SARAWAK GENERAL HOSPITAL TB INFECTION ......2018/09/06 · After the latest Mesyuarat Jawatankuasa Kawalan Infeksi TB Bil. 2/2017 HUS, it was decided that an update of the pre‐existing

SARAWAKGENERALHOSPITALTBINFECTIONCONTROLPOLICY2NDEDITION2018

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Editorial Board First Edition by: Dr Tie Siew Teck (Head of Respiratory Unit, SGH) NS Saidah Suhaili (Head Nurse, Respiratory Unit, SGH) Second Edition by: Dr Chan Swee Kim (Physician, SGH) Dr Dygku Siti Rafidah bt Pg Hashim (Public Health Physician, Head of Clinical Epidemiology and Hospital Safety, SGH) Dr Mirunaaleni Selvaraju (Medical Officer in Charge, TB Unit, Kuching) Dr Anselm Su Ting (Occupational Health Physician) Dr Tie Siew Teck (Respiratory Physician, Head of Respiratory Unit, SGH) Dr Chua Hock Hin (Infectious Disease Physician, SGH) PPKP Safeeya Bong (Assistant Environmental Health Officer, SGH) Endorsed by: Dr Chin Zin Hing (Hospital Director, SGH) Cover Design by:


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Dr Kho Sze Shyang

Abbreviations AEHO AFB

Assistant Environmental Health Officer (a.k.a. PPKP)Acid‐ Fast Bacilli

CDC Centers for Disease ControlCEHS Clinical Epidemiology and Hospital SafetyHCW Health Care WorkerHEPA High‐Efficiency Particulate AirIGRA Interferon Gamma Release AssayKPAS Kesihatan Pekerjaan dan Alam Sekitar (OSH)NICE The National Institute for Health and Care ExcellenceNIOSH OHU

National Institute for Occupational Safety and HealthOccupational Health Unit

OSH PPE PPKP PTB

Occupational Safety and HealthPersonal Protective Equipment Penolong Pegawai Kesihatan Persekitaran (a.k.a. AEHO) Pulmonary Tuberculosis

RCU SGH

Respiratory Day Care UnitSarawak General Hospital

TB Tuberculosis TB IC Tuberculosis Infection ControlTST Tuberculin Skin Test / Mantoux testUKA Unit Kesihatan AwamWHO World Health Organization


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Foreword

Despitecontinuousefforts in fightingTB, thenumberofTBcases inMalaysia, specifically inSarawakcontinuestorise.Being the tertiary referral centreofSarawak,SarawakGeneralHospital (SGH) is leading theState in the fight against TB. Thus it is important to have a comprehesive policy to avoidshortfallsandcomplacency.Thisistoprotectbothpatientsandhealthcareworkeragainstthishighlyinfectiousdisease.Itiscrucialforallhospitalstaff,includingthealliedhealthandsupportservicestobeawareofandtakeprecautionsinmanaginginfectiousdiseaselikeTB.Asrecommendedbythe“GuidelineonPreventionandManagementofTuberculosisforHealthCareWorkerinMinistryofHealthMalaysia2012”,awrittenTBInfectionControl(IC)PolicyforSGHhasbeeninplacesince2014.ItshowsafirmstandbytheadministrationofSGHtohalttheincreasedincidenceofTBamongMinistryofHealthworkersthroughpreventionprogramsintheworkplace.Thepre‐existingSGHTBICPolicyhasnowbeenreviewedandupdatedtostrengtheneffortsofpreventingunprotectedexposureandcross‐transmissionofTB. Dr Chin Zin Hing Director Sarawak General Hospital


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Table of Contents EditorialBoard..................................................................................................................................................................iiAbbreviations...................................................................................................................................................................iiiForeword............................................................................................................................................................................iv1.INTRODUCTION...........................................................................................................................................................11.1EpidemiologyofM.Tuberculosis.................................................................................................................11.2TBStatisticsintheGeneralPopulation......................................................................................................11.3TBStatisticsinHealthCareWorkers.........................................................................................................2

2.OBJECTIVES...................................................................................................................................................................42.1GeneralObjective.................................................................................................................................................42.2SpecificObjectives...............................................................................................................................................4

3.TERMS OF REFERENCE.................................................................................................................................................53.1SuspectedTBpatient.........................................................................................................................................53.2InfectiousTBpatient:.........................................................................................................................................53.3HighTBRiskAreas:............................................................................................................................................53.4InpatientTBIsolationrooms:........................................................................................................................63.5SurgicalMask:.......................................................................................................................................................63.6Respirator...............................................................................................................................................................63.7N95Mask.................................................................................................................................................................63.8UserSealCheck.....................................................................................................................................................63.9FitTest......................................................................................................................................................................73.10Poweredair‐purifyingrespirator(PAPR)..............................................................................................7

4.STAFFRESPONSIBILITIES......................................................................................................................................84.1SGHTuberculosisInfectionControlCommittee....................................................................................84.2SGHTBICTaskForce(TBIC‐TF)..................................................................................................................94.3TBLinkNurses......................................................................................................................................................94.4WardNursingSisters......................................................................................................................................104.5StaffClinicMedicalOfficers..........................................................................................................................104.6UnitKesihatanAwam(UKA).......................................................................................................................104.7HospitalSupportService...............................................................................................................................104.8EngineeringUnit...............................................................................................................................................114.9TBInfectionControlProgram(TBIC‐P):................................................................................................11

5.NEGATIVEPRESSUREROOMS...........................................................................................................................125.1Locations..............................................................................................................................................................125.2Maintenance........................................................................................................................................................12


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6. PERSONAL PROTECTIVE EQUIPMENT: The N95 Respirator.........................................................................136.1UserSealCheck..................................................................................................................................................136.2N95SupplyConservation..............................................................................................................................146.3FitTest...................................................................................................................................................................16

7. ADMISSION POLICY....................................................................................................................................................237.1SuspectedTBPatientatEmergencyDepartment(ED)....................................................................237.2AdmissionofPatient.......................................................................................................................................23

8. WARD PROCEDURE POLICY....................................................................................................................................268.1N95respirator...................................................................................................................................................268.2Patient...................................................................................................................................................................268.3VisitorsandCarers...........................................................................................................................................268.4MDRTB..................................................................................................................................................................268.5Procedures:.........................................................................................................................................................278.6Treatment............................................................................................................................................................28

9.SPUTUMACID‐FASTBACILLI(SAFB)TESTPOLICY................................................................................299.1Specimentaking................................................................................................................................................299.2Laboratoryprocessingsystem...................................................................................................................299.3Managementofspecimenbottlestock....................................................................................................29

