In 1994, CDC published the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health Care Facilities, 1994 (1).
The 1994 guidelines, which followed CDC statements issued in 1982 and 1990 (1,6,7), presented recommendations for TB infection control based on a risk assessment process. Despite the general decline in TB rates in recent years, a marked geographic variation in TB case rates persists, which means that HCWs in different areas face different risks (10).
The risk assessment process includes the assessment of additional aspects of infection control. Inpatient settings include patient rooms, emergency departments (EDs), intensive care units (ICUs), surgical suites, laboratories, laboratory procedure areas, bronchoscopy suites, sputum induction or inhalation therapy rooms, autopsy suites, and embalming rooms. In addition to close contacts, the following persons are also at higher risk for exposure to and infection with M.
Populations at high risk who are defined locally as having an increased incidence of TB disease. Persons who use tobacco or alcohol (40,41), illegal drugs, including injection drugs and crack cocaine (42–47), might also be at increased risk for infection and disease. HIV infection is the greatest risk factor for progression from LTBI to TB disease (22,39,48,49). All HCWs should be informed regarding the risk for developing TB disease after being infected with M. Vaccination with BCG probably does not affect the risk for infection after exposure, but it might decrease the risk for progression from infection with M. The first and most important level of TB controls is the use of administrative measures to reduce the risk for exposure to persons who might have TB disease.
Collaborate with the local or state health department to develop administrative controls consisting of the risk assessment, the written TB infection-control plan, management of patients with suspected or confirmed TB disease, training and education of HCWs, screening and evaluation of HCWs, problem evaluation, and coordination. Collaborate with the local or state health department to develop administrative controls consisting of the risk assessment and the written TB infection-control plan. Every health-care setting should conduct initial and ongoing evaluations of the risk for transmission of M. Consult the local or state TB-control program to obtain epidemiologic surveillance data necessary to conduct a TB risk assessment for the health-care setting. Determine which HCWs need to be included in a TB screening program and the frequency of screening (based on risk classification) (Appendix C). Identify areas in the setting with an increased risk for health-care–associated transmission of M.
Risk classification should be used as part of the risk assessment to determine the need for a TB screening program for HCWs and the frequency of screening (Appendix C).
The three TB screening risk classifications are low risk, medium risk, and potential ongoing transmission. The classification of medium risk should be applied to settings in which the risk assessment has determined that HCWs will or will possibly be exposed to persons with TB disease or to clinical specimens that might contain M. If uncertainty exists regarding whether to classify a setting as low risk or medium risk, the setting typically should be classified as medium risk. The following hypothetical situations illustrate how assessment data are used to assign a risk classification. Evaluation of HCWs for LTBI should include information from a serial testing program, but this information must be interpreted as only one part of a full assessment. Environmental control design specifications should be compared with guidelines from the American Institute of Architects (AIA) and other ventilation guidelines (117,118) (see Risk Classification Examples) and the installed system performance.
The number of AII rooms should be suitable for the setting based on AIA Guidelines and the setting risk assessment. Rationale for infection-control measures and documentation evaluating the effect of these measures in reducing occupational TB risk exposure and M. Importance of completing therapy for LTBI or TB disease to protect the HCW's health and to reduce the risk to others. Success of adherence to infection-control practices in decreasing the risk for transmission of M. Available tests and counseling and referrals for persons with HIV infection, diabetes, and other immunocompromising conditions associated with an increased risk for progression to TB disease. The primary TB risk to HCWs is the undiagnosed or unsuspected patient with infectious TB disease. The classification of the risk assessment of the health-care setting is used to determine how many AII rooms each setting needs, depending on the number of TB patients examined.
Older people living in care homes fall three times more frequently than individuals who still live in their own homes.


