Tb incident today

[kmoonshine, RN]

There are two sections of the ED where I work; there's the "major" area of the ED (which has negative pressure rooms) and there's a seperate "minor" area of the ED.

I came on my shift at 2:45 today, and the day shift nurse gave me report on a patient who had come through triage at 12:00 that day. The patient reported colored sputum production, sore throat, and fatigue over the past 4 days. He was visiting from out-of-state (his e-wife lived nearby, but his wife and mother were at home in Texas).

This patient was triaged to "minor care", and somehow his "story" started unraveling. He reported to the day shift nurse that he took medications for Tb, and it was his "choice". Minor care does not have any negative-pressure rooms, and no rooms in the major area of the ED were available. An N-95 mask was put on the patient at 12:20.

The patient began getting numerous phone calls from family/friends during his stay in minor care. The rooms in minor care do not have phones in them and obviously, we couldn't have the patient going in and out of the room so we took messages. The patient had a cell phone and had the means to call them should he wish. The day shift nurse documented that the patient wanted to get some rest and did not want any phone calls. Day shift called for a negative-pressure room upstairs at 2:15, and the patient was to be admitted for observation.

We got in touch with someone in Texas at about 3:30 who gave us the patient's "true" medical information (I don't know if it was the health department, or PCP...). The patient failed to mention he had a recent history of active Tb (+ skin test >10mm, suggestive findings on chest x-ray of TB, etc). We had no information regarding his compliance of treatment.

At 3:35 I went in the patient's room and found him with his mask off. I told him to put it back on, and he refused. He stated "the doctor said I didn't have to wear it". I dragged the MD in the room, who confronted the patient and told him he had to wear it. At about 3:45 I typed "no visitors" in the comment section of our tracking board. I figured we would have a bed upstairs soon, and I didn't like the idea of multiple visitors going in and out of the patient's room. The patient also expressed that he didn't want to be bothered by anyone.

At 4:00 I get a call from the charge nurse over in "major"; the patient's "mother" (who the patient said was in Texas) was trying to come in and see him and was yelling and screaming because she couldn't visit him. I guess the police had to get involved because she was swearing and threatening to harm the ED staff. I guess she also tried sneaking into the ED, which is locked down. I have no idea who this person was, and I doubt it was the mother. Then, his "wife" presented at triage demanding to see the patient (and the patient initially said his wife was in Texas).

I guess this whole thing turned into a big incident. I was told that the patient should have been allowed visitors, despite having Tb. However, the staff over in minor care (myself, another RN, and MD) felt that any visitors should wait to see the patient until we had him established in a neg. pressure room upstairs. The patient had all sorts of inconsistencies in his medical history and social history, and I felt that we were at a point where we had to assume he was contagious until proven otherwise. Additionally, two of the staff members were pregnant and I wanted to limit their chance of exposure as much as possible. The patient was also hostile to the MD and nursing staff.

All of this happened within 15-20 minutes from when I typed "no visitors" in the comment section. I never received any phone call from security or the "mother", and if I had I'm sure this situation could have been avoided. I had no idea that he would be having visitors since he initially said that all his family was in Texas (again, I have no idea who the visiting "mother" and "wife" truly were).

Having Tb doesn't exclude a patient from having visitors, and I encourage family and friends to see their loved one. But, all the inconsistencies in the patients story (coupled with a non-neg. pressure room) led me to decide that visitors in the minor care area were not in the best interest of other patients and staff. This was a facility issue, not a patient issue. Limiting the amount of visitors and number of times people were going in and out of his room was a priority to me.

So, here's this question: how should I have handled this situation? I know I will need to sit down with my supervisor tomorrow to discuss what happened today. Again, I believe this was a facility issue; we did not have the accomodations to meet the patient's needs while protecting the health of staff and other patients/visitors. Any insight into this issue would be much appreciated.

(I apologize ahead of time for any grammatical/spelling errors - it's been a long day!)

[Larry77, RN]

Yikes, sounds like mess...I hate it when patients either don't tell the whole story in triage or get miss-triaged.