10.NOTIFICATION.......................................................................................................................................................3010.1Legislation.........................................................................................................................................................3010.2MethodofNotification.................................................................................................................................3010.3E‐Notifikasi.......................................................................................................................................................3110.4TBNotificationFlowchart..........................................................................................................................3710.5AuditofTBnotification...............................................................................................................................38

11.DE‐ISOLATIONPOLICY.......................................................................................................................................3911.1De‐isolationcriteria......................................................................................................................................3911.2PTB.......................................................................................................................................................................3911.3MDRTB................................................................................................................................................................39

12. DISCHARGE FROM HOSPITAL POLICY...............................................................................................................4012.1SmearpositivePTB.......................................................................................................................................4012.2Foreigners.........................................................................................................................................................4012.3MDRTB................................................................................................................................................................4012.4DischargeProcessFlowChart..................................................................................................................41

13.DEATHOFTBPATIENTDURINGTREATMENT.......................................................................................4213.1Requirements..................................................................................................................................................42


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14.IN‐HOSPITALACTIONPLANFORDELAYEDDETECTIONOFSMEAR‐POSITIVETBINGENERALWARDS...................................................................................Error!Bookmarknotdefined.

15.HEALTHCAREWORKERSANDTB...................................................Error!Bookmarknotdefined.15.1Introduction........................................................................................Error!Bookmarknotdefined.15.2InvestigationofTBinHealthCareWorkers.........................Error!Bookmarknotdefined.15.3MedicalLeave.....................................................................................Error!Bookmarknotdefined.15.4ReturntoWorkPolicy....................................................................Error!Bookmarknotdefined.15.5RecordKeeping..................................................................................Error!Bookmarknotdefined.15.6ContactScreeningofTBinHealthCareWorkers...............Error!Bookmarknotdefined.15.7GuidelineforPrioritizationofContacts..................................Error!Bookmarknotdefined.15.8BaselineandPeriodicScreeningofTBinHealthCareWorkers.....Error!Bookmarknotdefined.15.9ScreeningLocation..........................................................................Error!Bookmarknotdefined.15.10TypeofScreening..........................................................................Error!Bookmarknotdefined.15.11MantouxTest/TuberculinSkinTest(TST).......................Error!Bookmarknotdefined.15.12Management....................................................................................Error!Bookmarknotdefined.15.13ScreeningReports..........................................................................Error!Bookmarknotdefined.

REFERENCES.....................................................................................................Error!Bookmarknotdefined.

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1. INTRODUCTION

1.1 Epidemiology of M. Tuberculosis

Tuberculosis (TB) is an infection caused by Mycobacterium tuberculosis which is transmitted via airborne particle called droplets nulei. The droplets are generated through couch, sneeze, shout, speak or spit from a laryngeal or pulmonary TB patient. Droplets may travel for 3 feet before gravity pulls them to the ground. Risk of TB transmission depends on; concentration of infectious droplet in the air, duration of exposure, environmental factor, characteristic of the TB patient and the person exposed to TB. Risk of contracting TB can be reduced isolation of patient with active TB, taking effective anti TB treatment and taking appropriate control measures.

1.2 TB Statistics in the General Population In 2017, Malaysia recorded 26,168 new TB cases, and Sarawak remains the third highest state with 2,797 cases. With a population of 2,697,300, TB incidence is thus 104 per 100,000 population – putting Sarawak as a truly high‐burden area by WHO standards. Of the 2,797 cases in Sarawak, 379 (13.6%) were picked up via active case detection, proving the importance of notification and screening. In Sarawak, Kuching Division (Kuching, Padawan, Bau, Lundu) recorded highest cases of TB in 2017, with 586 cases (22%), followed by Miri with 467 cases (18%) and Sibu 351 cases (13%). There were a total of 214 cases of TB notified from Kuching District alone: comprising 80 smear‐positive pulmonary TB (PTB), 66 smear‐negative PTB; and 68 extrapulmonary TB. As a tertiary centre receiving cases from various other districts as well, Sarawak General Hospital (SGH) admits and diagnoses an even greater number of patients, with a total of 328 notified from SGH in 2017, comprising 111 smear‐positive PTB (one of which was multidrug‐resistant TB), 131 smear‐negative PTB, and 86 extrapulmonary TB.

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1.3 TB Statistics in Health Care Workers

Studies of the risk of nosocomial transmission of M. tuberculosis performed in developing countries have shown that HCWs caring for infectious TB patients are at risk of M. tuberculosis infection and disease. Ineffective TB infection control (IC) measures facilitate M. tuberculosis transmission in these health care settings.

The incidence of TB among HCW in Malaysia continues to rise, with 289 HCW afflicted in 2017. Almost three‐quarters of HCW with TB were working in hospitals, with clinic HCW making up the rest. This reflects an urgent need to strengthen our hospital infectious control measures.

Source:BahagianKawalanPenyakit,KementerianKesihatanMalaysia

Table1‐1:HealthCareWorkerDiagnosedwithTBinSarawak2017

HCWinSarawak NumberMedicalOfficer(MO) 7PenolongPegawaiPerubatan(PPP) 1JururawatTerlatih(JT) 8JururawatMasyarakat(JM) 1JuruTeknologiMakmalPerubatan(JTMP) 2PembantuPerawatanKesihatan(PPK) 4Others 3Total 26

Source:BahagianKawalanPenyakit,KementerianKesihatanMalaysia

286 289

118.0

0.0

20.0

40.0

60.0

80.0

100.0

120.0

140.0

0

50

100

150

200

250

300

350

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Notifica

tion rate per 100

,000

TB Cases

Year

TB Cases among HCW NR HCW NR Population7 cases change

diagnosis

Figure1.1:TBAmongHealthCareWorkerinMalaysia,2002‐2017

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In 2017, seven SGH HCW contracted TB: 2 of whom were smear‐positive, 4 were culture‐positive. There were 3 doctors, 2 nursing staff, 1 lab tech, and 1 PPK. All were likely occupational TB, as none had known TB contact outside of the hospital. Frequently identified shortfalls in SGH were lack of awareness regarding user seal check of the N95, low index of suspicion with delayed presentation and delayed diagnosis of TB even among HCW; as well as lack of baseline screening – the last of which compounded difficulties in identifying source of infection. Of the 657 HCW in SGH who underwent Mantoux screening in 2017, 9% (59) were positive (>15mm). Apart from TB screening defaulter, other challenge that may compromise HCW as well as other patient safety is late detection of TB among inpatient. Figure1.2:PulmonaryandExtraPulmonaryTBamongHCWinSGH,2012to2017

Figure1.3:TBMortalityamongSGHHCW,2012‐2017

Source: Public Health Unit, Sarawak General Hospital, 2018

2

7

4

6

4

63

3 1

0

5

10

2012 2013 2014 2015 2016 2017

ExtrapulmonaryPTB

4

22

3 1 2 3 10510152025

DIEDAlive

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2. OBJECTIVES After the latest Mesyuarat Jawatankuasa Kawalan Infeksi TB Bil. 2/2017 HUS, it was decided that an update of the pre‐existing SGH TB IC Policy was needed to strengthen the efforts of preventing our SGH HCW from unprotected exposure to TB. Hence, this second edition has been produced. This policy applies to all individuals in the employ of SGH and it is specifically aimed at staff who are likely to come into contact with patients who have known or suspected tuberculosis apart from ensuring the staff would be able to care for patients with TB safely. It provides operational guidance on administrative, engineering and environmental control measures as well as the use of personal protective equipment.

