Continuation phase

Treatment is continuous throughout the course and appropriate arrangements are made if the patient needs to transfer his or her care to another management unit

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Accommodating patient mobility (click to view)

During a minimum of 6 months treatment (2 years for a patient with MDR-TB), patient care may be transferred between health care providers. This may be from hospital to community care as the patient becomes stronger; from one location to another if the patient moves home or travels for any length of time; or from an urban to a community clinic, e.g., if the patient went to a central location for diagnosis but returned home for ongoing treatment. If the patient has a good relationship with the health-care worker and understands the need to continue treatment, he or she is more likely to inform the service if personal circumstances change and he or she can no longer attend the same clinic for treatment.

Minimising gaps in treatment (click to view)

Special attention needs to be paid to the continuation of treatment while the patient’s care is being transferred from one management unit to another. Treatment should not be interrupted, as gaps in treatment increase the risk of relapse and the development of drug resistance.

Case study

You are a healthcare worker at the TB management unit. You have been working closely with Karan, a 28 year-old agriculture worker. Karan was diagnosed with TB about 2 months ago. You have been giving him DOT at a local farm. His temporary farm job is coming to an end and you realize that Karan will soon be heading out of the town to look for more work. You have spoken to him about where he will be going next. He tells you that he is going to a farm. He is not exactly sure where it is, but he thinks he remembers the farm is located near the main city.
Ref: CDC (2009) http://www.cdc.gov/tb/education/ssmodules/module8/ss8reading6.htm

Read and Reflect: What steps will you take before Karan leaves your clinic to ensure the continuity of care?

Documentation regarding patient transfer (click to view)

Patients who move from one management unit to another need to be recorded as a “transfer out” from the unit they leave and “transfer in” at the new unit. Treatment outcomes for those who “transfer in” should be sent to the management unit where they were first registered and included in that unit’s quarterly reports. This prevents duplication or omission in the reporting of treatment outcomes.

Documentation: Tuberculosis referral/transfer form

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.

Audit your practice when supporting a patient to
transfer from one management facility to another

Best Practice Requirement

Your Current Practice

Identify Gaps in your Practice

A referral system is in place that is common to and understood by all
management units that you have contacted in the past

A Tuberculosis Referral/Transfer
Form is completed in triplicate:
One copy given to the patient to take with them to the new management unit
Second copy is kept by the referring management unit
Third copy is given to the District Tuberculosis Coordinator

Before leaving, patients are given clear guidance about the importance of continuing their treatment

The patient is given a reasonable supply of medication to cover their period of travel before they are likely to be able to register elsewhere for ongoing treatment

If the patient arrives from another management unit they are registered as a transfer in. The bottom part of the transfer form is sent back to the referring unit to confirm that the transfer has taken place

If we do not get confirmation of arrival of our patient from the new management unit. We contact the new unit to check this. If not, the District Tuberculosis Coordinator is informed

Patients who are going to another country or are not sure of their destination, they are given advice about seeking help on arrival. They are encouraged to present to a health facility as soon as possible with a record of their diagnosis, the duration and type of treatment they have received and the address of the management unit where they are registered

As a management unit starting a transferred patient’s treatment we record the treatment outcome, no matter where the patient has gone

How is your practice?

Best Practice Requirement

Your Current Practice

Identify Gaps in your Practice

The health-care worker is competent to organise the transfer and complete all necessary documentation clearly, promptly and accurately

Our aim is to support patients throughout their treatment and ensuring they understand the importance of finishing the course. This helps to ensure they will inform us of any plans to move or leave

The health-care worker most involved with the patient’s treatment sees it as their responsibility to ensure that the patient’s treatment
is continued elsewhere rather than feeling that it is no longer their concern

Patients will remain on the appropriate treatment in spite of moving away from their original management unit. This can be monitored via the TB register and quarterly cohort analysis.

Use the following box to develop an action plan on how you will improve your
practice with regards to Management of patient transfer to another unit/facility

Things you will change about the records and forms you complete and give to the patient, the new unit
and the District Coordinator, to ensure a complete and safe transfer of a TB patient to another facility or unit

Things you will change about the information you give your patients,
who are moving away from your unit, about continuing their treatment

Things you will change about how others in your team engage with patients,
who are moving away from your unit, arrange and check for patient transfer.

List yours and others training needs and identify how you will address them to
enable best practice during transfer of patients to a different TB treatment facility

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