SOUTHEASTERNNATIONALTUBERCULOSISCENTER(SNTC)HTTP://SNTC.MEDICINE.UFL.

EDU

Managing Tuberculosis Suspects/Cases in Corrections

Clinical Pathway
INITIAL
WHEN
DONE

DATE
COMPLETED

Immediately place all tuberculosis (TB) suspects in negative airborne infection isolation (AII) room.

Obtainsputumcontainers(36)fromthehealthdepartment(HD)orlaboratory.Collectsputumspecimenson3separatedays
oratleast8hoursapart(withonefirstmorningspecimen)Ifunabletoexpectorate,mayneedsputuminductioneitheronsite
atfacility,HDorlocalhospital).

Provideinstructionstoinmateandstaffonhowtoobtainawitnessedsputumspecimen,includingtheneedforimmediate
refrigerationaftercollectionandensuringthecontainer(bothinnerandouter)islabeledcorrectly,priortosendingspecimen
tolaboratory(ifpossible,useHDstatelab).

Obtain,collectandroutesputumspecimen(witnessed)foracidfastbacillus(AFB)smear,nucleicacidamplification(NAA)test,
MycobacteriumtuberculosisDirect(MTD)testandculture.

Day 1

VISIT

PLEASE REMEMBER TO INITIAL AND DATE AFTER COMPLETING EACH TASK

Obtainmedicalhistoryincludingsigns,symptomsanddurationofsymptomsofTBdisease.

Physician/ARNP/PAperformsphysicalexamination.

OfferHIVcounselingandtesting.DrawbloodforHIVtest.Obtainbaselinetests/resultsifapplicable,(i.e.,liverenzymessuch
asSerumglutamicoxaloacetictransaminase(SGOT)andSerumglutamicpyruvictransaminase(SGPT),bilirubin,creatinine,
completebloodcount(CBC),plateletcount,uricacid,asordered).

PlaceTSTatthistime,ifnotalreadydone.

Obtainweight/performbaselinevisualacuity/testingforred/greencolorblindnessifapplicable.

Obtainchestxray(CXR)ifnorecentoneisavailable.Placesurgicalmaskonpatientwhentransporting.

NotifyHDofsuspect/casebyphoneandinwriting(usingcopyofappropriateTBmedicalreportandtreatmentplan).

HaveTBnursecasemanagerorcorrectionsnurse/designeeinstructthepatientabouttheneedformedicationsand
reactions/sideeffectsofmedications,andincludetheneedfordirectlyobservedtherapy(DOT).

ProvideeducationalinformationaboutTBandplanforfuturecare,includingtheneedformonthlyclinicvisitstoseethe
physician,nurse,orhealthdepartmentTBprogramstaff.

Obtainprescriptionforfourdrugtherapy.Medications:(Rifampin,Isoniazid,PyrazinamideandEthambutol).

AdministermedicationsusingstrictDOT(DOT=DirectlyObservedTherapy=swallowing,notsimplydeliveryofmedications)

Discussandhavepatientsignmedicalreleaseformsasnecessary.

DiscussandhavepatientsignacknowledgementofappropriateTBcounselingandeducationformsforHDandfacilitymedical
record.

Identifypatientasneedingnotificationtomedicalstaffpriortorelease.Beginplanningforeventualreleasefromfacility.

BegincontactinvestigationinconjunctionwiththeHDcasemanager(ifoneisneeded)peryourHDsinstructions.Youmaybe
instructedtowaituntilthesputumresultsreturn.DeterminethisinconjunctionwiththeHDTBProgram.

Reporttotheadministrator/directorofthefacilitythatthepatientisplacedinanegativeAirborneInfectionIsolation(AII)
roomandtheneedforassistanceifcontactinvestigationisneededorrequired.

Placewritteninformationinclassifications/releasefolderfornotificationtomedical/healthdepartmentcasemanagerpriorto
releasefromfacility.

Identifyinfectiousperiod:

Obtain2 earlymorningsputumspecimenorperformsputuminduction.Labelappropriatelyandsendtohealth
department/statelabforsmear,NAA(orMTD)andculture.

FROM(date)

TO(date)

ObserveforstrictDOT(swallowingofmedications),includingcheckingtheamountofmedication.

Day 2

nd

Examinethemedicationadministrationrecord(MAR)forrefusals/medicationmissing,etc.

Obtainsputumresultsfromday1(1 specimen)ifavailable.

ReadTSTandrecordresultsinchartinmm(ifapplicable).

IfTST+and/or+AFB/MTD,consultwithphysician/healthdepartmentcasemanager.
Day 3

st

Obtainsputumresultsfromday2(2 specimen)ifavailable.

nd

ReviewCXRreport/filmwithphysician/healthdepartmentcasemanager.

ContinuedailyDOTwithfourdrugtherapyfornext2monthsasdirectedbyphysicianoruntildirectedotherwisebyhealth
departmentcasemanager/physician.Monitorfornonadherence.(Note:ifHIV+,administermedicationsdailyoverfirsttwo
monthsoftreatment).