2.1 General Objective To provide a guideline in the prevention and control of TB infection among patients as well as HCWs in SGH

2.2 Specific Objectives

1. To provide standard of care in TB patients tailored to SGH settings

2. To reduce the risk of TB transmission between patients to HCWs and vice versa in a health‐care setting

3. To promote and improve TB control measures in health‐care setting

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3. TERMS OF REFERENCE

3.1 Suspected TB patient Suspected TB patient is a person in whom a diagnosis of Infectious TB disease is being considered, whether or not antituberculosis treatment has been started.

3.2 Infectious TB patient: 3.2.1 A person with smear positive PTB, on treatment for less than 2 weeks. 3.2.2 A suspected TB patient not on treatment. 3.2.3 A person who has relapsed PTB whose first sputum culture result is not yet

available. 3.2.4 A person with TB on inadequate/inappropriate antiTB. 3.2.4 Any MDRTB patient, including previously treated MDRTB patient or suspected

having MDRTB.

3.3 High TB Risk Areas: 3.3.1 Emergency Department 3.3.2 Isolation ward/Room 3.3.3 All in‐patient wards and treatment/procedure room 3.3.4 All outpatient clinics and treatment/procedure room 3.3.5 HIV patient management facilities. 3.3.6 ICU/HCU/CCU 3.3.7 All Endoscopy areas. 3.3.8 Operation theater 3.3.9 Laboratory Department 3.3.10 Outpatient Department 3.3.11 Radiology Department 3.3.12 Physiotherapy and Rehabilitation 3.3.13 Dental Clinic

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3.4 Inpatient TB Isolation rooms: 3.4.1 Isolation room with negative pressure and HEPA filter. All 11 rooms at “Wad

Pengasingan Penyakit Berjangkit” and 2 rooms at Female Medical Ward (Level 8). There are also 2 negative pressure rooms in Neurosurgical HDU.

3.4.2 Single room at other medical wards except medical 4 ward. 3.4.3 Single room at non‐medical ward (e.g. surgical ward, orthopedic ward etc)

3.5 Surgical Mask: A loose‐fitting, disposable type of facemask that creates a physical barrier between the

mouth and nose of the wearer and potential contaminants in the immediate environment. Surgical masks are fluid resistant and provide protection from splashes, sprays, and splatter. Surgical masks do not seal tightly to the wearer’s face, do not provide the wearer with a reliable level of protection from inhaling smaller airborne particles, and are not considered respiratory protection.

3.6 Respirator

A device worn over the nose and mouth to protect the wearer from hazardous materials in the breathing zone. Respirators must be certified by NIOSH for the purpose for which they are used.

3.7 N95 Mask

A generally used term for a respirator with NIOSH‐approved N95 particulate filter material, which captures at least 95% of airborne particles. It is not resistant to oil.

3.8 User Seal Check

An action conducted by the respirator user to determine if the respirator is properly seated to the face. HCW should perform a user seal check each time they put on the respirator. User seal checks are not substitutes for qualitative or quantitative fit tests.

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3.9 Fit Test

The use of a protocol to qualitatively or quantitatively evaluate the fit of a respirator on an individual.

3.10 Powered air‐purifying respirator (PAPR)

An air‐purifying respirator that uses a blower to force air through filters or cartridges and into the breathing zone of the wearer. This creates a positive pressure inside the face piece or hood, providing more protection than a non‐powered or negative‐pressure half mask APR.

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4. STAFF RESPONSIBILITIES

4.1 SGH Tuberculosis Infection Control Committee

4.1.1 Members 1. Hospital Director (Chairman) 2. Public Health / Occupational Health Unit (Secretariat) 3. Medical Officer In Charge of Kuching TB Unit 4. Respiratory Physician 5. Infectious Disease Physician 6. Infection Control Unit Matron 7. Medical Isolation Ward Sister 8. Hospital Matron In Charge 9. HOD Medical Department 10. HOD Paediatric Department 11. HOD Emergency Department 12. HOD Anaesthesiology 13. HOD Surgery Department 14. HOD Radiology Department 15. HOD Pharmacy Department 16. Intensive Care Unit Matron 17. Respiratory Unit Sister 18. Microbiologist 19. Tuberculosis Infection Control Nurse 20. Hospital Engineer

4.1.2 Responsibility

1. Responsible for the development, monitoring and review of the TB Infection Control Program (TBIC‐P) in SGH.

2. Responsible for the implementation, monitoring and review of HCW TB Screening.

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4.2 SGH TB IC Task Force (TBIC‐TF)

4.2.1 Members

1. Head of SGH Clinical Epidemiology and Hospital Safety 2. Assistant Environmental Health Officer of SGH UKA 3. Infection Control Unit Nursing Sister 4. Respiratory Unit Physician 5. Respiratory Unit Nursing Sister 6. Respiratory Unit Staff Nurse in Charge of Mantoux Test 7. Medical Officer In Charge of Kuching TB Unit 8. Staff Clinic Medical Officer in Charge


1. Implementation of TB IC program/plan. 2. Training, education, testing and evaluation of HCW on TB IC

measures.

