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TB Skin Test Placement/Reading Policy (102.061)

TB Skin Test Placement/Reading Policy (102.061) - Policies, Clinical, UWMF Clinical, UWMF-wide, Clinical Policies and Procedures, Infection & Infection Control

102.061

UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE

TITLE: TB SKIN TEST PLACEMENT/READING POLICY

Effective Date: May, 2008 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education

Reviewed July, 2008 August, 2010 February, 2012 November, 2014 April, 2015


PURPOSE: To provide guidelines for placing and reading TB skin tests at the University of Wisconsin
Medical Foundation (UWMF) and Department of Family Medicine (DFM) clinics for patients who present to a
UWMF or DFM clinic for a TB skin test placement or read with or without an appointment with a provider.

POLICY: The clinical staff will utilize the following guidelines to place, read and document TB skin tests.

ξ The placement of a TB skin test should be done by appointment only; ie provider or nurse visit.
ξ UWMF patients and new employees who present for TB skin test reading at a clinic other than where
the TB skin test was placed can be seen as long as documentation of the placement is presented or
obtainable. Patients are to be registered and charged as a ‘no charge’ nurse visit. New employees
should not be registered or charged.
ξ Any NON-UWMF patient who presents to a UWMF clinic for a reading of a TB skin test placed
elsewhere must provide documentation of placement. Patient will be registered, checked in, and
charged a provider or nurse visit.
ξ If the patient has a reading greater than or equal to 5 mm the patient will be seen by one of the
providers.

SUPPLIES:
ξ Sterile disposable tuberculin syringe with safety needle
ξ Purified protein derivative (PPD) vial
ξ Alcohol prep swabs
ξ 2 x 2 gauze pads or cotton ball
ξ Ruler or calipers with millimeter (mm) measurements
ξ Health Link TB Test workflow document (link)

PROCEDURE:

1. Clarify order.

2. Utilize TB Smart Set.
Note: Use the TB Smart Set for all TB skin test placements; nurse visit or provider visit.
Note: Follow the TB Test Health Link workflow (link)

3. Prior to TB skin test placement, complete the “screening” questions within the TB Smart Set
ξ Screening questions to be completed by the Physician, or other trained clinical staff.
ξ Follow screening questions criteria in Smart Set
ξ If Smart Set was closed prior to asking the screening questions, use the smart phrase .nptbscreen
within the progress note area to ask the patient the screening questions.


4. Provide patient with CDC handout – What you need to know about the TB skin test;
http://www.cdc.gov/tb/publications/pamphlets/TB_skin_test.pdf (link)

5. Applying Tuberculin Skin Test:
a) Check PPD (purified protein derivative) vial for proper strength (5TU per 0.1ml), expiration date
of vial, and date vial was opened (vials must be discarded 28 days after being opened regardless of
expiration date).
b) Withdraw 0.1 ml from vial using sterile technique.
c) Give medication intradermally per UWMF Administering Intradermal Injection policy.
ξ Wheal should be 6-10 mm in diameter.
ξ If wheal is less than 6 mm in diameter repeat test.
ξ Repeat test site must be at least 2 inches away from original site.
ξ Second injection site should be circled to indicate that this is the site that should be read if
wheal is 6-10 mm in diameter.
ξ If second wheal is less than 6 mm in diameter consult another staff member.
Note: PPD is to be given in the left forearm, unless there is scarring, rash or lack of appendage
on that side.
Note: DO NOT perform skin test in areas with excess hair, acne, tattoos, redness, swelling,
visible veins, or insufficient subcutaneous tissue

6. Post application patient teaching:
ξ DO NOT apply a bandaid or lotion and do not rub or scratch site after placement
ξ Instruct patient to report severe reaction (e.g. extensive erythema, blistering, severe itching)
prior to the reading time
ξ Instruct patient to return in 48-72 hours after placement
*Schedule patient’s appointment as above
*Provide patient’s AVS

7. Document application of TB skin test following the steps found in the TB Test Health Link document
(link).
8. Reading the TB Skin Test (Mantoux TB skin test).
a) TB test must be read by trained clinical staff 48 -72 hours after placement.
b) In a well-lighted area, observe injection site for erythema and blistering, then gently rub finger over
site to detect induration. Erythema is not measured, only induration. See “Reading the Tuberculin
Skin Test” diagram below.
c) Lines drawn by a pen, on both sides of the induration, provide a visible record of the margins of
induration for accurate measurement.
d) If induration is present, measure diameter:
*The diameter of the indurated area is measured transversely across the forearm
(perpendicular to the long axis) using Mantoux-testing calipers or other acceptable measuring
device. Longitudinal induration is not measured.

ξ All measurements are recorded in millimeters. If there is no induration, record result as “0
mm.” Do not use terms such as “positive,” “negative,” or “no reaction.”

ξ Induration equal to or greater than 5 mm must be reported to provider. Document referral to
provider in Enter/Edit Results Narrative section as noted on the Health Link document (link).



