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Respiratory isolation of tuberculosis patients using clinical guidelines and an automated clinical decision support
C A Knirsch1, N L Jain, A Pablos-Mendez
1Department of Medicine, College of Physicians and Surgeons, Columbia University, New York City, USA.
Objective:
To evaluate a clinical guideline and an automated computer protocol for detection and respiratory isolation of tuberculosis (TB) patients.
Design:
An automated computer protocol was tested on a retrospective cohort of adult culture-positive TB patients admitted from 1992 to 1993 to Columbia-Presbyterian Medical Center and evaluated prospectively from July 1995 until July 1996.
Setting:
A large teaching hospital in New York City.
Patients:
171 adult patients admitted from 1992 to 1993 and 43 patients admitted between July 1995 and July 1996.
Interventions:
The 1990 Centers for Disease Control and Prevention guidelines for preventing transmission of TB were adapted to formulate clinical guidelines to ensure early isolation of TB patients at Columbia-Presbyterian Medical Center.
Results:
Implementation of a clinical respiratory isolation protocol resulted in a significant improvement in TB patient isolation rates, from 45 (51%) of 88 in 1992 to 62 (75%) of 83 in 1993 (P<.001). In testing automated protocols, the theoretical improvement would have identified an additional 27 patients not isolated by clinicians, making the overall isolation rate 134 (78%) of 171. For the prospective evaluation, 30 (70%) of 43 TB patients were isolated by clinicians adhering to the clinical protocol. Four additional patients were identified by the automated TB protocol, making the combined isolation rate 34 (79%) of 43.
Conclusions:
A clinical policy to isolate TB patients and suspected human immunodeficiency virus-infected patients with cough, fever, or radiographic abnormalities improved isolation of culture-documented TB patients from 1992 to 1993. Automated computer protocols were successful in identifying additional potentially infectious patients that clinicians failed to place on respiratory isolation. Clinical and automated protocols combined resulted in better isolation rates than a clinical protocol alone.