4.3 TB Link Nurses

4.3.1 Members 1. Staff Nurses in various units, who have been trained and are familiar

with standard operating procedures in managing patients with TB

4.3.2 Responsibility 1. Counseling of TB patients 2. Ensuring compliance with standard operating procedures in TB

management, including notification of diagnosis, death, etc 3. Monthly report of TB admissions to respective wards, to be sent to

RCU for compilation of data 4. Ensuring standard operating procedure awareness in other HCW of

their units

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4.4 Ward Nursing Sisters 4.4.1 Responsibility 1. Requisitioning of N95 models / sizes fit tested to their staff

2. Ensuring responsible use and recording of N95 PPE 2. Ensuring availability of sputum bottles for AFB collection 3. Ensuring implementation of appropriate infectious control workflow

4.5 Staff Clinic Medical Officers 4.5.1 Responsibility 1. HCW screening and counseling 2. Calling of identified HCW contacts for screening

4.6 Unit Kesihatan Awam (UKA) 4.6.1 Members The unit consist of a Public Health Physician, Pegawai Kesihatan Persekitaran (PKP) and Penolong Pegawai Kesihatan Persekitaran (PPKP). PKP and PPKP was formerly known as Health Inspector (HI). The unit is responsible in performing all public health duties such as epidemiology, enforcement and environmental safety and health but in smaller scale. 4.6.2 Responsibility 1. Interview and investigation of HCW with TB for: i. Investigation of contacts ii. Workplace investigation

2. Compilation of data for HCW diagnosed or screened for TB 4.7 Hospital Support Service One Medicare Sdn. Bhd. is the company that has been awarded the Hospital

Support Services for SGH since 2015. Its services related to the management of TB indirectly are bioelectrical engineering, cleansing and clinical waste management. Their work specification is based on concession agreement.


1. Terminal cleaning of isolation room. 2. Monthly and ad hoc maintenance of negative pressure gauge

and air‐conditioning system in isolation rooms 3. Annual change of HEPA filter and checking of parameters in

isolation rooms

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4.8 Engineering Unit 4.8.1 Members

Unit consist of engineer and assistent engineer.

4.8.2 Responsibility 1. Oversight/Monitoring of OneMedicare services/facility

management. 2. Technical engineering advice

4.9 TB Infection Control Program (TBIC‐P): Table4‐1:TBInfectionControlProgram

Activity Frequency Target site / staff Implementer

New staff briefing 3 monthly New staff OHU / Infection Control Unit

TB Infection Control CPC Yearly All Infection Control Unit SGH TB Infection Control Policy CME

6 monthly All TB IC Task Force

SGH TB Link Nurse Training / Refresher

6 monthly SGH TB Link Nurses TB IC Task Force

N95 User Seal Check Audit

6 monthly Medical Isolation Ward, TB Lab

Infection Control Unit

N95 Mask Fit Test

Yearly Medical Isolation Ward, TB Lab, RCU

Infection Control Unit, with Infection Control Link Nurses

Tissue Test Weekly All Negative Pressure Isolation Rooms

Infection Control Link Nurse

TB IC Committee Meeting and Policy Review

6 monthly TB IC Committee Members

TB IC Task Force

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5. NEGATIVE PRESSURE ROOMS

The Negative Pressure Room also known as Airborne Infection Isolation Room is used to house patients who are suspected or infected with airborne microorganisms eg TB. It refers to the negative pressure relationship between the patient room and the corridor; i.e. the air pressure in the patient room is more negative than the corridor. In a Negative Pressure Room, air shall flow from the corridor to the patient room so as to protect the environment.

5.1 Locations Negative Pressure Rooms in SGH for airborne diseases are in Medical Isolation Ward, Female Medical Ward, and Neurosurgical High Dependency Unit.

5.2 Maintenance

5.2.1 Nurses in charge of patients in these rooms should check the differential pressure of the room pressurization monitor daily, and ad hoc upon suspicion of any problems. 5.2.2 Infection Control Link Nurse in these units should conduct the tissue test at the door, as well as at the exhaust behind the patient bed weekly, and ad hoc upon suspicion of failure of negative pressures. 5.2.3 Parameter check should be done periodically by DOSH recognized hygienist:

Table5‐1:SummaryofNegativePressureRoom@AIIRParameters

Source: Engineering Services Division, Ministry of Health Malaysia, Guideline On Conceptual Design And Engineering Requirements For Isolation Room, 2017

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6. PERSONAL PROTECTIVE EQUIPMENT: The N95 Respirator 6.1 User Seal Check 6.1.1Beforeconductingthenegativeandpositivepressurechecks,moveheadfromside‐

to‐sideandupanddownslowlywhiletakinginafewslowdeepbreaths.16.1.2PositivePressureCheck2

Completelycovertheoutsideoftherespiratorwithbothhands.Donotpushtherespiratoragainst face.Donotdisturbpositionof the respirator.Withhands inplaceonthesurfaceoftherespirator,exhalesharply.

Ifairleaksaroundnose,readjustthenosepiece.

Ifairleaksatedges,workthestrapsbackalongthesidesofhead.

6.1.3NegativePressureCheck

Withhandsstillinplaceovermask,inhaledeliberately.Themaskshoulddepressslightlyinward.

6.1.4AnotherfacepieceshallbeselectedandretestediftheHCWfailstheusersealcheck

testsdespiteadjustmentofnosestripandelasticbands.

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6.2 N95 Supply Conservation AllHCWneedtotakestepstoconservesupplyofN95.6.2.1AppropriateUsage N95masksshouldNOTbegiventopatientsorrelatives.6.2.2PreferentialUsage

Minimize the number of individuals who need to use the N95, for example,preferentialentranceofHCWsduringroundsintotheisolationsiderooms,ratherthanthewholeteam.

6.2.3SteppingDown

Even if patient remains in the general ward isolation side room, if SAFB x 3negative,theHCWthennolongerhastowearN95toentertheroom.

6.2.4Reuse

Reuse refers to the practice of using the same N95 respirator by the same HCW for multiple encounters with patients but removing it (‘doffing’) after each encounter. The respirator is stored in between encounters to be put on again (‘donned’) prior to the next encounter with a patient. Tuberculosis is not transmitted via contact and, therefore, reuse by the same wearer is acceptable as long as the filtering facepiece respirator is not damaged or soiled.

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Procedures for Reuse (Adapted from CDC Recommendations)3 Hand hygiene

Clean hands with soap and water or an alcohol‐based hand sanitizer before and after touching or adjusting the respirator (if necessary for comfort or to maintain fit).

Avoid touching the inside of the respirator. If inadvertent contact is made with the inside of the respirator, perform hand hygiene as described above.

Storage

Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses.

To minimize potential cross‐contamination, store respirators so that they do not touch each other and the person using the respirator is clearly identified.

Storage containers should be disposed of or cleaned regularly.

Discard After aerosol generating procedures If contaminated with blood, respiratory or nasal secretions, or other bodily fluids

from patients After close contact with any patient co‐infected with an infectious disease

requiring contact precautions After 5 uses per device, or at the end of the nursing shift

TheuseofN95aloneshouldnotbeusedasthemaincontrolmeasuresinceitcanonlyworkifstandardworkpracticeandenvironmentalcontrolsareinplace. Sources:

1 RPP Appendix E: User Seal Check Procedures of NIOSH. CDC. Hospital RespiratoryProtectionProgramToolkit.ResourcesforRespiratorProgramAdministrators. May 2015. RPP Appendix E: User Seal Check Procedures. p92.

