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Collaboration With School Nurses
Improving the Effectiveness of Tuberculosis Screening
Cynthia W. DeLago, MD;
Nancy D. Spector, MD;
Beth Moughan, MD;
Mary M. Moran, MD;
Hans Kersten, MD;
Laura Smals, MD
Arch Pediatr Adolesc Med. 2001;155:1369-1373.
ABSTRACT
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Objective To compare tuberculosis skin test (TST) reading rates between children
whose tests were read by school nurses following specific requests by physicians
and those who relied on their parents to get their tests read, either at school
or at the physician's office.
Design A randomized controlled trial.
Setting An urban hospital-based pediatric practice.
Participants Healthy low-income Hispanic and African American children aged 5 to
17 years whose physicians ordered TSTs at their routine physical examinations.
Subjects attended 1 of 68 public schools. Nurses at these schools were willing
to read student TSTs, and received instructions about how to read and report
the results back to the physician's office.
Intervention Subjects were randomized to a control group (routine TST placement,
with no physician–to–school nurse communication) or to an intervention
group (routine TST placement, with physician–to–school nurse communication).
Main Outcome Measures Tuberculosis skin test reading rates between the 2 groups were compared.
Impediments to TST reading and reporting were investigated.
Results One hundred thirty-four children were enrolled, 54 (40%) in the control
group and 80 (60%) in the intervention group. More patients in the intervention
group had their TSTs read by 72 hours compared with those in the control group
(74 [92%] vs 30 [56%]; P<.001). The low reading
rate in the control group was best attributed to communication failures.
Conclusion Systematic collaboration with school nurses can increase TST reading
rates.
INTRODUCTION
TUBERCULOSIS (TB) is a serious health problem that disproportionately
affects the poor. Eighteen thousand new cases of TB occur annually in the
United States, and approximately 15 million people have latent TB infection.1 According to the Philadelphia Department of Health,
the new case rate of TB in Philadelphia in 1996 was 20 cases per 100 000,
with 10% of the cases occurring in children.
Our urban residency-based pediatric practice in Philadelphia is located
in a high-prevalence area for TB. Many of our patients have additional TB
risk factors, such as recent immigration from Latin America, close contact
with prison inmates and drug-abusing adults, and homelessness. At the inception
of this study, patients were screened for TB every 2 to 3 years. From September
1, 1999, to December 31, 1999, however, only 43% of school-aged patients who
had tuberculosis skin tests (TSTs) placed by us had the tests read by a health
professional (physician or school nurse) within 72 hours. This problem has
been reported by other urban centers.2, 3
The best way to screen for TB is with the TST or the Mantoux test. The
Committee on Infectious Diseases of the American Academy of Pediatrics recommends
targeted screening of high-risk groups.4, 5
Before instituting targeted screening, we sought to find a way to improve
the reading rate of the test in our population.
Cheng et al2 tested 5 strategies to increase
TST reading rates in an urban population. All groups received verbal and written
instruction about the TST. The group that only received this intervention
demonstrated a reading rate increase of 13 percentage points. Two other strategies,
completing school forms contingent on return for test reading and dispatching
nurses to children's homes to read TSTs, further increased reading rates to
a statistically significant degree; however, the school form completion strategy
could only be used on a few patients receiving TSTs and the home nurse visit
strategy proved too costly. The other 2 strategies did not show statistically
significant improvements in reading rates. The lesson learned from this study
was that a new strategy should be convenient and simple, so that it is adaptable
to real life and affects many of those tested.
Collaborating with school nurses to read TSTs placed at the child's
routine physical examination is one such strategy. The American Academy of
Pediatrics' Committee on Infectious Diseases supports using other health care
professionals to read TSTs if a physician is not readily available.5 This article reports the results of a randomized controlled
study that compared the percentage of TSTs read within 72 hours using our
protocol with a more systematic approach that facilitated TST reading by school
nurses.
PARTICIPANTS AND METHODS
This study was conducted at an urban hospital-based pediatric practice
serving predominately low-income African American and Hispanic children. The
institutional review board at the MCP Hahnemann University School of Medicine,
Philadelphia, approved the study protocol. We recruited healthy children between
the ages of 5 and 17 years whose physicians ordered TSTs as part of their
physical examinations. Only the first child encountered from each family was
included, and the child had to be accompanied by a parent or guardian. Any
child receiving the TST as part of a diagnostic evaluation for an illness
was excluded. Children had to be enrolled at 1 of 68 participating public
schools, which included 50 elementary, 12 middle, and 6 high schools. Many
schools were involved because there are more than 150 public schools within
an 8.0-km radius of the clinic. Parochial and private schools were not included.
