Digital Repository Doctoral Projects Fall 2021 Implementation of a Tuberculosis Education Toolkit for Health Care Providers Heidi O’Neal Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON O’Neal, H. (2021) Implementation of a Tuberculosis Education Toolkit for Health Care Providers. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Implementation of a Tuberculosis Education Toolkit for Health Care Providers by Heidi O’Neal A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 12, 2021 Jessica Bartlett, DNP, CNM, RN, IBCLC__(signature) Faculty Advisor/Committee Chair (Jessica Bartlett, DNP, CNM, RN, IBCLC) Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director Running head: IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 1 Implementation of a Tuberculosis Education Toolkit for Health Care Providers Heidi O’Neal Weber State University Annie Taylor Dee School of Nursing December 12, 2021 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 2 Acknowledgments This scholarly project has become a reality thanks to the help of Weber State University’s DNP faculty through advisement and mentorship throughout this program. I would especially like to thank Dr. Jessica Barlett and Dr. Mary Anne Reynolds for answering numerous questions and editing several editions of this paper over the past several semesters. I would also like to acknowledge the support of my project consultants, Lori Gittings and Amy Carter, during the planning, development, implementation, and evaluation stages of my project. The knowledge and experience of these two wonderful nurses greatly added to my project, and I am lucky to have had the opportunity to work with both of them again. Last but most certainly not least, I need to express my gratitude to my family for their unwavering love and support during all of my academic endeavors. No matter how much I may have doubted myself along the way, they have always encouraged me and helped me reach my potential. I am especially thankful for my husband, Ben O’Neal, who has been my biggest champion and cheerleader and has listened to all of my insecurities and frustrations without judgment. Ben always seems to know what I need to hear to get me to pick myself up and brush myself off before I begin my next battle. IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 3 Abstract Tuberculosis (TB) continues to pose a threat to public health, with more than 80% of reported cases believed to result from asymptomatic and untreated infections. It is estimated that up to 13 million people in the United States have latent TB infection, which has a five to 10 percent risk of converting to active disease if left untreated. This project aimed to improve health care providers’ understanding of TB by assembling and implementing a toolkit containing evidence-based guidelines and educational materials. The clinical nursing staff at the Weber-Morgan Health Department (N=17) were given a pretest before receiving a copy of the toolkit, which contained guidelines, educational handouts, and videos. Employees were then asked to review the toolkit and begin using it to educate clients receiving TB tests or treatment at the health department. After the toolkit review, the clinical nursing staff (N=16) received a post-test, satisfaction survey, and utilization questionnaire to evaluate the toolkit’s effectiveness. Pretest results demonstrated various knowledge gaps, with 88% of the staff responding. Post-tests were completed by 69% of the staff and showed an average score improvement of 11% compared to pretests. The utilization questionnaires and satisfaction surveys demonstrated that 91% of respondents used the toolkit and believed it improved their understanding of TB. Appropriate knowledge of TB can improve accurate diagnosis and treatment for patients. The TB education toolkit provides health care providers with the necessary tools to increase their understanding of TB and help them to educate patients appropriately, leading to early identification and treatment. Keywords: tuberculosis, screening, diagnosis, treatment, provider understanding, education, toolkit IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 4 Implementation of a Tuberculosis Education Toolkit for Health Care Providers According to the Centers for Disease Control and Prevention (CDC) (2020), there were 8,916 reported cases of tuberculosis (TB) in the United States in 2019, averaging just under three cases per 100,000 of the overall population. Of the reported cases of TB in the United States, more than 80% were the result of untreated and asymptomatic infections, with an estimated 13 million people in the country believed to have latent tuberculosis infection (LTBI). The cost of treating people who test positive for TB can range substantially and is dependent upon whether they have LTBI, drug-susceptible TB, or a drug-resistant form of TB. Recent estimates of cost for treating one person with TB infection are as follows: $600 to treat LTBI, $19,000 to treat drug-susceptible TB, $175,000 to treat multidrug-resistant TB, and $544,000 to treat extensively drug-resistant TB (CDC, 2020). While the cost of treating drug-resistant TB is extraordinarily high, ideally, this can be avoided through effective screening and treatment initiatives. Between 1995 and 2014, TB control efforts in the United States have resulted in the prevention of approximately 319,000 cases, with a resulting cost savings of up to $14.5 million (CDC, 2020). Problem Statement Nurses at Weber-Morgan Health Department who investigate positive TB test results within Weber and Morgan counties are continually faced with addressing the issue of people being misdiagnosed with TB or misinformed about treatment requirements and transmission risk. Primary care providers (PCP) in Weber County often send their patients directly to the health department for the treatment of TB based on positive results from a tuberculosis skin test (TST), which can result in unnecessary stress and worry for patients or can increase the risk of transmission. Educating and supplying healthcare providers with resources about TB screening methods, diagnosis, and treatment regimens may lead to more accurate diagnosis and treatment IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 5 of patients. Search Criteria A review of the recent literature was performed after conducting a database search utilizing the Academic Search Premier, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, and PubMed databases. The following keywords and terms were used during the search: tuberculosis, screening, diagnosis, testing, transmission, provider knowledge, and provider education. Search limitations were set only to include articles written in English from 2010-2020, although some of the articles referencing earlier works were also included when relevant. Articles were reviewed and sorted based on pertinent themes or concepts that were identified. The following themes or concepts were common in the available literature and will be addressed in further detail in the following literature review: tuberculosis, screening methods, diagnosis of tuberculosis, and provider education. Literature Review Tuberculosis While it is estimated that the bacteria that causes TB has been around for millions of years, the name of the illness was first coined in 1834 by Johann Schonlein (CDC, 2016). The discovery of Mycobacterium tuberculosis as the bacteria responsible for causing TB was announced on March 24, 1882, by Dr. Robert Koch. One hundred years later, March 24 received the designation of World TB Day (CDC, 2016). At the time this discovery was made, TB was responsible for the deaths of one out of every seven people in Europe and the United States. TB has only been tracked by public health officials in the United States since 1893, when New York City became the first area to track and report information about the infection (CDC, 2016). The first nationwide data on TB for the United States was reported in 1953, with 84,304 cases for the IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 6 previous year. Public health officials around the country now conduct regular surveillance efforts for TB and publish reports of the findings on an annual basis (CDC, 2016). Description. TB is an infectious illness caused by the bacterium M. tuberculosis that most commonly infects the lungs but can potentially infect any part of the body. When TB infects the lungs, the illness is spread through airborne particles released when someone with TB speaks, coughs, or sings (CDC, 2016). Not everyone exposed to TB will develop the active disease because when the body’s immune system works as expected, a granuloma forms around the TB bacteria keeping it from multiplying and spreading within the body. When this happens, the person has what is known as LTBI. These individuals exhibit no symptoms of TB and are not contagious to others (CDC, 2016). According to the U.S. Preventive Services Task Force (USPSTF) (2016), of the individuals exposed to TB, approximately 30% will develop LTBI, and five to 10 percent of those people will eventually convert to active TB if they are left untreated. Individuals most at risk for developing active TB are infants and children, illicit drug users, the elderly, people infected with TB