Identifying TB - sputum testing

A good relationship is developed with the patient while symptoms, signs and risk factors consistent with TB are assessed and investigated appropriately

Importance of early diagnosis (click to view)

The diagnostic phase is critical to effective case finding. By the time an individual with symptoms arrives at a health facility, he or she has already realised that something is not right and has decided to seek help. If that person is given confusing advice or not treated well, he or she may never return or follow any instructions given.

Early diagnosis prevents the spread of TB (susceptible or resistant) because the sooner someone is diagnosed and started on treatment
a) the less physical damage will be suffered by the patient physically
b) the shorter the time the patient will remain infectious

Early diagnosis is one of the key administrative measures recommended to control the spread of infection and is essential in the community as well as in health care facilities.

Read more: WHO Policy on TB Infection Control in Health-care Facilities, Congregate settings and Households (2009)

Identifying a suspect case for further investigation (click to view)

It is recommended that all patients who have been coughing for 2-3 weeks or more should have their sputum sent for AFB smear examination, as chronic cough is the most common symptom of TB. Other symptoms include night sweats, fever loss of appetite, weight loss, malaise, fatigue, breathlessness and chest pain. In later stages of pulmonary TB patients may suffer with haemoptosis. These symptoms are even more indicative of TB if the patient has had contact with someone known to have the disease. Ensuring that health-care workers have an adequate level of awareness about TB symptoms will prevent cases being missed. Special care should be taken when assessing children, as symptoms vary and they seldom produce sputum, which means they are more difficult to diagnose

Read more: Standard 1 in Standards for Diagnosis in ISTC TBCTA (2006)

Read more: Chapter Vlll. The Management of tuberculosis in Management of the Child with Cough or Difficult Breathing A Guide For Low Income Countries, Union (2005), Second Edition

It is important to understand the epidemiology in the context of your work environment as well as the levels of TB in different parts of the world which a patient may visit or from where s/he may originate. This can help you to assess the likelihood that a patient has been in contact with the disease.

Presentation 1 shows the Worldwide spread of TB. It offers you a chance to think about the level of TB in your local region

Ordering the appropriate tests (click to view)

It is important to order the appropriate tests in order to save time and money. The most effective test for finding infectious TB is sputum smear microscopy for Acid Fast Bacilli (AFB) (Standard 2 is about how to take a Sputum sample for AFB). It is recommended that all patients who have been coughing for 2-3 weeks or more should have their sputum sent for AFB (full form) smear examination. Chronic cough is the most common symptom of TB. Chest radiographs may be useful in diagnosing the disease in the smear-negative patient but their interpretation can be unreliable in identifying active TB. When assessing a patient it is also essential to take a good history and identify and potential risk of possible drug resistance namely previous treatment or known contact.

Learn more: Risk factors and insight of what is a skin test for TB

	Read more: Standards 2-6 in Standards for Diagnosis in ISTC, TBCTA (2006)
	Read more: Chapter 5 Case Finding Strategies [DR-TB] in Guidelines for the programmatic management of drug-resistant tuberculosis WHO (2006)

Assessing the patient and building trust (click to view)

Look at the video and answer the questions

Role-play 1: Good practice assessment of patient who might have a TB

The patient’s response to the possibility that he or she may have TB will vary according to:
• her/his knowledge and understanding of the disease, and
• any experience s/he has either personally or through family/friends who may have suffered from it.
A good relationship needs to be developed at the earliest contact with the patient so that s/he has confidence in the service, trusts the information given and comes back for further appointments. Time taken with a patient in the earliest stages will pay off for both of you if s/he does have TB.

Role-play 2: What happened when Mary first met the nurse

Do you have the resources required for best practice?

Best Practice Requirement

Your Current Practice

Identify gaps in your practice

The health-care worker assessing the symptomatic patient has been given the responsibility and appropriate training to do so.

The health-care worker assessing the symptomatic patient is familiar with the signs and symptoms with regard to TB.

The health-care worker assessing the symptomatic patient is familiar with the treatment available for TB.

The health-care worker assessing the symptomatic patient can assess each patient’s response to the fact that he or she may have TB and react accordingly.

The health-care worker assessing the symptomatic patient is able to order the correct tests or refer the patient to the appropriate facility.

There are procedures in place so that the patient is who very sick can be referred to an appropriate Medical Officer.

Your service offers patients with sufficient privacy to maintain their confidentiality during assessment and follow-up consultations.

The patient can be given accurate and clear instructions as to how and where to collect the results of his or her examinations.

TB treatment is available free of charge, and this fact is emphasised to the patient.

How is your practice?

Best Practice Requirement

Your Current Practice

Identify gaps in your practice

Healthcare workers have the skills to build a relationship with the patient by listening to his or her concerns and remaining non-judgemental

Healthcare workers are able to reassure the patient that all personal information given will remain confidential.

Healthcare workers act responsibly and take personal details, including name, home and work address, contact telephone numbers, etc., so they can follow up and contact the patient if required

Healthcare workers take a full medical history, including duration of symptoms and presence of other medical conditions.

Healthcare workers can explain to the patient what tests will be done and the reasons for doing them.

Healthcare worker checks to see if each patient came back to collect their results.

Healthcare workers assessing the patients are sensitive to the patient’s response to being tested for TB, answer questions as clearly as possible

The service offers health education sessions to waiting patients, including a question and answer session

All patients are diagnosed without delay, and by the time they return for their results they already have some understanding of the disease and its treatment.

The correspondence
between the laboratory register and the TB patient register, shows all patients
return for results
and follow-up appointments.

The relevant number of good quality sputum samples will be received by the laboratory for investigation. A system will be in place (including an agreed turnaround time from receiving specimens to reporting results) to ensure that results are fed back accurately and without delay. From the laboratory register it will be possible to see how many specimens were examined per patient and the percentage of positive results among patients coming for diagnosis or for follow-up. There will be a correlation between the laboratory register the TB register and the patient treatment cards.

Use the following box to develop an action plan on how you will improve
your practice with regards to initial assessment of the patient

Things you will change in the patient assessment form

Things you will change about the way you talk to patients during an initial assessment/consultation

Things you will change about how others in your team talk to patients during an initial assessment/consultation

List yours and others training needs and identify how you will address them to enable best practice during initial consultations and assessment

Tuberculosis Coalition for Technical Assistance (2006) International Standards for Tuberculosis Care. The Hague: Tuberculosis Coalition for Technical Assistance
Union (2005) Management of the Child with Cough or Difficult Breathing A Guide For Low Income Countries, Second Edition
Union (2007) Best Practice for the Care of patients with Tuberculosis: Chapter III Identifying an active case of TB
WHO (2009) WHO Policy on TB Infection Control in Health-care Facilities, Congregate settings and Households
WHO (2006) Guidelines for the programmatic management of drug-resistant tuberculosis

Care prevention and management of tuberculosis