2 3M Personal Safety Division. Particulate Respirator N95. 8210Plus/8210/0748/8110S. User Instructions. Fitting Instructions. 2015.

3 CDC. NIOSH. Recommended Guidance for Extended Use and Limited Reuse of N95FilteringFacepieceRespiratorsinHealthcareSettings.March13,2014

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6.3 Fit Test Fit testing is one of the most important parts of the respirator program because it is the only recognized tool to assess the fit of a specific respirator model and size to the face of the user. OSHA requires employers to make available sufficient number of models and sizes of respirators so that employees can be provided with a respirator that is comfortable and fits well. Employees are only allowed to use the make, model, style, and size of respirator or respirators for which they have been successfully fit tested.

Fit testing is required for all users of respirators with tight‐fitting facepieces. The fit test ensures that, when donned properly, the selected brand and size of respirator fits adequately to protect the wearer from excessive inward leakage of contaminant through the face seal. The fit test must be repeated annually and whenever the HCW reports, or the supervisor, makes visual observations of any changes in the employee’s physical condition, such as weight gain or loss, facial scarring, or dental changes, that could alter fit of the facepiece.

Fit testing must be performed by an individual knowledgeable in respiratory protection, and qualified to follow the protocol and train the HCW to properly put on and take off the respirator.

Records of fit tests must be kept on file until the next annual test is performed, HCWs should use only the respirator model and size for which they have passed a fit test.

The fit test kit currently available in SGH is the qualitative Bitrex® Aerosol Fit Test with hood enclosure.

Source: NIOSH. CDC. Hospital Respiratory Protection Program Toolkit. Resources for Respirator Program Administrators. May 2015. p.40.

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6.3.1 Fit Testing Procedures: General Requirements.

1. The HCW may not eat, drink (except plain water), smoke, or chew gum for 15 minutes before the test.

2. The HCW shall be allowed to pick the most acceptable respirator from a sufficient number of respirator models and sizes so that the respirator is acceptable to, and correctly fits, the user.

3. Prior to the selection process, the HCW shall be shown how to put on a respirator, how it should be positioned on the face, how to set strap tension and how to determine an acceptable fit. A mirror shall be available to assist the subject in evaluating the fit and positioning of the respirator.

4. The HCW shall be informed that he/she is being asked to select the respirator that provides the most acceptable fit. Each respirator represents a different size and shape, and if fitted and used properly, will provide adequate protection.

5. The HCW shall be instructed to hold each chosen facepiece up to the face and eliminate those that obviously do not give an acceptable fit.

6. The more acceptable facepieces are noted in case the one selected proves unacceptable; the most comfortable mask is donned and worn at least five minutes to assess comfort. If the HCW is not familiar with using a particular respirator, the HCW shall be directed to don the mask several times and to adjust the straps each time to become adept at setting proper tension on the straps.

7. Assessment of comfort shall include a review of the following points with the HCW and allowing the HCW adequate time to determine the comfort of the respirator.

(a) Position of the mask on the nose (b) Room for eye protection (c) Room to talk (d) Position of mask on face and cheeks

8. The following criteria shall be used to help determine the adequacy of the respirator fit: (a) Chin properly placed;

(b) Adequate strap tension, not overly tightened (c) Fit across nose bridge; (d) Respirator of proper size to span distance from nose to chin; (e) Tendency of respirator to slip; (f) Self‐observation in mirror to evaluate fit and respirator position.

9. The HCW shall conduct a user seal check.

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10. The test shall not be conducted if there is any hair growth between the skin and the facepiece sealing surface, such as stubble beard growth, beard, mustache or sideburns which cross the respirator sealing surface. Any type of apparel which interferes with a satisfactory fit shall be altered or removed.

11. If a HCW exhibits difficulty in breathing during the tests, she or he shall be referred to a doctor, to determine whether the test subject can wear a respirator while performing her or his duties.

12. If the HCW finds the fit of the respirator unacceptable, the HCW shall be given the opportunity to select a different respirator and to be retested.

13. Exercise regimen. Prior to the commencement of the fit test, the HCW shall be given a description of the fit test and the HCW's responsibilities during the test procedure. The description of the process shall include a description of the test exercises that the subject will be performing. The respirator to be tested shall be worn for at least 5 minutes before the start of the fit test.

14. The fit test shall be performed while the HCW is wearing any applicable safety equipment that may be worn during actual respirator use which would interfere with respirator fit.

15. Dated records of the fit test outcomes for each HCW should be kept by the Infection Control Link Nurse of the Unit.

16. HCW should be given a wallet‐sized fit test verification card upon passing the fit test, to ensure that they can easily recall the model for which they have been tested.1

1Adapted from: Association of Occupational Health Professionals in Healthcare. Tools for Your Work. N95 Respirator Training and Fit Testing Verification Card. 2009.

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6.3.2 Bitrex® (Denatonium Benzoate) Solution Aerosol Qualitative Fit Test Protocol.

The Bitrex® (Denatonium benzoate) solution aerosol QLFT protocol uses the published saccharin test protocol because that protocol is widely accepted. Bitrex® is routinely used as a taste aversion agent in household liquids which children should not be drinking and is endorsed by the American Medical Association, the National Safety Council, and the American Association of Poison Control Centers. The entire screening and testing procedure shall be explained to the test subject prior to the conduct of the screening test.

6.3.2.1 Taste Threshold Screening.

The Bitrex® taste threshold screening, performed without wearing a respirator, is intended to determine whether the individual being tested can detect the taste of Bitrex.

(1) During threshold screening as well as during fit testing, subjects shall wear an enclosure about the head and shoulders that is approximately 12 inches (30.5 cm) in diameter by 14 inches (35.6 cm) tall. The front portion of the enclosure shall be clear from the respirator and allow free movement of the head when a respirator is worn.

(2) The test enclosure shall have a 3/4 inch (1.9 cm) hole in front of the HCW's nose and mouth area to accommodate the nebulizer nozzle.

(3) The HCW shall don the test enclosure. Throughout the threshold screening test, the HCW shall breathe through his or her slightly open mouth with tongue extended. The HCW is instructed to report when he/she detects a bitter taste.

(4) Using a DeVilbiss Model 40 Inhalation Medication Nebulizer or equivalent, the test conductor shall spray the Threshold Check Solution into the enclosure. This nebulizer shall be clearly marked to distinguish it from the fit test solution nebulizer.

(5) The Threshold Check Solution is prepared by adding 13.5 milligrams of Bitrex® to 100 ml of 5% salt (NaCl) solution in distilled water.

(6) To produce the aerosol, the nebulizer bulb is firmly squeezed so that the bulb collapses completely, and is then released and allowed to fully expand.

