A Tuberculosis Mystery and the Infection Preventionist's Dilemma: The Case Study

IP LifeLine From Infection Control Today

This case study examines a complex situation encountered by an infection preventionist (IP) in a hospital in California. It highlights the challenges of managing patient isolation, addressing established but potentially flawed practices, and fostering interdepartmental collaboration. The case involves a patient admitted for labor and delivery who was placed on airborne isolation despite a lack of clear clinical indications. This situation presented a dilemma for the IP, requiring careful consideration of patient safety, staff concerns, and established hospital protocols.

The Initial Consultation

It was a Thursday afternoon when the behavioral health unit contacted the IP for guidance. They had a patient, "Jane," transferring from labor and delivery. Jane was on a 72-hour psychiatric hold for suicidal ideation and, critically, had an active order for airborne isolation. The behavioral health unit staff expressed significant concerns. They lacked the necessary airborne isolation room and were not N95 fit-tested, raising concerns about potential exposure risks. They needed advice on transferring Jane to a unit equipped to handle her medical needs. The IP acknowledged their concerns and promised to investigate the situation, review Jane's chart, and develop a plan of action.

Unraveling the Mystery: The Investigation

The IP began a thorough investigation, starting with an in-depth review of Jane's medical records and a consultation with the labor and delivery unit. The goal was to understand the rationale behind the airborne isolation order. The information gleaned painted a concerning picture. Jane, who was unhoused, had been admitted the previous day in active labor.

Upon admission, the attending labor and delivery physician had placed her on airborne precautions. However, the chart review revealed no documented evidence—no imaging, provider notes, or relevant history—to support this decision. The only indication was an active order for a QuantiFERON gold test to diagnose latent tuberculosis (TB) infection. While a positive result could indicate latent TB, there were no documented symptoms suggestive of active pulmonary TB.

Additionally, Jane had no chest X-rays, sputum results, or pending tests to rule out active pulmonary TB. Puzzled by the lack of supporting evidence and concerned they may be missing something, the IP contacted the local public health department to check for any documented history of TB or TB testing. They confirmed that no records for Jane existed.

Infection preventionist looking in on a tuberculosis patient.

(AI image by author)

A Deeper Dive: Uncovering the Root Cause

Still perplexed, the IP contacted the charge nurse in labor and delivery, hoping for additional insights. This conversation revealed a long-standing, concerning practice. The attending physician in labor and delivery routinely placed all unhoused patients on airborne precautions pending the results of a QuantiFERON gold test. The rationale was that unhoused individuals were considered at higher risk for TB exposure and other infectious agents.

Furthermore, the physician believed that pregnancy and the living conditions of unhoused individuals could compromise their immune systems, increasing their susceptibility to active TB. This practice, while seemingly well-intentioned, clearly deviated from established guidelines for airborne isolation.

The Dilemma: Balancing Patient Safety and Established Practice

The IP now faced a difficult decision. Jane, clearly not meeting the criteria for suspected TB, was on airborne precautions due to a standard practice on the unit based on perceived risk factors. The IP recognized the common challenge of encountering established processes that don't align with current best practices. In these instances, IPs must weigh the risk to the patient in support of the practice against the need to intervene and change the practice on the spot. Unilateral decisions in such situations can have significant downstream impacts, requiring careful consideration.

Navigating the Complexities: A Peer-Centered Approach

The IP considered 2 options: (1) maintain airborne precautions and transfer Jane to a medical floor with a negative pressure room, or (2) remove the airborne precautions and reeducate the staff, allowing Jane's admission to the behavioral health unit. While seemingly straightforward, the decision was complicated by the ingrained nature of the existing practice.

In these moments, an IP needs to lean into their understanding of their organizational culture and the cues given by the staff. Understanding both helps inform our approach without jeopardizing key relationships. Unfortunately, the attending physician who admitted Jane was unavailable until the following week.

Understanding Staff Perceptions

The IP learned that the behavioral health unit was uncomfortable accepting a "rule-out TB patient," even without clinical evidence of active TB. They respected the labor and delivery physician who placed the order and were aware of the pending QuantiFERON gold test. Even if they acknowledged the lack of clinical indicators for pulmonary TB, they were concerned that the physician might have access to information they lacked. The IP recognized that removing airborne precautions would likely lead the behavioral health unit staff to perceive that they were being placed at risk for TB exposure if the patient were admitted to the unit.

A Collaborative Solution: Interim Management

Recognizing the complexities of the situation and the need for a timely solution, the IP consulted with their manager. They proposed admitting Jane to a medical-surgical unit with a 1:1 sitter until the QuantiFERON gold results were available or a discussion with the labor and delivery attending could occur. The manager agreed, and the IP secured approval from the behavioral health unit attending and the medical-surgical nursing director. Jane was transferred to the medical-surgical unit, and fortunately, her suicidal ideation improved, leading to her discharge at the end of the 72-hour hold.

Hotwash and Lessons Learned: Implementing Change

The following week, the IP met with the labor and delivery attending physician. Before the meeting, the IP reviewed local, state, and federal guidelines for TB prevention and control. During the meeting, the IP explained how Jane's case was handled in the physician's absence, reviewed Jane's chart, and highlighted the lack of clinical documentation to support the use of airborne precautions in this case. They engaged in a collaborative discussion about the impact of this practice on staff and patients. Ultimately, the IP successfully gained the physician's buy-in to discontinue the practice, resulting in a valuable learning experience for both parties.

Conclusion: The Power of Collaboration and Curiosity

This case study illustrates the intricate nature of clinical decision-making, especially when dealing with ambiguous information and conflicting practices. The IP navigated a challenging scenario by approaching the situation with curiosity, prioritizing peer relationships, and considering staff perceptions while prioritizing patient safety and well-being. The collaborative efforts of the behavioral health unit, labor and delivery unit, and medical-surgical team were instrumental in successfully resolving this complex case.

This experience underscores the importance of open communication, critical thinking, and a willingness to examine established practices with curiosity. A peer-centered approach, which values staff input and understanding, creates opportunities to enhance patient safety and maintain essential interprofessional relationships. By sharing this case study, the hope is to empower other IPs to navigate their own complex situations, focusing on patient safety and collaborative problem-solving.