TB NURSE CASE MANAGEMENT CLINICAL PATHWAY
Purpose:
The TB Nurse Case Management Clinical Pathway (NCMCP) provides a sequential list of tasks, decisions, and
interventions performed during the care of a presumptive or confirmed TB case that will:
Reduce missed opportunities for improving care
Ensure interventions remain within the current standard of care
Assist in prioritizing numerous competing interventions
Improve TB outcomes
This tool has information and links you should find helpful. Taking advantage of the NCMCP electronic links to forms,
guidance, and directives, associated with specific steps can only be done if used electronically. In addition to its
electronic format the NCMCP can be printed and used as a checklist. This does not replace documentation of work
performed. All progress notes should continue to be robust but concise.
Instructions:
1. In print form, there are many underlined titles, words, and citations. These are hyperlinks to documents,
protocols, and supporting information that refer to specific steps of the NCM process.
2. If you would like to review a protocol or process or print a form, view the NCMCP electronically. You may want
to download the tool and save on your desktop for quick and easy use.
3. You can retrieve resources two ways:
a. Put your cursor on the underlined words then control/click and the document will open up for you to
view.
b. Right click the underlined words and in the drop down list select “open hyperlink.”
4. This pathway includes items that may not apply to your specific case. However, it serves as a reminder that a
step should be considered even if it does not apply to the current situation. Here are two examples:
a. Initial Report box: 3rd statement is “Arrange to visit client while hospitalized.” If the case is home, it is
obvious this wouldn’t apply.
b. Day 1 box: 10th statement “Place a TST or draw an Interferon Gamma Release Assay if not done.” If a
result is documented, no repeat is needed. This would not apply.
5. Each row in the NCMCP tool is a core component of TB NCM and should be thought of as a necessary step unless
determined otherwise. If you are unsure, speak to your supervisor or call TB control to speak with one of the
nurse consultants.
6. The “how to make it happen” steps are determined locally. If you are unsure or unaware of how to get
something accomplished contact your nursing supervisor, district medical director or other recognized authority
located in your district.
7. Of course, if the state office can be of assistance in any way, never hesitate to call (804) 864-7906.
1
VDH TB 08/2021
TB NURSE CASE MANAGEMENT CLINICAL PATHWAY
TB Nurse Case Management Directives Done
Initial Document on the Active TB Case Summary. Review information from the reporting source.
Notification Request medical records that provide the information needed to complete the Active TB Case
(Initial report) Summary.
Provide guidance to reporting source regarding Airborne Infection Isolation precautions (AII).
Presumptive and confirmed TB clients should be in AII if inpatient until standards for release from
isolation are met. Estimate potential infectiousness (site of disease, bacteriology, symptoms).
Arrange to visit the client in the hospital, their home or any other location within one workday.
If in a healthcare facility, contact the infection control nurse and the unit nurse in addition to
the client to arrange the visit.
Initiate the discharge plan if hospitalized. If discharge is imminent ensure the TB Treatment/
Discharge Plan has been completed by the hospital provider, reviewed and signed by the district
health director or other designated person (often TBNCM) before discharge
Use weight given during intake to calculate TB medication dosages “Treatment of Drug
Susceptible Tuberculosis,” 2016, Pg5 and 26 (You will reweigh the client as soon as possible)
Perform the initial client interview; confirm client medical/psychosocial/demographic
Day 1 information, complete the TB and Newcomer Health History, discuss public health coordination
with clients clinician
Notify TB control through REDCap of reported presumptive/confirmed case if not already done
Provide and review literacy and language appropriate TB educational materials: TB educational
materials
Provide an overview of the TB treatment plan including: monthly nursing/clinician visits.
Provide contact information for clinic/NCM and TB medication fact sheets
Obtain signatures on HIPAA required forms - Notice of privacy practices, Authorization to
Release PHI
Read, explain and obtain signature on the Patient Isolation Instructions
Read, explain and obtain signature for Directly Observed Therapy Agreement. Arrange for time
and place for DOT. Notify the Outreach Worker
Use a drug interaction checker to determine any drug/drug interactions with TB treatment
regimen. After obtaining a list of current medications. Give drug interaction report to clinician
for review. Document all medications on the Medication List.