(7) An initial ten squeezes are repeated rapidly and then the HCW is asked whether the Bitrex® can be tasted. If the HCW reports tasting the bitter taste during the ten squeezes, the screening test is completed. The taste threshold is noted as ten regardless of the number of squeezes actually completed.

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(8) If the first response is negative, ten more squeezes are repeated rapidly and the HCW is again asked whether the Bitrex® is tasted. If the HCW reports tasting the bitter taste during the second ten squeezes, the screening test is completed. The taste threshold is noted as twenty regardless of the number of squeezes actually completed.

(9) If the second response is negative, ten more squeezes are repeated rapidly and the test subject is again asked whether the Bitrex® is tasted. If the HCW reports tasting the bitter taste during the third set of ten squeezes, the screening test is completed. The taste threshold is noted as thirty regardless of the number of squeezes actually completed.

(10) The test conductor will take note of the number of squeezes required to solicit a taste response.

(11) If the Bitrex® is not tasted after 30 squeezes (step 10), the HCW is unable to taste Bitrex® and may not perform the Bitrex® fit test.

(12) If a taste response is elicited, the HCW shall be asked to take note of the taste for reference in the fit test.

(13) Correct use of the nebulizer means that approximately 1 ml of liquid is used at a time in the nebulizer body.

(14) The nebulizer shall be thoroughly rinsed in water, and shaken to dry.

Source: NIOSH. CDC. Hospital Respiratory Protection Program Toolkit. Resources for Respirator Program Administrators. May 2015. Part 1. OSHA‐Accepted Fit Test Protocols.

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6.3.2.2 Bitrex® Solution Aerosol Fit Test Procedure.

(1) The test subject shall don the enclosure while wearing the selected respirator. The respirator shall be properly adjusted.

(2) A second DeVilbiss Model 40 Inhalation Medication Nebulizer or equivalent is used to spray the fit test solution into the enclosure. This nebulizer shall be clearly marked to distinguish it from the screening test solution nebulizer.

(3) The fit test solution is prepared by adding 337.5 mg of Bitrex® to 200 ml of a 5% salt (NaCl) solution in warm water.

(4) As before, the HCW shall breathe through his or her slightly open mouth with tongue extended, and be instructed to report if he/she tastes the bitter taste of Bitrex.

(5) The nebulizer is inserted into the hole in the front of the enclosure and an initial concentration of the fit test solution is sprayed into the enclosure using the same number of squeezes (either 10, 20 or 30 squeezes) based on the number of squeezes required to elicit a taste response as noted during the screening test.

(6) After generating the aerosol, the HCW shall be instructed to perform the following exercises:

Test Exercises:

The respirator shall not be adjusted once the fit test exercises begin. Any adjustment voids the test, and the fit test must be repeated. The HCW shall be questioned by the test conductor regarding the comfort of the respirator upon completion of the protocol. If it has become unacceptable, another model of respirator shall be tried.

Each test exercise shall be performed for one minute:

1. Normal breathing. In a normal standing position, without talking, the HCW shall breathe normally.

2. Deep breathing. In a normal standing position, the HCW shall breathe slowly and deeply, taking caution so as not to hyperventilate.

3. Turning head side to side. Standing in place, the HCW shall slowly turn his/her head from side to side between the extreme positions on each side. The head shall be held at each extreme momentarily so the HCW can inhale at each side.

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4. Moving head up and down. Standing in place, the HCW shall slowly move his/her head up and down. The HCW shall be instructed to inhale in the up position (i.e., when looking toward the ceiling).

5. Talking. The HCW shall talk out loud slowly and loud enough so as to be heard clearly by the test conductor. The subject can read from a prepared text such as the Rainbow Passage, count backward from 100, or recite a memorized poem or song.

Rainbow Passage

When the sunlight strikes raindrops in the air, they act like a prism and form a rainbow. The rainbow is a division of white light into many beautiful colors. These take the shape of a long round arch, with its path high above, and its two ends apparently beyond the horizon. There is, according to legend, a boiling pot of gold at one end. People look, but no one ever finds it. When a man looks for something beyond reach, his friends say he is looking for the pot of gold at the end of the rainbow.

6. Bending over. The HCW shall bend at the waist as if he/she were to touch his/her toes.

7. Normal breathing. Same as exercise (1).

(7) Every 30 seconds the aerosol concentration shall be replenished using one half the number of squeezes used initially (e.g., 5, 10 or 15).

(8) The HCW shall indicate to the test conductor if at any time during the fit test the taste of Bitrex® is detected. If the HCW does not report tasting the Bitrex, the test is passed.

(9) If the taste of Bitrex® is detected, the fit is deemed unsatisfactory and the test is failed. A different respirator shall be tried and the entire test procedure is repeated (taste threshold screening and fit testing).

Source: NIOSH. CDC. Hospital Respiratory Protection Program Toolkit. Resources for Respirator Program Administrators. May 2015. RPP Appendix D: Selected Fit Test Protocols.

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7. ADMISSION POLICY

7.1 Suspected TB Patient at Emergency Department (ED)

7.1.1 Identification of patient with chronic cough (>2 weeks) should be performed at triage area, and patient directed to decon room once identified.

7.1.2 All suspected TB patients should be directed to the ED isolation area or “decon

room”. 7.1.3 Decision of admission/discharge/transfer should be expedited if possible

without compromising patient safety. 7.1.4 Do not wait for sputum AFB result while decision on placement of suspected TB

patient.

7.2 Admission of Patient

7.2.1 Active TB should be managed as outpatient unless indicated for admission. 7.2.1 Suspected TB patient who do not require admission should be referred to

nearest TB clinic with referral later stating reason of referral and imaging performed. The referred TB clinic needs to be informed by phone about the patient’s particulars (including name, IC, address and contact number). A record of patient’s particulars needs to be kept by Emergency Department and pass to TB clinic as soon as possible.

7.2.2 Medical Isolation Ward (Ward Penyakit Berjangkit) is the primary ward of

admission for all suspected PTB patients after authorized by physician in‐charge of medical isolation ward.

7.2.3 If no bed is available at Medical Isolation Ward, then case to be admitted to

Female Medical Ward negative pressure isolation rooms (2 rooms). 7.2.4 If option 6.2.2 and 6.2.3 are not available, admit patient to single‐bed room in

Medical Ward.

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7.2.5 If option 7.2.4 is not available, admit patient to single room at non‐medical ward after discussed with doctor in‐charge of respective ward.

7.2.6 For disciplines other than medical, admit patient to single room of the

respective ward. 7.2.7 Patient referred from other hospital/clinic should have PTB status (at least 3

sputum AFB) known if possible. 7.2.8 Physician accepting referral from other hospital/clinic of stable patient with

suspected infectious TB to arrange for direct admission to Medical Isolation Ward if possible.