ξ Refer to the following chart when determining the skin test result.
9. Document reading of TB skin test following the steps found in the Health Link document (link).
10. Special Considerations:
ξ In a 2 step TB skin test:.
ξ CDC recommends second placement one to three weeks after first. Place the 1st PPD skin test in the
left forearm and the 2nd PPD skin test in the right forearm
ξ Use the above recommendations unless:
o There is scarring, rash or lack of appendage on that site
o There are areas with excess hair, acne, tattoos, redness, swelling, visible veins, or insufficient
subcutaneous tissue
ξ CDC recommends second placement one to three weeks after first.
ξ Complete entire screening questionnaire.
ξ If patient has active TB complete the following:
ξ Acute & Communicable Disease Case Report form (DPH 4151) within 24 hours; provided by the
State Department of Health and Family Services
http://www.dhs.wisconsin.gov/forms/F4/F44151.pdf
ξ Notify UWMF Employee Health/Infection Control.
ξ If patient has a TB skin test reading of equal to or greater than 5 mm AND is symptomatic and proper
Airborne Precautions were not followed during visit, complete steps above and the following:
ξ a PSN (Patient Safety Net) report
Induration of ≥ 5 mm is
considered positive for
Induration of ≥ 10 mm is considered
positive in
Induration of ≥ 15 mm is
considered positive in
ξ Human
immunodeficiency
virus (HIV) positive
persons
ξ Recent contact with
persons with infectious
TB
ξ Persons with fibrotic
changes on chest
radiograph consistent
with prior TB
ξ Persons with organ
transplants and other
immunosuppressed
patients (including
patients taking a
prolonged course of
oral or intravenous
corticosteroids or TNF-
α antagonists)
ξ Persons who have come to the United
States within the last 5 years from areas
where TB is common (including Asia,
Africa, Eastern Europe, Russia, or Latin
America)
ξ Injection drug users
ξ Persons who live or work in high-risk
congregate settings (including prisons and
jails, nursing homes and other long-term
facilities for the elderly, hospitals and
other health care facilities, residential
facilities for patients with acquired
immunodeficiency syndrome (AIDS), and
homeless shelters)
ξ Mycobacteriology laboratory personnel
ξ Persons with certain medical conditions
that place them at high risk for TB
(including silicosis, diabetes mellitus,
severe kidney disease, some types of
cancer, and some intestinal conditions)
ξ Children younger than 5 years of age, or
infants, children, and adolescents exposed
to adults in high-risk categories
ξ Persons with no known
risk factors for TB

ξ Notify Employee Health of exposure to employees or patients.
d) If the patient has a paper form to complete, document the form was completed in the
progress note section and return original form to patient.

WRITTEN BY: Danielle Varnell, RN, Clinical Staff Educator
LaVay Morrison, RN, Clinical Staff Educator
Jeanne Venzke, RN, BSN, MS, Employee Health Infection Control & Safety
Kathy Southard, RN, Employee Health Infection Control & Safety
Sandy Jacobson, Clinic Manager

REVISED: Staci Stafford Eve Christoffersen, BSN, RN, Clinical Staff Educator

REVIEWED: Laura Vergeront, RN, BSN, MPH, Employee Health Infection Control
Carrie Boeckelman, RPh, Manager, Ambulatory Pharmacy Services

RESOURCES:

1. CDC NCHHSTP Division of Tuberculosis Elimination. (2004). The Mantoux tuberculin skin test wall
chart. Retrieved from
http://www.cdc.gov/tb/publications/Posters/images/Mantoux_wallchart.pdf
2. Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and
TB Prevention, & Division of Tuberculosis Elimination. (2013). Core curriculum on
tuberculosis:What the clinician should know. Retrieved from
http://www.cdc.gov/tb/education/corecurr/pdf/corecurr_all.pdf
3. Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and
TB Prevention, & Division of Tuberculosis Elimination. (2011, October). TB elimination
tuberculin skin testing. Retrieved
fromhttp://www.cdc.gov/tb/publications/factsheets/testing/skintesting.pdf
4. Centers for Disease Control and Prevention. (2011, June). Tuberculosis TB Fact Sheets. Retrieved from
http://www.cdc.gov/tb/publications/factsheets/testing/skintesting.htm
5. New York City Department of Health and Mental Hygiene. (2006, May). The Mantoux tuberculin skin
test: A guide for providers. Retrieved from http://www.nyc.gov/html/doh/downloads/pdf/tb/tb-
hcp-tst-guide.pdf
6. UWHC policy 12.50 Ambulatory Tuberculin Bacillus (TB) Skin Testing Procedures
7. Wisconsin Department of Health Service. (2008, August). ACUTE & COMMUNICABLE DISEASE
CASE REPORT. Retrieved from http://www.dhs.wisconsin.gov/forms/F4/F44151.pdf

Delegation Protocol Number 92, TB Skin Test Ordering Delegation Protocol – Adult/Pediatric – Outpatient,
should be reviewed when this policy is revised.


AUTHORIZED BY: Richard Welnick, MD, Medical Director, Ambulatory Clinic Operations, UWMF
Sandra A. Kamnetz, MD, Vice Chair, Department of Family Medicine

__________________________________________________________________________________________
Medical Director, UWMF Date

__________________________________________________________________________________________
Vice Chair, Department of Family Medicine Date