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Clinical Pathway: Managing Tuberculosis


Suspects/Cases in Corrections
TB case management in correctional facilities can be a challenge to administrators and infection
control staff who have not worked with tuberculosis for some time. There are many components that
must be accomplished, including identification and isolation, reporting, diagnosis and treatment, and
planning for the eventual release of the inmate. Through the use of this form, the medical staff can
identify all the steps needed when caring for a case of tuberculosis, infectious or not.
BEST PRACTICE: Case management is best done in conjunction with the local health department
whenever possible.
This form can aid in the day to day tasks required when caring for an inmate with tuberculosis (TB).
Through the use of this form, the nurse completing these tasks can be assured that all aspects of TB
are complete and up to date, and any areas where further assistance is required can be identified
early in treatment.

Terminology and Definitions


Airborne Infection Isolation (AII) Room Formerly, negative pressure isolation room, an AII Room is a
single-occupancy patient/inmate-care room used to isolate persons with a suspected or confirmed airborne
infectious disease. Environmental factors are controlled in AIIRs to minimize the transmission of infectious
agents that are usually transmitted from person to person by droplet nuclei associated with coughing or
aerosolization of contaminated fluids. AIIRs should provide negative pressure in the room (so that air flows
under the door gap into the room); and an air flow rate of 6-12 Air Changes per Hour (ACH) (6 ACH for
existing structures, 12 ACH for new construction or renovation); and direct exhaust of air from the room to
the outside of the building or recirculation of air through a HEPA filter before returning to circulation (MMWR
2005; 54 [RR-17])
Break in Exposure date the infected individual was isolated/removed from the contacts.
Conversion A tuberculin skin test increase of 10mm or more within a 2-year period, regardless of age
(i.e., 5/10/05 TST = 4mm, tested again 3/17/07 TST = 16mm.)
Test Conversion Rate calculation is identified by dividing the number of conversions among
workers by the number of workers who were tested and had prior negative results during a certain
period.
Contacts contacts are categorized and assessed according to priority, and include high-priority and
medium priority. A contact is a person who has shared the same air space with a person who has TB
disease for a sufficient amount of time to allow possible transmission of M. tuberculosis.
High-priority - those persons most likely to become infected (were in close proximity of the
infectious case and for prolonged periods of time) and most likely to develop active TB disease once
infected (HIV+, other immune compromised, drug users, silicosis, etc.).
Medium-priority those persons who spent time with or was physically close to the inmate and,
once infected, may develop active TB disease (low body weight, diabetes, organ transplant, cancers,
renal disease, etc.
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Low-priority those persons with short duration of exposure (includes officers and staff who do not
have prolonged exposure).
Exposure the length of time spent with a person with active infectious TB disease during his/her
infectious period.
Index Case the first inmate that comes to your attention as a TB case
Infectious Period the period during which a person with TB disease might have transmitted M.
tuberculosis organisms to others. For inmates with positive AFB sputum smear results, the infectious
period begins 3 months before the collection date of the first positive smear result or the date of
collection for the first consistently negative smear results. For inmates with negative AFB sputum
smear results, the infectious period extends from 1 month before the symptom onset date and ends
when the inmate is placed into airborne infection isolation (AII), whichever is earlier.
Latent TB Infection a person infected with the bacteria Mycobacterium tuberculosis. The person
with LTBI shows no signs or symptoms of active TB, and has a negative chest x-ray and negative
symptom screen.
Suspect a person in whom the diagnosis of TB disease is being considered, regardless of whether
anti-TB therapy has been started.

BEST PRACTICE: Begin and complete the contact investigation in conjunction with the local health
department whenever possible.

INMA
TE

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NAM
E
ID #

DOB

Clinical Pathway: Managing Tuberculosis


Suspects/Cases in Corrections
Name of person completing this form:
Name of Health Department Staff Assist:

Title:
________

Title:

Instructions: Initial and Date after each task. Observe Respiratory Precautions when speaking with infectious tuberculosis (TB)
suspects/cases. Assure proper isolation and treatment of suspect/case.
Obtain sputum containers (3-6) from the health department (HD) or laboratory. Collect sputum specimens on 3 separate days or
at least 8 hours apart (with one first morning specimen) If unable to expectorate, may need sputum induction either on-site at
facility, HD or local hospital). Remember: Always wear a N95 mask when working with a TB suspect, and anytime a TB
suspect is out of isolation, they should wear a surgical mask until no longer infectious. They do not have to wear a mask while
alone in a negative AII room.

