Evaluation of a new Health Code requirement for discharging infectious

tuberculosis patients from NYC hospitals

Michelle M. Macaraig, MPHAssistant Director for Planning and Policy

Bureau of Tuberculosis ControlNYC Department of Health and Mental Hygiene

Today’s 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

Background

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

BTBC criteria for discharging patients with suspected or confirmed TB from the hospital

Assess if patientcan be treated as an outpatient

Begin treatment appropriate regimen

Obtain approval from BTBC to discharge patient

NYC Health Code Amendment

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

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

Implementation and Process for Submitting

Hospital Discharge Plans

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

Hospital discharge forms

Available on NYC Health Department’s website: www.nyc.gov/health/tb

Discharge plan approval process

Determination72 hour before discharge Within 1 business day

Provider • discusses discharge plan issues with DOHMH • revises plan• informs DOHMH

Provider submits Hospital Discharge Approval Request Form to BTBCvia fax

BTBC physician • Reviews discharge plan • Makes determination• Communicates withhospital provider

Not Applicable

Approved

Not approved

Determination

• Approved: criteria for discharge met• Not approved: additional actions or

information needed • Not applicable: extrapulmonary TB

cases, noninfectious cases, atypical mycobacterium (NTM)

Evaluation

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?

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

Results

Submission of hospital discharge plans

Sputum smear positive TB patients *

97

*Suspected and confirmed

Discharged smear positive

48 (50%)

Still in hospital33 (34%)

Discharged smear negative

16 (17%)

Plan submitted22 (46%)

No plan submitted26 (54%)

Plan submitted

9 (56%)

No plan submitted

7 (44%)

Plan submitted10 (30%)

No plan submitted23 (70%)

Patients discharged from the hospital while acid fast bacilli sputum smear positive, by

submission of discharge plan (n=48)

H1

H2

H3

H4

H5

H6

H7

H8

H9

H10

H11

H12

H13

H14

H15

H16

H17

H18

H19

H20

H21

H22

H23

H24

H25

H26

H27

0

1

2

3

4

5

6Plan submitted No plan submitted

Hospital

Nu

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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)

Initial determination for discharge plans submitted to BTBC

Not approved 14 (35%)

Approved24 (60%)

Not Applicable2 (5%)

Primary reasons for initial determination of “Not Approved” among discharge plans (n=14)*

Reasons # %

Home assessment not complete 6 43

Discharge plan form incomplete 3 22

DOT not offered/agreed 2 14

Discharged to congregate setting/unstable residence

1 7

Inadequate treatment regimen 1 7

Children <5 in house not evaluated 1 7

*Some submitted plans had multiple issues that may have contributed to “not approved” determination

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

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

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

Thank You!

Questions?

Extra slides

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

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

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

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; 463-510

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!

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