All schools had a nurse on site on Wednesday, Thursday, or Friday to read
the TSTs placed Monday, Tuesday, or Wednesday.
Patients were enrolled from January 10, 2000, to May 31, 2000. School
nurses from all 68 schools were recruited to participate at 1 of 4 group meetings
arranged to explain the study protocol, collect school information, and review
the proper TST reading technique. Instruction about the TST reading technique
was based on recommendations by the American Thoracic Society,6
as described in an article by Seibert and Bass7
and depicted in a Centers for Disease Control and Prevention videotape.8 Nurses were shown this videotape during the meeting.
Of the 68 nurses, 15 did not attend the meeting. They were enrolled individually
by telephone. Information and diagrams based on the article by Seibert and
Bass were faxed to these nurses.
At the inception of this study, little information existed about where
our patients attended school. Initially, the 40 closest schools were enrolled.
After several weeks, we realized many students were not being recruited because
of school affiliation. Subsequently, 28 more schools with similar demographics
and close proximity to the clinic were enrolled.
PATIENT RECRUITMENT PROCESS
The investigators (C.W.D., N.D.S., B.M., M.M.M., H.K., and L.S.) obtained
written consent and interviewed parents or guardians about demographics from
scripted questionnaires in either English or Spanish, with the aid of an interpreter.
Eligible patients were randomly assigned to the control or intervention group
by an allocation system using sealed opaque envelopes containing the group
assignment. We anticipated an effect size of only 15 to 20 percentage points,
necessitating a sample size of about 175 patients per group. Therefore, 350
envelopes were prepared, shuffled, numbered, and drawn in order, as each new
patient presented.
After group assignment was made, instruction was given as follows: All
parents were educated about the purpose of the TST and the importance of getting
it read in 48 to 72 hours. Written reminders listing the TST reading date
and the clinic telephone number were given to each parent. Next, each control
group parent or guardian was instructed to bring his or her child back to
the clinic between 8:30 AM and 4:30 PM on weekdays to have the test read or
to ask the child's school nurse to read the test and call our office with
the result. Instructions given to control group parents were the same as those
given to all parents or guardians of school-aged children who received TSTs
at our clinic before and during the study period. We provided some additional
information to this group while explaining the purpose of the study and obtaining
consent.
Intervention group parents or guardians received the same information
as control group parents with the exception of test-reading instructions:
TSTs were to be read only by the school nurse. Parents or guardians gave us
permission to notify the nurse about test placement by facsimile or telephone
and to request test reading in 48 to 72 hours. Nurses were instructed to report
the results directly to us on the day the test was read. Any child noted to
have an indurated TST result was told to return to our office after school
for an official reading by a physician. Nurses were asked to report the degree
of induration in millimeters. Negative test results were reported as 0 mm.
Parents or guardians of children who did not have their tests read were
called within 1 week of test placement. A scripted interview was used for
this call. School nurses were also called if the parent could not explain
why the test was not read.
ANALYSIS
We assumed a 43% return rate (based on the return reading rate 3 months
before the study commenced) and a Hawthorne effect between 10 and 15 percentage
points when calculating the sample size. The Hawthorne effect estimate was
based on the increase in the TST reading rate observed by other investigators2 when education was introduced as a strategy for a
similar population. We estimated our control group reading rate would increase
to about 55% once the study commenced because the enrollment process might
influence behavior. Initially, we determined we would need to enroll 162 patients
per group to give us 80% power to detect an effect size of 15 percentage points.
Four months into the study, we recognized that the effect size was closer
to 30 percentage points. We recalculated the number of subjects needed to
give us 80% power to detect an effect size of 30 percentage points (increasing
the return reading rate from 55% to 85%) for a 2-tailed test,  = .05,
using the z statistic to compare proportions of dichotomous
values; this number was about 35 per group.
Demographic characteristics were compared by calculating the means and
medians of the children's ages or by calculating the frequency distribution
and  2 of the characteristics listed in Table 1 using computer software (Epi-Info 6; Centers for Disease
Control and Prevention, Atlanta, Ga). Comparison of the TST reading rates
between the control and the intervention groups was analyzed using the 2 test. Telephone call responses were examined to identify common reasons
for failing to have tests read.
