Care prevention and management of tuberculosis

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Starting treatment > Care and Registration
  • Standard statement
  • Rationale
  • Resources
  • Professional practice
  • Outcome
  • References

Each patient is registered appropriately, started on an approved treatment regimen and given practical advice, support and information according to their individual needs and concerns.

nurse and patient
Identification of appropriate management unit (click to view)

It is essential for all patients who are diagnosed with TB to be registered at an appropriate management unit as soon as possible after diagnosis so that they can receive the care they need and their progress can be monitored. Each patient should be given the option to be followed up at the management unit that is most convenient for them. A patient may attend a large hospital or clinic known to provide services for TB and be unaware that there is a facility closer to her/his home. Referring her/him to a local unit will also alleviate pressure from larger units. If the patient is found to have DR-TB, the patient is given appropriate treatment based on country policy and needs to be managed by a unit approved for the treatment of DR-TB.
It is essential to keep a record at the centre where the diagnosis of TB was made in order provide a means for ensuring that the patient has been registered and started treatment at the management unit s/he has been referred to - this includes specialist DR-TB facilities. It is also the responsibility of the unit that made the diagnosis to report on the eventual treatment outcome.

learn more Read more: Union 2007 Best Practice Guide, Chapter 4, Starting treatment
st peters addis ababa
Registering the patient and starting the correct treatment (click to view)

Each patient needs to be prescribed an approved treatment regimen according to their laboratory results, treatment history. The overwhelming majority will be treated with first-line anti TB drugs.

learn more Read more: TBCTA (2006) Standard 7&8: Standards for Treatment
learn more Read more: Union (2010) Chapter 4 Treating TB in Management of Tuberculosis: A Guide to the essentials of good practice
Those with suspected or confirmed drug resistance either a locally approved standard regimen or a tailored to their DST will need to be prescribed
learn more
Read more: WHO (2006) Chapter 7 Treatment strategies for MDR-TB in Guidelines for the programmatic management of drug-resistant tuberculosis
learn more Read more: Union (2005) Chapter 8 in Union (2005) Management of the Child with Cough or Difficult Breathing A Guide For Low Income Countries, Second Edition
patients with masks
Clear, accurate and timely documentation (click to view)

Standardised recording and reporting systems help to evaluate patient progress and treatment outcome and give a picture of how the programme is performing overall. All documentation must be completed clearly and accurately as soon as the TB diagnosis is confirmed. This includes : Laboratory register, TB register, Patient treatment card, Quarterly Reports

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

It is important at an early stage to get details of the patient’s address as well as details of a close friend or relative through whom the patient can be contacted. The earlier this information is documented the better, in case for some reason the patient does not attend and needs to be traced. As some patients may be reluctant to give accurate contact details at first, and may only do so once they have gained trust in the service, it is useful to check regularly if any of the details have changed or are due to change

register
Offering an HIV test (click to view)
As TB is one of the main opportunistic infections associated with HIV, all TB patients should be tested for HIV. The earlier it is found that someone is infected with HIV, the sooner he or she can be offered advice and treatment to prevent opportunistic infections, prolong life, and decrease the possibility of further transmission. It will also present an opportunity to offer diagnostic and care services to the patient’s partner who may be at significant risk from contact with both HIV and TB.
This is covered in more detail in TB and HIV: HIV Testing
learn more Read more: Union 2007 Best Practice Guide, Chapter 7, HIV testing

TB and HIV
Assessing the patient’s social and psychological needs (click to view)

Consultation with a patient who has recently been diagnosed needs to involve more than just telling her/him that s/he has TB, giving them the medication and recording the information. To ensure the patient can understand the TB diagnosis and engage with the treatment it is important to allow the patient to express her/his fears and worries.
TB can often be a stigmatising disease leading to a patient feeling rejected and isolated. Support from trusted family members, friends or community NGOs will help to alleviate this so it is important to discuss who the patient feels will be able to fulfill this role. Offer to discuss the situation with people the patient trusts so that he/she has the opportunity to ask questions and understand the situation the patient is in.