Note: At any point during incarceration the inmate is released or transferred to another facility, complete
information must be sent along with the inmate.

Day 1

INITIAL
WHEN
DONE

DATE
COMPLET
ED

Immediately place tuberculosis (TB) suspect in negative airborne infection isolation (AII) room.
Instruct inmate and staff on how to obtain a witnessed sputum specimen, including the need for
immediate refrigeration after collection and ensuring the container (both inner and outer) is
labeled correctly, prior to sending specimen to the Health Department or state laboratory.
Obtain, collect and route sputum specimen (witnessed) from the state lab for acid fast bacillus
(AFB) smear, nucleic acid amplification (NAA) test, Mycobacterium tuberculosis Direct (MTD) test
and culture.
Obtain medical history including signs, symptoms and duration of symptoms of TB disease.
Ensure the physician/ARNP/PA performs a physical examination.
Offer HIV counseling and testing. Draw blood for HIV test. Obtain baseline tests/results if
applicable, (i.e., liver enzymes such as Serum glutamic oxaloacetic transaminase (SGOT) and
Serum glutamic pyruvic transaminase (SGPT), bilirubin, creatinine, complete blood count (CBC),
platelet count, uric acid, as ordered).
Place TST at this time, if not already done.
Obtain weight/perform baseline visual acuity/testing for red/green color blindness if applicable.
Obtain chest x-ray (CXR) if no recent one is available. Place surgical mask on inmate when
transporting.
Notify HD of suspect/case by phone and in writing using appropriate TB medical report and
treatment plan.
Instruct the inmate about the need for medications and reactions/side effects of medications, and
include the need for directly observed therapy (DOT).
Provide educational information about TB and plan for future care, including the need for monthly
clinic visits to see the physician, nurse, or health department TB program staff.
Discuss findings with physician and obtain prescription for four-drug therapy. Medications:
(Rifampin, Isoniazid, Pyrazinamide and Ethambutol) as appropriate.
Administer medications using strict DOT (DOT = Directly Observed Therapy = swallowing, not
simply delivery of medications)
Discuss medical release forms and have inmate sign as necessary.
Provide TB education and document in the medical record. Have inmate sign the TB
Acknowledgement Form (if available).

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4
INITIAL
WHEN
DONE

DATE
COMPLET
ED

Begin planning for eventual release from facility using Discharge/Release Planning Forms.
Begin contact investigation in collaboration with the HD case manager (if contact investigation is
needed) per your HDs instructions. As appropriate, you may be instructed to wait until the sputum
results return. Determine this in conjunction with the HD TB Program. NOTE: Use the Clinical
Pathway: TB Contact Investigation for Corrections if available.
Report the suspect/case to the Corrections Administration (as per your protocol)
Place written information in classifications/release folder for notification to medical/health
department case manager prior to release from facility.
Estimate the infectious
period:

FROM (date)

TO
(date)

Day 2

Obtain (early morning) sputum specimen or perform sputum induction. (Note: Label
appropriately and send to health department/state lab for smear, NAA (or MTD) and culture).
Observe for strict DOT (swallowing of medications), including checking the amount of medication.
Examine the medication administration record (MAR) for refusals/medication missing, etc.
Obtain sputum results from day 1 (1st specimen) if available.
Read TST and record results in chart in mm (if applicable).
NOTE: Check Day 1 for any tasks unfinished.
Review results and consult with physician/health department case manager if TST+ and/or
+AFB/MTD.
Obtain sputum results from day 2 (2nd specimen) if available. Ensure reports are in medical record.

Day 3

Review CXR report/film with physician/health department case manager and ensure report is in
medical record.
Continue DAILY DOT with four-drug therapy for next 2 months as directed by physician or until
directed otherwise by health department case manager/physician. Monitor for non-adherence.
(Note: twice weekly is not recommended in corrections)
NOTE: Check Day 2 for any tasks unfinished.
BEST PRACTICE: work with your custody staff to ensure the inmates custody record is flagged to
prevent release until medical is notified of impending release. Begin planning for potential
release.
Ensure medical staff is informed prior to inmate release.