within the past two years, HIV positive individuals, those with weakened immune systems, and people who received incorrect TB treatment previously (CDC, 2016). Incidence. Overall, there has been a decreasing trend in the number of TB cases reported each year in the United States; however, since data was first published, there have been eight years when an increase was reported over the prior year’s numbers. The most recent increase occurred in 2015, with an overall increase of nearly two percent from the previous year and a case increase of approximately one per 100,000 (CDC, 2018). This information demonstrates that TB is not a disease of the past, as many may believe, but rather is very much a constant danger that will continue to be a threat until it is eradicated. IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 7 Screening methods. Two different screening methods are used to screen for TB, the Mantoux TST and interferon-gamma release assays (IGRA) or TB blood test. Currently, there are no recommendations on which test to use, and this choice is often a matter of cost and availability (CDC, 2016). IGRA testing does have more reliability when used for individuals who have received the Bacillus Calmette–Guérin (BCG) vaccine, the immunocompromised, or those who are unlikely to return to have their TST read within the appropriate time frame. If an individual receives a positive result for either the TST or IGRA, it demonstrates that they have been infected with the TB bacteria, but further evaluation is required to determine whether they have active or latent TB or a history of BCG vaccination (CDC, 2016; USPTF, 2016). The accuracy of the screening method being used is often a consideration for health care providers; however, data has shown inconsistent results regarding whether the TST or IGRA is superior for detecting TB. Abdel-Samea, Ismail, Fayed, and Mohammad (2013) touted the superiority of IGRAs, specifically QuantiFERON-TB Gold, over TSTs, while Lee, Kim, and Lee (2011) demonstrated that there was virtually no difference between the two screening methods. Ultimately, deciding which TB screening test to use lies with the provider and should consider cost and other factors that would impact the likelihood of patient participation (L. Gittings, RN, personal communication, April 14, 2020). Recommendations for TB screenings vary based on an individual’s risk factors, with screening recommended for higher-risk individuals and not low risk. Someone is at a higher risk for TB infection if they are in contact with active TB, live or work in high-risk settings, such as long-term care centers, homeless shelters, or correctional facilities, come from a country with high rates of TB, and health care workers who care for patients at high risk for TB (CDC, 2016). Identifying individuals who are at risk for the development of TB is the first step to ensure that IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 8 they are appropriately screened and treated if screening results are positive (CDC, 2016; USPSTF, 2016). While they may not be considered high risk, it is recommended that individuals working in healthcare settings receive a pre-employment TB screening consisting of either a two-step TST or an IGRA. Currently, it is not recommended that these individuals receive repeat annual testing unless they have a known exposure to TB (CDC, 2019). Screening providers. Individuals requiring TB testing will often be directed to the local health department for cost and convenience purposes and the employees’ expertise in this environment for administering and interpreting TB screening tests. Most primary care offices, laboratories, and even some pharmacies can also administer and interpret TB screening tests but may not have the same expertise as health department employees regarding other elements of TB (L. Gittings, RN, personal communication, April 14, 2020). Consequences/Outcomes No matter which testing method a health care provider chooses to use to screen patients for TB, they must be familiar with how to perform the test correctly and accurately interpret the result. Providers must also understand recommendations for treating LTBI to prevent the development of active TB later in life and which treatment regimens are appropriate for active TB to help to reduce transmission rates and save lives (CDC, 2016; Getahun, 2015). Sharma, Vashishtha, Chauhan, Sreenivas, & Seth (2017) compared the usage of TST and IGRA screening methods to diagnose LTBI in household contacts of pulmonary TB. This prospective cohort longitudinal study found that while neither of these screening methods indicated the likelihood of developing active TB in the future, TST is a better option in high-risk, low-resource areas because of the low cost and lack of requirement for technical expertise, specialty labs, or venipuncture. Researchers also found that household ventilation, tobacco IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 9 usage, and malnutrition were the most significant contributing factors to developing active TB for household contacts with LTBI. The implications of this study for practice are that it would be more cost-effective and more feasible for high-risk TB areas or locations that lack resources to use the TST for screening and that health care providers should educate household contacts of TB about the risk factors associated with the increased likelihood for the development of active TB. Identifying those most at risk for the development of active TB will help health care providers effectively offer preventive TB treatment to help offset the risk and decrease TB transmission. In 2018, the worldwide death toll from TB was one and a half million people, making it the number one cause of death from an individual infectious agent and one of the top ten causes of death overall. An estimated 10 million people became infected with TB in 2018, over one million of whom were children (World Health Organization [WHO], 2020). While globally, the rate of TB has decreased by two percent annually, this was far from the four to five percent needed to reach the milestone set for 2020 as part of the End TB Strategy. Effective diagnosis and treatment strategies are some of the best ways of reducing the TB burden worldwide, as the life-saving impact of these efforts has spared at least 58 million people from death related to TB from 2000 to 2018 (WHO, 2020). Accurate Diagnosis of Tuberculosis The first step to an accurate diagnosis of TB is correctly administering the screening test and evaluating an individual’s risk factors. Administration of a TST consists of injecting a small amount of a purified protein derivative of tuberculin solution into the dermis of the lower arm, which must then be evaluated 48-72 hours later by a qualified health care professional. IGRAs require a small amount of blood to be collected in the appropriate container(s), determined by the IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 10 brand of the test being used, and sent to a laboratory for processing, which removes the risk of misinterpretation by inexperienced health care providers (CDC, 2016). The second step to accurately diagnosing TB is to understand how to interpret test results correctly. Interpreting the result of a TST requires health care providers to evaluate the area for any induration and, if present, to measure the induration accurately over the horizontal plane, not including any associated redness. Based on a person’s risk factors, an induration can measure anywhere from five millimeters upward for the test to be interpreted as a positive result (CDC,2016). Without proper training and practice, there is a high likelihood that the results of a TST will be misread, resulting in either false-positive or false-negative results. A study by Kendig et al. (1998) that looked at more than one hundred health care providers showed there was a wide range of variability among their measurements on a standardized induration model measuring 15 millimeters, with 93% of providers incorrectly interpreting the result as negative. False-positive results are also possible from a TST, as Page, Gibbins, Driscoll, and CDC (2006) demonstrated. Nine firefighters in Mississippi were diagnosed with LTBI after their TSTs were read as positive. After evaluating each firefighter’s risk factors and symptoms and repeating the TB tests using IGRAs, all results came back negative, demonstrating that none of the nine firefighters had LTBI and were incorrectly diagnosed initially. The ability to identify at-risk individuals and recognize the symptoms of active TB, such as a prolonged cough, night sweats, fever, unintended weight loss, and general weakness and fatigue, is necessary for health care providers to ensure the appropriate screening of patients and accurate diagnosis of active TB (U.S. National Library of Medicine, 2018). Evaluation of an individual’s medical history and symptoms, along with timely follow-up testing, can help providers identify cases of LTBI so that patients can be appropriately educated about available IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 11 treatment regimens to reduce the risk of developing active TB in the future (CDC, 2016). Latent tuberculosis infection. The diagnosis of LTBI consists