1. Evaluation of a new Health Code requirement for discharging infectious tuberculosis patients from NYC hospitals Michelle M. Macaraig, MPH Assistant Director for Planning and Policy Bureau of Tuberculosis Control NYC Department of Health and Mental Hygiene

2. Todays presentation Background Describe the new health code hospital discharge requirements Describe the Bureau of TB Control (BTBC) implementation process Provide preliminary evaluation results Discuss common issues related to hospital discharges

3. Background

4. Outpatient treatment of TB TB patients could be treated successfully as outpatients No significant difference between hospital and outpatient treatment Requirements for successful treatment include: –Prescription of the correct chemotherapy –Compliance with medication doses Directly observed therapy Completion of a minimum number of doses

5. BTBC criteria for discharging patients with suspected or confirmed TB from the hospital Assess if patient can be treated as an outpatient Begin treatment appropriate regimen Obtain approval from BTBC to discharge patient

6. NYC Health Code Amendment

7. Rationale In 2009, 83% (255/308) of respiratory smear positive TB patients were hospitalized BTBC has observed private practitioners deviate from recommended TB management practices BTBC must be able to influence and ensure TB practices conform with accepted standards Legal and regulatory approach would be effective

8. NYC Health Code amendment New York City Health Code Article 11 Section 21(4) –Hospitals/providers must obtain approval from health department at least 72 business hours before discharging infectious* TB patients –DOHMH [through BTBC] must respond to the request for approval within one business day New requirement was implemented in November 2010 *positive sputum smear from a pulmonary or laryngeal source

9. Implementation and Process for Submitting Hospital Discharge Plans

10. Implementation Communicated the health code amendment –Announcement made to public hospitals –Letters sent to health care providers –Memo sent to BTBC staff Developed forms and guides Developed a plan to review and provide feedback to providers Trained BTBC staff Modified sections of the TB registry to track discharge requests

11. Hospital discharge forms Available on NYC Health Departments website: www.nyc.gov/health/tb

12. Discharge plan approval process Determination72 hour before dischargeWithin 1 business day Provider discusses discharge plan issues with DOHMH revises plan informs DOHMH Provider submits Hospital Discharge Approval Request Form to BTBC via fax BTBC physician Reviews discharge plan Makes determination Communicates with hospital provider Not Applicable Approved Not approved

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

14. Evaluation

15. Evaluation questions Are hospitals/providers compliant with the new health code requirement? What proportion of discharge requests met criteria for discharge? What were the reasons discharges were not approved?

16. Analysis Identified all hospitalized infectious TB patients who were reported to BTBC between November 1, 2010-March 1, 2011 Reviewed discharge plans Obtained data from the NYC TB registry

17. Results

18. Submission of hospital discharge plans Sputum smear positive TB patients * 97 *Suspected and confirmed Discharged smear positive 48 (50%) Still in hospital 33 (34%) Discharged smear negative 16 (17%) Plan submitted 22 (46%) No plan submitted 26 (54%) Plan submitted 9 (56%) No plan submitted 7 (44%) Plan submitted 10 (30%) No plan submitted 23 (70%)

19. Patients discharged from the hospital while acid fast bacilli sputum smear positive, by submission of discharge plan (n=48)

20. 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 BTBC physician to respond to treating provider was 0 days (range: <1-3)

21. Initial determination for discharge plans submitted to BTBC

22. Primary reasons for initial determination of Not Approved among discharge plans (n=14)* Reasons#% Home assessment not complete643 Discharge plan form incomplete322 DOT not offered/agreed214 Discharged to congregate setting/unstable residence 17 Inadequate treatment regimen17 Children <5 in house not evaluated17 *Some submitted plans had multiple issues that may have contributed to not approved determination

23. Conclusion Compliance with the new Health Code provision was low Timeframe requirements for submission of discharge plans were not met Over half of discharge plans were approved at initial review Most common reason for disapproval of a request was incomplete home assessment followed by incomplete discharge request form

24. Future Considerations Continue collaboration with hospitals Monitor submission of hospital discharge plans Outreach to hospitals/providers experiencing issues with plans Evaluate impact of initiative at one year

25. 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

26. Thank You! Questions?

27. Extra slides

28. 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

29. Responsibilities of providers Complete and legible forms 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 Discharges 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

30. Responsibilities of BTBC 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

31. 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 WHO1960, 23; 463-510 Tuberculosis Chemotherapy Centre, Madras. Bull WHO 1960, 23; 463-510

32. 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!

33. 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 ones life