Day 5 Week 2

Day 4

Obtain sputum results and other labs from day 3 (3rd specimen) if available.
Continue to monitor MAR to ensure inmate is taking medications and no side effects are noted.
Check release status with classifications/release personnel to see if any changes have occurred,
including pending transfers/releases to other facilities.
Contact laboratory/HD for results of lab tests, (NAA/MTD), baseline tests (if not yet reported to
HD/correctional facility). Ensure HD has same information.
If smear negative for M. tb., discuss with HD case manager/physician for continuation/changes in
scope of contact investigation. (Note: continue with treatment until evidence proves noninfectiousness per HD)
Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking medications.
Check release status with classifications/release personnel as per instructions above.

Week 3

Continue medications (monitor MAR) as directed by HD case manager/physician.


Obtain sputum x 3 for smear and culture every 2 weeks (or per local HD protocol) until negative
for smear/culture.
Discuss continuation of contact investigation with HD case manager/physician if applicable.

Week 4

Check release status with classifications/release personnel


Clinic visit with physician, ARNP, PA, or RN for evaluation of status and medications, include a
complete chart review by health personnel.
Check weight, visual acuity, red/green colorblindness, as applicable. Draw and monitor SGOT and
uric acid if on PZA as ordered.
Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as
prescribed.
Contact laboratory/HD case manager for culture results (may take 4-6 weeks) if not yet received.
Review all labs with physician/HD case manager. Conduct a monthly case management team
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5
INITIAL
WHEN
DONE

DATE
COMPLET
ED

meeting to discuss inmates progress, include HD case manager. Monitor MAR for DOT..
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Check release status with classifications/release personnel.

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Weeks 5-7

INITIAL
WHEN
DONE

DATE
COMPLET
ED

Obtain sensitivity results from laboratory if culture results have returned. If sensitive to all
medications, discuss with HD physician/case manager the possibility of discontinuing Ethambutol
now.
Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as
prescribed.
Check release status with classifications/release personnel.
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Ensure inmate continues regularly scheduled clinic visits with physician, ARNP, PA, or RN, to
include complete chart review and MAR review.
Draw SGOT and uric acid if still on PZA/other labs as ordered. Obtain and record weight.
If still on Ethambutol, check visual acuity and color blindness.

Week 8

Obtain CXR; review results with the physician and include comparison with previous x-ray to
determine if inmates x-ray is improving, worsening or stable.
Cultures and sensitivity studies should be back by now. If not, check with the laboratory. ( Note: If
sensitive to all medications, ask physician for order to discontinue EMB and PZA, which is generally
discontinued after 2 months of treatment. If the smears and cultures have not converted to
negative, the inmate needs to be re-evaluated for possible resistance to one or more TB
medications. If this happens, additional specimens and sensitivity studies should be done. (Note: if
the inmate has not received 2 months of PZA, may need to treat for 9 months as ordered by
physician.)
Discuss with HD case manager/physician if this suspect is a TB case or LTBI. Is other information
needed to make this determination? Note on progress notes if additional information is needed.
(Note: If inmate is a TB case, the HD will report to State Health Office.)
Discuss with the inmate if s/he is improving/feeling better with medications.
Continue DOT as directed. Continue to monitor MAR to ensure the inmate is taking medications.
NOTE: If the inmate is not a TB case and is identified as LTBI, discontinue treatment as ordered by
the HD TB physician.
Conduct monthly case management team meeting to discuss inmates progress. Include county
HD case manager and all other team members (medication nurse, physician, etc.) BEST PRACTICE:
Recommend including custody or classification supervisor.
Check release status with classifications/release personnel for change in scope.
Discuss continuation of contact investigation with HD case manager/physician if applicable.

9-11Weeks

NOTE

If the inmate has cavitary lesions in their lungs, or if their culture is positive after 2 months of treatment with four drugs
that the inmate is sensitive to, treatment should be extended to a minimum of 4 months after the inmate converts the
cultures to negative per CDC guidelines. Discuss with HD staff.
Continue to collect sputum x3, if smears and cultures are still positive. If negative, collect sputa as
directed by HD TB program staff.
Continue DOT. If inmate has been on daily DOT for 2 months, begin twice or thrice weekly DOT after
discussion with HD case manager/physician.
(Note: if HIV+, administer medications minimally 3x week).
Check release status with classifications/release personnel.
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Repeat CXR if needed.
Monthly clinic visit with physician, ARNP, PA, or RN, including chart review.

