
Hospital Discharge Approval Request Form (TB 354) and Instructions
Hospital Discharge Planning Checklist for Tuberculosis Patients
Available on NYC Health Department’s website:

31. TB forms located on the Bureau of TB Control’s website: www. nyc
TB forms located on the Bureau of TB Control’s website:
For providers-Guidelines and Forms --
Bottom circle takes to 19 and then 20; Top circle takes to 20

32. Guidelines and Forms-Hospital Discharge Approval Request and Treatment Plans

34. checklist

35. Prescriptions have been filled inappropriately, ie INH only and not RPE, or not at all.

37. Weekend and holiday discharges need to be planned and discussed in advance

38. What the DOHMH Would Like From Providers
Complete and legible forms
Expected date of discharge
Appropriate contact information for the treating physician/attending MD
Notification of any issues with medications, side effects or abnormal lab values
Specialized nursing needs : PICC lines, injections
Discharge to congregate settings or home care agency referrals
Discharges to other jurisdictions requiring interstate notification
How many days of medication provided to patient
Follow-up appointment date –should be close to date of discharge
Discharges to other jurisdictions require a discussion with health agencies

39. What Does the DOHMH Need to Do Prior to Discharge?
Field staff need to interview patient to elicit contacts
Home assessment should be done
Patient to agree to home isolation and DOT
Sign agreements for both
Follow up appointment is made

40. Update on Hospital Discharge Plan Submissions November 1- March 1, 2011

41. Acid Fast Bacilli Sputum Smear Positive TB Patients97
Discharged smear negative
16 (17%)
Discharged smear positive
48 (50%)
Still in hospital
33 (34%)
97 AFB sputum smear positive TB patients reported to the health department during Nov 1-March 1
Main point 54% of smear positive patients discharged from hospitals had no hospital discharge plans submitted
Plan submitted
22 (46%)
No plan submitted
26 (54%)
Plan submitted
9 (56%)
No plan submitted
7 (44%)
Plan submitted
10 (27%)
No plan submitted
23 (73%)
*Suspected and confirmed

42. Patients Discharged While Acid Fast Bacilli Sputum Smear Positive (n=48)
27 hospitals that discharged 48 smear positive patients
12 of the hospitals have not submitted discharge plans
High admitters are not submitting plans
27 hospitals that discharged 48 smear positive patients from the prior slide
2 that had most number of discharges did not consistently submit plans.-High admitters are not submitting plans upon discharge
Hosp 1-maimodies
Hosp 2-columbia

43. Compliance With Health Code Time Requirements
Median days from discharge plan submission to planned discharge was 1 day (range: -4 to 5)
23% (9/41) of plans submitted did not have a planned discharge date
Median number of days for DOHMH physician to respond to treating MD was 0 days (range: <1-3)
Plans are not submitted as required by law
4 days after discharge to 5 days prior to discharge. Median is one day prior to discharge which is on day of discharge.
For DOHMH physician response, 3 days means we could not get in touch with physicians/or holiday/.

44. Initial Approval Status of Discharge Plan Submissions

45. Reasons For Initial Disapproval*# %
Home assessment not complete 6 27
Discharge plan form incomplete 5 23
DOT not offered/agreed 4 18
Discharged to congregate setting/unstable residence 3 14
Inadequate treatment regimen 2 9
Children <5 in house not evaluated
Home assessment not done” d/c plan submitted on day of discharge, couldn’t gain entry into house. D/cing patients on Friday.
Reason that home assessment was not complete was due to discharge plans being submitted on the day of discharge, or entrance to the home was not available
*Discharge plans may be disapproved for more than one reason

46. Discharge of Non-NYC Residents
Non-NYC residents (i.e., patients with a non-NYC address as their place of residence) admitted to a NYC hospital
An approval for discharge will not be granted if the plan is to discharge to an address outside of NYC until the patient has become non-infectious i.e., unless public health officials in the receiving jurisdiction give explicit approval for the discharge of an infectious patient. DOHMH staff, through the Interstate Desk, will communicate all out-of-jurisdiction discharge plans with TB control in the jurisdiction to which patient is to be transferred/discharged to seek further guidance.
Patient can only be approved for discharge if the local health department gives explicit approval
If a non-NYC resident who is admitted to a NYC hospital is being discharged to a verifiable New York City address, DOHMH staff will treat this patient like a NYC resident.
NYC DOHMH will communicate discharge plans with patient’s local health department prior to discharge/transfer
Infectious TB patient will be discharged only upon approval of local health department
If a patient is being discharged to a verifiable NYC address, a discharge plan must be submitted

47. Discharge of NYC Residents from Non-NYC Hospital
NYC DOHMH will work with discharging hospital &/or the local public health authorities to ensure discharge plans conform to NYC standards
NYC residents admitted to a hospital outside of NYC
The section of the Health Code that mandate discharge approvals only applies to facilities in New York City. Facilities outside New York City are not bound by this requirement. Those facilities will have to adhere to local public health laws and regulations. Therefore, NYC DOHMH staff have no authority in approving or denying requests from facilities outside the five boroughs. We will however work with local public health authorities to ensure that discharge plans conform to minimum standards.

