Appendix B. Tuberculosis (Tb) Risk Assessment Worksheet
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6128
MMWR
December 30, 2005
Appendix B. Tuberculosis (TB) risk assessment worksheet
This model worksheet should be considered for use in performing TB risk assessments for health-care settings and nontraditional facility-based settings.
Facilities with more than one type of setting will need to apply this table to each setting.
✓ or Y = Yes
Scoring:
X or N = No
NA = Not Applicable
1. Incidence of TB
Rate
a. What is the incidence of TB in your community (county or region served by the health-care
Community ___________________
setting), and how does it compare with the state and national average?
State ________________________
b. What is the incidence of TB in your facility and specific settings, and how do those rates
National ______________________
compare? (Incidence is the number of TB cases in your community during the previous year.
Facility _______________________
A rate of TB cases per 100,000 persons should be obtained for comparison.)* This information
Department 1 _________________
can be obtained from the state or local health department.
Department 2 _________________
Department 3 _________________
c. Are patients with suspected or confirmed TB disease encountered in your setting (inpatient and
outpatient)?
1) If yes, how many are treated in your health-care setting in 1 year? (Review laboratory data,
No. patients
infection-control records, and databases containing discharge diagnoses for this
Year
Suspected
Confirmed
information.)
1 year ago
_______
_______
2 years ago _______
_______
5 years ago _______
_______
2) If no, does your health-care setting have a plan for the triage of patients with suspected or
confirmed TB disease?
d. Currently, does your health-care setting have a cluster of persons with confirmed TB disease
that might be a result of ongoing transmission of Mycobacterium tuberculosis ?
2. Risk Classification
a. Inpatient settings
1)
How many inpatient beds are in your inpatient setting?
Quantity ______________________
2)
How many patients with TB disease are encountered in the inpatient setting in 1 year?
Previous year _________________
(Review laboratory data, infection-control records, and databases containing discharge
5 years ago ___________________
diagnoses.)
___ Low risk
3)
Depending on the number of beds and TB patients encountered in 1 year, what is the risk
___ Medium risk
classification for your inpatient setting?
___ Potential ongoing transmission
_______
4)
Does your health-care setting have a plan for triaging patients with suspected or confirmed
TB disease?
b. Outpatient settings
Previous year _________________
1)
How many TB patients are evaluated at your outpatient setting in 1 year? (Review
laboratory data, infection-control records, and databases containing discharge diagnoses
5 years ago ___________________
for this information.)
_______
2)
Is your health-care setting a TB clinic? (If yes, a classification of at least medium risk is
recommended.)
_______
3)
Does evidence exist that a high incidence of TB disease has been observed in the
community that the health-care setting serves?
_______
4)
Does evidence exist of person-to-person transmission in the health-care setting? (Use
information from case reports. Determine if any TST or blood assay for M. tuberculosis
[BAMT] conversions have occurred among health-care workers [HCWs].)
_______
5)
Does evidence exist that ongoing or unresolved health-care–associated transmission has
occurred in the health-care setting (based on case reports)?
_______
6)
Does a high incidence of immunocompromised patients or HCWs in the health-care setting exist?
_______
7)
Have patients with drug-resistant TB disease been encountered in your health-care setting
Year encountered ______________
within the previous 5 years?
Date of classification ____________
8)
When was the first time a risk classification was done for your health-care setting?
_______
9)
Considering the items above, would your health-care setting need a higher risk classification?
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