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GUIDELINES & TOOLS

for HOSPITAL DOTS LINKAGE

(HDL)

TBCAP project C3 APA2PPM Sub-group meeting, Cairo

Jan Voskens

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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

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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

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HDL Framework

COORDINATINGBODY: :

HDL team

Local Stop TB PartnershipLocal Stop TB Partnership

GovernmentNTP

Partners

DistrictsDistricts

Health CentersHealth Centers

Hospitals

Health Office

Professional Organisations

Providers: Private, NGO’s,etc

pppp

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Steps for HDL

I. Planning

II. Implement the external network

III. Implement the internal network

IV. Monitoring and evaluation

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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

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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

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II. Steps to build HDLexternal Network

• Advocate and mobilize resources • Establish local coordinating body for HDL • Define Terms of Reference for interagency

collaborations (MoU) • Carry out baseline assessment of facilities• Develop implementation plan including

– HRD– Establishing referral system– Supervision and problem solving support

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COMPONENT TOOLS FOR IMPLEMENTING HDL

Advocacy National TB Program policy on HDL, endorsed by MOH ISTC Memorandum of Understanding, Terms of Reference Hospital directive

Planning and Implemen-tation

Baseline assessment tool Hospital Implementation Plan Referral mechanism

Human resource development

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)

Monitoring and evaluation

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

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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

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Referral Coordinator

Referring hospital ‘A’

Receiving Health facility ‘B’

Feed back of informationNotification of referral

Generic referral mechanism

SMS, phone

Referral register

Phone directory

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Indicators:1. Confirmed sputum diagnosis rate:

No. pts. diagnosed in hospital with smear confirmation X 100 %

No. of patients diagnosed by hospital

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 X 100 % No. of patients that dropped out after referral

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• Availability of telephone directory of facilities in cluster area (province, district)

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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 and/or district or local NTP-

hospital MOU

• Establish Hospital DOTS Unit (DOTS executive room)

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Internal network

PATIENT

EMERGENCY ROOM

SPECIALIZED CLINICS and

WARDS incl VCT/ART

GENERAL CLINICS and WARDS

Ho spital DOTS UNIT & DOTS

team

PATHOLOGY

LABORATORY

RADIOLOGY

HOSPITAL IEC

PHARMACY

MEDICAL RECORD

OTHER (i.e. SOCIAL SERVICES)

Community Others Health

Centre

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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

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TASKS Option 1 Option 2 Option 3 Option 4

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

Recording and reporting of cases

Follow-up on defaulters

Training to hospital staff

Supervision of networks

Laboratory EQA

Monitoring and evaluation

Clinical functions

Public health functions

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