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Tripping up over the two-step TST

A safety officer was perplexed. What to do with a student nurse, new to the organization, who objected to a two-step baseline tuberculin skin test (TST), which the organization required under its OSHA policy?

She had a TST less than a year ago—it was negative—so why do another? Furthermore, her physician asked to see the OSHA documentation that required the two-step TST.

Of course the safety officer couldn’t find it.

First of all, eliminate the OSHA angle. Similar to volunteers, [1] students are usually not covered under OSHA. Deciding if a situation is really an OSHA matter is one of the first things to analyze, as we will explain in the OSHA Healthcare Advisor’s “Q&A Roundtable: Solutions to Your Compliance Challenges” audioconference, [2] Tuesday, May 19, 1:00-2:00 p.m. (Eastern). See below for more information.

Second, since OSHA pulled the TB standard before it became law in 2002, most prudent healthcare organizations look to CDC guidelines to develop a TB prevention plan [3].

Fortunately the guidelines are clear on this point with a nice table (see below) that explains when to give the two-step TST, and when to give the one step TST.

According to the CDC, if the last negative TST was greater than 12 months ago, administer the two-step test. If the last negative test was equal to or less than 12 months ago, administer the one-step. With the exception of a positive TST, all the scenarios call for some TST to establish a baseline for healthcare workers new to a setting.

It looks like the student and her physician are arguing contrary to CDC guidelines.

CDC guidelines are not mandatory, but if you are going to flout them, or fudge on them, even a little, you should have a good reason and document it with a risk assessment. Even then you might run afoul of state health department regulations which frequently follow CDC guidelines.

Click on the table for a larger image
bozx-1-indications-for-two-step-tst [4]

Source: Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health-Care Settings, 2005

hcpro-audio-conference-logosm [2]Did you find this advice helpful? Learn how you can get all your OSHA questions answered by registering for OSHA Healthcare Advisor’s “Q&A Roundtable: Solutions to Your Compliance Challenges” audioconference, [2] Tuesday, May 19, 2009, 1:00-2:00 p.m. (Eastern).