of a positive result from the initial TB screening method followed by a negative chest x-ray or other laboratory testing and a lack of associated TB symptoms. Treatment for LTBI is often shorter in duration and utilizes fewer medications than those used for active TB disease, resulting in increased completion rates and reduced complications. LTBI treatment utilizes isoniazid, rifapentine, and rifampin in different combinations and durations, ranging from three to six months (CDC, 2016). Four preventive treatment regimens are available to reduce the risk of an individual with LTBI of converting to active TB later in life. Deciding whether to take preventive treatment should be based upon an individual’s risk factors (CDC, 2016; Getahun et al., 2015). If a patient chooses to receive treatment for LTBI, adhering to the treatment regimen is essential for achieving the desired outcome and avoiding the development of drug-resistant TB. The rifampin, rifampin plus isoniazid, or rifapentine plus isoniazid treatment regimens shorten a patient’s overall treatment time from six to nine months down to three to four months, which helps increase treatment completion rates and reduce potential issues with hepatotoxicity (Getahun et al., 2015). The use of six to nine months of isoniazid monotherapy is no longer commonplace due to resistance issues, length of therapy, and potential side effects. Both the National Tuberculosis Controllers Association (NTCA) and the CDC now recommend using short-term therapy lasting three to four months for the treatment of LTBI (CDC, 2020). Active tuberculosis disease. TB remains a public health issue, and for countries with low incidence rates, such as the United States, it can be easy to underestimate the risk that TB can pose to the general public. In most countries with low rates of TB, vulnerable populations are disproportionately impacted by TB because of living conditions, health discrepancies, and IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 12 lack of resources (Heuvelings, de Vries, & Grobusch, 2017). Because vulnerable people are generally concentrated in urban areas, exposure to individuals with active TB is more likely, and these at-risk individuals need to be identified, screened, and treated to prevent the spread of TB. Lack of knowledge of TB among health care workers in low incidence countries, along with misconceptions and stigma among the general population, can impede the efforts of public health officials to improve screening and diagnostic efforts and reduce the overall impact of TB in the community (Heuvelings et al., 2017). TB disease requires the use of multiple medications to reduce the risk of developing drug resistance. Treatment for active TB utilizes combinations of isoniazid, rifampin, ethambutol, and pyrazinamide for six to nine months or longer if issues arise (CDC, 2016). Barriers to Accurate Diagnosis and Treatment According to the WHO (n.d.), the most common barriers to accessing TB care are geographical, socio-cultural, economic, and health system barriers. Most of these barriers are experienced by those with lower incomes and education levels, which generally increases the lack of knowledge about TB and the associated risks and symptoms. Lack of knowledge within the health care community is also a barrier to accurate diagnosis and treatment. Because of this lack of knowledge, the multi-agency response to TB coordinated by the CDC includes training of health care professionals for improving the diagnosis and treatment of TB as one of five main considerations (Castro et al., 2016). Sima, Belachew, and Abebe (2019) reported that lack of TB knowledge is common among health care providers, with 64% of the health care providers who participated in their study demonstrating poor overall TB knowledge and 68% demonstrating poor understanding of TB diagnosis. Undiagnosed cases of TB can result in increased rates of infection and increased costs IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 13 of health care to the affected communities. According to Castro et al. (2016), the direct cost of drug-susceptible TB cases is $17,000, while the cost to society because of lost productivity due to premature death can be upwards of $44,000 per case. Consequences/Outcomes Nyasulu et al. (2018) explored the perceptions, beliefs, and understanding of TB in community members in three rural villages. This qualitative phenomenological study found that while most participants believed TB was curable and would willingly seek diagnosis and treatment if they experienced symptoms of the disease, some were concerned about the social stigma associated with TB, which impacted their willingness to seek medical care for their symptoms. The implications of this study for practice are that it would be beneficial for health care providers and public health institutions to work on the implementation of educational initiatives to improve the knowledge, understanding, and perceptions of TB, which can help to reduce the associated social stigma and increase the likelihood of people seeking timely medical care for symptoms. Heuvelings, de Vries, & Grobusch (2017) evaluated the effectiveness of interventions for diagnosis and treatment of TB among hard-to-reach populations in countries with a low or moderate incidence of TB, such as the United States. This systematic review compared 19 research articles that utilized various methodologies and found that while it was difficult to support major conclusions because of the varied data regarding the populations and interventions, there were some consistent findings. Some interventions were determined to offer more benefit because they were convenient and cost-effective, which are major considerations for underserved populations. Monetary incentives were effective for improving TB identification and management for the homeless population and drug users. Cooperation IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 14 between services, use of directly observed therapy, and enhanced case management contributed to improved treatment compliance and outcomes. The implications of this study for practice are that it is important to identify who is part of the hard-to-reach population so that TB interventions can be identified and utilized with this group to offer them the best possible outcomes. Solutions Currently, public health departments play the most significant role in promoting TB screening and treatment measures in the community. TB is a reportable illness, which means that health care providers must report any suspected or positive TB cases to their local public health department for evaluation and follow-up (CDC, 2012; Utah Department of Health, 2019). Disease investigators at local public health departments conduct investigations for all reported positive TB results in their jurisdiction, and after determining the correct diagnosis for each person, will recommend and provide treatment as appropriate (L. Gittings, RN, personal communication, April 14, 2020). The proposed solution for addressing this clinical problem is implementing a TB toolkit to provide educational resources for health care providers, helping address knowledge gaps providers may have regarding TB screening, diagnosis, and treatment. The TB toolkit consists of fact sheets, guidelines, educational handouts for patients, and web-based continuing education courses and webinars about TB that are currently available through the CDC. Hempel, O’Hanlon, Lim, Danz, Larkin, and Rubenstein (2019) reported that satisfaction is generally high with quality improvement toolkits, and they often have positive impacts on clinical processes. Literature Review Summary The literature demonstrates that TB is an ongoing health threat in the United States and IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 15 that adequate knowledge regarding screening, diagnosis, and treatment are essential for health care providers (USPTF, 2016; Castro et al., 2016). Health care providers must also understand the importance of identifying at-risk individuals and providing the appropriate educational resources for patients to reduce the risk of TB development and improve treatment utilization and completion rates for those with LTBI (Getahun et al., 2015). The data also demonstrates that supportive services, increased use of case management, and monetary incentives may help ensure LTBI treatment adherence among homeless individuals and drug users (Heuvelings et al., 2017). Theoretical Framework The Juran Trilogy The model utilized to address this clinical problem during the implementation of the Doctor of Nursing Practice (DNP) project was the Juran Trilogy. According to Finkelman (2018), this is a quality improvement model focusing on the customer and meeting their needs. This three-step model stresses the importance of recognizing the primary concerns regarding change before deciding what needs to be done to address those concerns. The first step in the Juran Trilogy was quality planning, during which the customer was identified and their needs determined. Deciding on a service or product to meet the customer’s needs also occurred during this step (Finkelman, 2018). For this DNP project, the customers were the health care providers who administer and evaluate TB