learn more Read more: TBCTA (2006) Standard 9: Standards for Treatment
learn more Check your practice and reflect
nurse and patient outside
Assessing the patient’s knowledge and understanding of TB (click to view)
The successful treatment of the patient requires that the patient understands what is happening. Each patient will have a different level of knowledge and understanding about TB, depending on what they have already heard and whether they have known someone who has had the disease. It is important to find out what they know so that they can be given the information they need, correcting misconceptions and concentrating on the areas they are most concerned about. The patient and, if possible, at least one member of the family or a trusted friend, should clearly understand the answers to the following questions:
What is tuberculosis?
How is it treated?
How does the disease spread?
What measures can be taken to limit its spread?
The use of appropriate visual materials can be helpful, but should never replace one-to-one discussion, and the amount of information covered at any one time will depend on the individual patient’s needs and concerns.
tb
Continuing to build a good relationship (click to view)
Being diagnosed with TB can be a very traumatic event in a person's life and presents many challenges that they must cope with. A good relationship can be built by listening carefully to the patient. It is important at the beginning of treatment to create a time to counsel the patient regarding her/his disease, the prescribed treatment, and how the diagnosis and treatment may affect her/his lifestyle. This will encourage her/him to attend for treatment and follow-up visits. If a patient feels that staff are rude or too busy to care, s/he is less likely to want to come back. Spending time with a patient early on can save time in the long run by preventing irregular attendance, default, treatment failure and prolonged treatment.
Pointers for good communication
• Listen carefully
• Use open questions, e.g., those starting with “what”, “how”, “why”, etc., to encourage fuller responses
• Think about it from the patient’s point of view
• Hear and respect patients’ beliefs, values, customs and habits
• Work together with the patient as an equal partner
• Smile and look at the patient when they are speaking and when you are talking to them
• Check with the patient that you understand by repeating back a summary of what he or she has told you
• Take a long term view
• Use touch (e.g., squeezing or shaking the hand) if appropriate to reassure and show support
 
Audit your practice
Action Plan

Do you have the resources required for best practice?

Best Practice Requirement

Your Current Practice

Identify gaps in your practice

In places where the bulk of patients tend to go to one large well-known TB centre, a system should be in place for those diagnosed with the disease, to be offered a choice of management unit to attend for ongoing care. They should then be referred to this management unit to be registered and commenced on treatment. The referral system should be monitored by the Regional Coordinator to make sure that the people referred arrive and are registered at the appropriate management unit.

Treatment cards and TB registers must be available and the health-care worker should have the knowledge to complete them clearly, promptly and accurately.

Good communication skills are needed to:
- assess patients’ existing knowledge about TB and its treatment;
- give accurate information according to their needs and understanding;
- show that the service cares about them;
- encourage them to return to the clinic as arranged.

Health-care workers responsible for diagnosing TB are competent to choose and record the correct treatment category and commence the appropriate treatment regimen.

The health-care worker has sufficient knowledge about the disease and its treatment to assess the level of information required by the patient and respond to their questions accurately.

Health-care workers have access to appropriate reference literature regarding TB and its management.

Supporting information is available in leaflet form in the appropriate languages, which can be given to the patient to reinforce the main messages.

There is someone available if the patient has a problem and needs advice and the patient has clear details as to how to get help if they need it.

 

 

Check your practice

Question for your practice

Your answer

Does your unit include patients who have to travel long distances for treatment?

Can these patients visit a clinic or unit that is near where they live?

Do you identify an appropriate unit for your patients when they are first diagnosed?

Are you able to link with facilities and units local for your patients, to register your patients for care with them?

Can you provide training for staff in other units, who may look after your patients?

Does your unit have a provision to record treatment details of patients referred to other units for treatment?

Are their systems in place that can help you follow-up and check how your patients are doing in the other unit?

 

If you are unable to identify an appropriate management unit and enable follow-up for your patients, plan your steps to improve your practice here.

These questions will help you develop your action plan

Do patients need alternatives to attending your facility for treatment?

What alternatives can you offer?

If you are unable to identify an appropriate management unit and enable follow-up for your patients in a facility other than your own what steps can you take to address this situation?

Who do you need to work with to achieve this?

How will you ensure the patient receives the care they need once you have referred them?

 
Patients will be accurately registered at an appropriate management unit and all information including results will be correctly entered in the treatment card and TB register. Patients will understand their condition, its treatment and where they can go to if they need help. The initial assessment will provide the basis for a patient-centred plan of care, which will be minimise barriers to treatment, including the selection of the best “TB treatment facility” where DOT will be performed. The success of this standard can be measured by comparing the information in the TB register with the information on the treatment card and laboratory register; default rates in the intensive phase; and direct feedback from patients.

Use the following box to develop an action plan on how you will improve your practice with regards
to recording your patients results, treatment and informing them of their diagnosis

Things you will change when explaining to the patient what is their TB result

Things you will change about the way you record TB results and treatment

Things you will change about how others in your team collect, record and follow up patients diagnoses and treatments

List yours and others training needs and identify how you will address them to enable best practice during recording diagnosis, treatment and giving TB results to patients

 


Please print this form and begin developing your practice

 

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