Friday, August 1, 2008

Tackling tuberculosis

Yesterday morning, a gap appeared in my schedule for the first time in 14 months; tuberculosis rounds skipped a weekly meeting as we begin winding down our strenuous efforts to battle a tuberculosis outbreak in Yellowknife’s homeless population. Finding patients, dealing with substance abuse and adjusting regimens for toxicity often seemed straightforward in comparison to the task we were given by local administrators: prevent the next outbreak.

For nearly 5 years, a small collection of hospital and Public Health staff have met twice a month to review all TB cases in the Northwest Territories. Although I chair the group, I began with very little knowledge of the disease and its treatment. I was willing, however, to serve as a figurehead (being the only physician), to ensure a connection between Public Health, community nurses and hospital staff as patients moved between the hospital and the community during their long treatment courses.

In the process, a wealth of knowledge gradually rubbed off on me as the lab staff, community nurses, infection control nurse and TB program coordinator all contributed their perspectives to patients’ care. Since all of the TB players were around the table, we also began adjusting our standing orders, hospital policies and communication pathways to better suit the needs that we identified in the course of patient care. We had no terms of reference, no budget and no official status in the hospital; life was good under the radar.

Then came the outbreak - and with it some finger-pointing between health boards, since the index case was missed for at least 6 months. Contact tracing identified hundreds of individuals potentially exposed to tuberculosis, many of whom had no phone number or fixed address. For years, I had been trying to keep TB on the agenda of physicians and administrators, pointing out the high rates in the NWT of both latent and active disease. Suddenly, everyone was interested in tuberculosis, and our little rounds group had to grow up, with terms of reference, a reporting structure, and minutes of our “systems rounds” where we left no stone unturned in examining the barriers to TB diagnosis and treatment.

An astute nurse pointed out that the first 6 cases had all slept in the same room at the local shelter, for a minimum of 5 nights out of the 2 weeks prior to the index case being diagnosed. In response, the TB program coordinator asked for an inspection of the shelter’s ventilation, and we worked closely with shelter staff to choose a new air filtration system – then lobbied the Department of Health to pay for it. The shelter staff were trained to be “cough monitors” – common in developing countries but not often used in Canadian TB control programs – (unless you happen to live in Yellowknife).

The infection control nurse pointed out that our isolation strategy would quickly overload our hospital’s resources, if several patients were simultaneously on treatment or under investigation. The Medical Health Officer (now an enthusiastic rounds participant) researched and developed a new isolation policy. “Coming soon to a hospital near you… a portable sputum induction isolation booth!” she announced, as we oohed and aahed over the glossy photos – and again, lobbied for the necessary funds to be released.

And what about the jail? Our TB patients often spent time in corrections, so the relevant nurses called in to meetings to confirm continuity in treatment regimens. We streamlined communications, and drafted a protocol for treatment of latent TB within the correctional system so that no opportunity (especially a 4-month prison sentence) will be missed in the prevention of active disease.

One of the emergency room physicians offered his department’s help in the investigation of contacts. “I know all these people you’re looking for,” he told a Public Health nurse. “I stitch up their cuts on Saturday nights. Just tell me what you need, and I’ll start getting sputum samples.” Designing an interdepartmental flagging system was complicated, but we tiptoed through the confidentiality and information transfer issues until a practical, ethical solution was found. In retrospect, this initiative alone would have prevented the Yellowknife outbreak, since the index patient sought care multiple times in the ER and various clinics; but there had been no way to flag his need for sputum samples.

To create a body of physicians comfortable with treating TB, I offered a 6-week course on Saturdays to interested nurses and doctors. Surrounded by journal articles, case summaries, and the Canadian TB Standards one Friday evening, I wondered how I found myself in this position. I think the call of the rural physician will always be, “Do what needs to be done.” Sometimes that means writing letters about ventilation systems, or visiting the nurses at the jail, or simply educating myself to do the task at hand. There is expertise and help, if we can recognize it in a shy lab technician or a shelter worker; but these unsung heroes often need a physician’s support to make their voices heard, and to see their work come to fruition.


debido said...

Absolutely riveting posts - beautifully written and full of concise & compassionate insights into northern culture and the joys/challenges of delivering healthcare there. As a former community nurse (now nursing teacher) I love every one of Amy's posts - and wonder if there might be a book in the offing? Thank-you!

Dr.Rutledge said...

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TD said...