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Distribution of Characteristics of the 134 Children and Their Families
by Group Assignment*
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RESULTS
SAMPLE GROUP DIFFERENCES
When we first began recruiting patients, we were bound to draw envelopes
in numerical order as dictated by the randomization process described. After
several months, it became apparent that the effect size was actually 30 percentage
points. Statistically, only 35 patients are required in each group to demonstrate
an effect of 30 percentage points above the anticipated baseline reading rate
of 55%. Therefore, we made the decision to complete the study at the end of
the school year, because we attained an adequate sample size in each group.
At that point, the distribution of randomly assigned patients was unequal.
If we continued to recruit all 350 patients, we would have finished with equal
numbers in each group.
PARTICIPANT DEMOGRAPHICS
Six hundred thirty-four school-aged children presented to the clinic
and had TSTs placed during the study period. Of these children, 157 (25%)
were eligible for the study and 143 (23%) were recruited. Four parents refused
to participate. Five patients were dropped from the study: 2 were enrolled
erroneously, and 3 control group school nurses were accidentally sent facsimiles.
Final enrollment was 134 children (21%), with 54 (40%) in the control group
and 80 (60%) in the intervention group. Patients were excluded from the study
for various reasons (Figure 1).
Many patients were ineligible because of school affiliation. Although we tried
to involve enough schools, we quickly learned that our patients hailed from
a wide geographic area involving many schools. In retrospect, we needed to
enroll twice as many schools to capture most patients.
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Figure 1. Patient enrollment process. TST
indicates tuberculosis skin test.
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Fourteen eligible patients were missed. Three parents left before consent
could be obtained. Eleven patients were not recognized as attending eligible
schools. In 3 cases, the parent could not pronounce or spell the school name.
Eight others were missed because of staff oversight.
The children's ages ranged from 5 to 17 years. Participants in each
group did not differ for age, sex, race, insurance status, household member
with a previously positive TST result, mode of transportation to the clinic,
single-parent status, or employment status of the primary caretaker (Table 1).
TST READING RATES
The TST reading rate for school-aged children during the 4 months preceding
patient enrollment was 43%. During the study period, the reading rate increased
to 56% in the control group, and to 93% in the intervention group. This difference
was statistically significant (P<.001) (Figure 2).
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Figure 2. Tuberculosis skin test (TST) reading
results: systematic collaboration with school nurses (intervention group)
vs no collaboration with school nurses (control group). The difference between
the 2 groups was significant (P<.001).
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Of the 28 control group parents whose children did not have documented
TST results, 27 were contacted. Four tests were later verified as being read
by the school nurse. Of the remaining 23, all but one of those contacted intended
to have the school nurse read their child's test. Seven tests were not read
because of school absence. In one other case, the child did not go to the
nurse when summoned. Thirteen others were not read because the parents failed
to effectively communicate their wishes to the school nurses. Two other parents
made no effort to get the tests read.
All of the school nurses of the 11 intervention group patients who did
not have a documented TST result after 96 hours were called. Four of these
patients actually had the test read by 72 hours, but the result was not communicated
back to the investigators because of technical problems. One other child in
the intervention group had the test read at the right time but had it read
at our clinic instead of school. Of the remaining 6 patients, 3 tests were
not read because of school absence, 2 tests were not read because the student
did not go to the nurse's office when summoned, and 1 nurse received the facsimile
72 hours after test placement.
During the study period, 8 of the 634 children had positive TST results
(1 in the control group, 1 in the intervention group, and 6 in the group deemed
ineligible for the study) using 10 mm or greater as the cut point.9 Three of these children had risk factors (all in the
nonstudy group); one had a household contact with an active case of TB. Because
the reading rate in the nonstudy group was only 40%, it is difficult to estimate
the true incidence of TST conversion.
COMMENT
Tuberculosis screening of high-risk populations is considered one of
the essential components of a successful TB control program.10
Unfortunately, TB screening efforts in urban areas are plagued with low turnouts
for TST reading. Health care professionals working in high-risk areas are
encouraged to collaborate with local TB control programs and each other to
enhance TB screening efforts.5, 11
During the enrollment process, almost all of the control group parents
wanted the school nurse to read the TSTs. Their behavior supported this preference,
because only 3 of 54 control group patients returned to the clinic for test
reading. Parent–to–school nurse communication failures were primarily
responsible for lack of TST reading or reporting. Our efforts to streamline
communication between physicians and school nurses greatly improved TST reading
rates in the intervention group. Other benefits of this intervention included
the following: (1) increased education of school nurses about TB; (2) improved
school nurse awareness of proper test reading and reporting; (3) more accountability
for reporting and recording TST results, especially in a large-volume clinic;
and (4) better planning to read TSTs, because we identified days when school
nurses could read the tests.
