Intensive phase - patient care and monitoring

Patient progress and DOT arrangements are monitored according to a schedule agreed upon between the Unit Coordinator, all health-care workers and other individuals designated to be involved in the care of TB patients.

patient

Addressing patient priorities (click to view)

Patients with TB often have many other concerns, which they may feel are more important and so may affect their ability to adhere to treatment. Patients should be treated with respect and feel they can discuss problems as they arise. The service should be able to respond to problems promptly to minimise the potential for treatment to be interrupted. If the patient trusts the service he or she is more likely to give their correct contact details. The patient will also be more likely to inform the service if something has happened which will prevent them from attending clinic, for example, if he or she needs to attend a funeral in another locality. It is very important that an open dialogue is maintained between the patient and the health-care worker so that issues such as these can be discussed as they arise and alternative arrangements can be made to prevent treatment being interrupted.

Addressing patient priorities

Management of adverse drug effects (click to view)

The patient needs to be encouraged to recognise and report adverse drug effects so that they can be properly managed. It is very important that you note and take action if patients report side effects due to TB medication. The consequences of ignoring the side effects and failure to educate and support patients for continuing or changing their TB medication can result in Multi-drug resistant TB and prolonged treatment for the patient. If the patient has MDR-TB, then the risk is that they will develop XDR-TB

	Read more: Union (2010) Chapter 4 Treating TB in Management of Tuberculosis: A Guide to the essentials of good practice
	Read more: WHO (2006) Chapter 11 Initial evaluation, monitoring of treatment and management of adverse effects in Guidelines for the programmatic management of drug-resistant tuberculosis
	Read more: WHO (2006) ANNEX 1Drug information sheets in Guidelines for the programmatic management of drug-resistant tuberculosis

Management of late patients (click to view)

A patient who fails to attend when expected should be contacted as soon as possible in order to minimise treatment interruption (Intensive phase: Tracing patients who do not attend for appointments (late patients). Prompt, persistent and sympathetic follow-up of late patients, although time consuming, can demonstrate to the patient that people care, which can in turn motivate him or her to continue treatment.

Follow-up sputum examination (click to view)

A follow-up sputum AFB smear examination is required to confirm that the disease has converted from smear-positive to smear-negative. This is important not only in terms of the progress of the individual patient but also to direct the proper treatment of the patient (for example, changing from the initial intensive to the continuation phase of treatment). As for diagnosis, the correct completion of sputum request forms and labelling of sputum containers for follow-up examination is essential for the accurate and timely feedback of results.

Learn more: Story of a TB patient who is now sputum negative

If the patient remains smear positive after two months of treatment there is a possibility that s/he is drug resistant. At this stage you will need to assess the patient’s clinical condition, discuss adherence and collect a sputum sample for culture and DST. If the patient was diagnosed with MDR-TB at the outset, then sputum is collected monthly for microscopy, culture and DST

	Reflect
	TBCTA (2006) Standard 10 in Standards for Treatment

Accurate documentation (click to view)

Throughout the intensive phase the treatment card, the TB register and the laboratory register must be kept up-to-date to monitor the progress of individual patients as well as provide accessible, accurate information for monitoring the regularity of treatment during the intensive phase. The same is true of the documentation relating to a patient on treatment for drug resistant TB whose injection or intensive phase may last for more than six months until s/he is culture negative.

Please see: Starting treatment > Registration and care of newly diagnosed TB patients > Rationale > Clear, accurate and timely documentation for more information on this aspect of patient care and monitoring.

TBCTA (2006) Standard 11 in Standards for Treatment

Support for the person responsible for directly observed treatment (click to view)

The person designated as responsible for observing treatment needs to feel valued and encouraged in order to stay motivated and to be able to continue to motivate the patient. If not, he or she may feel taken for granted. Regular meetings or phone contact will help to achieve this with encouragement to make contact if a problem arises.

	Video: Rhoda
	Refelect

Please refer to Standard Starting Treatment > Arranging DOT for more information on this aspect of patient care and monitoring.

Do you have the resources required for best practice?

Best Practice Requirement

Your Current Practice

Identify gaps in your practice

Health-care workers with knowledge and understanding of TB and its treatment

Health-care workers who can recognise and refer patients with severe adverse drug effects and manage patients with minor adverse effects

Health-care workers who understand factors that affect adherence (Error! Reference source not found.) have an attitude of caring and are prepared to take responsibility for treatment outcomes.

Availability of the necessary forms and registers and health-care workers who can complete them clearly promptly and accurately.

Each management unit and associated TB treatment facility needs to have a system in place to follow up irregular patients (see Error! Reference source not found.).

Collaboration with support services and other organisations that could assist the patient.

Possibility of admitting very sick patients, although this may result in other costs to patients.

Supervision to maintain good practice

Check your practice

Best Practice Requirement

Your Current Practice

Identify gaps in your practice

Each patient is assessed according to the variables set out in table 5 (addressing patient priorities)

At the end of the intensive phase the patient is assessed physically to ensure adequate progress has been made and his or her sputum has converted from smear positive to smear negative.

Sputum specimens should be obtained and examined in the week before the results are needed so that they are available to evaluate whether the patient can progress to the continuation phase.

If the patient was initially diagnosed with extrapulmonary TB other signs of physical improvement should be sought e.g. weight gain, increased energy

All patients who remain smear positive after two months of treatment are assessed with regard to:
o The regimen they have been prescribed during the intensive phase: e.g., is it appropriate?
o Any problems they may have had taking treatment as prescribed;
o Any misunderstandings about the treatment regimen – e.g., are they taking the correct dose at the correct intervals?
o Any problems with regard to the person supervising their treatment

Care should be planned and regularly assessed according to individual patient needs.

As at any time during treatment severe adverse drug effects should be identified, recorded and referred to an appropriate medical officer without delay.

Minor adverse drug effects should be identified, recorded and managed at the management unit.

Documentation including the TB register, treatment cards and the laboratory register are up-to-date.

An identified person checks the treatment cards against the TB register every week to ensure the information is complete.

Supplies of drugs and materials are maintained.

If a patient does not attend for DOT, it is marked clearly on the treatment card. Telephone contact or a home visit is made to address any problems and encourage the patient to resume treatment.

Partnerships are developed with other agencies in the local area to give patients access to additional support according to their needs

The intensive phase of treatment is completed successfully. This can be measured using the patient treatment card and the TB register.

Use the following box to develop an action plan on how you will improve your practice with
regards to contact tracing when a new patient is diagnosed with TB

Things you will change about the way you talk to patients about their priorities and drug
side effects, and follow-up treatment after smear negative results in intensive phase.

Things you will change about how you and your team manage late patients, follow up sputum
examinations during intensive phase, document changes to patient treatment, and communication with DOTS workers.

List yours and others training needs and identify how you will address them to enable best practice
for patient care and monitoring during intensive phase.

What else needs to happen to make these changes a reality? Who needs
to do what? Who will lead the change process?

Please print this form and begin developing your practice

Tuberculosis Coalition for Technical Assistance (TBCTA, 2006) International Standards for Tuberculosis Care.
Union (2005) Management of the Child with Cough or Difficult Breathing A Guide For Low Income Countries, Second Edition
Union (2007) Best Practice For The Care Of Patients With Tuberculosis: Chapter V.: Care During The Intensive Phase: Promotion Of Adherence
Union (2010) Management of Tuberculosis: A Guide to the essentials of good practice
WHO (2006) Guidelines for the programmatic management of drug-resistant tuberculosis
WHO (2009) WHO Policy on TB Infection Control in Health-care Facilities, Congregate settings and Households

Care prevention and management of tuberculosis