screenings in Weber County. The customer’s needs were acquiring adequate knowledge of TB transmission, symptoms, and risks to accurately diagnose and treat patients with positive TB tests. The customer benefited from the toolkit for providing easily accessible, scientifically accurate, and up-to-date educational resources designed for health care providers and patients. IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 16 The second step in the Juran Trilogy was quality improvement, which required developing a plan for the service or product needed to meet the needs of the customer(s) (Finkelman, 2018). For this DNP project, a toolkit of educational resources was implemented for health care providers that addressed knowledge gaps about TB and helped them provide appropriate educational materials for their patients. The third and final step of the Juran Trilogy was quality control, and this was when the process demonstrated that the needs of the customers had been met and that the change was sustainable (Finkelman, 2018). This final step was completed after the evaluation and analysis of the DNP project data were completed. Project evaluation included the utilization of pre and post-implementation surveys to assess providers’ understanding of TB screening, diagnosis, and treatment and determine their satisfaction level after using the toolkit. Practice Change Expected Outcomes/Goals At the conclusion of this project, health care providers in Weber County who provide TB screenings for patients will have an increased understanding of TB, leading to more accurate diagnosis and treatment for patients. The project’s first aim was to assemble TB guidelines and educational materials developed by the CDC into a toolkit enabling providers to quickly reference information and provide educational handouts for patients. The project’s second aim was to improve the education of patients being screened for TB, ensuring that patients receive accurate information and appropriate educational materials from health care providers. Measures were established using pre and post-implementation provider knowledge assessments, utilization questionnaires, and satisfaction surveys. Setting IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 17 The setting utilized for the focus of this clinical problem was the Weber-Morgan Health Department. The Weber-Morgan Health Department provides TB screening services to their clientele and follows up on positive or suspected TB cases within their jurisdiction. Within this setting, implementation of a toolkit containing information about TB screening, diagnosis, and treatment designed for health care providers addressed common misconceptions about TB and ideally contributed to more accurate diagnosis and reduced rates in the community. Population The population of significance for the focus of this clinical problem are the health care providers who administer TB screenings and evaluate the results for citizens living in Weber and Morgan counties, the fourth and nineteenth most populated counties in Utah, respectively (Utah Demographics, 2020). For sustainability purposes, the health care providers utilizing the TB toolkit may range from registered nurses to physicians and nurse practitioners. Because various healthcare providers may be tasked with administering and evaluating TSTs, this project provided guidance and resources for the full spectrum of health care providers, such as physicians, nurse practitioners, physician assistants, and registered nurses. The health care providers at the Weber-Morgan Health Department using the toolkit are all registered nurses with either an associate or bachelor level of nursing education. Nurses working at the Weber-Morgan Health Department are cross-trained to work in the various areas of the nursing clinic, requiring a broad range of knowledge regarding public health issues. These nurses have a wide range of experience working in public health. The newest members of the nursing team have worked for the health department for less than one year, while the most senior members have worked there for nearly two decades (A. Carter, RN, personal communication, July 16, 2021). The front desk staff at the health department often answer questions from IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 18 community members, schedule appointments for TB testing and follow-up, and work as medical translators for Spanish-speaking patients, so a basic understanding of TB is also beneficial for them. Need or Gap PCPs in Weber County often send their patients directly to the health department for TB treatment based on positive results from a TST without evaluating disease symptoms or following up with a chest X-ray, which can result in unnecessary stress and worry for patients and increase the risk of transmission. The goal of addressing this problem was to provide health care providers in Weber County with education and resources regarding TB to increase their knowledge and lead to more accurate diagnosing and treatment of patients. Project Purpose The purpose of this DNP project was to implement a TB education toolkit at the Weber-Morgan Health Department to reduce knowledge gaps and increase health care providers’ overall understanding of TB, resulting in improved accuracy of diagnosis and treatment. Priorities for the project included generating buy-in from the health care providers who administer and evaluate TB tests in Weber County, ensuring project sustainability, and addressing ethical issues before implementation began. The timeline for completion of project planning occurred during the 2020 fall semester and 2021 spring semester, from late August 2020 through the end of April 2021. Implementation The TB education toolkit pre-implementation project planning consisted of collecting various evidence-based materials developed by the CDC to improve health care providers’ knowledge of TB. Gathering and putting together the most useful information for the toolkit IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 19 required a careful and thorough evaluation of the extensive variety of TB materials available on the CDC’s website. Extra consideration was given to special case considerations, such as individuals with human immunodeficiency virus (HIV) or other illnesses that affect the immune system and increase the risk of TB. Providers who participate in using the toolkit have the opportunity to receive the additional benefit of earning continuing education credits for completing the TB educational training available through the CDC’s website (CDC, 2020). After the appropriate resources were selected for the toolkit, examples were printed to use as references during the implementation phase. Reusable universal serial bus (USB) devices contain copies of the downloadable toolkit materials. A USB device containing the toolkit resources was given to Weber-Morgan Health Department’s nursing supervisor, Amy Carter, to implement the TB education toolkit within clinical nursing services. Implementation of this project required a DNP student leader with effective communication and organizational skills to empower and motivate others to improve outcomes through positive change. The DNP student project leader led by example, promoting quality and safety improvement through collaboration with knowledgeable professionals (Reavy, 2016). The first phase of implementation for the DNP project consisted of unveiling the toolkit to Amy Carter, the new expert consultant for the DNP project, the epidemiology program manager, and a nursing supervisor at the Weber-Morgan Health Department. After reviewing the materials in the toolkit with Amy, she gave feedback on how she would like to expand the reach of the toolkit to other health care providers. The Weber-Morgan Health Department is now using the toolkit while providing client education when administering and evaluating TSTs in the clinic. Strengths of this setting included strong support and two expert consultants during project planning, implementation, and evaluation. Lori Gittings was the first expert consultant IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 20 for the project and was the previous TB program manager for the health department. Lori guided the pre-implementation process, including helping to suggest evidence-based resources for inclusion in the toolkit. Additional benefits of this setting were the built-in relationships the health department has with local providers, which will help increase the project’s reach and improve sustainability. Barriers to implementation were scheduling conflicts of the health department while conducting mass immunization clinics for COVID-19. Implementation of the TB toolkit at the Weber-Morgan Health Department was initiated on July 16, 2021. Project Considerations Ethical challenges included ensuring that patient education materials provided in the toolkit were available in English and Spanish to limit language barriers as Caucasians and Hispanics are the two largest population groups in Weber County (Utah Demographics, 2020). The stigma associated with TB was another potential ethical issue and can be addressed by providing patient evaluation and education in private settings. Weber State University’s Institutional Review Board (IRB) reviewed