SOUTHEASTERNNATIONALTUBERCULOSISCENTER(SNTC)HTTP://SNTC.MEDICINE.UFL.EDU

VISIT

INITIAL
WHEN
DONE

DATE
COMPLETED

Obtainsputumresultsfromday3(3 specimen)ifavailable.

ContinuetomonitorMARtoensurepatientistakingmedicationsandnosideeffectsarenoted.

Checkreleasestatuswithclassifications/releasepersonnel.

Contactlaboratory/HDforresultsoflabtests,(NAA/MTD),baselinetests(ifnotyetreportedtoHD/correctionalfacility).
EnsureHDhassameinformation.

IfsmearnegativeforM.tb.,discusswithphysicianforcontinuation/changesincontactinvestigationbasedonpossibilityof
diagnosisofTB.Also,discusswithHDcasemanager/physician.

PLEASE REMEMBER TO INITIAL AND DATE AFTER COMPLETING EACH TASK

Week 8

Weeks 5-7

Week 4

Week 3

Day 5 Week 2

Day 4

rd

NOTE

ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingmedications.

Checkreleasestatuswithclassifications/releasepersonnel.

DiscusscontactinvestigationwithHDcasemanager/physicianifapplicable.

Continuemedications(monitorMAR)asdirectedbyHDcasemanager/physician.

Obtainsputumx3forsmearandcultureevery2weeks(orperlocalHDprotocol)untilnegativeforsmear/culture.

DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.

Checkreleasestatuswithclassifications/releasepersonnel

Clinicvisitwithphysician,ARNP,PA,orRNforevaluationofstatusandmedications,includeacompletechartreviewbyhealth
personnel.

Checkweight,visualacuity,red/greencolorblindness,asapplicable.DrawandmonitorSGOTanduricacidifonPZAas
ordered.

ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.

Contactlaboratory/HDcasemanagerforcultureresults(maytake46weeks)ifnotyetreceived.

Schedulemonthlycasemanagementteammeetingtodiscusspatientsprogress,includeHDcasemanager.MonitorMARfor
DOT.

DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.

Checkreleasestatuswithclassifications/releasepersonnel.

Obtainsensitivityresultsfromlaboratoryifcultureresultshavereturned.Ifsensitivetoallmedications,discusswithHD
physician/casemanagerthepossibilityofdiscontinuingEthambutolnow.

ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.

Checkreleasestatuswithclassifications/releasepersonnel.

DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.

Continueregularlyscheduledclinicvisitswithphysician,ARNP,PA,orRN,toincludecompletechartreviewandMARreview.

DrawSGOTanduricacidifstillonPZA/otherlabsasordered.Obtainandrecordweight.

IfstillonEthambutol,checkvisualacuityandcolorblindness.

ObtainCXR;includecomparisonwithpreviousxraytodetermineifpatientsxrayisimproving,worseningorstable.

Culturesandsensitivitystudiesshouldbebackbynow.Ifnot,checkwiththelaboratory.Ifsensitivetoallmedications,ask
physicianforordertodiscontinueEMBandPZA,whichisgenerallydiscontinuedafter2monthsoftreatment.Ifthesmears
andcultureshavenotconvertedtonegative,thepatientneedstobereevaluatedforpossibleresistancetooneormoreTB
medications.Ifthishappens,additionalspecimensandsensitivitystudiesshouldbedone.(Note:ifthepatienthasnot
received2monthsofPZA,mayneedtotreatfor9monthsasorderedbyphysician.)

DiscusswithHDcasemanager/physicianifthissuspectisaTBcase.Isotherinformationneededtomakethisdetermination?
Noteonprogressnotesifadditionalinformationisneeded.

Discusswiththepatientifs/heisimproving/feelingbetterwithmedications.

ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingmedications.

Schedulemonthlycasemanagementteammeetingtodiscusspatientsprogress,includeHDcasemanager.

Checkreleasestatuswithclassifications/releasepersonnel.

DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.

Ifthepatienthascavitarylesionsintheirlungs,oriftheircultureispositiveafter2monthsoftreatmentwithfourdrugsthatthepatientissensitiveto,
treatmentshouldbeextendedtoaminimumof4monthsafterthepatientconvertstheculturestonegativeperCDCguidelines.

SOUTHEASTERNNATIONALTUBERCULOSISCENTER(SNTC)HTTP://SNTC.MEDICINE.UFL.EDU

INITIAL
WHEN
DONE

DATE
COMPLETED

Continuetocollectsputumx3,ifsmearsandculturesarestillpositive.Ifnegative,collectsputumsasdirectedbyHDTB
programstaff.

ContinueDOT.IfpatienthasbeenondailyDOTfor2months,begintwiceorthriceweeklyDOTafterdiscussionwithHDcase
manager/physician.
(Note:ifHIV+,administermedicationsminimally3xweek).

Checkreleasestatuswithclassifications/releasepersonnel.

DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.

RepeatCXRifneeded.

Monthlyclinicvisitwithphysician,ARNP,PA,orRN,includingchartreview.

DrawSGOT/labsasordered.Obtainandrecordweight.

ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.

Conductmonthlycasemanagementteammeetingtodiscusspatientsprogress.IncludecountyHDcasemanagerandallother
teammembers(medicationnurse,physician,etc.)(HINT:Recommendincludingcustodyorclassificationsupervisor)

Checkreleasestatuswithclassifications/releasepersonnel.

DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.

Weeks
24-26

Weeks
21-23

Week 20

Weeks
17-19

Week 16

Weeks
13-15

Week 12

Weeks
9-11

VISIT

PLEASE REMEMBER TO INITIAL AND DATE AFTER COMPLETING EACH TASK

ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.

Checkreleasestatuswithclassifications/releasepersonnel.

DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.

Monthlyclinicvisitwithphysician,ARNP,PA,orRN,toincludecompletechartandMARreview.

DrawSGOT/labsifordered.Obtainandrecordweight.

ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.

Conductmonthlycasemanagementteammeetingtodiscusspatientsprogress.IncludeHDcasemanagerandallotherteam
members.(BESTPRACTICE:Recommendincludingcustodyorclassificationsupervisorintheteammeetings)

Checkreleasestatuswithclassifications/releasepersonnel.

DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.

ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.

Continuecontactinvestigationifapplicable.

Checkreleasestatuswithclassifications/releasepersonnel.

DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.

Monthlyclinicvisitwithphysician,ARNP,PA,orRN,toincludechartreviewandMARreview.

DrawSGOT/labsasordered.Obtainandrecordweight.

ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.

Conductmonthlycasemanagementteammeetingtodiscusspatientsprogress.IncludeHDcasemanagerandallotherteam
members.(BESTPRACTICE:Recommendincludingcustodyorclassificationsupervisorinteammeetings)

Checkreleasestatuswithclassifications/releasepersonnel.

DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.

ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.

Checkreleasestatuswithclassifications/releasepersonnel.

DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.

ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.

Iftreatmenthasbeencompleted,obtainfinalchestxrayandsputum,ifable.

Finalclinicvisitwithphysician/clinician(ifapplicable).Reviewchartforcompletenessorneedforcontinuation.

CompletecertificateofcompletionforTBtreatmentcard(ifapplicable).Placeinpatientsproperty.

NotifyHDcasemanagerofcompletionoftherapy(ifapplicable).

Reviewchartforcompletionofcontactinvestigation,etc.Mayneedtocontinueafterpatientstreatmenthascompleted
(afterweek26).

Checkreleasestatuswithclassifications/releasepersonnel.

DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.

SOUTHEASTERNNATIONALTUBERCULOSISCENTER(SNTC)HTTP://SNTC.MEDICINE.UFL.EDU

INITIAL
WHEN
DONE

DATE
COMPLETED

ContinueDOTasdirected(ifapplicable).ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.

Continuecontactinvestigationifapplicable.

Monitorreleasestatuswithclassifications/releasepersonnel.

Conductmonthlycasemanagementteammeetingtodiscusspatientsprogress.IncludeHDcasemanagerandallotherteam
members.

DiscussneedforcontinuationoftreatmentifneededwithHDcasemanager/physician.

Updatetreatmentplantoreflectongoingcareofpatient.

DrawSGOTandotherlabsasneeded.Obtainandrecordweightregularly.

Documentnumberofdosesinclinicalrecordonappropriatesheet.

Intheeventtheinmateistransferredorreleasedpriortocompletionoftreatment,medicationsmustbesentwiththeinmate,
alongwithacopyofthemedicaladministrationrecord(MAR),copiesofchestxrays/resultsandcopiesofanylabworkthe
inmatehasobtainedduringhis/herincarceration.

ThelocalHDTBnursecasemanagershouldalsobegivencopiesoftheaboveinformation,toensuretheirrecordisuptodate
andcurrent.

Contacttheagency/localHDpriortorelease/dischargeforcontinuityofcareifapplicable.

NOTE

Transfers or
Releases

Week 27 to End of Treatment

(if applicable)

VISIT

PLEASE REMEMBER TO INITIAL AND DATE AFTER COMPLETING EACH TASK

BESTPRACTICE:Ifthepatienthascavitarylesionsintheirlungs,oriftheircultureispositiveafter2monthsoftreatmentwithfourdrugsthatthepatient
issensitiveto,treatmentshouldbeextendedtoaminimumof4monthsafterthepatientconvertstheculturestonegative.

COMMENTS/NOTES

Note:IndicateN/A(=NotApplicable)iftaskdoesnotneedtobedoneordoesnotapply.Thisindicationwillensurethatthetaskwasnotmissedor
overlookedbystaff.

NURSE

COMPLETING CLINICAL PATHWAY

Signature

Title

Initials

Date

Signature

Title

Initials

Date

CASE
MANAGER

ASSISTING WITH CLINICAL PATHWAY

AT ANY POINT, IF THE PATIENT IS RELEASED

OR TRANSFERRED TO ANOTHER FACILITY,
COMPLETE INFORMATION MUST BE SENT
ALONG WITH THE INMATE PATIENT

NAME

ID#

DATEOFBIRTH