Elicit contact information if appropriate determine the need for a contact investigation
Place TST, draw an Interferon Gamma Release Assay (IGRA) if not done and [Link] not confirmed
Do baseline diagnostic testing: Ishihara and Snellen for vision. Audiometry and Rhomberg
testing is not needed if initiating standard RIPE treatment, needed for second line drugs only
Do: AST, ALT, bilirubin, alkaline phosphatase, platelet count, creatinine, HIV, if not done within
the last month “Treatment of Drug Susceptible Tuberculosis”, 2016, pg.7. Document results on
Lab Flow Sheet
Do HgbA1c, whether the client has a history of diabetes or not, if not done in the prior 3 months
Do Hepatitis B and Hepatitis C screening if client has risk factors (IV drug use, birth in Asia or
Africa, HIV +)
Collect observed #1 sputum specimen. Assure GeneXpert (NAAT) on all initial smear positive
specimens Recommended sputum sample collection schedule. Provide sputum containers for
collection over next two days or schedule an induction if needed. Provide instructions for how
to collect a sputum. Induce if necessary. Document date collected on Bacteriology Flow sheet.
2
VDH TB 08/2021
TB NURSE CASE MANAGEMENT CLINICAL PATHWAY
Done
Request a CXR if recent exam is not available
Ensure client has a medical exam if not done to date
Plan source for TB meds based on cost effectiveness
Prepare the Directly observed therapy log
If the client is hospitalized, arrange for the home assessment
Develop plan to address potential barriers to adherence.
If housing/ food support is anticipated access all local avenues for assistance before submitting
a request for AHIP funds. Requests should be submitted through REDCap.
Day 2 Revisit incomplete steps from Day 1
Continue gathering health information from reporting site
Prioritize contacts and transmission locations identified and initiate contact evaluation (CI)
plan. Notify a Nurse Consultant if a special setting is identified (school, work site, etc) and may
lead to media attention. For environmental assessment assistance, contact the surveillance
team.
Collect #2 sputum specimen today. If unable, induce with clinician order. Document date of
collection on Bacteriology Flow Sheet.
Continue DOT
Day 3 Revisit or continue incomplete steps from Day 1 and Day 2
GeneXpert results should be available by the end of the day
Review lab test results and share with treating clinician (TST/IGRA, sputum smear and NAAT,
blood work, etc)
Estimate the infectious period. Continue planning and coordinating CI plan. Sputum AFB smear
negative respiratory site of disease requires a contact investigation plan, particularly if the
client was symptomatic or had cavitary disease.
Assess home environment for transmission potential and additional contacts
Collect #3 sputum specimen today. If unable, induce with clinician order. Document date of
collection on Bacteriology Flow Sheet (The next sputum will be collected in 7 – 10 days)
Recommended sputum sample collection schedule
Continue DOT
Ensure client has a medical exam if not done to date
Day 4 Revisit incomplete steps from Day 1,2 and Day 3
Notify TB control of reported presumptive/confirmed case if not already done electronically
through REDCap on day 1
Initiate Report of Verified Case of Tuberculosis (RVCT) in the Virginia Electronic Disease
Surveillance System (VEDSS), Page 1 - 3
Continue executing CI plan – re-interview the patient. Must notify TB Nurse Consultant if
possible media attention.
Read and record TST results two to 3 days after placement, If T-Spot, download results from
“Snap client portal”, If QuantiFERON done, look for results from Fairfax or LabCorps
Continue DOT
Sputum smear results should be available by this time on the 3 initial sputum collected. Record
Within 1 week
results on Bacteriology Flow Sheet. Smear positive/negative clients with a respiratory site of
of notification
disease, clinical symptoms of TB and/or cavitary disease should have a (CI) plan.
Carry out CI plan for high priority contacts (TST or IGRA, CXR, sputum, medical exam). Do not
delay the CXR for children <4 and immune suppressed individuals while awaiting results of
TST/IGRA (Standard of care for completion is 1 week)
3
VDH TB 08/2021
TB NURSE CASE MANAGEMENT CLINICAL PATHWAY
Done
Implement interventions for anticipated and known barriers for adherence. Seek assistance
from community social service agencies before seeking AHIP assistance
Contact TB control nurse consultants for Therapeutic Drug Monitoring (TDM) for all known
diabetic clients, those with results of a HgbA1c > 6.5 and HIV positive clients.
Continue DOT
Week 2 Continue TB education of client, and family and friends, if aware of diagnosis
Continue DOT. Plan for nurse’s home visit in the next 2 weeks.
Monitor drug side effects (SE), adverse drug reactions (ADR), and scheduling concerns to assure
treatment plan is successfully implemented
Continue CI plan and ensure all high priority contacts have begun appropriate window period
treatment if TST/IGRA negative. All high priority TST/IGRA positive clients should have
completed their evaluation (started treatment for TB infection: MMWR Guidelines for the
investigation of contacts of persons with infectious TB (2005) beginning on Pg17)
Ensure all medium priority contacts have been evaluated (standard of care for completion is
within 14 days)
Document the 60th day of treatment on the top left area of the bacteriology form. This date is
not the same as the 60th dose. This is the calendar date 60 days from the day treatment began.
