Capstone PPT Koranda 2014 1115AM

Lindsay KorandaRush University College of Nursing

EVIDENCE BASED PRACTICE PROTOCOL:

TUBERCULOSIS SCREENING AND TESTING GUIDELINES FOR

EVANSTON TOWNSHIP HIGH SCHOOL HEALTH CENTER

Lack of detailed tuberculosis screening and testing guidelines at the school-based health center.

PROBLEM STATEMENT

In 2010, an estimated 11,182 children were infected with tuberculosis (TB) in the U.S. [ 1 ]

One-third of the global population has latent TB. [ 2 ]

For childhood TB alone, $80 million will be spent addressing the problem, $40 million on treatment, and another $40 million will be put towards research globally. [ 3 ]

CLINICAL PRACTICE PROBLEM

In the late 1980’s and early 1990’s, the AAP recommended universal TB testing for all children, even if they had no risk factors.

In 1996, the recommendations were revised to focus on the concept of risk factor screening.

Based on the response from the risk assessment questionnaire, children and adolescents with at least one positive risk factor should be tested for TB. [ 1 ]

HISTORY OF GUIDELINES

Evanston Township High School (ETHS) Health Center is partnered with NorthShore University Healthsystem, serves children and adolescents in kindergarten up to 12 th grade, ages 5 to 22 years old.

District 202 & 65

Students are seen at the clinic for a wide array of reasons, from acute & chronic illnesses, to physicals and vaccinations.

The healthcare providers play the role of a primary care provider (PCP) or supplement to the students’ PCP. [ 1 ]

BACKGROUND

Worldwide plan developed by the World Health Organization in 2006.

The vision is a TB-Free world.

The goal is to dramatically reduce the global burden of TB by 2015.

The targets are: To reduce prevalence and deaths due to TB by 50%

compared with baseline by 2015. To eliminate TB as a public health problem by 2050.

STOP TB STRATEGY

Study 1: Practice policies for TB testing in CT Findings:

60% of providers read AAP guidelines 62% agreed to being knowledgeable on the TB testing policies

for their school district 85% screened for TB prior to testing 19% reported that a TST was required and 5% reported requiring

neither [1]

Study 2: Case study: Consequences of universal testing for school entrance 11 weeks into treatment with isoniazid (INH), a 4-year-old

girl started having symptoms, which eventually progressed into liver toxicity, requiring a liver transplant. [2]

LITERATURE REVIEW CONCLUSIONS

Study 3: Overall specificities and sensitivities of tuberculin skin test (TST) and interferon-gamma release assay (IGRA) IGRAs were found to be slightly more specific, but equally as

sensitive, in comparison to TSTs [1]

Study 4: Effectiveness of TB tests in pediatric population Findings were consistent with above study Further research is needed for IGRAs and children under 2 years old

[2]

Study 5: Cost-effectiveness of TB testing 38% of the schools required TSTs for admission into kindergarten $1.27 million in savings if universal testing were to be eliminated [3 ]

LITERATURE REVIEW CONCLUSIONS

“Case rates of tuberculosis for all ages are higher in urban, low-income areas and in nonwhite racial and ethnic groups; 80% of reported cases in the United States occur in Hispanic and nonwhite people.” [1 ]

Children 14 years and younger who were born outside of the U.S. make up 25% of newly diagnosed TB cases. [ 2 ]

NEED FOR EBPP

The H.S.- Comprised of:

43.4% White, 30.9% Black, and 16.6% Hispanic [1]

Current enrollment in the clinic is 1,899 students Out of those enrolled, 885 have All Kids

Many international students coming from all parts of the world, many are high-prevalent regions.