We did not test the school nurses' ability to read TSTs accurately because
we did not ask them to decide which tests were positive. Patients with any
degree of induration were referred back to us within 24 hours for TST reading,
examination, and treatment, if necessary. All 5 study patients referred back
to the clinic were seen within 24 hours. Nurses had a tendency to overread
induration. This contradicts the findings of Kendig et al,12
possibly because the circumstances for TST reading by school nurses in this
intervention were different from those imposed by their study.
Several biases were present in the study design. Two of these potentially
increased the intervention group reading rate. First, the study was not blinded.
School nurses receiving facsimiles to read TSTs knew these were intervention
patients and may have been more conscientious about reading and reporting
results. This does not seem to be the case, however, because control group
parents relied heavily on school nurses to read their children's tests. When
this was effectively communicated to the nurse and the child was not absent,
the tests were read in all cases but 1 in the control group and 2 in the intervention
group.
A second bias was introduced by contacting intervention group nurses
after sending them their first facsimile. While this helped ensure the functionality
of facsimile machines, it was potentially an extra reminder. Eighty patients
were enrolled in the intervention group from 35 different schools; therefore,
45 intervention group nurses did not receive a telephone call in addition
to the facsimile. Of this group, 40 patients (89%) had their TSTs read on
time. Thus, the additional telephone call did not influence the intervention
group results enough to alter our conclusions.
Last, was bias introduced by limiting patient enrollment to specific
schools? Parochial, private, charter, and home schools were excluded. Parents
sending their children to these schools might respond differently to the charge
of getting TSTs read on time. The reading rate of the 43 patients attending
these schools was 42%; exclusion of this group did not seem to introduce bias.
Limiting recruitment to children attending schools closest to our clinic
may have introduced bias if transportation or convenience influenced the test-reading
rate. Selective student enrollment from schools closest to the clinic might
skew the control group reading rate to be higher than average. The converse
would be a lower than average reading rate among ineligible patients. Indeed,
the return rate for patients who were ineligible for the study because they
attended nonparticipating public schools during the study period was 40%,
slightly lower than the baseline of 43% observed before the study commenced.
One of the strengths of this program is its real-life applicability.
Many urban outpatient clinics already rely on school nurses to help read TSTs
(Harriet Weinstein, RN, oral communication, March 9, 2000). Nurse recruitment
is not difficult if group meetings can be arranged. A designated telephone
line for nurses to report results also improves the communication process.
Despite the lack of year-round school nurse availability, this intervention
is worthwhile for inner-city youth of low socioeconomic status, and can be
expanded to preschool-aged children attending programs in which nurses or
other health care professionals can be instructed to identify children with
indurated TST results. This intervention is adaptable to e-mail, if patient
confidentiality can be assured.
Collaboration with health care professionals with access to children
successfully "bridges the gap" to improve TST reading rates. A physician's
ability to determine whom to screen is preserved; reading is more convenient
for parents or guardians; and verification, management, and treatment of positive
test results reverts back to the primary physician.
AUTHOR INFORMATION
Accepted for publication June 21, 2001.
Presented (as a final requirement for a Primary Care Faculty Development
Fellowship) at the Michigan State Primary Care Research and Development Conference,
East Lansing, June 8, 2000; and as a poster at the Societies for Pediatric
Research/Ambulatory Pediatric Association Spring Meeting, Baltimore, Md, April
30, 2001.
We thank the Michigan State Primary Care Faculty Development Fellowship
Program's faculty for their critical appraisal and expertise.
What This Study Adds
Screening patients with risk factors for TB with the TST or the Mantoux
test is recommended; however, the effectiveness of the TST is of no value
if it is not read. Our experience and the experience of others working in
urban practices where many patients have risk factors is that only half of
the TSTs placed are read. Interventions to improve reading rates have been
minimally successful.
This study provides clinicians with another way to improve TST reading
rates. We found that school nurses are reliable resources for reading TSTs
once their roles are clearly assigned and communication is streamlined.
From the Section of General Pediatrics, St Christopher's Hospital for
Children and MCP Hahnemann University School of Medicine, Philadelphia, Pa.
Corresponding author and reprints: Cynthia W. DeLago, MD, Section
of General Pediatrics, St Christopher's Hospital for Children and MCP Hahnemann
University School of Medicine, Erie Avenue at Front Street, Philadelphia,
PA 19134-1095 (e-mail: Cynthia.W.DeLago{at}drexel.edu).
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