Week 3 Gather information for CI initial 502 electronic submission into REDCap. Report due by Week 4
Continue to search for clues regarding contacts, particularly with smear positive clients
Assure smear results for all bacteriology specimens collected to date have been recorded on the
Bacteriology Flow Sheet
Collect sputum for AFB smear and culture, record on Bacteriology Flow Sheet. One sputum will
be collected every 7 – 10 days going forward until two consecutive cultures are negative
If clinician visit is scheduled for Week 4, collect sputum, blood work as ordered, and perform
other monitoring this week so it is available by clinician visit.
Review DOT documentation to assess adherence. Be sure daily observation for signs of non-
adherence are reported and documented thoroughly in the client’s medical record. Continue
DOT.
Monthly clinical assessment by NCM or clinician. Assess client’s status; weight, vital signs, visual
Week 4
acuity, TB symptoms, client report, bacteriology, adverse drug events etc.
Forward all updated labs to treating clinician for review
Discuss option for change to intermittent therapy during the intensive phase with treating
clinician (thrice weekly over twice weekly is preferred) Caution: clients with an initial high
burden of disease should have shown a significant response to therapy to consider intermittent
therapy this early in treatment
Clients at high risk for hepatotoxicity may require lab work. Check with treating clinician
Contact lab for most up to date results on AFB specimens (May take 6 weeks for culture
results to be final from DCLS)
Collect sputum for AFB smear and culture. If smears have converted to negative plan for
release from isolation if: (1) likelihood of resistance is low, (2) at least 2 weeks of TB treatment has
been completed, (3) the clinical picture has improved, and (4) smear positivity is improved. Must
have 3 negative smears to return to congregate setting. (MMWR Controlling TB in the US –
2005; Box 3)
Continue to identify contacts. CI plan: ensure all high priority contacts have begun window
period treatment, if prescribed. MMWR Guidelines for the investigation of contacts of persons
with infectious TB (2005) beginning on Pg17
4
VDH TB 08/2021
TB NURSE CASE MANAGEMENT CLINICAL PATHWAY
Done
Submit CI initial 502 information to REDCap if not already done
If not already started, begin window period treatment on TST/IGRA negative high priority
contacts (children <4, immune compromised)
Share all updated orders, recommendations, case management strategies with ORW
Continue DOT
Week 5 - 7 Final culture results should be available by 6 weeks after collection
Critical action – if culture conversion has not occurred and a client had cavitary evidence on
their initial radiography, one sputum must be collected before the 60th day after treatment
began. If this applies, plan now for one sputum collection between the 57-59 day. Note this on
the DOT record in the comment section. (Treatment of Drug-Susceptible Tuberculosis – Pg21)
Susceptibility results should be available within 2 weeks after final culture is received
If client is slow to respond to treatment, (smears not improving, no clinical improvement)
re-evaluate adherence, consider TDM
If client is pansensitive – discuss discontinuing Ethambutol with the treating clinician
CI – Ensure adherence to LTBI treatment for contacts on window period treatment or those
with LTBI. Consult with ORW to locate those who are non- adherent. Continue with evaluations
on newly identified contacts, if any
In preparation for 8 week visit with clinician do weight, vital signs, visual acuity, labs if ordered
If client is a clinical case (culture negative) repeat CXR and request comparison with initial
imaging
Continue DOT
Begin planning for repeat TST/IGRA on contacts over the next month. Each contact who had a
negative TST/IGRA is tested a second time a minimum of 10 weeks after the date of last
exposure to the infectious case.
This is a critical juncture in case management. Several activities occur that determine case
Week 8 confirmation, treatment changes, length of treatment, future monitoring, and the CI. This is
also when an unexpected TB drug resistant case will be discovered
“Hit the wall” behavior - Common time for adherence issues to arise. Most clients are now
smear negative, no longer in isolation and feeling better.
Sputum collection between the 57-59 day of treatment if culture conversion has not occurred
and the client had cavitary evidence on radiography.
If clinical or bacteriological improvement is not evident by 60 days of treatment, discuss with
treating clinician: Evaluate adherence, consider TDM. Continue to collect 1 sputum every 7 – 10
days
Calculate the number of doses taken during the initial phase. When 8 weeks of Pyrazinamide
(PZA) have been taken, discuss discontinuing PZA with the treating clinician only if sensitivities
are available. Do not stop PZA unless you have carefully counted doses. When less than 8
weeks of PZA is taken, treatment will need to be extended.
Monthly clinical assessment - RN or clinician
Labs, if needed, weight, and vital signs
Discuss change to intermittent regimen with treating clinician. Daily or thrice weekly only (not
twice weekly) for HIV positive patients, diabetic patients and others who are immune suppressed.
