Innovative TB risk scoring tool enhances patient care and workflow

Caitlin Dugdale, MD, MSc, and Kimon Zachary, MD, physicians in the Division of Infectious Diseases at Massachusetts General Hospital (MGH) and assistant professors of Medicine at Harvard Medical School, are co-lead authors of a new study in Infection Control and Hospital Epidemiology, TB or Not TB? Development and Validation of a Clinical Decision Support System for the Evaluation of Suspected Tuberculosis.

Erica Shenoy, MD, PhD, Chief of Infection Control at Mass General Brigham and an Associate Professor of Medicine at Harvard Medical School, is senior author of the study.

Summary:

Patients with suspected tuberculosis (TB) require special precautions in healthcare facilities, and cases of TB have been rising in the US over the past several years. These precautions include isolating persons with suspected TB in patient rooms with specialized air handling known as airborne infection isolation rooms.

To improve our ability to assess patients for potential TB infections, we developed a TB risk scoring tool by reviewing past patient data. This tool was then integrated into the electronic health record with the label "TB or Not TB."

The tool helps clinicians assess, once their TB workup is complete and apparently negative, whether infection control precautions can be discontinued, ensuring accurate decisions for TB isolation, alleviating workload and improving patient experience.

The tool has been validated and is now in use at all MGB sites.

Background:

Infection Prevention and Control (IPC) programs are tasked with implementing the appropriate isolation of patients with suspected or confirmed communicable diseases to reduce the risk of healthcare-associated infections to patients and mitigate occupational risks to healthcare personnel.

However, patient isolation can negatively impact clinical workflows, access to care, and hospital capacity, highlighting the critical importance of safe and efficient deisolation protocols. System-based solutions for isolation and deisolation, including clinical decision support tools, are increasingly needed to:

• Support patient and healthcare personnel safety
• Reduce cognitive and administrative burden on clinicians
• Enhance clinician well-being

A team of infection prevention experts, infectious disease physicians and researchers at Massachusetts General Hospital (MGH) developed a risk scoring tool by reviewing the records of past patients who had been diagnosed with TB and those who had been deemed at risk but turned out not to have TB. They created a validated model to assess the likelihood of TB infection before discontinuing isolation precautions.

Then this same team joined with developers in clinical informatics and digital health to program the scoring model into the electronic health record in the form of a tool called "TB or Not TB."

If a patient is identified as needing evaluation for TB, they are labeled as "TB-Risk," prompting the correct isolation in the specialized hospital room and use of personal protective equipment. Once the healthcare provider believes, given the patient's symptoms, test results and/or risk factors, that TB is no longer a possibility, they can use the TB or Not TB tool to determine if it is safe to discontinue isolation precautions.

What are the clinical implications and next steps?

This tool will positively impact patient care and clinician workflows. In a rigorous analysis of TB evaluations across the MGB system over six years, the tool correctly identified all instances in which TB infection was present and ensured that all those patients would remain safely isolated during their work up.

At the same time, the tool was able to identify about a quarter of cases where TB was highly unlikely. This allows tool those patients to come out of isolation safely and efficiently, which may increase bed capacity, alleviate workload, reduce the time spent on infection control consultations, and improve the patient experience.