Week 12

Draw SGOT/labs as ordered. Obtain and record weight.


Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as
prescribed.
Conduct monthly case management team meeting to discuss inmates progress. Include county HD
case manager and all other team members (medication nurse, physician, etc.) BEST PRACTICE:
Recommend including custody or classification supervisor.
Check release status with classifications/release personnel.
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as
prescribed.
Check release status with classifications/release personnel.
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Weeks

Discuss continuation of contact investigation with HD case manager/physician if applicable.

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8
INITIAL
WHEN
DONE

DATE
COMPLET
ED

Monthly clinic visit with physician, ARNP, PA, or RN, to include complete chart and MAR review.

Week 16

Draw SGOT/labs if ordered. Obtain and record weight.


Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as
prescribed.
Conduct monthly case management team meeting to discuss inmates progress. Include county HD
case manager and all other team members (medication nurse, physician, etc.) BEST PRACTICE:
Recommend including custody or classification supervisor.
Check release status with classifications/release personnel.

17-19Weeks

Discuss continuation of contact investigation with HD case manager/physician if applicable.


Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as
prescribed.
Continue contact investigation if applicable.
Check release status with classifications/release personnel.
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Monthly clinic visit with physician, ARNP, PA, or RN, to include chart review and MAR review.

Week 20

Draw SGOT/labs as ordered. Obtain and record weight.


Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as
prescribed.
Conduct monthly case management team meeting to discuss inmates progress. Include HD case
manager and all other team members. BEST PRACTICE: Recommend including custody or classification
supervisor in team meetings.
Check release status with classifications/release personnel.
21-23Weeks

Discuss continuation of contact investigation with HD case manager/physician if applicable.


Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as
prescribed.
Check release status with classifications/release personnel.
Discuss continuation of contact investigation with HD case manager/physician if applicable.
Continue DOT as directed. Continue to monitor MAR to ensure inmate is taking all medications as
prescribed.

24-26Weeks

If treatment has been completed, obtain final chest x-ray and sputum, if able.
Ensure the inmates final clinic visit with physician/clinician (if applicable). Review chart for
completion of therapy or need for treatment continuation.
Complete certificate of completion for TB treatment card (if applicable). Place in inmates property.
Notify HD case manager of completion of therapy (if applicable).
Review chart for completion of contact investigation, etc. May need to continue after inmates
treatment has completed (after week 26).
Check release status with classifications/release personnel.
Discuss continuation of contact investigation with HD case manager/physician if applicable.

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NOTE

Transfers or Releases Week 27 to End of Treatment

(if applicable)

Continue DOT as directed (if applicable). Continue to monitor MAR to ensure inmate is taking all
medications as prescribed.
Continue contact investigation if applicable.
Monitor release status with classifications/release personnel.
Conduct monthly case management team meeting to discuss inmates progress. Include HD case
manager and all other team members.
Discuss need for continuation of treatment if needed with HD case manager/physician.
Update treatment plan to reflect ongoing care of inmate.
Draw SGOT and other labs as needed. Obtain and record weight regularly.
Document number of doses in clinical record.

In the event the inmate is transferred or released prior to completion of treatment, medications must be sent with the
inmate, along with a copy of the medical administration record (MAR), copies of chest x-rays/results and copies of any lab
work the inmate has obtained during his/her incarceration.
The local HD TB nurse case manager should also be given copies of the above information, to ensure the HD record is up
to date.
Contact the agency/local HD prior to release/discharge for continuity of care (if applicable).

BEST PRACTICE: If the inmate has cavitary lesions in their lungs, or if their culture is positive after 2 months of treatment
with four drugs that the inmate is sensitive to, treatment should be extended to a minimum of 4 months after the inmate
converts the cultures to negative.

COMMENTS/NOTES

Note: Indicate N/A (= Not Applicable) if task does not need to be done or does not apply. This indication will ensure that
the task was not missed or overlooked by staff.

NURSE

NAME OF PERSON COMPLETING CLINICAL PATHWAY

Signature

Title

Initials

Date

Title

Initials

Date

HD CASE MANAGER

HEALTH DEPARTMENT STAFF ASSISTING WITH CLINICAL PATHWAY

Signature

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AT ANY POINT, IF THE INMATE IS RELEASED


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

NAME
ID #
DATE OF BIRTH

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