the purpose and goals of this DNP project and approved the exemption status of the project. Project sustainability was an important consideration and will come from a commitment to persistent improvement by the Weber-Morgan Health Department. Amy Carter has already compiled a list of at least a half dozen local health care providers or facilities who could also benefit from using the toolkit. Commitment to change and quality improvement must be system-wide to ensure sustainability (Finkleman, 2018). The DNP leader was responsible for conceiving new ideas to support knowledge generation among health care providers, including using the TB education toolkit. The DNP leader actively communicated with the Weber-Morgan Health Department to ensure a IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 21 successful implementation and a solid foundation for project sustainability. Evaluation and Analysis The DNP project’s overall goal was that provider understanding of TB would improve when using the TB education toolkit. Evaluation of whether this goal was met determined if the practice change was effective. Various survey tools and descriptive statistics were used to complete the DNP project evaluation and analyze the associated data. Evaluation Methods Project evaluation consisted of pre and post-test TB knowledge assessment questionnaires (Appendix A), toolkit utilization questionnaires (Appendix B), and satisfaction surveys (Appendix C) that were given to all participating providers. The utilization questionnaires determined which TB education toolkit items were most frequently used and whether providers participated in any of the CDC’s continuing education opportunities. The pretest was given to participating health care providers before introducing them to the toolkit. The post-test, utilization questionnaire, and satisfaction survey were distributed to participating providers approximately one month after implementing the TB toolkit to assess changes in knowledge level and perception of the toolkit’s value and benefit for the practice and patients. The satisfaction survey also assessed whether providers felt that their understanding of TB improved since they began using the toolkit. It was expected that an improvement in provider knowledge and understanding of TB would occur after implementing the TB toolkit. Any improvement in providers’ knowledge and understanding of TB demonstrated that the practice change was effective. Data Analysis Data analysis consisted of descriptive statistics, including the number of local health care IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 22 providers participating in using the toolkit, the number of providers who completed the TB continuing education activities offered by the CDC, and the number of providers who felt their understanding of TB improved after using the toolkit. This data was collected from the TB knowledge pretest and post-test assessments (Appendix A), utilization questionnaires (Appendix B), and satisfaction surveys (Appendix C). In addition, a comparison of the scores on the TB knowledge assessment questionnaires (Appendix F) was conducted, including the mean improvement for scores on the post-test compared to the pretest. Data demonstrating that providers used the toolkit resources or accessed the continuing education opportunities available from the CDC to improve their understanding of TB indicated that the practice change was effective. TB knowledge assessment pretests were distributed to all 17 members of the Weber-Morgan Health Department’s clinical nursing staff, consisting of 13 nurses and four front desk staff. Fifteen completed pretests were returned for review from 13 nurses and two members of the front desk staff. The pretest participation rate among clinical nursing staff employees was 88%, with a 100% participation rate for the public health nurses. Results of the pretests demonstrated a low score of 40, a high score of 85, a mean score of 59.6, and a median score of 59 out of a possible score of 100. A variety of knowledge gaps were discovered based on the results of the pretests. The most significant knowledge gaps identified were difficulty identifying medications used to treat TB and their common adverse effects. Most of the pretests also demonstrated a lack of knowledge of active TB, such as common symptoms, diagnostic tests, infectious period, treatment duration, and the development of drug resistance. Approximately one month after the clinical nursing staff began reviewing the toolkit materials and using them with patients receiving TB tests or treatment at the health department, IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 23 they were asked to complete a TB knowledge assessment post-test, satisfaction survey, and utilization questionnaire to evaluate the toolkit’s effectiveness. Eleven members of the clinical nursing staff completed the post-test, satisfaction survey, and utilization questionnaires, equalling a 69% participation rate. All of those who completed the toolkit evaluation were nurses. One person who had previously completed a pretest was no longer working at the health department when the toolkit evaluation began. The post-test results demonstrated a low score of 57.5, a high score of 92.5, a mean score of 72.3, and a median score of 71 out of a possible 100. There was an overall improvement of 11% on average in post-test scores compared to the pretests. The charts in Appendix D and Appendix E show the individual scores for each of the pretests and post-tests. The nurses who completed the pretest are identified with an asterisk by their initials. The utilization questionnaire results demonstrated that 10 of the 11 respondents reported using the toolkit. However, this usage ranged from infrequently to weekly among the nursing staff members. Three respondents reported completing a TB self-education course since receiving the toolkit, and five reported exploring the websites recommended in the toolkit. The resources that were felt to be the most useful for practice by the public health nurses were patient education handouts and medication information. The Satisfaction survey results demonstrated that 100% of the nurses who reported using the toolkit also reported their understanding of TB had improved. Additionally, 100% of the nurses who used the toolkit reported strongly agreeing that the resources were user-friendly and the educational handouts were helpful for patients. Finally, nine of the nurses using the toolkit reported strongly agreeing that it did not negatively impact their workload, while one reported agreeing somewhat with this statement. IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 24 Discussion, Recommendations, and Conclusion Discussion Feedback from Amy Carter, project consultant and nursing supervisor at the Weber-Morgan Health Department, suggests a high likelihood for the sustainability of the DNP project. The pretest results demonstrated a need for further TB education and resources for health care providers. The nurses at the health department are tasked with protecting public health, and because of this, they need a strong foundation of knowledge relating to infectious diseases such as TB. The materials in the toolkit ensure that the public health nurses at the Weber-Morgan Health Department have the appropriate resources to increase their TB knowledge and provide the most effective care and education for their patients. Nursing practice can benefit from this project because nurses often administer and evaluate TB screening tests. The TB education toolkit provides health care providers with the necessary tools to improve their understanding of TB and help them to educate patients appropriately. As demonstrated by Sima, Belachew, and Abebe (2019), a lack of TB knowledge can result in poor care delivery for TB patients. In Weber County alone, Amy Carter was able to list at least a half dozen local health care facilities that directly care for people at high risk for TB infection who could benefit from using the TB toolkit. The number of facilities in the community that treat people at risk for TB infection demonstrates the need for educational resources to ensure adequate knowledge for health care providers while also ensuring the sustainability of the DNP project. The implementation process for the DNP project took place much later than initially planned due to a change in project consultants and scheduling conflicts related to the ongoing COVID-19 pandemic. The most effective part of the implementation process was working with IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 25 the Weber-Morgan Health Department’s clinical nursing services because they are directly responsible for investigating positive or suspected TB cases within their jurisdiction. This responsibility, along with the health department’s commitment to protecting public health, make them the perfect partner for this DNP project. The most challenging part of the implementation process was completing the transition to a new project consult, coordinating schedules to meet, and explaining the background and vision for the DNP project before implementation could begin. In the future, it would be beneficial to try to ensure project consultants have no intent on leaving their