Length of Hospital Stay in Patients admitted for Rule Out Tuberculosis at

Riverside County Regional Medical Center

Ravneet Singh, M.D.

Depinder Mann, M.D.

2

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.

3

Rates of Reported TB Cases California and Riverside, 1990–2004

02468

1012141618

1990 1992 1994 1996 1998 2000 2002 2004

Year

Cases per 100,000 population

California

Riverside

Background

Race/Ethnic Composition of Reported TB Cases* and County Population**, Riverside County

0.5

22.7

3.9

15.9

57.1

0.74.7 5.8

47.2

40.0

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Native Am. Asian/Pac.Is Black/Af.Am White Hispanic

Per

cen

t C

om

po

siti

on

.

% of TB Cases

% of County Population

* Years 2000-2005**Year 2004 Estimate

Background

5

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.

6

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.

7

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

ResultsResults

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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

10

Reasons for Extended Length of Stay

74

71

14

12

0 20 40 60 80

Inability To Collect AFB OnTime

Incomplete Public HealthForms

Unable To Follow HomeIsolation Regulations

Prison Delay

patients

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Length of Stay MetricsPatients (Lacking AFB + Incomplete Public Health + Home Isolation + Prison Delays) 0

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) 5

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Reason #1 for Extended Stay

• Inability to collect three consecutive sputum samples for AFB smears and cultures.

13

• 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 #2 for Extended Stay

14

15

16

• 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 #3 for Extended Stay

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• 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.

Reason #4 for Extended Stay

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Limitations of the Study

• Retrospective chart review.

• Small sample size.

• Specific to a county hospital setting.

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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.

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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 ProtocolRecommended TB Protocol

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TB PROTOCOL All questions contained in this questionnaire are strictly confidential

and will become part of your medical record.

Name (Last, First, M.I.): M F DOB:

Ethnicity: Hispanic African American Caucasian Asian Other

Admitting Diagnosis: Date of admission: Time:

TB HISTORY

Past Exposure to TB: Yes No

If “Yes”, Treatment

PPD Skin Test and Results

Chest X-Ray (PA and Lateral Views) on Admission Yes No

Place Patient in Respiratory Isolation Yes No

1. AFB Sputum Collection for Smear and Culture – Q AM x 3

Date Number of Sample Sent to Public Health

Sample 1

Sample 2

Sample 3

2. If Sample Number 1 not obtained, Charge Nurse to call Respiratory Therapist (RT) for Sputum Induction

3. If RT unable to induce sputum, call Nurse/ Resident for Gastric Aspirate

4. If Gastric Aspirate not obtainable (?????), Nurse to call Infection Control and pulmonologist for bronchioalveolar lavage

5. Resident to start filling out Public Health Form on day of admission (complete information including weight of patient)

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Future Research• Run a pilot projectpilot 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.

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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

Questions and Answers?