Chest Infections |

Addressing the Burden of Unnecessary Airborne Isolation for Suspected Pulmonary Tuberculosis FREE TO VIEW

David Eshak, MD; Harmeen Goraya, MD; Neha Sharma, MD; Olufisayo Otusanya, MD; Virginia Chung, MD
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Jacobi Medical Center / Albert Einstein College of Medicine, Bronx, NY

Chest. 2015;148(4_MeetingAbstracts):80A. doi:10.1378/chest.2271083
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SESSION TITLE: Chest Infections

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Sunday, October 25, 2015 at 01:30 PM - 03:00 PM

PURPOSE: Patients admitted with suspected active pulmonary tuberculosis (PTB) are often placed on airborne isolation, but few actually have PTB. Patients are isolated until they have three negative Acid Fast Bacilli (AFB) sputum smears collected 8-24 hours apart. Prior studies report that airborne isolation may decrease patient-provider interaction, delay actual diagnosis, waste resources, have adverse psychological effects on patients, and lower patient satisfaction. Nucleic acid amplification (NAA) may offer a quicker way to rule-out PTB. We assessed the burden of unnecessary airborne isolation for suspected PTB to identify opportunities for quality improvement.

METHODS: We performed a retrospective chart review in a 457-bed urban public teaching hospital which has over 20,000 admissions annually. The electronic health record was queried for all AFB samples in 2011. Non-respiratory samples were excluded, as were samples from outpatients or pediatric patients. We quantified the isolation days of patients ruled-out for PTB, and used Medicare reimbursement data to compare the projected hospital costs using serial AFB testing versus a single NAA test.

RESULTS: After exclusions, there were 96 admitted patients placed on airborne isolation for suspected active PTB: 60.4% (58/96) were culture negative, 37.5% (36/96) had non-tuberculous mycobacteria, and 2.1% (2/96) had culture-confirmed mycobacterial tuberculosis. The 94 patients ruled out for PTB were isolated for a collective 410 days (mean 4.52 days, median 4.0 days, SD 3.94). Projected cost savings of using a single NAA to rule-out PTB was $5,340 for an average patient.

CONCLUSIONS: Most patients placed on airborne isolation were ruled-out for PTB (97.9%). There is opportunity to reduce the burden of unnecessary airborne isolation. First, AFB samples were often sent at least one day apart - i.e. beyond 8-24 hours. This highlights logistical barriers and an opportunity to educate clinicians whom order AFB daily rather than at shorter intervals. Second, there are alternatives to serial AFB testing. NAA can be quick (~2-4 hours) and inexpensive (as low as ~$10/sample), potentially averting a 3-day admission. In 2015 the Food and Drug Administration approved the Cepheid Xpert MTB/RIF Assay as a NAA alternative. This warrants further study of NAA and its cost-effectiveness.

CLINICAL IMPLICATIONS: Airborne isolation to rule-out PTB imposes a high burden on patients and is costly. Alternative approaches to serial AFB testing, including NAA, may reduce isolation days and costs.

DISCLOSURE: The following authors have nothing to disclose: David Eshak, Harmeen Goraya, Neha Sharma, Olufisayo Otusanya, Virginia Chung

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