current position until after the DNP project has been implemented and all data has been collected and evaluated. Recommendations The future success of the toolkit will be determined by the number of health care providers and patients that benefit from an improved understanding of TB after using the associated educational resources. Based on the results of the TB knowledge assessment pretests from the clinical nursing staff at the Weber-Morgan Health Department, there is a valid need for the toolkit’s resources within the health care community. Amy Carter requested permission to share the toolkit with health care providers who regularly consult with the health department. Granting the health department permission to share the resources of the TB toolkit as they deem fit appears to be the best way to further the reach of the toolkit and ensure the sustainability of the DNP project. Conclusion TB remains a significant health care consideration in the United States even after years of control efforts. Within the jurisdiction of the Weber-Morgan Health Department, the lack of knowledge of TB by the general population and health care professionals are the greatest barriers IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 26 to coordinated screening, treatment, and control efforts (L. Gittings, RN, personal communication, April 14, 2020). Addressing this clinical problem by implementing a TB education toolkit for local health care providers helped improve the overall TB knowledge of the participants and provide the tools needed to educate patients. The role of the DNP student leader was integral for project management, including toolkit development and implementation, along with monitoring the use of the toolkit’s resources and evaluating the data from the various surveys and questionnaires distributed to the health care providers using the TB toolkit. IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 27 References Abdel-Samea, S. A., Ismail, Y. M., Fayed, S. M. A., & Mohammad, A. A. (2013). Comparative study between using QuantiFERON and tuberculin skin test in diagnosis of mycobacterium tuberculosis infection. Egyptian Journal of Chest Diseases and Tuberculosis, 62(1), 137-143. doi:10.1016/j.ejcdt.2013.02.003 Castro, K. G., Marks, S. M., Chen, M. P., Hill, A. N., Becerra, J. E., Miramontes, R., . . . LoBue, P. A. (2016). Estimating tuberculosis cases and their economic costs averted in the United States over the past two decades. The International Journal of Tuberculosis and Lung Disease : The Official Journal of the International Union Against Tuberculosis and Lung Disease, 20(7), 926-933. doi:10.5588/ijtld.15.1001 Centers for Disease Control and Prevention. (2020a). Tuberculosis: Data and statistics. Retrieved from https://www.cdc.gov/tb/statistics/default.htm Centers for Disease Control and Prevention. (2020b). CDC’s TB work saves lives and money. Retrieved from https://www.cdc.gov/nchhstp/budget/infographics/tb.html Centers for Disease Control and Prevention. (2020c). Infection control. Retrieved from https://www.cdc.gov/infectioncontrol/index.html Centers for Disease Control and Prevention. (2018a). Tuberculosis: Latent TB infection in the United States - published estimates. Retrieved from https://www.cdc.gov/tb/statistics/ltbi.htm Centers for Disease Control and Prevention. (2012). Tuberculosis: Menu of suggested provisions for state tuberculosis prevention and control laws. Retrieved from https://www.cdc.gov/tb/programs/laws/menu/caseid.htm Centers for Disease Control and Prevention. (2018b). Tuberculosis: Reported tuberculosis in the IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 28 United States, 2018. Retrieved from https://www.cdc.gov/tb/statistics/reports/2018/table1.htm Centers for Disease Control and Prevention. (2020d). Tuberculosis: Self-study modules - continuing education activities: Self-study modules on tuberculosis 1- 5 WB4358. Retrieved from https://www.cdc.gov/tb/education/ssmodules/cont_ed_regist.htm Centers for Disease Control and Prevention. (2019b). Tuberculosis: TB screening and testing of healthcare personnel. Retrieved from https://www.cdc.gov/tb/topic/testing/healthcareworkers.htm Centers for Disease Control and Prevention. (2016a). Tuberculosis: Testing for TB infection. Retrieved from https://www.cdc.gov/tb/topic/testing/tbtesttypes.htm Centers for Disease Control and Prevention. (2016b). Tuberculosis: Testing for tuberculosis. (Fact Sheets). Retrieved from https://www.cdc.gov/tb/publications/factsheets/testing/tb_testing.htm Centers for Disease Control and Prevention. (2016c). Tuberculosis: Treatment for TB disease. Retrieved from https://www.cdc.gov/tb/topic/treatment/tbdisease.htm Centers for Disease Control and Prevention. (2016d). Tuberculosis: Treatment regimens for latent TB infection. Retrieved from https://www.cdc.gov/tb/topic/treatment/ltbi.htm Centers for Disease Control and Prevention. (2016e). Tuberculosis: Tuberculin skin testing. (Fact Sheets). Retrieved from https://www.cdc.gov/tb/publications/factsheets/testing/skintesting.htm Centers for Disease Control and Prevention. (2016f). Tuberculosis: Who should be tested. Retrieved from https://www.cdc.gov/tb/topic/testing/whobetested.htm Centers for Disease Control and Prevention. (2016g). Tuberculosis: World TB day 2020. IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 29 Retrieved from https://www.cdc.gov/tb/worldtbday/history.htm Finkelman, A. (2019). Quality improvement: A guide for integration in nursing. Burlington, MA: Jones & Bartlett Learning. Getahun, H., Matteelli, A., Abubakar, I., Aziz, M. A., Baddeley, A., Barreira, u., . . . Raviglione, M. (2015). Management of latent mycobacterium tuberculosis infection: WHO guidelines for low tuberculosis burden countries. European Respiratory Journal, 46(6), 1563-1576. doi:10.1183/13993003.01245-2015 Hempel, S., O’Hanlon, C., Lim, Y., Danz, M., Larkin, J., & Rubenstein, L. (2019). Spread tools: a systematic review of components, uptake, and effectiveness of quality improvement toolkits. Implementation Science, 14(1), 83. https://doi.org/10.1186/s13012-019-0929-8 Heuvelings, C. C., de Vries, S. G., & Grobusch, M. P. (2017). Tackling TB in low- incidence countries: Improving diagnosis and management in vulnerable populations. International Journal of Infectious Diseases, 56, 77-80. doi:10.1016/j.ijid.2016.12.025 Intermountain Healthcare. (2020). Health information: Infection control. Retrieved from https://intermountainhealthcare.org/health-information/about-your-hospital-stay/infection-control/ Kendig, E. L., Jr., Kirkpatrick, B. V., Carter, W. H., Hill, F. A., Caldwell, K., & Entwistle, M. (1998). Underreading of the tuberculin skin test reaction. Chest, 113(5), 1175+. Retrieved from https://link-gale.com.hal.weber.edu/apps/doc/A20766988/ HRCA?u=ogde72764&sid=HRCA&xid=4f3c3ed8 Lee, J. E., Kim, H., & Lee, S. W. (2011). The clinical utility of tuberculin skin test and interferon-γ release assay in the diagnosis of active tuberculosis among young adults: A IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 30 prospective observational study. BMC Infectious Diseases, 11(1), 96-96. doi:10.1186/1471-2334-11-96 Nyasulu, P., Sikwese, S., Chirwa, T., Makanjee, C., Mmanga, M., Babalola, J. O., . . . Munthali, A. C. (2018). Knowledge, beliefs, and perceptions of tuberculosis among community members in Ntcheu district, Malawi. Journal of Multidisciplinary Healthcare, 11, 375-389. doi:10.2147/JMDH.S156949 Page, E. H., Gibbins, J. D., Driscoll, R. J., & Centers for Disease Control and Prevention (CDC). (2007). Evaluation of results from occupational tuberculin skin tests - Mississippi, 2006. Morbidity and Mortality Weekly Report, 56(50), 1316-1318. Reavy, K. (2016). Inquiry and leadership: A resource for the DNP project. Philadelphia, PA: F.A. Davis Company. Sima, B. T., Belachew, T., & Abebe, F. (2019). Health care providers’ knowledge, attitude and perceived stigma regarding tuberculosis in a pastoralist community in Ethiopia: A cross-sectional study. BMC Health Services Research, 19(1), 19-11. doi:10.1186/s12913-018- 3815-1 U.S. National Library of Medicine. (2018). Tuberculosis. Retrieved from https://medlineplus.gov/tuberculosis.html U.S. Preventive Services Task Force. (2016). Latent tuberculosis infection: Screening. (Draft Recommendation Statement). Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/latent-tuberculosis-infection-screening Utah Demographics. (2020). Weber county population. Retrieved from https://www.utah- demographics.com/weber-county-demographics IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 31 World Health Organization. (n.d.). EQUI-TB: Poverty and TB – linking research, policy, and practice. Retrieved from http://www9.who.int/management/BarrierstoAccessingTBCare.pdf World Health Organization. (2020). Tuberculosis: Key facts. (Fact Sheets). Retrieved from https://www.who.int/news-room/fact-sheets/detail/tuberculosis IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 32 Appendix A Tuberculosis Knowledge Assessment Pre/Post-Test 1. What are the main symptoms of pulmonary tuberculosis? Please select all that apply. Severe headache Rash Nasal congestion Cough with blood Cough ≥3 weeks Nausea Diarrhea Fever Chest pain Sore throat Night sweats Weight loss Back pain Fatigue 2. What causes tuberculosis? Please select only one answer. Virus Bacteria Fungus Protozoa Unsure 3. Does a positive Mantoux tuberculosis skin test mean a definite TB infection? Please select only one answer. Yes No Unsure 4. Should a patient with positive IGRA test be referred for further examination for active or latent tuberculosis? Yes No Unsure 5. Does a negative chest X-ray exclude TB infection? Please select only one answer. IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 33 Yes No Unsure 6. How is tuberculosis transmitted? Please select all that apply. Through contact with blood Through sharing dishes and eating utensils Through the air when a person with TB coughs or sneezes Through saliva from kissing Through touching objects in public spaces 7. Is a person with latent tuberculosis contagious? Please select only one answer. Yes No Unsure 8. What is minimum duration of therapy for active TB? Please select only one answer. 