Some students leave the country during the summer to go on mission trips that typically last for 6 to 8 weeks. [2]

NEED FOR EBPP

WORLDWIDE TB INCIDENCE

Evanston- 1-3% have no health insurance and 2-6% are on Medicaid. In 2012, 17% of residents had an income of $25,000 or less

and 23% had an income of $25,000 to $50,000. Rated as a “middle-need” community when it comes to

prevention and access to health care. [1]

In 2012- 9,951 TB cases in the U.S. 347 in Illinois 146 in Chicago 89 in Suburban Cook County [2]

4 at ETHS Health Center [3]

NEED FOR EBPP

Three categories:

Structure

Process

Outcome

All of these elements have an impact on each other

DONABEDIAN PARADIGM

1. Annual risk assessment questionnaire

2. Targeted testing Only testing children with at least one risk factor

3. If one or more risk factors are present, choosing the most appropriate test

Tuberculin skin test (TST), also known as the Mantoux or PPD

Interferon-gamma release assay (IGRA) Two branded in U.S.: QuatiFERON-TB Gold (QFT) and T-Spot (also known

as the Elispot)

EVIDENCE BASED PRACTICE PROTOCOL

Risk Assessment Questionnaire New questions added Existing questions expanded Student as an individual

EBPP Easy-to-read algorithm format Added detail

DIFFERENCE BETWEEN OLD & NEW

NO YES1. Where you born outside of the U.S.?*If yes, what country?2. Were any of your family members born outside of the U.S.? 3. Has a family member or anyone that you’ve been in close contact with had tuberculosis disease?4. Has a family member ever had a positive TB skin test?

RISK ASSESSMENT QUESTIONNAIRE

NO YES5. Have you traveled outside of the country for one week or more and had contact with residents of that country?*If yes, what country6. Have any of your family members recently traveled to another country? 7. Have you ever been tested for HIV, with positive results? 8. Have you ever used illegal drugs?9. Do you have regular contact with an adult/s who are: homeless, have been in jail, use illegal drugs, or have HIV?

*Changes highlighted in RED

EBPP

See handout

Mission trip students should be tested upon return only if they traveled to a country with high incidence of TB infection

Testing should be at least 10 weeks after trip. [1]

International students should be tested upon entrance into school.

Suggestions for adherence improvement include: incentives for follow-up visits, confidentiality confirmation, and reminders. [ 2 ]

EBPP IMPLEMENTATION

1. 100% of staff (FNPs and pediatricians) will read the EBPP, as evidenced by a sign off sheet.

2. All five staff members should be well educated on the new protocol, as evidenced by passing (with a score of 80% or higher) a quiz that wil l be taken one month after implementation of the protocol.

3. All students will be screened upon admission to school (starting in kindergarten), and annually thereafter.

4. Staff members will report that they feel more competent in situations related to TB, as demonstrated by a discussion that will take place two months after implementation of the new protocol.

5. All students who are treated with medication for TB infection will fol low up monthly throughout their treatment course (DOT), as evidenced by documentation in Epic.

6. TB positive patient visits will be properly coded with the ICD system, as evidenced by documentation in Epic.

OUTCOME EVALUATIONS

Risk assessment questionnaires Cost: paper & ink

Salary of providers & support staff, medical supplies, and funding from state all remain unchanged.

TSTs done at SBHC Free

QFTs for insured students $230 (before insurance) at NorthShore lab $323.40 (before insurance) at local Quest lab

QFTs for uninsured students $30 (based on sliding scale) at Erie Family Health Center Free at Cook County Department of Public Health

COST IMPLICATIONS

Ultimately, it is the APNs role to identify, evaluate, and manage acute and chronic diseases.

While there lacks a gold standard for tuberculosis testing, APNs must still be competent in knowing what populations are at greater risk, how to administer the risk assessment survey, when to test and which test to choose.

Continuing education to stay on top of latest research and guidelines.

SIGNIFICANCE TO APN ROLE

In the end, no matter which test is used, the most important take home point is to look at the patient as a whole This means looking at risk factors, symptoms, and history

of exposure, rather than solely the test result.

Emphasis is put on the growing change in management of tuberculosis What used to be managed inpatient by specialists is now

commonly seen in the outpatient setting by primary care providers. [1]

PEARLS

THE END