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The Managerial Role In TB Interviewing and Large Scale

Contact InvestigationsMark Wolman

NJ Medical School Global Tuberculosis Institute

February 14, 2011

Outline

• The role of the TB interview and contact investigation in a TB program

• The role of the Program Manager in implementing quality assurance practices for TB interviewers and investigators in a TB program

• Case review and its practical application from the Program Manager’s perspective

Managing Program Activities

• Is the activity being carried out?

• How well is it done?

• What are the outcomes?

• How do they compare with national, state and local TB Program objectives?

How Do You Think We’re Doing in Contact Investigations?

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US Contact Investigations Outcomes (1)

15400146561286914664139371704814444Contacts not evaluated

75410732817148973319774248523880239Contacts identified

Nat’l ObjectiveEvaluation Indices

66% 85%63%61%59%59%60%56%Completed treatment

72%69%71%73%72%70%69%Started treatment for LTBI

23%24%25%26%26%22%24%Contacts w/ LTBI1%1%1%1%1%1%1%Contacts w/ disease

60010 95%586245862058655634876819065795Contacts evaluated8%8%8%7%8%8%9%Cases w/ no contacts

16.215.214.914.015.217.915.2Contacts per case

4649482147985233508047715275Sputum smear positive13779140971451514840150561594616309Cases reported

2006200520042003200220012000Year

Background - 2• CDC estimates on average 15 contacts identified

for every verified pulmonary/laryngeal TB case in the U.S.

– 22-26% are infected with TB– 1% of identified contacts are diagnosed with disease

at time of diagnosis– 10% of newly infected (immunocompetent) contacts

will develop TB disease during their lifetime

• Incidence of TB disease among close contacts is 700/100,000

– For every 1000 contacts identified and evaluated approximately 7 cases are diagnosed with TB

CDC, 2000

• In a CDC national study of 1080 smear positive pulmonary TB patients interviewers failed to identify

– contacts for 8% of TB patients– non-household contacts for 33% of patients– work contacts for 89% of employed patients

Marks, et al, 2000

Background - 3 Background - 4

CDC findings indicate the need for improved skills among interviewers for the purpose of identifying all high and low risk contacts to reported TB suspects and cases.

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All TB Cases Began as TB ContactsJust Two Examples Why Quality

Contact Investigations Are Important…..

• 30-40% of infants aged 0-1 develop TB disease within 1 year of infection

– 25% of these pediatric cases are extra-pulmonary• 66% are diagnosed with lymph node TB

• 6% are diagnosed with miliary TB

• Of those infants who are identified as a contact to a known infectious or potentially infectious TB case 10% who are TST negative develop TB disease

Core Activity

• Contact Investigation is a core activity in a TB Control Program

– TB interview is critical to the contact investigation– Quality of interview skills have a direct impact on

contact investigation outcomes– Essential that all designated TB staff are trained in the

skills of interviewing

Interviewer Knows what questions to ask patient?

Knows how to ask questions

to patient?

Potential Number contacts

Identified?

Poorly trained with little experience

Not really…. Moot point/doesn’t even know what to ask

None… maybe 1?

Partially trained with some experience

Kind of…. Sort of…. Probably 1-3

Properlytrained with experience

Yes Yes Maximum

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Role Of Program Manager - 1

• Program Managers should implement quality assurance practices for contact and source case investigations for the purpose of

– Monitoring the overall effectiveness of the interview process

– Identifying staff training needs on the methods of effective interviewing

– Developing, evaluating and improving the skills of both the experienced and inexperienced interviewers

Role Of Program Manager - 2

• Program Managers should provide appropriate training and on-going evaluation for all program staff conducting TB interviews as accomplished through

– Education• CDC Self-Study Modules on Tuberculosis• Familiarity with local health department program

policies – patients to be interviewed– time frames for interview initiation and completion– documentation

• Effective TB interviewing training course

– Training• Shadowing

– Observing• Modeling

– Simulating• Role-Playing

– Practicing

– Offer environments and opportunities for• Demonstration of various patient scenarios and

techniques of interviewing

• Time for questions and discussion

Role Of Program Manager - 3

– Bridging the Gap between novice and experienced interviewer

• TB Control staff member conducts actual interview with patient and with Program Manager present

• Program Manager should intervene only if interviewer– loses train of thought or becomes distracted– loses focus– becomes intimidated– omits important tasks– exhibits poor interpersonal skills– provides inaccurate information

Role Of Program Manager - 4

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Quality Assurance

• Quality assurance for the novice and experienced interviewer can be accomplished through the development and proper use of an assessment instrument which will ideally

– Help improve interview skills– Assist in the process of staff development– Ensure a thorough evaluation

• Assessment can be conducted through observation of the interview and review of contact investigation activities

– Interview audits should be completed periodically for all TB interviewers regardless of experience