48. Process for Submitting Treatment Plans

49. Treatment Plan Approval Process
Within 1 month of
treatment start date
Treating provider
discusses treatment
plan issues with
DOHMH
revises plan
informs DOHMH
DOHMH case manager
contacts treating
provider
obtains completed
treatment plan form
DOHMH physician
reviews treatment plan
makes determination
communicates with

50. TB Treatment Plan Form
NYC Health Department case manager will provide the treatment plan form to treating physician for completion
Treatment plan form does not replace Report of Patient Services Form (TB 65)
This form does not replace the Report of Patient Services form (TB 65) which must
also be submitted to the Health Department for every monthly visit of patients with active
tuberculosis

52. Future Considerations
Continue collaboration with hospitals/providers
Monitor submission of hospital discharge/treatment plans
Outreach to hospitals/providers experiencing issues with plans
Continue to evaluate impact of initiative

53. Conclusion
Submit discharge plans for infectious TB patients within 72 business hours of planned discharge
Submit treatment plans within one month of treatment initiation
Ensure forms are complete/accurate
Refer to NYC DOHMH guidelines & resources
Call 311 to consult with DOHMH TB experts
Submit discharge plans for infectious TB pts within 72 hours of planned discharge
Submit completed forms (Treating MD contact numbers at the facility ie; pagers, phone number)
Treating MD contact numbers at the facility ie; pagers, phone number
Can not discharge until discharge plan approved and approval letter sent???
Discharge plans that do not meet the criteria for submission
Plans will still be reviewed by BTBC provider and feedback provided

54. Acknowledgements
NYC DOHMH Bureau of TB Control Provider Outreach Project Working Group
NYC DOHMH Bureau of TB Control Staff
NYC Infection Control Nurses and Practitioners

55. For Consultation call:
311
DOHMH TB Hotline

56. Hospital Discharge Policy

57. Amendments to Tuberculosis (TB) Reporting Requirements in New York City -1
Section of the New York City Health Code
Physicians and/or persons in charge of hospitals who report infectious TB cases must obtain consultation with and consent of the Department at least 72 hours prior to discharging such cases from inpatient care.
Patients will only be discharged after the department has determined that discharge will not endanger the public health.
The department will respond to the attending physician within one business day of the consultation.

59. Amendments to Tuberculosis (TB) Reporting Requirements in New York City -2
Providers who assume the care of newly diagnosed cases of TB should submit within one month of treatment initiation a proposed treatment plan to the Department for review
Include name of medical provider who is responsible for treatment, names and duration of prescribed anti-TB drugs, anticipated date of treatment completion and a plan for promoting adherence to prescribed treatment.
Form will be provided by the Bureau

61. Light yellow <= national rate
Orange <= NYC rate
Dark red > NYC rate

62. TB Laboratory Case Definition
Isolation by culture of M. tuberculosis complex from a clinical specimen OR
Demonstration of M. tuberculosis from a clinical specimen by nucleic acid amplification (NAA) test (when used in accordance with FDA approved product labeling) OR
Demonstration of acid-fast bacilli (AFB) in a clinical specimen when a culture has not been or cannot be obtained
TB is confirmed by laboratory techniques but can be diagnosed clinically. The following 2 slides will go over the CDC TB case definitions. The TB laboratory definition is via Isolation by culture of M. tuberculosis complex from a clinical specimen OR Demonstration of M. tuberculosis from a clinical specimen by nucleic acid amplification (NAA) test (when used in accordance with FDA approved product labeling) OR Demonstration of acid-fast bacilli (AFB) in a clinical specimen when a culture has not been or cannot be obtained
NAA test should be used as per FDA approval: only in respiratory specimen and in patients who have been treated for TB 7 days or less (or more than 1 year ago)
Although not included in this definition, patients with pathologic specimens c/w TB are also reportable, as described later 62 62 62

63. TB Clinical Case Definition
Evidence of TB infection based on a positive tuberculin skin test or FDA approved blood test
AND
One of the following:
 Findings compatible with current TB disease, such as an abnormal, unstable (worsening or improving) chest radiograph, or
Clinical evidence of current disease (e.g.. fever, night sweats, cough, weight loss, hemoptysis)
Improvement on current treatment with two or more anti-TB medications
The clinical definition for TB include all the following criteria:
Evidence of TB infection based on a positive tuberculin skin test AND
One of the following:
(1)  Findings compatible with current TB disease, such as an abnormal, unstable (worsening or improving) chest radiograph, or
(2) Clinical evidence of current disease (e.g.. fever, night sweats, cough, weight loss, hemoptysis) AND
Improvement on current treatment with two or more anti-TB medications
What is a TB suspect: anyone with signs or symptoms/radiological findings c/w TB and the right epidemiology is a TB suspect. A suspect is as per the treating physician: if a providers think TB and order tests to show that the patient has TB, the patients is a suspect and should be reported. If the patient is stared on Rx even with negative smear/culture, that is a definite reason for reporting – promptly. 63 63 63