2weeks 6 weeks 6 months 9 months 1 year Unsure 9. Which of these medications are used for the treatment of tuberculosis in the United States? Please select all that apply. Isoniazid Clarithromycin Levofloxacin Moxifloxacin Rifampin Ethambutol Streptomycin Ethionamide Pyrazinamide Amoxicillin Cycloserine Rifapentine Rifabutin IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 34 10. What is DOT? (Short answer) - Directly observed therapy 11. What is the primary diagnostic test that is usually requested in order to confirm or rule out a case of active pulmonary TB? Please select only one answer. Chest X-ray IGRA test Sputum Smear Microscopy/Culture Mantoux tuberculosis skin test Blood Culture Unsure 12. When can a TB patient be considered as noninfectious? Please select only one answer. Patient has completed the whole treatment Patient has negative chest X-ray Patient has no cough Patient has received adequate TB treatment for a minimum of 2 weeks Patient’s IGRA test converts from positive to negative Unsure 13. What are some of the most common adverse effects from TB medications? Please select all that apply. Headache Rash Loss of appetite Hair loss Nausea Vomiting Involuntary movements Unexplained bruising Numbness or tingling of extremities Restlessness 14. What is the likelihood of someone with untreated latent TB developing active TB disease? Please select only one answer. 0-5% 5-10% 10-15% IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 35 15. How does tuberculosis become drug resistant? Please select all that apply. Immune systems of people with TB are less responsive to treatment Not completing a full course of TB treatment Incorrect medication dosage or length of treatment Unavailability of medications for proper treatment *Correct answers are highlighted IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 36 Appendix B Tuberculosis Toolkit Utilization Questionnaire 1. Of the resources available in the TB toolkit, which were most useful for your practice? a. Patient handouts b. Informational DVDs c. Educational courses d. Medication information e. Recommended websites f. Infographics 2. How often did you use the TB toolkit? a. Never b. Infrequently c. Monthly d. Weekly e. Multiple times a week f. Daily 3. Have you completed one of the TB self-education courses? a. Yes b. No 4. Which topics would you have liked to have additional information about in the toolkit? a. TB testing methods (IGRA & TST) b. Interpreting TB test results c. Risk factors for TB d. Medications for treating TB e. Diagnostic tests for TB 5. Have you accessed any of the websites recommended in the toolkit? a. Yes b. No IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 37 Appendix C Tuberculosis Toolkit Satisfaction Survey 1. My understanding of tuberculosis has improved after using the toolkit.  Strongly disagree  Disagree somewhat  Uncertain  Agree somewhat  Strongly agree 2. The tuberculosis toolkit contained useful tools and information for my practice.  Strongly disagree  Disagree somewhat  Uncertain  Agree somewhat  Strongly agree 3. The resources in the toolkit were user friendly.  Strongly disagree  Disagree somewhat  Uncertain  Agree somewhat  Strongly agree 4. The toolkit contained information about TB that would be helpful for patients.  Strongly disagree  Disagree somewhat  Uncertain  Agree somewhat  Strongly agree 5. Using the toolkit did not negatively impact my workload.  Strongly disagree  Disagree somewhat  Uncertain  Agree somewhat  Strongly agree IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 38 Appendix D IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 39 Appendix E IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 40 Appendix F IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 41 Appendix G Questions and Answers About Tuberculosis Questions and Answers About Tuberculosis (TB) provides information on the diagnosis and treatment of TB infection and TB disease. Key audiences for this booklet are people with or at risk for TB; people who may have been exposed to someone with TB; people who provide services for those at high risk for TB, such as correctional officers, homeless shelter workers, and emergency responders; and people who want to learn more about tuberculosis. This publication is also being developed in Spanish and will be available in the coming months. TABLE OF CONTENTS What is TB? Why is TB still a problem in the United States? How is TB spread? Who is at risk for getting TB? IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 42 What is latent TB infection (LTBI)? What is TB disease? Who is at risk for TB disease? What are the symptoms of TB disease? What is the difference between latent TB infection (LTBI) and TB disease? Should I get tested for TB? What are the tests for TB infection? What if I have a positive test for TB infection? What if I have been vaccinated with bacille Calmette-Guérin (BCG)? If I have latent TB infection (LTBI), how can I avoid developing TB disease? What are the side effects of medicines to treat latent TB infection (LTBI)? What if I have HIV infection? If I was exposed to someone with TB disease, can I give TB to others? How is TB disease treated? What are the side effects of TB disease medicines? Why do I need to take TB medicines for so long? What are multidrug-resistant TB (MDR TB) and extensively drug-resistant TB (XDR TB)? What is directly observed therapy (DOT)? How can I remember to take my TB medicines if I am not on DOT? How can I keep from spreading TB? Additional TB Resources IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 43 Appendix H IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 44 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 45 Appendix I IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 46 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 47 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 48 Appendix J IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 49 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 50 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 51 Appendix K IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 52 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 53 Appendix L IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 54 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 55 Appendix M IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 56 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 57 Appendix N IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 58 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 59 Appendix O IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 60 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 61 Appendix P IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 62 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 63 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 64 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 65 Appendix Q IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 66 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 67 Appendix R IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 68 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 69 Appendix S IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 70 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 71 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 72 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 73 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 74 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 75 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 76 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 77 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 78 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 79 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 80 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 81 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 82 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 83 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 84 Appendix T IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 85 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 86 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 87 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 88 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 89 