Just a comment though, it is my understanding that the N-95 or TB masks are to protect us from the outside and actual TB patients need to have a standard (for us it's a hard shelled blue mask) sealing mask placed to keep their "germs" in.

Also it sounds like it was probably a good thing you didn't allow visitors with the messed up family dynamics in this situation plus to er' in the side of safety is in my opinion is always a good thing. The management thing is just because they don't like complaints and want us to make everyone "so happy" and give positive feedback on all the polls or surveys--

[mamalle]

In our ER- its up to the visitors to decide whether they want to go in or not- its their choice and decision to make. we still put the signs up on the doors and leave masks outside of the room. If there is a issue once they are here and any disruptions- then we get our OT police officer involved. We have through the years discussed visitors and how many but there has never been a policy on it drawn up- so its up to the individual nurse which really doesnt help if there is a issue

[kmoonshine, RN]

"Just a comment though, it is my understanding that the N-95 or TB masks are to protect us from the outside and actual TB patients need to have a standard (for us it's a hard shelled blue mask) sealing mask placed to keep their "germs" in."

Thanks for the feedback Larry77. I have heard various recommendations for face masks. I've heard that a surgical face mask should be worn by the patient anytime they are outside of their isolation room or if they have visitors. However, if a patient is not in a standard isolation room with negative pressure, is a surgical mask still acceptable to wear?

On a side note, this patient was able to put on the N-95 mask without difficulty (and faster than I can put one on), which leads me to believe he was withholding medical info from us...he needed no instruction on how to apply the mask.

[VegRN]

If there is any suspicion of TB, this pt should have been transferred to a negative pressure room immediately.

Can you really mandate "no visitors" though? I am not really sure why you put a note in saying "no visitors" if he was claiming they were all out of state. Holding visitors until the room is available may be appropriate since no other beds were available but stamping no visitors on the pt with no stop time is bound to piss people off.

One side note, pts with TB are not allowed to leave our hospital if they are non compliant with treatment like this guy seems. It is a public health issue and we have called security on people like this that try to leave. And security detains them. We then work with the public health agency to attempt to ensure compliance before they are allowed to leave.

And if a pt is not wearing their mask and the MD said he had to, I would also get security involved since he was not in a negative pressure room.

I would check with the policies in your hospital, in situations like this, I would have called security to get him to comply.

[arual56]

There are two sections of the ED where I work; there's the "major" area of the ED (which has negative pressure rooms) and there's a seperate "minor" area of the ED.

I came on my shift at 2:45 today, and the day shift nurse gave me report on a patient who had come through triage at 12:00 that day. The patient reported colored sputum production, sore throat, and fatigue over the past 4 days. He was visiting from out-of-state (his e-wife lived nearby, but his wife and mother were at home in Texas).

This patient was triaged to "minor care", and somehow his "story" started unraveling. He reported to the day shift nurse that he took medications for Tb, and it was his "choice". Minor care does not have any negative-pressure rooms, and no rooms in the major area of the ED were available. An N-95 mask was put on the patient at 12:20.

The patient began getting numerous phone calls from family/friends during his stay in minor care. The rooms in minor care do not have phones in them and obviously, we couldn't have the patient going in and out of the room so we took messages. The patient had a cell phone and had the means to call them should he wish. The day shift nurse documented that the patient wanted to get some rest and did not want any phone calls. Day shift called for a negative-pressure room upstairs at 2:15, and the patient was to be admitted for observation.

We got in touch with someone in Texas at about 3:30 who gave us the patient's "true" medical information (I don't know if it was the health department, or PCP...). The patient failed to mention he had a recent history of active Tb (+ skin test >10mm, suggestive findings on chest x-ray of TB, etc). We had no information regarding his compliance of treatment.

At 3:35 I went in the patient's room and found him with his mask off. I told him to put it back on, and he refused. He stated "the doctor said I didn't have to wear it". I dragged the MD in the room, who confronted the patient and told him he had to wear it. At about 3:45 I typed "no visitors" in the comment section of our tracking board. I figured we would have a bed upstairs soon, and I didn't like the idea of multiple visitors going in and out of the patient's room. The patient also expressed that he didn't want to be bothered by anyone.

