Negative-pressure isolation rooms were reported for 33 of 56 hospitals (59 percent), 15 of 35 prisons (43 percent), and 4 of 9 nursing homes (44 percent) but no shelters. Respiratory protection was reported for nearly 60 percent of hospitals but less than 20 percent of prisons, shelters, and nursing homes. Overall, 42 percent of facilities received citations, most for noncompliance with respiratory protection requirements. (The inspections occurred before the National Institute for Occupational Safety and Health [NIOSH] had certified the N95 respirators, which were less expensive and generally more convenient and comfortable than the devices previously certified.) Again, because inspections were generally prompted by complaints, the results may reflect a negative bias.

State and Other Inspections

New York State officials examined tuberculosis isolation procedures in 22 New York City hospitals in 1992, 1993, and 1994 (Stricof et al., 1998). They reviewed medical and laboratory records to collect information about patient risk factors and history, signs and symptoms, length of time in the emergency department, turnaround time for laboratory reports, timing of isolation and treatment, and other information. They also directly observed and evaluated isolation rooms and isolation practices. From 1992 to 1994, they found that hospitals made substantial progress in correcting deficits in tuberculosis control measures. The percentage of isolation rooms with negative pressure increased from 51 to 80 percent. The number of patients with active tuberculosis sharing rooms dropped from 13 percent to zero, and the percentage of patients with suspected or diagnosed tuberculosis isolated upon admission increased from 75 to 84 percent. The number of facilities able to process smears 7 days a week increased from 40 to 95 percent. Despite improvements, the inspections also revealed continuing problems in some areas, including open doors and windows for isolation rooms and isolation rooms without negative pressure.

In addition to any state-specific requirements, states must survey and inspect nursing homes annually to assess compliance with Medicaid certification requirements set by the U.S. Health Care Financing Administration (HFCA). HCFA requires that nursing homes have an infection control program. Recent data (June 2000) showed that states had cited 10.8 percent of facilities for deficiencies in their infection control programs, 0.9 percent for deficiencies related to isolation of residents, 0.1 percent for deficiencies related to employees with (any) communicable disease, and 6.4 percent for hand-washing and infection control deficiencies (AHCA, 2000).

One on-site study (supported by NIOSH and the California Department of Health) compared written tuberculosis control policies with actual



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