Care prevention and management of tuberculosis

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Continuation phase > Case management
  • Standard statement
  • Rationale
  • Resources
  • Professional practice
  • Outcome
  • References

Ongoing support is available according to patient need and the necessary follow-up investigations are carried out.

tb teams

Reassessment of patient needs (click to view)

The patient is gaining more control and responsibility, having become accustomed to the treatment and moved on from feeling unwell and vulnerable as he or she did in the intensive phase. It is important at this stage to reassess the patient’s needs and update plans of care to reflect this new situation, especially if he or she is transferring from DOT to self-administered medication (e.g., if Rifampicin is discontinued in the second phase of treatment). If not, the patient may feel that it does not matter too much whether they continue medication or not.

ethiopian food
Flexibility in response to problems faced by the patient & Minimising the cost to the patient (click to view)

Responses should be prompt and appropriate, with continued commitment to care. Trust can be built and patients can be motivated if they feel that their priorities are taken seriously. The problem may not be directly related to the patient’s treatment, but if ignored may present a barrier to treatment in the future.
Costs to the patient should be kept to a minimum to maintain his or her ability to continue treatment. For example, unnecessary clinic appointments, that may incur travel costs and interrupt the patient’s work should be avoided.

video presentation Watch: TB nurse describes follow-up for patients in both the intensive and the continuation phase
video presentation Watch: An example of a DOT service set up at the treatment centre for patients with MDR-TB
reflect Reflection: Compare service approaches in treatment of patients in the videos shown. How does your unit manage patients in different phases of the treatment? Is there anything you would like to change?
patient
Follow up sputum smear examination at 5 months and Assessing treatment outcomes (click to view)
A follow-up AFB sputum smear examination is required after 5 months of treatment for all patients who were originally sputum smear-positive to either confirm progress or identify treatment failures. A positive sputum smear after five months of treatment defines treatment failure and indicates the need for culture and DST to be carried out as there is a risk of the patient being drug resistant.
Sputum is usually collected monthly for a patient on second-line drugs for microscopy and culture to monitor progress.
video presentation Read more: TBCTA (2006) Standard 10 in Standards for Treatment
Reassessment of the patient during this stage is important to find out what might have happened during the patient’s treatment which may account for the fact they are still smear positive. It is important to look at the drugs they have taken throughout the course, adherence patterns and results after the intensive phase. Once you find out more it will be possible to manage her/his second course of treatment with more success by addressing any previous problems she/he may have encountered (e.g. drug stockouts, side effects, loss of support). Do not assume non-adherence or blame the patient if anything she/he will take some convincing that treatment will work if they failed first time around.
video presentation Reflect on your practice
Assessing and recording the treatment outcome for each patient is essential to understanding the performance of the TB control programme. Sputum is re-examined at the end of the patient’s treatment to confirm that “cure” has occurred, which is a much stronger indicator of treatment success than “treatment completion”.
Documentation (click to view)

As for diagnosis and the first follow-up specimen, the correct completion of sputum request forms and labelling of sputum containers is essential for the accurate and timely feedback of results. Results should be entered in the laboratory register, the treatment card and the TB register as soon as they become available so that any health-care worker can assess the patient’s progress and ensure that correct treatment is being given. The accuracy of quarterly reports on treatment outcomes depends on the accuracy of the information in the TB register. Quarterly reports in turn demonstrate how well the programme is performing .

video presentation Documentation: An example of a Daily Administration form to be completed during continuation phase of the treatment

 

visiting patient

Do you have the resources and organisational
set-up required for best practice?

Best Practice Requirement

Your Current Practice

Identify Gaps in your Practice

All patients originally registered as “new smear-positive pulmonary” cases
have their sputum examined at 5 months to ensure that it has remained smear negative

If it is impossible for patients to produce sputum it may be necessary to collect and process saliva in order to have comprehensive treatment information

If the smear examination is positive at 5 months the patient’s case is recorded as a treatment failure and started on a retreatment regiment

Sputum is re-examined at the end of treatment to confirm that “cure” has occurred

Prompt and accurate documentation of the tests ordered, dates and results is maintained

If a patient fails to collect a supply of medication as arranged, this is clearly on the treatment card

A patient who does not attend when expected is traced using a non-judgemental approach and seeking to assess and address the reasons for their nonattendance

Patients who find it difficult to adjust to separation from the service at the end of their treatment are supported as required.