7.2.9 All MDRTB patients, including suspected/previously treated/on treatment

MUST be admitted to negative pressure isolation room. 7.2.10 All HIV patients suspected to have infectious TB should be admitted. 7.2.11 All infectious TB patients requiring mechanical ventilation should be admitted

to medical isolation room if possible. 7.1.12 If option 7.2.11 is not available, medical officer responsible for admitting the

patient needs to discuss with anesthetist on placement of patient. 7.2.13 Medical officer responsible for admitting a suspected PTB patient is also

responsible to identify placement of patient. 7.2.14 Patients should be adequately resuscitated in ED before transfer to isolation

rooms

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Algorithm for Admission of Suspected / Infectious TB Patient for Medical Discipline in Decontamination Room

MO to prioritize review of patient in Decon Room

Patient meets definition of Suspected / Infectious TB

Patient

Patient is deemed NOT Infectious TB patient

Admit general medical ward as per usual, or transfer out of Decon Room to appropriate ER zone if general medical ward bed not available

yet

Call Medical Isolation Ward (ext. 4391) to check bed availability and check on current physician‐in‐charge of Medical Isolation

Ward

Medical Isolation Ward bed available

Medical Isolation Ward bed NOT available

Medical Isolation Ward bed NOT currently available but deemed

necessary for patient

MO to call physician‐in‐charge of Medical Isolation Ward to

greenlight admission

Call FMW for Negative‐Pressure Isolation Room; or if

not available, call MMW or Medical3 for single‐bed isolation room

MO to call physician‐in‐charge of Medical Isolation Ward for

endorsement and identification of any patients fit for transfer out of

Medical Isolation Ward

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8. WARD PROCEDURE POLICY

8.1 N95 respirator 8.1.1 All staff attending Infectious TB patients, including escorting attendants,

should use N95 mask. 8.1.2 The N95 is not required for smear‐negative TB, unless performing aerosol‐

generating procedures. 8.1.3 Although extrapulmonary TB with no lung involvement is considered non‐

infectious, N95 is still required if performing aerosol‐generating procedure or wound irrigation

8.2 Patient

1. Should be discouraged from moving out of their isolation room. 2. Infectious TB patients must wear a surgical mask if requiring movement out of

the isolation room, during transport of patients from one facility to another or within a facility, e.g. for procedures, unless precluded by respiratory distress / oxygen requirement. If transport between facilities is required, patients should be transported in well‐ventilated vehicles (i.e. with the windows open) as much as possible. Attendants should wear N95 mask.

8.3 Visitors and Carers

1. Carers should be limited to minimum and use surgical mask 2. Visitors should be discouraged, and limited to 2 at one time and use surgical

mask. 3. Children below 5 years old should be strongly discouraged from visiting TB

patient 8.4 MDRTB

1. ALL VISITORS of MDRTB patient MUST use N95 mask.

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8.5 Procedures:

8.5.1 Sputum AFB report turn‐around‐time should be 24hours or less, including weekends and public holidays.

8.5.2 Imaging

1. Patients should wear a surgical mask to the Radiology Department, unless in respiratory distress / requiring oxygen mask support.

2. Staff in charge should call Radiology Department to inform when sending infectious TB patients for imaging. The radiologic procedure should be expedited – i.e. avoid infectious patient waiting time in Radiology Department. If possible, the radiologic procedure should be performed during times of less patient traffic.

3. For patients in Medical Isolation Ward, where an in‐house portable X‐ray machine is available, Chest X‐rays should be performed in situ – to avoid unnecessary movement of infectious patient out of the ward.

4. Infectious TB status should be clearly indicated in imaging request forms.

8.5.3 Chest physiotherapy should not be performed until smear turns negative.

8.5.4 Invasive procedures (especially cough‐inducing procedures) should be postponed

until 2 weeks of antiTB treatment, if possible.

8.5.5 Bronchoscopy

1. Bronchoscopy should not be performed until smear turns negative, except for life‐saving indication.

2. If bronchoscopy is required for life‐saving purposes in smear‐positive infectious PTB, HCW should don PAPR, and procedure should preferably be performed in Medical Isolation Ward negative pressure rooms.

3. If smear‐negative, but suspicion of infectious PTB remains high,

bronchoscopy should performed with at least N95 protection, preferably in the Medical Isolation Ward negative pressure rooms.

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8.6 Treatment 1. Anti TB treatment should be initiated AS SOON AS POSSIBLE, once active TB is

suspected.

2. Nebulization of Infectious TB patient should be done in a single room, preferably in negative pressure isolation room. Inhalers, if required, should be provided as soon as possible, to cut down on unnecessary nebulizations.

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9. SPUTUM ACID‐FAST BACILLI (SAFB) TEST POLICY 9.1 Specimen taking

9.1.1 All new patients suspected of pulmonary TB should have SAFB AS SOON AS POSSIBLE, with 3 consecutive samples sent off daily, INCLUDING WEEKENDS, to expedite de‐isolation if negative; or expedite initiation of treatment to render patient less infectious if positive.

9.1.2 Staff to ensure that sputum collection bottles are given to patients promptly,

including while in ER / Decon Room 9.1.3 First spot sputum sample for SAFB to be collected at anytime whenever patient is able

to expectorate 9.1.4 Subsequent sputum samples to be collected in the morning, or at any other time of

day if patient had failed to expectorate in the morning 9.1.5 Doctors to fill up TBIS 20C request forms for SAFB promptly at the point of review and

staff to ensure that sputum bottles are sent off to TB Lab as soon as sampled 9.2 Laboratory processing system

9.2.1. Lab turn around time is 24 hours after receipt of sample, including weekends

9.2.2 Staff in charge to trace SAFB results promptly – routinely available from TB lab by 4pm on the same day if samples have been sent in the morning.

9.3 Management of specimen bottle stock

Ward Sisters to ensure appropriate ordering and adequate stock of sputum bottles in ward at all times. Stock queries should be made to Lab Media Room (extension 3020), or Bacteriology Lab (ext 3019).

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10. NOTIFICATION 10.1 Legislation

Under Prevention and Control of Infectious Disease Act 1988, it is mandatory for all forms of tuberculosis to be notified within 1 week of confirmed diagnosis or upon initiation of anti‐TB, including trial of therapy.

10.2 Method of Notification

A complete notification include: 1) Form “Notifikasi Penyakit Berjangkit Yang Perlu Dilaporkan: Borang Notis:

Rev/2010” (refer below) AND 2) Borang TBIS 10A‐1/pind.1. (refer page 32). Notification is followed by informing the UKA directly by phone (082‐241454/ 082‐241462) or through TB liason officer to the official TB SGH Whatsapp group.

