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Policies,Clinical,UW Health Clinical,Infection Control

Control of Tuberculosis (4.1.1)

Control of Tuberculosis (4.1.1) - Policies, Clinical, UW Health Clinical, Infection Control

4.1.1


UW HEALTH CLINICAL POLICY 1
Policy Title: Control of Tuberculosis
Policy Number: 4.1.1
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: August 7, 2015

I. PURPOSE

To prevent the spread of tuberculosis (TB) to healthcare personnel, patients and visitors.

II. POLICY ELEMENTS

A. A TB Risk Assessment will be performed annually to address incidence of TB disease within the facilities
and evaluate work practice and engineering controls put into place to mitigate risk of transmission.

B. A facility TB Exposure Control Plan based on the TB Risk Assessment will be reviewed at least annually and
updated as needed. The UW Health TB Exposure Control Plan incorporates all procedures for the
prevention and control of TB within UW Health.

III. PROCEDURE

A. The TB Exposure Control Plan shall be followed by all staff as the procedure for prevention and control of
TB infection within all areas of UW Health.
B. Physicians, nurses, respiratory therapists and all other healthcare personnel must have a high index of
suspicion for tuberculosis.
C. Any patient with suspected or confirmed tuberculosis will immediately be placed under airborne precautions
in a designated negative pressure airborne infection isolation (AII) room and all persons entering the room
must comply with isolation precautions.
D. Airborne Precautions will be maintained until pulmonary tuberculosis is ruled out, the patient is no longer
infectious, or is discharged.
E. Hospital staff, employees and volunteers performing relevant duties or working in locations deemed at high
or moderate tuberculosis exposure in the Respiratory Protection Plan will be fit-tested for an N-95 respirator
at the time of hire and annually thereafter.
F. All UW Health staff, employees and volunteers performing relevant duties or working in locations deemed at
high or moderate risk of tuberculosis exposure in the Respiratory Protection Plan will be screened for TB
infection at the time of hire or acceptance of volunteer duties and annually thereafter. Those individuals
found to have positive TB tests will be referred to a physician for evaluation for tuberculosis disease and
consideration of chemoprophylaxis for latent tuberculosis infection (LTBI).
G. Employees infected with human immunodeficiency virus (HIV) will be given the option, at their request, of
not working in hospital areas where exposure to unrecognized active tuberculosis is most likely to occur.
H. When previously unrecognized active pulmonary tuberculosis is discovered in a patient or healthcare
worker, and personnel or patients have been exposed, every effort will be made to identify all exposed
persons and provide or facilitate appropriate medical follow-up.
I. Newly diagnosed cases of active tuberculosis will be reported to the appropriate Public Health Agencies by
Infection Control Department personnel or relevant clinic staff.
J. Employees will be educated about tuberculosis, its transmission and steps to prevent transmission at the
time of hire and annually thereafter.

IV. COORDINATION

Author(s): Infection Control Practitioner
Senior Management Sponsor: SVP, Patient Care Services and CNO
Approval committees: Infection Control Committee; UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: June 15, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.



UW HEALTH CLINICAL POLICY 2
Policy Title: Control of Tuberculosis
Policy Number: 4.1.1


V. APPROVAL

Peter Newcomer, MD
Chief Medical Officer for UW Health

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REFERENCES

-American Thoracic Society, Centers for Disease Control and Prevention, and the Infectious Disease
Society of America. 2003. Treatment of Tuberculosis. Morbidity and Mortality Weekly Report, 52(RR11):1-
77. Accessible at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm
-American Thoracic Society and Centers for Disease Control and Prevention, 2000. Targeted Tuberculin
Testing and Treatment of Latent Tuberculosis Infection. American Journal of Respiratory and Critical Care
Medicine,161: S221-S247
-Centers for Disease Control and Prevention. Core Curriculum on Tuberculosis. Fourth Edition, 2000.
-Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health Care Settings, 2005.
Morbidity and Mortality Weekly Report, 54: (RR-17) Accessible at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm?s_cid=rr5417a1_e
-UWHC Administrative P&P #13.07, "Standard Precautions and Transmission-based Precautions (Isolation)
for inpatient settings."
-UWHC policy #13.28, “Standard Precautions and Transmission-based Precautions (Isolation) for
Ambulatory Settings.”
-UWHC Administrative P&P #13.21, "Communicable Disease Exposure Response."
-UWHC Administrative P&P #13.04, "Communicable Disease Reporting."
-UWHC Administrative P&P #12.49, "Respiratory Protection Program."
-UWHC Administrative P&P Policy #9.21, "Non Employee Health Screening."
-UWHC Administrative P&P #9.20, “Pre-Employment Health Assessment”
-UWHC Nursing Patient Care Departmental P&P #10.11, “Inpatient Tuberculin Bacillus (TB) Skin Testing
Procedure”
-UWHC TB Risk Assessment
-UWHC TB Exposure Control Plan

VII. REVIEW DETAILS
Version: Revision
Next Revision Due: December 7, 2017
Formerly Known as: Hospital Administrative policy #13.17