Development of a research-based protocol to rule out tuberculosis by means of continuous quality improvement techniques

Centers for Disease Control and Prevention guidelines mandate that patients be kept in respiratory isolation until three negative results of acid-fast bacillus smears, obtained on three separate days, have been documented. This mandate, coupled with the increased prevalence of Tuberculosis and a limited number of isolation rooms, indicated that an effective system needed to be developed to avoid unnecessary time spent in isolation. When it was found that patients spent a mean of 6.6 days in isolation before three negative results of acid-fast bacillus smears were obtained, a quality improvement project was initiated by the department of medicine. A multidisciplinary group with representation from epidemiology, nursing, medicine, the microbiology laboratory, and respiratory therapy reviewed current practice and developed a protocol to rule out tuberculosis. The protocol, which incorporates gastric lavage and sputum induction, facilitates the collection and processing of specimens within a target of 4 days from the time of placement in isolation. The protocol was reinforced by traditional staff education and large posters displayed on nursing units for easy reference. The mean time spent in isolation to rule out tuberculosis was significantly decreased with the protocol to 4.9 days (p< 0.001). After implementation, 56.6% of patients were out of isolation within 4 days, compared with only 2.6% before the protocolʹs implementation. This represents both a significant cost saving and improved patient outcomes. Current efforts center on continuous maintenance and improvement of these gains.