Reducing patient waiting time to

initiate tuberculosis treatment at Gulu

Regional Referral Hospital Sr Louise Angee

Dr Sheila Baingana

Dr Yoventino Agel

Gulu Regional Referral Hospital

Dr Christine Nalwadda

Makerere University College of Health Sciences,Institute of Public Health

Dissemination Workshop

20th August 2010

20/08/2010 GRRH

Introduction

Uganda is among the 22 tuberculosis high burden countries.

Annual incidence is 402/100,000 and

mortality 92/100,000. There has been a 10% annual increase in cases since 1995. TB/HIV coinfection ranges from 40-70%.

At Gulu Regional Referral Hospital 150-

200 tuberculosis patients are recruited every quarter. 23.9% completed treatment, 44.4% were transferred to other treatment centers, 28.2% defaulted, and 2.1% died in 1st quarter 2006.(NTLP 2006)

Problem specification

Through brainstorming, theme selection and multivoting, long waiting time had significant impact on quality of TB service provision at the hospital.

Data from outpatients at the TB ward was collected to quantify the problem. 95 patients over 10 days were reviewed.

Waiting times of patients reviewed at

TB ward 3-4/09/2008

0

20

40

60

80

100

120

0-20min 21-40min 41-60min 61-80min

Cum%

Patient no

Problem Statement

Over 50% of patients reviewed at Gulu TB Ward clinic in September 2008 have a waiting of over 40 minutes at each visit and 7 days from TB suspect to treatment initiation.

This is short of a target of 30 minutes and 5 days from suspect to diagnosis.

This results in patient dissatisfaction with the services, missed diagnoses, prolongation of infectiousness and the likelihood of default from treatment.

Justification

The causes of prolonged waiting time through fishbone analysis were found to be

• Inadequate planning for TB service provision

• staff and referring units not motivated and trained to refer and manage patients correctly

• Delays in having xrays and laboratory investigations done.

• Inadequate strategy to sustain interventions in TB control.

The countermeasures were feasible and effective and would result in earlier, accurate and patient friendly tuberculosis treatment initiation, adherence to treatment and better outcomes.

These formed the basis of project objectives.

LONG WAITING

TIME

Staff few

Not motivated

Not traied

Incorrectly

diagnosed

referrals

Difficulties in

getting xrays

Laboratory

delays

Inadequate

strategy to sustain

changes

Planning for TB

with Hospital

admiistration

Hospital CME

Training in TB

diagnosis and HIV

integrative

activities

Arrange transport to

Lacor Hospital

Rennovate laboratory

Integrate TB/HIV control

Project Objectives

To enhance planning for TB/HIV diagnosis and control at Gulu Regional Referral Hospital.

To train staff in effective diagnosis and management of tuberculosis.

To improve effeciency of tuberculosis referral and diagnosis at Gulu Hospital.

To sustain effect of interventions.

Project Activities

Objective Activities

1. To enhance planning with

the hospital administration for tuberculosis diagnosis management and control.

1.Meetings held with the medical superitendent and PNO to sensitise about project for allocation of staff and planning for xray transport,laboratory and workshops

2.Staff rotated to TB ward, CMEssessios ongoing

2.To train hospital and referring staff in TB diagnosis and management.

2 workshops on TB diagnosis and management and TB/HIV integrative activities held.

3. To improve efficiency of tuberculosis referral and diagnosis.

1.Regular transport planned and made operational

Portable xray begins function in April 2009

Project Activities

Objective Activity

2. Medical side laboratory planned for and incorporated into the on-going hospital renovation

4. To sustain effect of interventions

1.Tuberculosis meetings to be incorporated once a month with the VCT clinic meetings.

2.Dissemination to hospital and Faculty of Medicine planned.

3.Collaborative TB/HIV control team with TASO, Faculty of Medicine, Lacor Hospital, Infectious diseases Institute and NUMAT.

Project Outcomes

3 meetings held with administration. Arranged for staff allocation CME, workshops, transport, laboratory.

Staff rotated to TB ward.1 transferred out.

CMEs initiated, 3 sessions held, schedule made.

2 workshops held July 2009 for referring staff and Hospital staff-TB diagnosis and TB/HIV integrative activities.

Project Outcomes

Transport to Lacor Hospital for xrays till xray operational in 04/2009.

Laboratory on medical ward rennovated and operational:- mainly RCT performed

Procurement of computor for data storage in completion.

TB/HIV control integrated with GRRH and

Gulu University, Faculty of Medicine, TASO, Lacor Hospital, NUMAT, district NTLP Infectious Diseases Institute collaboration.

Evaluation

Waiting time before and after

project activities

0

10

20

30

40

50

0-20min 21-

40min

41-

60min

61-

80min

81-

100min

Before

After

Cumulative frequencies of waiting time

0

50

100

0-

20min

21-

40min

41-

60min

61-

80min

81-100

Before

Before

After

Lessons learnt

A team is able to plan and achieve objectives.

The hospital administration and other stakeholders are supportive to clearly set initiatives and targets.

Early notification to streamline activities is required.

Team motivation and focus can be supported by required reports and feedback from supervisors.

Funding not prerequisite for all activities

Ongoing planning required to sustain focus and integrate developments.

Challenges

Two fellows, team members have multiple roles. 1 member away 2 months leading to delay in time frame.

Irregular supply of anti TB drugs in the last 2 months, increasing workload of Sr Louise and delayed evaluation.

To maintain focus and action with multiple priorities.

Next Steps

To sustain monthly meetings to identify ad resolve other problems

To increase proportion of TB patients who have RCT to over 80% from abase line of <50%

To describe the locality of patients and the feasibility of community follow-up for vulnerable patients.

To sustain TB control in collaboration with Faculty of Medicine, NTLP team, Lacor Hospital, TASO and other stakeholders in area.

Acknowledgements

Our supervisors Dr Nalwadda Mr Buga and Mr Joseph Matovu.

NTLP Team Gulu, NUMAT, for support especially in the workshops, records and drug supply.

VCT Clinic, Faculty of Medicine for internet access.

IPH/CDC for funding.

GRRH for cooperation all phases.

Thank you