SOUTHEASTERNNATIONALTUBERCULOSISCENTER(SNTC)HTTP://SNTC.MEDICINE.UFL.

EDU

Managing Tuberculosis Suspects/Cases in Corrections

Clinical Pathway
INITIAL
DATE
VISIT PLEASE REMEMBER TO INITIAL AND DATE AFTER COMPLETING EACH TASK WHEN
COMPLETED
DONE

Immediately place all tuberculosis (TB) suspects in negative airborne infection isolation (AII) room.
Obtainsputumcontainers(36)fromthehealthdepartment(HD)orlaboratory.Collectsputumspecimenson3separatedays
oratleast8hoursapart(withonefirstmorningspecimen)Ifunabletoexpectorate,mayneedsputuminductioneitheronsite
atfacility,HDorlocalhospital).
Provideinstructionstoinmateandstaffonhowtoobtainawitnessedsputumspecimen,includingtheneedforimmediate
refrigerationaftercollectionandensuringthecontainer(bothinnerandouter)islabeledcorrectly,priortosendingspecimen
tolaboratory(ifpossible,useHDstatelab).
Obtain,collectandroutesputumspecimen(witnessed)foracidfastbacillus(AFB)smear,nucleicacidamplification(NAA)test,

MycobacteriumtuberculosisDirect(MTD)testandculture.
Obtainmedicalhistoryincludingsigns,symptomsanddurationofsymptomsofTBdisease.
Physician/ARNP/PAperformsphysicalexamination.
OfferHIVcounselingandtesting.DrawbloodforHIVtest.Obtainbaselinetests/resultsifapplicable,(i.e.,liverenzymessuch
asSerumglutamicoxaloacetictransaminase(SGOT)andSerumglutamicpyruvictransaminase(SGPT),bilirubin,creatinine,
completebloodcount(CBC),plateletcount,uricacid,asordered).
PlaceTSTatthistime,ifnotalreadydone.
Obtainweight/performbaselinevisualacuity/testingforred/greencolorblindnessifapplicable.
Obtainchestxray(CXR)ifnorecentoneisavailable.Placesurgicalmaskonpatientwhentransporting.
Day 1

NotifyHDofsuspect/casebyphoneandinwriting(usingcopyofappropriateTBmedicalreportandtreatmentplan).
HaveTBnursecasemanagerorcorrectionsnurse/designeeinstructthepatientabouttheneedformedicationsand

reactions/sideeffectsofmedications,andincludetheneedfordirectlyobservedtherapy(DOT).
ProvideeducationalinformationaboutTBandplanforfuturecare,includingtheneedformonthlyclinicvisitstoseethe

physician,nurse,orhealthdepartmentTBprogramstaff.
Obtainprescriptionforfourdrugtherapy.Medications:(Rifampin,Isoniazid,PyrazinamideandEthambutol).
AdministermedicationsusingstrictDOT(DOT=DirectlyObservedTherapy=swallowing,notsimplydeliveryofmedications)
Discussandhavepatientsignmedicalreleaseformsasnecessary.
DiscussandhavepatientsignacknowledgementofappropriateTBcounselingandeducationformsforHDandfacilitymedical

record.
Identifypatientasneedingnotificationtomedicalstaffpriortorelease.Beginplanningforeventualreleasefromfacility.
BegincontactinvestigationinconjunctionwiththeHDcasemanager(ifoneisneeded)peryourHDsinstructions.Youmaybe

instructedtowaituntilthesputumresultsreturn.DeterminethisinconjunctionwiththeHDTBProgram.
Reporttotheadministrator/directorofthefacilitythatthepatientisplacedinanegativeAirborneInfectionIsolation(AII)

roomandtheneedforassistanceifcontactinvestigationisneededorrequired.
Placewritteninformationinclassifications/releasefolderfornotificationtomedical/healthdepartmentcasemanagerpriorto

releasefromfacility.
Identifyinfectiousperiod: FROM(date) TO(date)
nd
Obtain2 earlymorningsputumspecimenorperformsputuminduction.Labelappropriatelyandsendtohealth

department/statelabforsmear,NAA(orMTD)andculture.
ObserveforstrictDOT(swallowingofmedications),includingcheckingtheamountofmedication.
Day 2

Examinethemedicationadministrationrecord(MAR)forrefusals/medicationmissing,etc.
st
Obtainsputumresultsfromday1(1 specimen)ifavailable.
ReadTSTandrecordresultsinchartinmm(ifapplicable).
IfTST+and/or+AFB/MTD,consultwithphysician/healthdepartmentcasemanager.
nd
Obtainsputumresultsfromday2(2 specimen)ifavailable.
Day 3

ReviewCXRreport/filmwithphysician/healthdepartmentcasemanager.
ContinuedailyDOTwithfourdrugtherapyfornext2monthsasdirectedbyphysicianoruntildirectedotherwisebyhealth
departmentcasemanager/physician.Monitorfornonadherence.(Note:ifHIV+,administermedicationsdailyoverfirsttwo
monthsoftreatment).
 SOUTHEASTERNNATIONALTUBERCULOSISCENTER(SNTC)HTTP://SNTC.MEDICINE.UFL.EDU

INITIAL
DATE
VISIT PLEASE REMEMBER TO INITIAL AND DATE AFTER COMPLETING EACH TASK WHEN
COMPLETED
DONE
rd
Obtainsputumresultsfromday3(3 specimen)ifavailable.
Day 4

ContinuetomonitorMARtoensurepatientistakingmedicationsandnosideeffectsarenoted.
Checkreleasestatuswithclassifications/releasepersonnel.
Contactlaboratory/HDforresultsoflabtests,(NAA/MTD),baselinetests(ifnotyetreportedtoHD/correctionalfacility).

