14.3 Administrative controls

The administrative controls aim at preventing the exposure to infectious droplet nuclei.

14.3.1 Patients triage

Upon entry into the health facility, a member of the medical staff should identify patients with a cough as soon as possible. Patients with a cough over two weeks should be sent to a separate waiting room if possible.

All patients with cough (including patients with less than two weeks of cough) should receive tissues or face masks, and they should be requested to cover their mouth and nose when they cough.

14.3.2 Patient, visitors and attendants' flow

Inside the TB department, circulation of patients and attendants is controlled:
– Encourage patients/attendants to spend as much time as possible outdoors if weather permits or in areas that are open on three or four sides.
– Have visible signage on entry doors to TB wards that forbid visitors to enter.
– Limit visitation duration, particularly for contagious patients.
– Encourage visits outside the building, especially for contagious patients.
– Have visiting areas well identified with signage.
– Before any visit, the nurse should provide information on transmission risk, including the usage of respirators if carers need to go in high risk areas, such as smear-positive, drug-resistant TB (DR-TB), re-treatment smear-positive inpatient units and areas or clinics were diagnosis of TB is being undertaken.
– Avoid that known or suspect TB patients go through areas where they may infect other patients, and vice versa, that patients without TB go through areas where they are unnecessarily exposed to the bacillus.

14.3.3 Segregation of hospitalized patients

Patients should preferably be treated in ambulatory care. Hospitalisation should be limited and reserved for clinically unwell patients.
TB wards must be separated from the others wards in the health structure compound.
Ideally, within the TB department, patients should be placed in single rooms. If this is not possible, cohort isolation must be implemented and different sections should be labelled according to the degree of contagiousness (smear/culture status) and risk of resistance.

The following is one scheme of separation. It does involve the use of some single isolation rooms (all TB inpatient facilities should have some isolation rooms. If none exist, a very high priority is to add some).
– Smear-positive patients with proven or suspected DR-TB, including chronic cases and retreatment cases that are likely to have MDR-TB. MDR-TB cases should have single isolation rooms (place in 2 to 4 person rooms with other MDR-TB patients if there are no single rooms and try to match DST patterns). It is particularly important not to mix MDRTB patients with extensively drug-resistant TB (XDR-TB) patients.
– Smear-positive patients with fully susceptible TB.
– Smear-negative patients (or patients who have converted), with proven or suspected DRTB (once patients are on effective treatment, they rapidly become non-contagious).
– Less or non-contagious TB: patients with smear-negative pulmonary TB (PTB), EPTB, patients having converted their sputum/culture and most children.
– Patients who are undergoing diagnosis as suspected cases: when possible do not hospitalize patients for diagnosis. If hospitalization is necessary, these patients need isolation rooms. Never put a patient who is not receiving TB medications in a TB ward.

If women and men are to be separated, this scheme requires at least 8 different wards and enough single rooms for suspect cases and MDR-TB patients.

14.3.4 TB IC training

All healthcare personnel should receive initial training on TB transmission, information on high-risk areas in the facility and on protective measures. Continuing education should be offered annually.

The training should also include how staff can teach patients, visitors and attendants about the risk of TB transmission and how to avoid it (cough etiquette, use of masks and respirators).