At 4:00 I get a call from the charge nurse over in "major"; the patient's "mother" (who the patient said was in Texas) was trying to come in and see him and was yelling and screaming because she couldn't visit him. I guess the police had to get involved because she was swearing and threatening to harm the ED staff. I guess she also tried sneaking into the ED, which is locked down. I have no idea who this person was, and I doubt it was the mother. Then, his "wife" presented at triage demanding to see the patient (and the patient initially said his wife was in Texas).

I guess this whole thing turned into a big incident. I was told that the patient should have been allowed visitors, despite having Tb. However, the staff over in minor care (myself, another RN, and MD) felt that any visitors should wait to see the patient until we had him established in a neg. pressure room upstairs. The patient had all sorts of inconsistencies in his medical history and social history, and I felt that we were at a point where we had to assume he was contagious until proven otherwise. Additionally, two of the staff members were pregnant and I wanted to limit their chance of exposure as much as possible. The patient was also hostile to the MD and nursing staff.

All of this happened within 15-20 minutes from when I typed "no visitors" in the comment section. I never received any phone call from security or the "mother", and if I had I'm sure this situation could have been avoided. I had no idea that he would be having visitors since he initially said that all his family was in Texas (again, I have no idea who the visiting "mother" and "wife" truly were).

Having Tb doesn't exclude a patient from having visitors, and I encourage family and friends to see their loved one. But, all the inconsistencies in the patients story (coupled with a non-neg. pressure room) led me to decide that visitors in the minor care area were not in the best interest of other patients and staff. This was a facility issue, not a patient issue. Limiting the amount of visitors and number of times people were going in and out of his room was a priority to me.

So, here's this question: how should I have handled this situation? I know I will need to sit down with my supervisor tomorrow to discuss what happened today. Again, I believe this was a facility issue; we did not have the accomodations to meet the patient's needs while protecting the health of staff and other patients/visitors. Any insight into this issue would be much appreciated.

(I apologize ahead of time for any grammatical/spelling errors - it's been a long day!)

I agree that the pt should have been placed in a neg air flow room immediately, but the situation regarding visitors is not something that is necessarily related to the "TB" issue. If the patient requested "no visitors" then it is our responsibility to abide by their wishes in that respect. It is no different than keeping parties who might be involved in a DV incident apart. Patient's have rights, one of which is to not be disturbed by visitors or phone calls. If anyone gives you trouble, refer them to the patient's rights policy regarding privacy.

[CritterLover, BSN, RN]

"just a comment though, it is my understanding that the n-95 or tb masks are to protect us from the outside and actual tb patients need to have a standard (for us it's a hard shelled blue mask) sealing mask placed to keep their "germs" in."

thanks for the feedback larry77. i have heard various recommendations for face masks. i've heard that a surgical face mask should be worn by the patient anytime they are outside of their isolation room or if they have visitors. however, if a patient is not in a standard isolation room with negative pressure, is a surgical mask still acceptable to wear?

on a side note, this patient was able to put on the n-95 mask without difficulty (and faster than i can put one on), which leads me to believe he was withholding medical info from us...he needed no instruction on how to apply the mask.

i was taught the same as larry: the n95 mask doesn't filter fully "both ways," so putting it on the patient doesn't do any more than putting a surgical mask on. (it filters efficiently what you breath in, not what you breath out)

[color=#483d8b]it doesn't do any less, either; it's just that the n95's are so incredibly expensive. see what your infection control nurse says.

[color=#483d8b]at least, that is how it was explained to me by infection control.

[color=#483d8b]as for the rest of the situation: the charge nurse should have done whatever was necessary to move patients around and get your man into a negative pressure room. no differnet than when all the beds are full and someone 'really sick" comes in. the least "sick" gets bumped to a hall bed, and the patient in the neg pressure room goes to their room. the only possible exception would be if all of the patients in the neg pressure rooms needed the negative pressure set-up.

[color=#483d8b]in that case, it falls on the house supervisor to expedite getting a neg pressure room upstairs cleaned out and ready, and quickly. it isn't acceptable to have a patient with active, untreated tb running around a hospital full of sick, compromised indivuduals.