Eighty percent of people living in care homes have a cognitive problem, so their memory, reasoning or spatial awareness may be impaired.
The GtACH was designed locally by researchers and clinicians who pulled together all the published literature on the measures people can take to help care home residents reduce their risk of falling over. The GtACH is an assessment tool presented in a grid-like format with boxes that can be ticked to indicate the risk factors for falling. Also, the manual contains information about interventions to try and overcome these risk factors. GtACH can therefore be used as a guide, as well as an assessment tool, which is why it's referred to as a guide to action. There are fall risk assessments available, but most of them have been designed for people living in hospital or living at home on their own.
We know that people who are on more than four medications a day are at a higher risk of falling than people who aren't on four medications a day and that those who have had a previous fall are more likely to fall again. What we are trying to do is get the care home staff and relatives to participate in using the assessment and interventions. We want to train about 80% of the staff in each care home, including everybody from the caretakers, cooks and cleaners, through to managers, so that everyone is aware of the factors that increase a resident’s risk of falling. We also like to find somebody at the care home who can act as the main contact point regarding these issues, so that somebody is responsible in the care home for ensuring staff are carrying out assessments at the same time. Although very small, our study did indicate that GtACH has reduced the number of falls in the care homes that have implemented it. We are planning to use 66 care homes across the UK – 33 that would use the intervention and 33 that would not. We've had positive feedback from the staff and the managers of care homes, as well as from people living in the care homes and their families, who are also able to look at the documentation and add their thoughts or tick boxes to find out what should be done. We're also talking to the AHSM regarding other care homes in the East Midlands that may be keen to try out this new tool. Her main research interests are stroke, community rehabilitation, older people, falls, primary care and social Care. In this process, health-care facilities were classified according to categories of TB risk,with a corresponding series of environmental and respiratory-protection control measures. However, because of multiple other potential risk factors that commonly occur among such persons, use of these substances has been difficult to identify as separate risk factors. Therefore, voluntary HIV counseling, testing, and referral should be routinely offered to all persons at risk for LTBI (1,50,51).
Give the supervisor or supervisory body the support and authority to conduct a TB risk assessment, implement and enforce TB infection-control policies, and ensure recommended training and education of HCWs. The risk classification for the setting should help to make this determination, depending on the number of TB patients examined.
The classification of low risk should be applied to settings in which persons with TB disease are not expected to be encountered, and, therefore, exposure to M.
If greater than or equal to six TB patients for the preceding year, classify as medium risk. If greater than or equal to three TB patients for the preceding year, classify as medium risk.
The risk classifications are for settings in which patients with suspected or confirmed infectious TB disease are expected to be encountered.
A home health-care agency employs 125 workers, many of whom perform duties, including nursing, physical therapy, and basic home care. Infection-control plans should address HCWs who transfer from one health-care setting to another and consider that the transferring HCWs might be at an equivalent or higher risk for exposure in different settings.
Data from the case reviews and observations in the annual risk assessment should be used to determine the need to modify 1) protocols for identifying and initiating prompt airborne precautions for patients with suspected or confirmed infectious TB disease, 2) protocols for patient management, 3) laboratory procedures, or 4) TB training and education programs for HCWs. There is often debate over the idea of people going into care homes as a solution to the fact they are falling at home but they can still fall in the care home. As people get older, we usually try and teach them how to use a walking stick or a walking frame, but it is much more difficult to teach people with dementia, which leaves them at a greater risk of falling over. It will tell you what to do if someone has a blood pressure problem, an eyesight problem or a problem drinking their fluids (inadequate fluid intake can also increase the risk of falling over).
If somebody is only having two drinks a day, for example, and they need to have at least six drinks a day to reducet their risk of falling over, we'll give the care home staff information containing ideas about how to get people to drink more fluids. We examine each individual part of the resident’s life and look at how much those aspects contribute to their risk of falling. In those cases, we would record that information so that the next person who comes to see them will know they're at an increased risk of falling and the reason why.


In cases where residents are cognitively intact and can do this themselves, staff could explain to them that if they do not drink a certain amount or walk a certain amount, that they will increase their risk of falling over. We would then measure the outcomes across all of the care homes to see whether it reduced falls or not. Most people who work in care homes aren't nurses or therapists, so we need something that care home staff would want to pick up and use. We would like to go and speak to them, train them, and maybe collect some information from their care homes. She works clinically as an occupational therapist in the community with stroke and older people patients and provides clinical input to health care of the elderly wards in an Acute Hospital. She was awarded a National Primary Care Research Development Award (1999 -2004) and a Post Doctoral Award (2005- 2007) by the Department of Health.
The 1994 guidelines, which followed statements issued in 1982 and 1990, presented recommendations for TB-infection control based on a risk assessment process that classified health-care facilities according to categories of TB risk, with a corresponding series of administrative, environmental, and respiratory-protection control measures. The risk for progression of LTBI to TB disease is highest during the first several years after infection (36–38).
Although HIV infection increases the likelihood of progression from LTBI to TB disease (39,49), whether HIV infection increases the risk for becoming infected if exposed to M.
The magnitude of the risk varies by setting, occupational group, prevalence of TB in the community, patient population, and effectiveness of TB infection-control measures. These control levels also reduce, but do not eliminate, the risk for exposure in the limited areas in which exposure can still occur. The TB risk assessment determines the types of administrative, environmental, and respiratory-protection controls needed for a setting and serves as an ongoing evaluation tool of the quality of TB infection control and for the identification of needed improvements in infection-control measures. After a determination that ongoing transmission has ceased, the setting should be reclassified as medium risk. During the preceding year, care was delivered to six patients with TB disease and approximately 50 persons with LTBI. The agency did not care for any patients with suspected or confirmed TB disease during the preceding year.
Infection-control plans might need to be customized to balance the assessed risks and the efficacy of the plan based on consideration of various logistical factors.
Care home staff would then use that to devise a plan rather than being confused about what they need to do. Part of the risk assessment is similar to a program review that is conducted by the local TB-control program (42).
Examples of assigning risk classifications have been provided (see Risk Classification Examples). The review should be based on the factors listed on the TB Risk Assessment Worksheet (Appendix B). The closer the proximity and the longer the duration of exposure, the higher the risk is for being infected.
DOT is the standard of care for all patients with TB disease and should be used for all doses during the course of therapy for TB disease and for LTBI whenever feasible.
The TB Risk Assessment Worksheet (Appendix B) can be used as a guide for conducting a risk assessment.
Risk classification: medium risk (Correctional facilities should be classified as at least medium risk). Use of respiratory protection can further reduce risk for exposure of HCWs to infectious droplet nuclei that have been expelled into the air from a patient with infectious TB disease (see Respiratory Protection). The term "health-care setting" includes many types, such as inpatient settings, outpatient settings, TB clinics, settings in correctional facilities in which health care is delivered, settings in which home-based health-care and emergency medical services are provided, and laboratories handling clinical specimens that might contain M. Risk classification: medium risk (with close ongoing surveillance for episodes of transmission from unrecognized cases of TB disease, test conversions for M.
The home health-care agency is based in a major metropolitan area and delivers care to a community where the majority of persons are poor and medically underserved and TB case rates are higher than the community as a whole.
Risk classification: low risk (because HCWs might be from populations at higher risk for LTBI and subsequent progression to TB disease because of foreign birth and recent immigration or HIV-infected clients might be overrepresented, medium risk could be considered).



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