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10.3 E‐Notifikasi An alternative to written notification (Borang Notis: Rev/2010) is online notification via national notification portal at www.enotifikasi.moh.gov.my. The input can be done by UKA or the respective ward themselves. The user ID and password can be obtained from CDC unit of local Divisional Health Office – Pejabat Kesihatan Bahagian (PKB).

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2) Borang TBIS 10A‐1/pind.1.

Page1/5

33

Page2/5

34

Page3/5

35

Page4/5

36

Page5/5

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10.4 TB Notification Flowchart Upon notification, PPKP from TBCP Unit of PKB Kuching will come to investigate the case:

TB Patient admitted and investigated

Patient plan of discharge will include follow up to the neraest Klinik Kesihatan for follow up

Patient discharged

TBCP Unit will investigate within 24 hours upon notification

Case will be referred to TBCP Unit and respective HUS TB link nurse

1)Patient started TREATMENT or 2)Patient confirmed or strongly suggestive TB but DIED BEFORE starting antiTB

Patient plan for discharge

‐TB Notification to the nearest PKB/PKD using

BORANG REV 2010 AND TBIS 10A‐1. Inform UKA.

‐Case will be handed over to the TBCP Unit PPKP from

nearest PKB

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10.5 Audit of TB notification Audit shall be performed by UKA to detect unreported cases of TB as per the diagram below:

10.5.1 All medical officer/specialist need to ensure that all positive lab investigations, patient started on anti TB trial, or patient died of TB before anti TB initiated must be notified. The patient and/or relatives must be informed about TB to facilitate investigation and control measures by the health department. 10.5.2 According to PREVENTION AND CONTROL OF INFECTIOUS DISEASES ACT 1988, Section 10 indicates the requirement to notify infectious diseases and Section 25 lineate the compound if failure to notify. Sources:

1) Garispanduan Pelaksanaan & Penyeliaan Program Kawalan Penyakit TB, JKN Sarawak, 2017 (Edisi ke 2)

2) Prevention And Control Of Infectious Diseases Act 1988

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11. DE‐ISOLATION POLICY Decisionofde‐isolationshouldbemadebyspecialistin‐chargeofthepatient.11.1 De‐isolation criteria

Deisolation of infectious TB patient can be done once all the following criteria are fulfilled.

1. Two weeks of appropriate TB drug therapy 2. Tolerance of the prescribed treatment 2. Compliance to the prescribed treatment 3. Signs of clinical improvement

11.2 PTB All suspected PTB with subsequent negative sputum AFB X3 can be deisolated, unless other indications for isolation exist.

11.3 MDRTB Timing of de‐isolation for MDRTB patient should be decided by Respiratory or Infectious Disease Physician.

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12. DISCHARGE FROM HOSPITAL POLICY 12.1 Smear positive PTB

12.1.1 Smear positive PTB patient can be discharged home once no other indication of hospitalization is present and the following criteria are met:

1. Household air is not being recirculated to other housing units (e.g. apartment complex)

2. No infant or children under age 5 years or persons with immunocompromising conditions are present in the household, unless if they already receiving TB treatment or LTBI treatment.

3. All immunocompetent household members have been previously exposed to the patient.

4. There should be clinical evidence of improvement and reasonable evidence of adherence to antiTB medication.

5. For patients who require commercial airline transport to return home, three negative AFB smears need to be demonstrated. Patients with active PTB should be informed not to fly until non‐infectious

12.1.3 If the above criteria are not met, patient should be isolated in the hospital for up

to 2 weeks 12.1.4 Infectious TB patients who attend out‐patient follow‐up should wear a surgical

mask while visiting any health facility until smear‐converted to negative. 12.2 Foreigners

All foreigners who are diagnosed as infectious TB should be treated until smear negative before being sent back to respective countries unless there are other reasons to do otherwise.

12.3 MDRTB

Timing of discharge for MDRTB patient should be decided by Respiratory Physician or Infectious Disease Physician.

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12.4 Discharge Process Flow Chart For discharge, pursuant to JKNS directive “JKNSWK/K/TBCP/5B/Jld.1(9) 2012”

* Date of planned registration at TBCP should be within 1‐2 days after discharge

TB Patient for discharge from ward

End

Staff to fax memo to TBCP Unit

Staff to fill "Memo Makluman Pesakit TB Discaj daripada Hospital"

TB Patient COMPLIANT to follow up

TBCP unit to ensure that patient registers as per the planned date*, and to continue and monitor patient during follow up

Staff to inform TBCP Unit under which patient has been planned for follow‐up, by telephone, to arrange date of follow‐up* with the TBCP. For non‐Medical Wards, the on‐call TB link nurse should also be informed about the patient to be discharged

End

TB Patient DEFAULTED follow up on the planned date

If patient not found within 24 hours, tracing to be attempted again at least weekly for 8 weeks until patient is found to continue follow up

TBCP to trace the patient within 24 hours

Continue follow‐up as per routine

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13. DEATH OF TB PATIENT DURING TREATMENT 13.1 Requirements

13.1.1 In the event of death, the causeofdeathmustbedetermined as causeddirectlybyTBorotherwise.

13.1.2TB‐relateddeathswillbeaudited to improve and avertmorepreventabledeathsinfuture.

13.1.3Thedoctorsinchargeofthepatientshouldfillupandsignoffontheforms:i)KuchingTBCPUnit’s“PenyiasatanKematianKesTibiDalamRawatan”

(referpage44)

ii) KKM’s TBIS 10J “Borang Penyiasatan Kematian Kes Tibi DalamRawatan”(referpage46)* Specialist in charge of the patient, should comment, specifically inregardstowhetherthedeathisduetoTBornot.

13.1.4Theformswillthenbesubmitted,toKuchingTBCPUnitviaRespiratoryDaycare,within3days.

13.1.5IfdeathisduetoTB,oriftheformsarenotreceivedbyKuchingTBCPUnit,thePhysician/MedicalOfficerinchargeofthedeceased,willbecalledforTBMortalityReview.(Itisthussugggestedthatthedoctorsinchargepreparepowerpointslidesforthemortalityearly,whilethecaseisstillfreshinmemory,withcapturedimagesof CXRs, and followup any relevant pending results, to avoid anymissingdataduringtheTBMortalityMeeting.)

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TBDeathduringTreatmentInvestigationForm1) BorangPenyiasatanKematianKesTibiDalamRawatan

(UnitKawalanTibi/KustaDaerahKuching)

Page1/2

SARAWAK GENERAL HOSPITAL TB INFECTION ......2018/09/06 · After the latest Mesyuarat Jawatankuasa Kawalan Infeksi TB Bil. 2/2017 HUS, it was decided that an update of the pre‐existing

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