Continuation phase - assessment

Patients are assessed at the end of their intensive phase of treatment and a plan is developed with the patient for the continuation phase during which they are likely to have less contact with the management unit.

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Managing the change in treatment (click to view)

As the patient begins to feel better, other priorities may start distracting him or her from treatment. If the patient has had DOT in the intensive phase and this is stopped in the continuation phase, it may be a signal to the patient that the treatment is not so important. It is essential to reiterate the need for ongoing treatment.

In the following video you can see Mr. Rosario, who is former TB patient who is now a volunteer DOT worker. His doctor told him to take the medication for 6 months but no one advised him for what to do in the continuation phase. He shares his story of what happened when he discontinued his TB drugs after 6 months of intensive phase. His story highlights the importance of accurate information and understanding of how the treatment works to cure the disease, and how long to continue the treatment.

Watch Mr. Rosario, a former TB patient who is now a volunteer DOT worker

Reassessment of the patient’s needs (click to view)

Reassessment of the patient’s physical, social and psychological needs will assist in the planning of appropriate patient-centred care in the continuation phase as the patient takes more control of and responsibility for his or her own treatment. Additional support may still be needed if, for instance, the patient is co-infected with HIV. Other sources of support should be explored with the patient, if necessary, to ensure continuation of care following the completion of TB treatment.

Watch a TB nurse Gladwel talk about how she ensures patients in the continuation phase continue to attend the clinic once a month, and how she also uses their expertise to support new patients in the intensive phase

Reflect on: How does your unit manage patients in different phases of the treatment?

Managing unforeseen events (click to view)

All sorts of life events can have an unexpected impact on treatment and the patient’s ability to continue. He or she may encounter bereavement, change jobs or need to move away at short notice. It is important to be prepared for such events and help the patient to readjust to his or her new circumstances while continuing to adhere to the treatment regimen. It is particularly important to discuss this with the patient when the treatment changes, as he or she will have less contact with the service in the continuation phase

Watch Kwanele, the motorcycle adherence officer and Solomon, the TB patient who has not been attending the clinic

Your skills in assessing and supporting patients
moving from intensive to continuation phase

Best Practice Requirement

Your Current Practice

Identify Gaps in your Practice

Good communication and assessment skills are needed as patient moves to continuation phase more than ever as the patient’s treatment changes

Adequate time is needed to reiterate important messages about the need to continue treatment without interruption and to encourage the patient to inform the health-care facility if there are likely to be changes in personal circumstances that may affect his or her ability to continue treatment and/or attend for follow-up appointments.

Health-care workers need to know when to send follow up sputum smears to the laboratory according to the patient category.

Documentation is essential at this time regarding the ordering and results of sputum smear tests as described in standard IV.2.

Efficient laboratory services are needed so that there is no delay in the examination of follow-up sputum smears (and routine cultures if DR-TB) and the treatment can be changed at the appropriate time

Section 1

Do you have the organisational processes required for best practice
in helping patients move from intensive to continuation phase?

Best Practice Requirement

Your Current Practice

Identify Gaps in your Practice

Adequate time is taken to reiterate important messages about the need to continue treatment without interruption

Patients are encouraged to inform the health-care facility if there are likely to be changes in personal circumstances that may affect his or her ability to continue treatment and/or attend for follow-up appointments

During the continuation phase a minimum of a monthly follow-up meeting is agreed between the
patient and the health-care worker who supervised the initial phase of treatment. This may involve home or clinic visits or a mixture of both, according to patient preference and available resources.

Patient is reassured that they can visit the facility at any time and that they must feel free to report any problems should they arise

Principles for sputum collection outlined in Standard 2 are applied when
giving the patient instructions to produce subsequent specimens at home & information on delivering the specimen to the right place at the right time is given

All requested and sent specimen dates and results of sputum smear tests are documented to inform further treatment strategies

Laboratory services are efficient and there is no delay in the examination of follow-up sputum smears. Hence treatment is changed immediately, if required.

Treatment card and laboratory register are completed as outlined in Standards 2 and 3

In cases where patients do not submit the required sputum sample no entry or an entry indicating “smear not done” in the TB register is recorded and patient is traced as outlined in Standard 2

Patients are opportunity to discuss practicalities of starting treatment at home

Patients are helped to develop a way of remembering when to take the medicine (before a routine activity such as a meal is useful)

Patients are advised regarding safe storage of the
drugs in a dark, dry place away from the reach of children

Any potential barriers to adherence are reassessed, such as a change in
routine, potential for mislaying drugs or having them stolen, alcohol addiction and treatment plan negotiated as appropriate with the patient

Patients are reminded how to recognise any potential adverse effects and report them, as in Standard 6

Your Action Plan for Improvement

Patients progress from the intensive to the continuation phase following reexamination of sputum. Information is available on each individual patient treatment card and the TB register. Patients continue treatment while developing greater self-reliance, gaining confidence and maintaining contact with TB service.

Use the following box to develop an action plan on how you will improve your practice
with regards to reassessing patients needs when they move to continuation phase

Things you will change about the way you discuss patients needs during
re-assessment and consultation when patients have completed 6 months of intensive treatment

Things you will change about how others in your team discuss patients needs
when patients have completed 6 months of intensive treatment

List yours and others training needs and identify how you will address them to enable best practice
re- assessment and support for patients when moving from intensive to continuation phase of treatment.

Tuberculosis Coalition for Technical Assistance (TBCTA, 2006) International Standards for Tuberculosis Care.

UNION (2007) Best Practice for the care of patients with tubersulosis, chapter 6

UNION (2010) Management of tuberculosis

Care prevention and management of tuberculosis