Patients are reassured if they have fears that without DOTS support they may become ill again

Preparation of patient for the end of his or her treatment starts by beginning to talk about it at least 2 months before completion is due

If, on assessment, a potential problem has been identified,
an appropriate plan of care is agreed with the patient and DOTS workers and evaluated regularly

We give our patients the facility’s contact numbers and numbers of their DOTS workers and are encouraged to contact the us if a problem arises

We find our patients contact us regularly and update us on any changes in their living and working situations that may impact on their treatment

Our service responds promptly to all patient needs and enquiries. The response is aimed at addressing the problem and ensuring all possible action is taken to prevent potential interruption
in treatment

As it may be necessary to refer the patient for additional support, we have developed links with other services, both governmental and voluntary

If the patient continues to have a designated person supporting
them the relationship may change with the less frequent follow-up in
the continuation phase.

Each patient needs to be assessed according to
the level of support he or she may need. It is recommended that there
should be at least monthly contact with the TB service.

At the end of treatment all records are complete and accurate:
Missing information in the TB register is regularly crosschecked with the patient card and the laboratory register to ensure that
any missing information corresponds to an absence of data and not to poor record keeping, e.g., the absence of a sputum examination result
at 5 months in the TB register means the sputum examination was not
performed only if we are sure it is not due to a lack of reporting or documentation.

 

 

How is your practice?

Best Practice Requirement

Your Current Practice

Identify Gaps in your Practice

Our health-care workers are competent to order a 5 month sputum examination and respond appropriately to results

Our health-care workers are competent to assess and record treatment outcomes.

Our healthcare workers take responsibility for maintaining contact with the patient and regularly evaluate his or her progress

All staff are knowledgeable about the factors affecting adherence outlined in the 12 Standards of TB Care. We are sensitive to the potential changes in patients’ circumstances during the continuation phase

All staff are skilled and disciplined recording all contact with patients

 

 

Assessing and recording the treatment outcome for each patient is essential to understanding the performance of the TB control programme. Sputum is re-examined at the end of the patient’s treatment to confirm that “cure” has occurred, which is a much stronger indicator of treatment success than “treatment completion”

The results of treatment for each individual patient should be recorded as they become available, as follows. The first of these events to occur is the event recorded as the result of treatment.

Possible results to be recorded in patient’s records

• Smear negative (cured) indicates an individual who was smear negative at the last month of treatment and on at least one previous occasion.
• Smear not done (treatment completed) indicates those patients who have completed treatment but whose smear results do not meet the criteria to be classified as smear negative or smear positive.
• Smear positive (failure) designates any new patient who remains or becomes again smear positive at 5 months or later during treatment, or a retreatment case who remains positive at the end of treatment.
• Died is recorded for patients who die for any reason during the course of their treatment, entered into the register at the time the death is reported.
• Defaulted is recorded for any patient who has failed to collect medication for more than 2 consecutive months after the date of the last attendance during the course of treatment. This should be entered into the register when the 2 months since the last appointment have lapsed.

o Those who are still on treatment at the time the treatment results are evaluated (15 months after the close of the quarter in which the patient was entered into the tuberculosis register) should be recorded as defaulted.

• Transferred indicates any patient for whom treatment results are unknown, who was to continue treatment at another centre to which the patient was transferred to continue treatment.

 

Learning from patients with successful treatment outcomes

A successful patient who has strived and completed their TB treatment can be an inspiration to other patients. In previous Standards we have seen example of how these patients are helping the new patients continue their treatment.

List ways in which you engage successful patients in your clinic to support your new and MDR patients.

 

Patients progress from the intensive to the continuation phase following re-examination of sputum. Information is available on each individual patient treatment card and the TB register.

Your Action Plan for Improvement

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.

 

 

 

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