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 90 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 91 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 92 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 93 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 94 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 95 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 96 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 97 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 98 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 99 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 100 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 101 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 102 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 103 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 104 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 105 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 106 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 107 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 108 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 109 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 110 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 111 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 112 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 113 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 114 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 115 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 116 Appendix U IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 117 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 118 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 119 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 120 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 121 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 122 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 123 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 124 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 125 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 126 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 127 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 128 Appendix V IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 129 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 130 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 131 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 132 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 133 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 134 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 135 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 136 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 137 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 138 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 139 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 140 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 141 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 142 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 143 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 144 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 145 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 146 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 147 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 148 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 149 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 150 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 151 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 152 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 153 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 154 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 155 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 156 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 157 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 158 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 159 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 160 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 161 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 162 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 163 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 164 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 165 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 166 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 167 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 168 Appendix W IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 169 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 170 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 171 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 172 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 173 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 174 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 175 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 176 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 177 IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 178 Appendix X IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 179 Appendix Y IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 180 Appendix Z IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 181 Appendix AA TB 101 for Health Care Workers TB 101 for Health Care Workers is a Web-based course designed to educate health care workers about basic concepts related to TB prevention and control in the United States. The target audience for the course includes newly hired TB program staff and health care workers in areas related to TB (such as individuals who work in correctional facilities or HIV/AIDS clinics). Start TB 101 for Health Care Workers This course was developed in partnership with: • Curry International Tuberculosis Centerexternal icon • Heartland National Tuberculosis Centerexternal icon • The Global TB Institute at Rutgers, the State University of New Jerseyexternal icon • Southeastern National TB Centerexternal icon Course can be accessed using the following link: https://www.cdc.gov/tb/webcourses/tb101/ IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 182 Appendix BB Self-Study Modules on Tuberculosis The Self-Study Modules on Tuberculosis are a series of educational modules designed to provide information about TB in a self-study format. The series consists of a total of nine modules that are separated into two courses. The first course, Modules 1-5, provides basic information on TB. The second course, Modules 6-9, provides more specific TB programmatic information. IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 183 Modules can be accessed from: https://www.cdc.gov/tb/education/ssmodules/default.htm IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 184 Appendix CC Core Curriculum on Tuberculosis: What the Clinician Should Know The Core Curriculum on Tuberculosis: What the Clinician Should Know presents information about TB for health care professionals. This document is intended for use as a reference manual for clinicians caring for persons with or at high risk for TB disease or infection. It is not meant to provide detailed answers to all public health or clinical questions about TB, and it is not meant as a substitute for any specific guidelines. It is anticipated that new guidelines will be published in the future that will supersede information in this document, and these new guidelines will be posted on the DTBE website. Continuing Education Credits The Centers for Disease Control and Prevention is accredited to provide continuing education (CE) for various professions. CE is offered free of charge. IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 185 The Interactive Core Curriculum on Tuberculosis was last updated in 2015. Please refer to the print Core Curriculum for the latest content. The Interactive Core Curriculum on Tuberculosis: What the Clinician Should Know provides clinicians and other public health professionals with information on diagnosing and treating latent TB infection and TB disease. The target audience of the course is clinicians caring for people with or at high risk for TB disease. Course can be accessed from: https://www.cdc.gov/tb/education/corecurr/index.htm#print IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 186 Appendix DD Provider TB Videos Why Should I Get Tested for Latent TB? https://www.youtube.com/watch?v=rBNmpBlwZ_Q Why Do I Need Treatment for Latent TB? https://www.youtube.com/watch?v=IQtuqi5rQ3E I Received a BCG Vaccine, Do I Still Need Latent TB Testing and Treatment? https://www.youtube.com/watch?v=2GA0xi5MlYU Treating Latent Tuberculosis https://www.youtube.com/watch?v=0mEtUyk6yU0 Eradicating TB from the modern world https://www.youtube.com/watch?v=J6dytO4vYVg IMPLEMENTATION OF A TUBERCULOSIS EDUCATION TOOLKIT 187 Appendix EE Patient TB Videos 5 Things to Know About TB https://www.youtube.com/watch?v=wA_fObLY6GE Tuberculosis, Causes, Signs and Symptoms, Diagnosis and Treatment https://www.youtube.com/watch?v=oh8b0WOOZPM The Differences Between Latent and Active TB in English (Accent from USA) https://www.youtube.com/watch?v=dc2Bxl8U-_0 California Department of Public Health https://www.youtube.com/watch?v=DiXKVxvU7FQ