Starting treatment - arranging dot

DOT will be arranged in the most convenient and reliable way possible taking into account the patient’s needs and wishes as well as local resources.

Directly Observed Treatment (click to view)

Directly observed treatment (DOT) is one of the five elements of the DOTS strategy and is designed to
1) assist the patient in completing a full course of TB treatment
2) document the patient’s intake of medication

It is recommended that DOT should be given during the intensive phase of treatment for all sputum smear-positive TB patients, the continuation phase of rifampicin-containing regimens and the whole retreatment regimen, as this has been shown to reduce the development of drug resistance but works best when it is carried out in a supportive way offering care as well as supervision.
If the patient is diagnosed with multidrug resistant TB the intensive phase of their treatment will last at least six months and involve a daily injection which will require daily contact with a health care worker. Depending on the country policy the patient may be cared for at home or hospitalized for anything up to the duration of the injection phase. Ongoing supervision and care is required to ensure the patient completes treatment without developing further resistance to the drugs.

Learn more: Why do we need DOTS

Minimising the cost to the patient (click to view)

It is important to keep costs as low as possible for the patient in financial as well as in social terms. Although treatment is mostly provided free of charge, transport can become expensive and the time needed to attend for DOT can interfere with work and/or family commitments. If a patient is required to be admitted for prolonged periods of time this can have serious consequences for both relationships and maintaining an income.
Reducing these costs will help the patient to adhere to his or her treatment. A patient may receive DOT outside of the management unit while maintaining the principle that they should be observed swallowing their tablets by a trained and supervised person. There may be a number of designated TB treatment facilities offering DOT and they should be referred to one that is most convenient for them, i.e., that they choose. Supervision

In ALL circumstances, the responsibility for care of patients, including direct observation of treatment, rests with the local management unit and its staff.

Read more: patient-centred care SA.pdf

Skills, knowledge and support for administering DOT (click to view)

DOTS needs to be administered in a caring and understanding manner. If the person responsible for administering DOTS does not, for example, understand his or her role, is unfriendly or does not listen if the patient has concerns, the patient may become demotivated and stop attending for treatment. Equally, if the person responsible does not receive adequate support or supervision, he or she may become demotivated or give the patient misleading information.

More information about selecting an appropriate DOT supporter can be found on pages 31-32 of the Best_Practice_Guide

Video: Meet Rhoda who volunteers as a community health worker for the Eastern Deanery AIDS Relief Programme in Nairobi. She is very positive about her work as you will see in subsequent clips, but here she describes some of the challenges she faces. She supports people with TB as well as HIV.

Reflect

Maintaining a good relationship with the patient (click to view)

It is essential to inform the patient about the different options that the management unit can offer for DOT. The selected option needs to be realistic for both health-care workers and patients, otherwise it will not succeed. Health-care workers should emphasise the support rather than the surveillance aspect in order to encourage the patient’s cooperation.

Learn more: Key role of nurses

Reflect on the nursing process in your service

Documentation of medication intake (click to view)

Every dose of medication taken by the patient and every AFBs sputum smear result should be recorded immediately on the treatment card so that the patient’s progress can be assessed and non-attendance can be identified daily.

Read more: WHO (2006) TB recording and reporting forms and registers

Do you have the resources required for best practice?

Best Practice Requirement

Your Current Practice

Identify gaps in your practice

However DOT is organised it should be realistic, manageable and sustainable for both the patient and the management unit at which the patient is registered.

Arrangements for DOT using TB treatment facilities outside of the management unit should be clearly defined in local and/or national guidelines and policies.

The treatment card should be held by the person observing treatment and this person should be able to complete it clearly, accurately and promptly.

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Alternatives to using the management unit for to administering treatment for TB will vary depending on the local setting and the resources available. However, the principle that patients should be observed swallowing their tablets by a trained and supervised person must be maintained.

Audit your practice when arranging DOT in the intensive phase for a TB patient

Do you have the resources and support required to enable DOTS in your practice?

Best Practice Requirement

Your Current Practice

Identify Gaps in your Practice

The patient’s needs and circumstances are assessed when they start treatment

DOT is organised taking the patient’s needs as well as service resources into account.

There is careful negotiation with all those involved and a clear plan as to who is responsible for what

The Unit Coordinator provides training, monthly supervision and support for the person responsible for observing the patient’s treatment

The Unit Coordinator is ultimately responsible for the success of the treatment

Good communication is maintained between all those involved in the care of the TB patient, from the management unit to the hospital clinic to the person designated to undertake direct observation of treatment

DOT is implemented successfully. This can be demonstrated by the treatment cards, which have every dose recorded and any gaps accounted for

DOT is implemented successfully. This can be demonstrated by the treatment cards, which have every dose recorded and any gaps accounted for.

Use the following box to develop an action plan on how you will improve
your practice with regards to organisation of DOTS for your patients

Things you will change in your practice to train DOTS workers

Things you will change in your practice to support DOTS workers and communicate with them to ensure
patients are receiving their treatment and all necessary documentation is completed

Things you will change about how others in your team engage with and support DOTS workers

List yours and others training needs and identify how you will address them to
enable best practice to support the DOTS strategy

WHO (2006) Revised TB recording and reporting forms and registers
ICN (2008) TB/MDR TB guidelines for nurses
UNION (2007) BP guide_3 starting treatment

Care prevention and management of tuberculosis