Interview Process And Skills Evaluation Form

Assessment

• Process Elements– Specific tasks the interviewer is expected to complete

during the interview

• Skills Elements– Communication techniques, problem solving and

analytical skills the interviewer demonstrates during the interview

Program Manager Recommendations

• Use of instrument facilitates discussion and provides an environment for– Encouraging the interviewer’s comments– Reviewing the evaluation form noting both

strengths and areas needing improvement– Offering specific techniques of interviewing– Establishing a mutually agreed upon plan for

improvement (if needed)– Providing a copy of the evaluation form to the staff

member

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Congregate Setting Investigations

• Require more sophisticated skills – Technical expertise in infectiousness and transmission– Skill and professionalism in dealing with site

management

• TB Program Managers should periodically review and assess the quality of congregate setting investigations within their program area for

– Appropriateness– Effectiveness– Professionalism

Common Congregate Setting Sites• Schools

– Elementary– Secondary – Colleges and universities

• Day care centers

• Houses of worship

• Hospitals and other health care settings

• Shelters

• Correctional facilities

• Workplace settings

• Social settings

Need for On-site Assessment• If sufficient program resources are available, the

Program Manager should ensure the on-site assessment of the congregate setting be initiated if the index case is diagnosed with suspected or confirmed respiratory TB and presents with

– Smear positive respiratory specimen and/or– Cavitary disease with cough or laryngitis

• Current CDC guidelines recommend that all potential settings for transmission should be visited within 5 business days of initiating the contact investigation or upon identification of setting

• An evaluation of congregate setting investigations will enable the Program Manager to

– Assess performance of both new and existing staff– Identify and address problems associated with

congregate setting investigations– Identify training needs– Review and analyze outcomes

Evaluation

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On-Site Assessment of Congregate Setting

• Determine potential for exposure and transmission– Program Manager should ensure that staff assessment

include accurate and detailed drawings and or photographs with emphasis on

• Room design(s)• Room size(s) in sq. feet• Ceiling height• Type of ventilation• Proximity of individuals in relation to index case

Restaurant Kitchen Area – Hand Drawing

Coat Manufacturer - Camera Daycare Center - Diagram

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Determining When To Expand AContact Investigation

Program Manager needs to consider the following factors for consideration of expansion

• Extent of recent transmission in identified contacts– Unexpected high rate of (+)TST results or– Evidence of secondary cases or– Transmission to contacts <5 years of age or– Documented TST conversions or– Change in TST status from negative to positive

• In absence of recent transmission investigations should not be expanded

Problems and Challenges

• Depending on the setting Program Managers need to be prepared for the following that can be associated with large-scale contact investigations

– Potential for a large number of identified contacts– Potential for vague information for determining contact

priorities– Potential for incomplete identity and locating

information – Challenges in maintaining patient confidentiality– Collaboration with officials and administrators who are

unfamiliar with TB– Media coverage

Skills & Performance Evaluation Skills & Performance Evaluation Cont’d

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Outcomes Evaluation Form Sample Summary Form

Sample Summary Form Cont’d Public Health Incident - 1

• Event– 50 y/o male diagnosed with confirmed pulmonary TB– Currently a resident of a halfway house

• Index case admitted to a local hospital on May 1 with a diagnosis of suspected pulmonary TB

• Regarding the contact investigation what information would you expect to be collected by the interviewer about the patient?

– Cough x3 months– Chest x-ray on admission read as abnormal with non-

cavitary disease– Sputum collected on May 3 &4 recorded as AFB smear

positive (3+)

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Public Health Incident - 2

– Identification of contacts and exposure environments during infectious period

– Treatment start date– Discharge plan– Susceptibilities if known– Name and location of halfway house

Public Health Incident – 3

• Next step?– Schedule management meeting and on-site

assessment of exposure environment – Assessment to be conducted with appropriate staff in

attendance

Public Health Incident – 4

• What information would you expect to be collected from the management meeting and the on-site exposure assessment?

• Two sections of residents– Federal inmates (100)– County/state parolees (500)– Index case a federal inmate with no interaction with

parolees– 30 staff on federal side– All 100 inmates ate at same time in congregate dining

area in a well ventilated open airy room– No assigned seating– 1333 sq ft with 10 ft ceiling

Cafeteria

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Public Health Incident - 5

• Sleeping quarters shared with 5 inmates

• Room measured 348 sq ft with 10 ft ceiling

• 3 double-deck bunk beds

• Moderate to poor ventilation

• Inmates must stay in room from 11pm-6am

• No counseling sessions nor outside work

Living Quarters

Public Health Incident - 6

• Based on the information collected from your staff what are your thoughts regarding this investigation?

– What recommendations would you expect from your staff?

• Test? If yes who and why?

• Not test? Rationale?

• Education sessions?

Public Health Incident - 7

• Information collected from this case can be used to complete assessment instruments and can be a valuable tool to evaluate the performance of both new and existing staff

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Resources

• Performance Guidelines for Contact Investigation: The TB Interview

www.umdnj.edu/globaltb/products/tbinterview.htm

• Tuberculosis Contact Investigation in Congregate Settings: A Resource for Evaluation www.umdnj.edu/globaltb/products/tbcontactinvestigation.htm

• CDC Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosiswww.cdc.gov/tb/publications/guidelines/default.htm