Prevention and Control of Tuberculosis in Correctional and Detention Facilities: Recommendations from CDC

Endorsed by the Advisory Council for the Elimination of Tuberculosis, the National Commission on Correctional Health Care, and the American Correctional Association

Disclosures

Morbidity and Mortality Weekly Report. 2006;55(27):1-44. 

In This Article

Program Evaluation

Six steps should be followed to ensure successful monitoring and evaluation of a TB-prevention and -control program:

  • identifying collaborators,

  • describing the TB-control program,

  • focusing the evaluation to assess TB risk and performance,

  • collecting and organizing data,

  • analyzing data and forming conclusions, and

  • using the information to improve the TB program.[169]

The purpose of program evaluation is to improve accountability, enable ongoing learning and problem-solving, and identify opportunities for improvement. The evaluation process should be designed to provide information relevant to the stakeholders. Measures should be simple and the communication of results meaningful.

TB control requires the collaboration of correctional systems, health departments, and other community agencies; effective program evaluation also involves teamwork. Early engagement of program staff and internal and external collaborators (including custody staff) helps ensure that the evaluation will yield the information that is most useful to stakeholders. Such engagement also promotes mutual cooperation for constructive change. Although multiple parties might be involved, each TB program should have a single person designated to be responsible for data quality and program evaluation. Designating staff for these activities helps ensure that continuity and accountability are maintained.

Underlying a useful evaluation is an understanding of how the TB program currently operates within the context of the facility. Evaluators should be knowledgeable about program goals and objectives, strategies, expected program-associated results, and the way in which the program fits into the larger organization and community. This information can typically be obtained by reviewing a facility's existing TB-control plan. In addition, all stakeholders should agree on program goals before the evaluation is undertaken.[169]

Risk Assessment. Each facility should assess its level of TB risk at least annually.[71] The TB risk assessment (see Screening) determines the types and levels of administrative and environmental controls needed. Assessment of a facility's risk level includes analysis of disease burden and facility transmission, which can be conducted by examining the following indicators:

  • Burden of disease
    -- community rates of TB disease (including other communities from which substantial numbers of inmates come; these data are available from local health departments),
    -- the number of cases of TB disease in the facility during the preceding year, and
    -- the number and percentage of inmates and staff with LTBI; and

  • Facility transmission
    -- the number and percentage of staff and inmates whose tests for TB infection converted and the reasons for the conversion,
    -- the number of TB exposure incidents (see Contact Investigation), and
    -- evidence of person-to-person transmission.

Conversion rates (as determined by annual testing) for staff and inmates should be determined and tracked over time to monitor for unsuspected transmission in the facility. In larger facilities, conversion rates for staff assigned to areas that might place them at higher risk for TB (e.g., booking and holding areas, day rooms, libraries, enclosed recreation areas, medical and dental areas, and transport vehicles) should be calculated and tracked. Staff should analyze contributing factors to TB exposure and transmission and plan for corrective intervention, as appropriate. The following performance measures should be considered when determining risk within all correctional facilities, including those that function as a contract facility within a larger correctional system:

  • the timeliness with which patients with suspected TB disease are detected, isolated, and evaluated (see Performance Measurement for Improving Quality); and

  • other factors (e.g., the total number of patients with TB housed in the facility and the number of persons housed in the facility who are risk for TB) that will help determine the controls needed.[71]

Performance Measurement for Improving Quality. The risk-assessment process enables the monitoring of risk for TB transmission (the key program indicator) and helps guide the focus and intensity of ongoing performance measurement and monitoring. Facilities at higher risk (e.g., those with cases of TB disease) benefit more from broader investigation of performance than facilities at lower risk. Risk-assessment findings should help guide the development of simple process performance measures for each pertinent area of TB prevention and control. These performance measures can then be used to monitor program implementation and intermediate outcomes. Treatment completion and continuity of care are key performance indicators. Each facility should have goals against which to measure performance in these areas (e.g., 100% of patients with TB disease will have documented treatment completion or, in the case of release or transfer, continuity of treatment on release). For LTBI, goals might be that 100% of patients released during treatment will have a documented referral for continuity of care in the community and that 90% of these patients will follow-up on their referral. The following are examples of possible performance measures that can be useful as part of a TB program evaluation, depending on the level of risk:

  • Timeliness of screening and isolation
    -- time from inmate admission to testing for TB infection,
    -- time from TB testing to obtaining test results,
    -- time from positive TB infection test results to obtaining a chest radiograph,
    -- time from identification of a suspect TB patient (either through symptoms or abnormal chest radiograph) to placement in an AII room,
    -- time from sputum collection to receipt of results, and
    -- time from suspicious result (either via radiograph, smear-positive result, or smear-negative/culture-positive result) to initiation of contact investigation;

  • Treatment
    -- the number and percentage of patients with LTBI who initiated treatment and the percentage of persons who completed the prescribed treatment for LTBI (excluding those released from or transferred out of the facility),
    -- the number and percentage of persons in whom TB disease was diagnosed who completed the prescribed treatment regimen (excluding those released from or transferred out of the facility), and
    -- the reasons for treatment interruption among persons who stop therapy; and

  • Continuity of care¶¶
    -- the number and percentage of patients released before completing treatment for TB disease or LTBI who had documented community appointments (or referrals) for continuity of care, and
    -- the number and percentage of patients with confirmed and suspected TB disease who kept their first medical appointment in the community.

Other pertinent performance measures for correctional facilities might include the adherence rates among inmates and staff who should undergo TB testing, the percentage of staff receiving TB education and training annually, and the percentage of inmates receiving TB education.

Assessment of Collaboration. On an annual basis, each program also should evaluate its success in working collaboratively with local and state public health departments in each area of TB control (e.g., screening, containment, and assessment). Correctional systems should meet with their respective public health departments each year to assess risk, update TB policies and procedures, and assess compliance regarding environmental control and respiratory protection recommendations (see Environmental Controls and Respiratory Protection). Correctional systems also should assess collaboration with other agencies to which the inmates are released.

Data Sources. As part of quality assessment, all facilities that house persons with confirmed or suspected TB disease should conduct periodic reviews of medical records for these patients and for a sample of patients with LTBI. In collaboration with the public health department, the review should be conducted at least annually in facilities with any confirmed or suspected cases of TB (including low-risk facilities) and quarterly in higher-risk facilities with numerous cases. The record review should compare actual performance against time standards, protocols, and goals for TB activities and outcomes (see Performance Measures for Improving Quality). Multiple tools are available for data collection (Appendix B).[131]

Medical records should contain information regarding TB history and risk factors, treatment, and all other interventions and dates to enable performance to be monitored. Other sources of data include log books, interviews with staff, and observations. Quality controls for TST placement and reading should be checked at least annually. The quality of the data used for calculating performance also should be verified.

Information Infrastructure. Effective program monitoring and evaluation is made possible through the reliable collection of valid data and through analysis of these data. Health-care professionals responsible for the prevention and control of TB within a correctional facility should have access to complete medical records and a database of essential TB-related activity and measurements. A retrievable aggregate record system is essential for tracking all inmates and for assessing the status of persons who have TB disease and LTBI, particularly in large jail and prison systems in which inmates are transferred frequently from one facility or unit to another. This record system should maintain at minimum current information about the location, screening results, treatment status, and degree of infectiousness of these persons. In addition to facilitating case management, such a record system provides facilities with the information necessary for conducting annual TB risk assessments, monitoring TB trends, measuring performance, and assessing the effectiveness of overall TB control efforts. Information contained in health records should always be kept confidential; all staff members involved in program evaluation should receive training to maintain the confidentiality of patient information.

Although medical databases can be maintained manually, electronic databases provide additional benefits by enabling a facility to 1) better track inmates for testing and case management, 2) access information regarding tests for TB infection, 3) share medical information regarding transferred inmates with other facilities, 4) link with the local health department, and 5) measure the effectiveness of TB-control efforts.

In a multifacility correctional system, evaluation data should be compiled for each facility separately and in aggregate. Data should be analyzed against standards, which can be defined externally (e.g., by national organizations or CDC-defined standards) or internally as established by the program collaborators.[170] Once analyzed, conclusions should be drawn from the data and recommendations for program improvement developed. The evaluation and recommendations should be shared with program staff, administrators, and partners, including the local public health department.

The final step in the evaluation process is to implement the recommendations to improve the TB program. Program staff should use data to identify and remove barriers to improving performance, and administrators should make necessary revisions to policies or procedures.

Because the evaluation process is cyclical, assessing whether recommendations have been implemented and whether outcomes are improved is crucial. Existing data can be used to clearly demonstrate the effects of implemented interventions.

¶¶ Public health departments typically track treatment completion rates for patients referred to their care.

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