Intensive phase - non attenders

Patients who do not attend when expected will be followed up, assessed and enabled to resume treatment as soon as possible.

A system needs to be in place to trace patients who miss their appointments for treatment (late patients). The best success will be achieved through the use of flexible, innovative and individualised approaches. The treatment and care the patient has received will inevitably have an impact on his or her willingness to attend in the future. In many cases there may be a simple obstacle that needs to be overcome to enable the patient to continue treatment successfully, so it is essential to find out what the problem might be. There will be patients who cannot be traced and not all those found will return for treatment; however, it is important to have made every attempt to return as many patients as possible to treatment.

NB: A well-defined system of late patient tracing is mandatory in all situations. However, when the rates are high (above 10%), any tracing system will be useless without also examining the service as a whole. Such an examination is necessary to identify and address the wider problems making it difficult for patients to attend.

trader

Prioritisation of the most infectious patients (click to view)

Sputum smear-positive patients who do not attend for treatment must be given priority, as they are most likely to be infectious and are most at risk of dying if not successfully treated. Every effort should be made to ensure that these patients receive a full, uninterrupted course of treatment. By doing so the number of infectious people in the community will be reduced, drug resistance will be prevented, more patients will be cured and fewer people will die.

Prompt action (click to view)

Late patients must be identified as soon as possible to avoid long gaps in treatment. The quicker they can be traced and encouraged to return to their treatment centre, the lower the risk of their condition deteriorating.

Clear, accurate and timely documentation (click to view)

Accurate contact details should be documented as soon as the patient starts treatment and regularly checked for any changes see Starting treatment - registration. Clear and prompt marking of the treatment card is essential to alert staff to patients who have not attended. Treatment cards are very useful to demonstrate how much of the course has been completed and how regularly drugs have been taken. In addition, they can help the patient see what progress he or she is making and how important every dose of medication is.

Ongoing analysis of the reasons given for non-attendance (click to view)

It is useful to collect information as to why the patient did not attend in order to identify and address the barriers he or she may be facing. It may be possible to make adjustments to treatment arrangements if there is a problem for an individual; but equally, if a problem is common to a number of patients, something more drastic may have to be done in terms of the way the whole service is offered.

“Kwanele Dlamini's motorbike can carry him to most rural homesteads in the eastern Lubombo Region of Swaziland, but he has to get off and walk the final rocky stretch to Solomon Ndwandwe's property and then duck a barbed-wire fence...”

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

Your reflection

The use of flexible and innovative approaches (click to view)

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Flexibility is required to adjust services in order to address issues identified in the analysis of reasons given for poor attendance. A satellite clinic may need to be set up to cater for a number of patients in a certain locality; clinic times may need altering, possibly with an overlap so that some staff start early and others stay late; messages may need changing, for instance, in the initial and/or ongoing education given to patients, etc.

An example of good practice:
In the video below a nurse who works in a TB clinic describes how her unit uses flexible and patient-centred approaches to trace patients who fail to attend.

Video: Following up patients who do not attend

Reflection

Your skills in tracing and supporting patients to continue treatment

Best Practice Requirement

Your Current Practice

Identify Gaps in your Practice

Our staff are skilled and understand the importance of
continuous treatment, within both identified TB services and other organisations that might be providing services to the patient, such as
social workers, pharmacists, etc.

All staff including doctors reinforce the need for complete treatment and regular sputum tests.

All staff strive to use good communication skills to negotiate with late patients in a caring and cooperative manner. All staff are aware that if a patient feels he or she will be chastised on returning to the management unit or other treatment facility, he or she may be reluctant return.

Do you have the organisational set-up and ethos
required to trace and support late patients?

Best Practice Requirement

Your Current Practice

Identify Gaps in your Practice

Our management unit or TB treatment facility has a clearly agreed process (including agreed timeframes) for following up late patients

Accurate, clear, and prompt records are kept on treatment cards to monitor adherence and attendance

If a patient does not attend for treatment the box on the treatment card representing
the day of the appointment is left blank, thereby clearly identifying the patient’s failure to attend. The same is true if the patient leaves hospital unexpectedly

The process requires treatment cards of all patients expected for treatment on any particular day to be placed in a slot. When patient’s have been seen
and registered the treatment cards are moved to a second slot. This process helps to immediately identify any patient who was expected but who did not show up for the scheduled appointment during the day

All those whose treatment cards remain in the first slot are contacted/visited within one week, if possible at the end of the day, to encourage them to return to the facility to continue treatment

Named people with defined responsibilities coordinate
this process, and the process is monitored by the Unit Coordinator

We have good communication systems with patients, families and communities that help us to locate a patient who has not attended the clinic as planned

Our unit has good communication with other organisations and with our own team to ensure the tracing process is transparent

Our patients are encouraged to contact the clinic if they are unable to attend for appointments so that alternative arrangements can be made. Patients have clear details of whom they should contact and how

Patients are reassured that regardless of reason of non-attendance they will be treated with kindness and understanding

We all ensure that our patients understand from the very beginning that every effort will be made to enable them to receive a full course of treatment and what steps will be taken if they do not attend

Patients are encouraged to share their reasons for non-attendance in a friendly and non-judgemental manner

Numerous attempts may be needed to track down a patient.

If the patient is not located within 2 months they are recorded as a ‘default’

If the patient cannot be found appropriate friends or relatives are encouraged to support the patient
to come to the clinic whenever he or she is able to do so

If the patient subsequently arrives at the treatment facility repeat the initial investigations, e.g., sputum examination for TB, are carried out

If the patient cannot (or will not) return to the treatment facility, an alternative plan of care that is acceptable to both the patient and the nurse is negotiated

Your Action Plan for Improvement

Use the following box to develop an action plan on how you will
improve your practice with regards to tracing late patient

Things you will change in your organisation’s process for tracing late patients

Things you will change about how you trace and negotiate treatment plans with your patients

Things you will change about how others in your team engage in the tracing and
treatment planning processes with the late patients attending your facility

List yours and others training needs and identify how you will address
them to enable best practice for tracing and treating late patients

For more information on forthcoming innovations in TB control please read ‘New Technologies for Tuberculosis Control: a framework for their adoption, introduction and implementation

Union (2007) Best Practice For The Care Of Patients With Tuberculosis: Chapter V.: Care During The Intensive Phase: Promotion Of Adherence

Care prevention and management of tuberculosis