GUIDELINES

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GUIDELINES TOOLS for HOSPITAL DOTS
LINKAGE(HDL)

• TBCAP project C3 APA2
• PPM 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

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

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

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HDL Framework
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Steps for HDL

• Planning
• Implement the external network
• Implement the internal network
• 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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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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Generic referral mechanism
Notification of referral
Feed back of information
Referral register
Referral Coordinator
Phone directory
SMS, phone
Receiving Health facility B
Referring hospital A
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Indicators

• Confirmed sputum diagnosis rate
• No. pts. diagnosed in hospital with smear
  confirmation X 100
• No. of patients diagnosed by
  hospital
• Successful referral rate
• No. of patients received at DOTS center X
  100
• No. of patients referred by hospitals
• 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
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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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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