Suspected Pulmonary Tuberculosis Admitted to a Semi-Private Room
Mr. R, 62, is admitted at 2330 to a medical unit with a 3-week history of productive cough, night sweats, a 9-kg weight loss, and a chest x-ray showing a cavitary lesion in the right upper lobe. Sputum for acid-fast bacilli was sent at admission; results are pending. Because no negative-pressure room was available, he was placed in a semi-private room with Mr. K, 70, who receives prednisone 40 mg daily for COPD. The charge nurse assigns a UAP in her second trimester of pregnancy to orient Mr. R to the room, obtain his admission weight, and take his vital signs. At 0100 Mr. R is found in the hallway in his gown, looking for the vending machine, saying, "Nobody told me I couldn't walk around." He is coughing frequently and does not cover his mouth.
1. Identify the infection-control failures in this admission and describe what you do now, before the smear results return.
Read the worked answer
The failures: a patient with a cavitary upper-lobe lesion, weight loss, and night sweats is a suspected active pulmonary TB case and should be placed in airborne precautions on suspicion, not after the smear returns; a semi-private room with an immunosuppressed patient is the worst available placement; and a coughing patient is loose in a public hallway.
Act now. Move Mr. R to an airborne infection isolation room - negative pressure, at least 6 air exchanges per hour, door closed. If no AIIR exists, transfer him per policy or cohort with another suspected TB case. Staff entering must wear a fit-tested N95 respirator or PAPR; the patient wears a surgical mask whenever he leaves the room. Notify the provider and infection control immediately, and expect orders for repeat sputum and a TB workup. Initiate an exposure evaluation for Mr. K, whose prednisone makes him high risk. Document the precaution start time and every notification. Do not wait for the smear - the delay is the exact window in which transmission occurs.
2. How will you handle the pregnant UAP and Mr. K, and what do you tell Mr. R about leaving his room?
Read the worked answer
Reassign the pregnant UAP before she enters the room. This is not punitive, and she should be told plainly why: pregnancy is a reason to avoid high-risk aerosol-generating exposure, and facility policy plus employee health determine what duties she may perform. Send her to employee health for a baseline TB screening and explain the follow-up schedule. Document the assignment change.
Mr. K has had significant unprotected exposure. Notify the provider and infection control, arrange a baseline IGRA or tuberculin skin test with a follow-up test, teach him the symptoms to watch for, and advocate for his move to a private room.
For Mr. R, teach in plain language without blame: "Your cough may be spread through the air, so we keep the door closed and you wear this mask whenever you leave the room - that protects other patients." Offer alternatives to wandering: a call bell for food and drinks, scheduled ambulation with a mask and supervision, and a television. Ask him to demonstrate understanding, and document the teaching and his response.
3. Mr. R needs a chest CT at 0800. Describe the safe transport process and your documentation priorities.
Read the worked answer
Call the CT department in advance so he is not left waiting in a public area; request a low-traffic time or route. Mr. R wears a surgical mask for the entire trip, and transporting staff wear fit-tested N95 respirators. Do not use a shared waiting room - ask for him to be taken directly into the scanning room. Limit the number of people in the transport, keep the door of his room closed while he is gone, and clean the wheelchair or stretcher afterward per policy.
Document the precautions in place and when they started, the surgical mask for transport, the notification to CT and to infection control, the provider notification, and who transported him. Note the patients and staff exposed before precautions were initiated and the follow-up arranged for them, including the pregnant UAP and Mr. K.
If Mr. R removes the mask during transport, do not argue in the hallway - stop, reposition the mask, remind him briefly, and continue. Note the behavior and any teaching repeated.