GUIDELINES & TOOLS for HOSPITAL DOTS LINKAGE (HDL)

TBCAP project C3 APA2 PPM Sub-group meeting, Cairo Jan Voskens 1

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Challenges to DOTS in hospitals

• Inadequate clinical management practices – no standardized protocols for diagnosis and treatment of TB – poor case holding and high rates of default • lack of resources and linkages • user fees • multiple services: TB suspects and TB patients identified in different units Risk for amplification of MDR !!

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Definition Hospital DOTS Linkage HDL

building a network between public and private clinical care facilities, (including primary, secondary and tertiary hospitals, academic hospitals and charity/ NGO hospitals ) and the national DOTS program

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Overall objectives

1. Ensure access to quality DOTS services for TB patients seeking care within the hospital sector based on International Standards of Tuberculosis Care (ISTC).

2. Enable hospitals (public and private, governmental and non-governmental) to implement TB control activities that are linked to the NTP 5

Specific objectives

1. ISTC endorsed and implemented by public and private hospital providers 2. Decreased diagnostic delays and cost savings to patients 3. Effective referral mechanism established 4. Improved monitoring of treatment and treatment outcomes for patients diagnosed in hospitals 5. Improved hospital laboratory quality assurance 6. Enhanced surveillance to measure performance 6

HDL Framework

Government NTP Partners Local Stop TB Partnership

Professional Organisations Health Office COORDINATING BODY : HDL team Providers: Private, NGO’s,etc

Districts

Health Centers pp pp pp pp pp

Hospitals 7

Steps for HDL

I.

II.

Planning Implement the external network III. Implement the internal network IV. Monitoring and evaluation 8

I. role of the central level

• determine overall policy direction (i.e. national guidelines and standards) • formulate regulatory frameworks (certification)

Steps:

• establish coordination of stakeholders: public-, private, NGO, medical schools, professional societies etc • build commitment among decision makers • develop implementation plan including – human resource development – enablers – monitoring and evaluation • mobilize resources • monitor and evaluate 9

enablers

• Free anti-TB medications • Training and in-service updates for staffs • Commodities supplied: surveillance, IEC materials, diagnostic supplies and equipment • Logistical support for laboratory EQA network • Corporate social responsibility to participate in NTP • Certification and accreditation 10

II. Steps to build HDL external Network

• Advocate and mobilize resources • Establish local coordinating body for HDL • Define

Terms of Reference

collaborations (MoU) for interagency • Carry out baseline assessment of facilities • Develop implementation plan including – HRD – Establishing referral system – Supervision and problem solving support 11

COMPONENT TOOLS FOR IMPLEMENTING HDL Advocacy Planning and Implemen tation

      

Human resource development



Monitoring and evaluation

        National TB Program policy on HDL, endorsed by MOH ISTC Memorandum of Understanding, Terms of Reference Hospital directive Baseline assessment tool Hospital Implementation Plan Referral mechanism Adapted NTP modules and training curricula (SOP, TB/HIV coordination, laboratory EQA) Training of trainer modules Job description for HDL coordinator and hospital DOTS team Standard operating procedures (SOP) NTP data recording and reporting forms for case management Modified patient treatment card to include information on place of diagnosis (i.e. referred from where?) Referral registry / defaulter tracing registry / electronic referral Supervision checklist Guidelines and formats for accreditation and certification 12

Referral system for patients diagnosed in hospitals

•

Develop SOP for patient referral

•

Appoint ‘’referral coordinator’’

•

implement tools:

–

Patient referral

– and

Referral feedback forms

– –

Patient referral register/log

kept by

referral coordinator

–

Default tracing form and Default tracing register/log

–

Telephone directory

of surrounding health facilities 13

Generic referral mechanism

Notification of referral Feed back of information Referral Coordinator Referral register SMS, phone Phone directory Referring hospital ‘A’ Receiving Health facility ‘B’

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Indicators:

1. Confirmed sputum diagnosis rate

: No. pts. diagnosed in hospital with smear confirmation No. of patients diagnosed by hospital X 100 %

2. Successful referral rate

: No. of patients received at DOTS center X 100 % No. of patients referred by hospitals

3. Successful referral tracing rate

: No. of patients retrieved for treatment No. of patients that dropped out after referral X 100 % • • • •

Other useful indicators:

Treatment outcomes of referred patients (compared to not referred pts) Referral coordinator appointed and in place Percentage of hospitals implementing SOP for patient referral

III. Steps to build HDL Internal Network (a)

• • •

Baseline assessment and planning of Internal Network

–

Assess existing hospital practices and give feedback

– –

Development of a specified HDL task mix hospital implementation plan

Sensitization and advocacy

–

Create hospital task force or DOTS committee

–

hospital directive

hospital

MOU

and/or district or local NTP-

Establish Hospital DOTS Unit

executive room) (DOTS 16

PATIENT Community

Others Health Centre

Internal network

GENERAL CLINICS and WARDS SPECIALIZED CLINICS and WARDS incl VCT/ART EMERGENCY ROOM LABORATORY RADIOLOGY PATHOLOGY

Hospital DOTS UNIT & DOTS team

PHARMACY MEDICAL RECORD HOSPITAL IEC OTHER (i.e. SOCIAL SERVICES) 17

Steps to build HDL Internal Network (b)

• Define SOP for – TB case management (diagnosis / treatment) – Patient referral • Internal (within facility) • External (to local TB treatment centers) • Develop HRD plan (based on selected task mix and SOP) • Integrate hospital laboratory into the EQA network of the NTP • Ensure proper surveillance and supervision 18

TASKS Clinical functions

Identify TB suspects Do smear microscopy/ culture per NTP guidelines) Diagnose TB Prescribe treatment Refer diagnosed patient to health center Supervise treatment or assign treatment observer Clinical follow-up

Public health functions

Recording and reporting of cases Follow-up on defaulters Training to hospital staff Supervision of networks Laboratory EQA Monitoring and evaluation

Option 1 Option 2 Option 3 Option 4 Public health functions of options 3 and 4 are variable and are normally context –specific

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Scaling up

• Phased wise expansion • Supervision: monitor hospital performance continuously

to assure QUALITY !!!

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Thank you!

Your comments and inputs on this draft are most welcome 21