EnsureHDhassameinformation.
Day 5 Week 2

IfsmearnegativeforM.tb.,discusswithphysicianforcontinuation/changesincontactinvestigationbasedonpossibilityof

diagnosisofTB.Also,discusswithHDcasemanager/physician.
ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingmedications.
Checkreleasestatuswithclassifications/releasepersonnel.
DiscusscontactinvestigationwithHDcasemanager/physicianifapplicable.
Continuemedications(monitorMAR)asdirectedbyHDcasemanager/physician.
Week 3

Obtainsputumx3forsmearandcultureevery2weeks(orperlocalHDprotocol)untilnegativeforsmear/culture.
DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.
Checkreleasestatuswithclassifications/releasepersonnel
Clinicvisitwithphysician,ARNP,PA,orRNforevaluationofstatusandmedications,includeacompletechartreviewbyhealth

personnel.
Checkweight,visualacuity,red/greencolorblindness,asapplicable.DrawandmonitorSGOTanduricacidifonPZAas

ordered.
Week 4

ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.
Contactlaboratory/HDcasemanagerforcultureresults(maytake46weeks)ifnotyetreceived.
Schedulemonthlycasemanagementteammeetingtodiscusspatientsprogress,includeHDcasemanager.MonitorMARfor

DOT.
DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.
Checkreleasestatuswithclassifications/releasepersonnel.
Obtainsensitivityresultsfromlaboratoryifcultureresultshavereturned.Ifsensitivetoallmedications,discusswithHD

physician/casemanagerthepossibilityofdiscontinuingEthambutolnow.
Weeks 5-7

ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.
Checkreleasestatuswithclassifications/releasepersonnel.
DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.
Continueregularlyscheduledclinicvisitswithphysician,ARNP,PA,orRN,toincludecompletechartreviewandMARreview.
DrawSGOTanduricacidifstillonPZA/otherlabsasordered.Obtainandrecordweight.
IfstillonEthambutol,checkvisualacuityandcolorblindness.
ObtainCXR;includecomparisonwithpreviousxraytodetermineifpatientsxrayisimproving,worseningorstable.
Culturesandsensitivitystudiesshouldbebackbynow.Ifnot,checkwiththelaboratory.Ifsensitivetoallmedications,ask
physicianforordertodiscontinueEMBandPZA,whichisgenerallydiscontinuedafter2monthsoftreatment.Ifthesmears
andcultureshavenotconvertedtonegative,thepatientneedstobereevaluatedforpossibleresistancetooneormoreTB
Week 8

medications.Ifthishappens,additionalspecimensandsensitivitystudiesshouldbedone.(Note:ifthepatienthasnot
received2monthsofPZA,mayneedtotreatfor9monthsasorderedbyphysician.)
DiscusswithHDcasemanager/physicianifthissuspectisaTBcase.Isotherinformationneededtomakethisdetermination?

Noteonprogressnotesifadditionalinformationisneeded.
Discusswiththepatientifs/heisimproving/feelingbetterwithmedications.
ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingmedications.
Schedulemonthlycasemanagementteammeetingtodiscusspatientsprogress,includeHDcasemanager.
Checkreleasestatuswithclassifications/releasepersonnel.
DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.

NOTE
Ifthepatienthascavitarylesionsintheirlungs,oriftheircultureispositiveafter2monthsoftreatmentwithfourdrugsthatthepatientissensitiveto,
treatmentshouldbeextendedtoaminimumof4monthsafterthepatientconvertstheculturestonegativeperCDCguidelines.
 SOUTHEASTERNNATIONALTUBERCULOSISCENTER(SNTC)HTTP://SNTC.MEDICINE.UFL.EDU

INITIAL
DATE
VISIT PLEASE REMEMBER TO INITIAL AND DATE AFTER COMPLETING EACH TASK WHEN
COMPLETED
DONE

Continuetocollectsputumx3,ifsmearsandculturesarestillpositive.Ifnegative,collectsputumsasdirectedbyHDTB

programstaff.
ContinueDOT.IfpatienthasbeenondailyDOTfor2months,begintwiceorthriceweeklyDOTafterdiscussionwithHDcase
Weeks
9-11

manager/physician.
(Note:ifHIV+,administermedicationsminimally3xweek).
Checkreleasestatuswithclassifications/releasepersonnel.
DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.
RepeatCXRifneeded.
Monthlyclinicvisitwithphysician,ARNP,PA,orRN,includingchartreview.
DrawSGOT/labsasordered.Obtainandrecordweight.
Week 12

ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.
Conductmonthlycasemanagementteammeetingtodiscusspatientsprogress.IncludecountyHDcasemanagerandallother

teammembers(medicationnurse,physician,etc.)(HINT:Recommendincludingcustodyorclassificationsupervisor)
Checkreleasestatuswithclassifications/releasepersonnel.
DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.
ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.
Weeks
13-15

Checkreleasestatuswithclassifications/releasepersonnel.
DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.
Monthlyclinicvisitwithphysician,ARNP,PA,orRN,toincludecompletechartandMARreview.
DrawSGOT/labsifordered.Obtainandrecordweight.
ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.
Week 16

Conductmonthlycasemanagementteammeetingtodiscusspatientsprogress.IncludeHDcasemanagerandallotherteam

members.(BESTPRACTICE:Recommendincludingcustodyorclassificationsupervisorintheteammeetings)
Checkreleasestatuswithclassifications/releasepersonnel.
DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.
ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.
Weeks

Continuecontactinvestigationifapplicable.
17-19

Checkreleasestatuswithclassifications/releasepersonnel.
DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.
Monthlyclinicvisitwithphysician,ARNP,PA,orRN,toincludechartreviewandMARreview.
DrawSGOT/labsasordered.Obtainandrecordweight.
ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.
Week 20

Conductmonthlycasemanagementteammeetingtodiscusspatientsprogress.IncludeHDcasemanagerandallotherteam

members.(BESTPRACTICE:Recommendincludingcustodyorclassificationsupervisorinteammeetings)
Checkreleasestatuswithclassifications/releasepersonnel.
DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.
ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.
Weeks
21-23

Checkreleasestatuswithclassifications/releasepersonnel.
DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.
ContinueDOTasdirected.ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.
Iftreatmenthasbeencompleted,obtainfinalchestxrayandsputum,ifable.
Finalclinicvisitwithphysician/clinician(ifapplicable).Reviewchartforcompletenessorneedforcontinuation.
CompletecertificateofcompletionforTBtreatmentcard(ifapplicable).Placeinpatientsproperty.
Weeks
24-26

NotifyHDcasemanagerofcompletionoftherapy(ifapplicable).
Reviewchartforcompletionofcontactinvestigation,etc.Mayneedtocontinueafterpatientstreatmenthascompleted

(afterweek26).
Checkreleasestatuswithclassifications/releasepersonnel.
DiscusscontinuationofcontactinvestigationwithHDcasemanager/physicianifapplicable.
 SOUTHEASTERNNATIONALTUBERCULOSISCENTER(SNTC)HTTP://SNTC.MEDICINE.UFL.EDU

INITIAL
DATE
VISIT PLEASE REMEMBER TO INITIAL AND DATE AFTER COMPLETING EACH TASK WHEN
COMPLETED
DONE

ContinueDOTasdirected(ifapplicable).ContinuetomonitorMARtoensurepatientistakingallmedicationsasprescribed.
Week 27 to End of Treatment

Continuecontactinvestigationifapplicable.
Monitorreleasestatuswithclassifications/releasepersonnel.
(if applicable)

Conductmonthlycasemanagementteammeetingtodiscusspatientsprogress.IncludeHDcasemanagerandallotherteam

members.
DiscussneedforcontinuationoftreatmentifneededwithHDcasemanager/physician.
Updatetreatmentplantoreflectongoingcareofpatient.
DrawSGOTandotherlabsasneeded.Obtainandrecordweightregularly.
Documentnumberofdosesinclinicalrecordonappropriatesheet.

Intheeventtheinmateistransferredorreleasedpriortocompletionoftreatment,medicationsmustbesentwiththeinmate,
alongwithacopyofthemedicaladministrationrecord(MAR),copiesofchestxrays/resultsandcopiesofanylabworkthe
Transfers or
Releases

inmatehasobtainedduringhis/herincarceration.
ThelocalHDTBnursecasemanagershouldalsobegivencopiesoftheaboveinformation,toensuretheirrecordisuptodate

andcurrent.
Contacttheagency/localHDpriortorelease/dischargeforcontinuityofcareifapplicable.
NOTE

BESTPRACTICE:Ifthepatienthascavitarylesionsintheirlungs,oriftheircultureispositiveafter2monthsoftreatmentwithfourdrugsthatthepatient
issensitiveto,treatmentshouldbeextendedtoaminimumof4monthsafterthepatientconvertstheculturestonegative.

Note:IndicateN/A(=NotApplicable)iftaskdoesnotneedtobedoneordoesnotapply.Thisindicationwillensurethatthetaskwasnotmissedor
overlookedbystaff.

COMMENTS/NOTES

COMPLETING CLINICAL PATHWAY

NURSE

Signature Title Initials Date

ASSISTING WITH CLINICAL PATHWAY

MANAGER

CASE

Signature Title Initials Date

NAME
AT ANY POINT, IF THE PATIENT IS RELEASED
OR TRANSFERRED TO ANOTHER FACILITY,
COMPLETE INFORMATION MUST BE SENT ID#
ALONG WITH THE INMATE PATIENT

DATEOFBIRTH