Continue DOT - Document changes in medication and dosages on the DOT sheet with new
dosages. Discuss changes with ORW
Verify if suspect should or should not be counted as a case of TB (consult RVCT instructions)
The clinician will base the decision to stop or continue treatment using historical and
current information (sputum, imaging, clinical improvement, etc.).
5
VDH TB 08/2021
TB NURSE CASE MANAGEMENT CLINICAL PATHWAY
Done
nd
Critical CI juncture 2 round testing is due a minimum 10 weeks after a contacts last date of
exposure to the case while infectious. Assure treatment initiation for infected contacts and
continue follow-up and reminder efforts.
Continue to collect sputum for AFB smear and culture until culture conversion. Collect 1 sputum
Week 9 - 11
every 7-10 days (3 per month)
Obtain prescriptions for change of dosages if needed for intermittent therapy
Complete information in RVCT VEDSS pages 1 – 3 and follow-up report 1 - drug susceptibility
results (if available)
Continue DOT
CI – continue efforts to assure 2nd round of testing is being performed
Evaluate results to determine need to expand investigation to next lower priority level.
For contacts on treatment: employ strategies to improve treatment initiation, adherence
and completion
Week 12 Monthly clinical assessment - RN or clinician
Labs if needed, weight, vital signs
CI – All initial contacts should have been completely evaluated.
Contacts identified later should have had their first TST/IGRA. Those identified as high priority
contacts should be placed on window period treatment if the initial test is negative and was
performed less than 10 weeks from exposure to the TB case while infectious
Ensure new orders, recommendations, or case management strategies are shared with the
ORW
Forward all recent lab results to treating clinician
Continue DOT
Sputum collection will likely be discontinued at this time. Sputum culture conversion is
expected by this time in the treatment. If culture conversion is not evident, notify the treating
clinician and TB control for recommendations
Week 13 – 15 CI – continue activities, monitor contact adherence to treatment
Continue DOT
Complete information in RVCT, VEDSS pages 1 – 3 and follow-up report 1 - Drug susceptibility
results if not already done
Week 16 Monthly clinical assessment - RN or clinician
Labs if needed, weight, vital signs
Ensure new orders, recommendations, or case management strategies are shared with
the ORW
Ensure treating clinician has most recent lab results
Continue DOT
Week 17 – 19 Continue DOT
CI – continue activities, monitor contact adherence to treatment
Week 20 Monthly clinical assessment - RN or clinician
Labs if needed, weight, vital signs
CI – continue activities, monitor contact adherence to treatment
Ensure new orders, recommendations, or case management strategies are shared with
the ORW
Continue DOT
Ensure treating clinician has most recent lab results
Week 21 - 23 CI – continue activities, monitor contact adherence to treatment
6
VDH TB 08/2021
TB NURSE CASE MANAGEMENT CLINICAL PATHWAY
Done
NCM responsibility: Calculate total dosages/ frequency to determine weeks taken during the
entire treatment course to ensure the client is on target for completing treatment in the next 4
weeks if treatment course is 26 weeks.
Repeat CXR for comparison with prior radiography and documentation of status at treatment
completion
Schedule client for final visit with clinician as treatment comes to completion
Final clinic visit with clinician. The treating clinician will confirm treatment completion
Week 24 - 26
with assistance from the NCM (weeks taken, culture conversion)
Continue DOT until required weeks have been taken. Notify ORW of remaining doses needed to
treat to completion.
Provide client with a written treatment summary that includes: Health department and treating
clinician contact information, diagnosis and site of disease, TST/IGRA results, CXR results,
treatment taken (medication, dosage, and number of weeks), final bacteriology, patient
education information
If client requests (not required), schedule client for follow-up appointment
Closing the Assure all information is complete, DOT sheet, bacteriology, other labs, contact investigation
case information
Complete RVCT Case Completion Report – follow-up 2 in VEDSS, all case information should be
complete at this point. If questions contact Surveillance team at (804) 864-7906
Complete the TB Case Completion Report and fax to TB control (804) 416-5178
Complete final CI 502 information and fax to TB control (804) 416-5178
Treatment may be extended beyond 26 weeks in the following circumstances
Resistance or intolerance to PZA
Less than 8 weeks of PZA taken
Delayed culture conversion
Interruptions in treatment (often due to drug intolerance) (Pg21)
Certain co-morbidities
If this occurs, continue ‘Week 20’ activities for the remaining weeks and follow week 24 – 26
as completion of treatment approaches.
Call VDH TB Control anytime if questions arise (804) 864-7906
7
VDH TB 08/2021
