Uganda is among 22 countries identified by the World Health Organization (WHO) as having a high burden of tuberculosis (TB). At Gulu Regional Referral Hospital (RRH) in Northern Uganda, an average of 80 patients every quarter are diagnosed with active TB. These clients are then initiated on an eight-month TB treatment course, as per Ugandan national guidelines. Although the national target for completion of TB treatment is 85%, quarterly completion rates from January to September 2011 at Gulu RRH ranged from 18.3% to 27.7%.
Several factors contributed to the poor outcomes in reaching the national target for completion of TB treatment. The TB clinic, staffed primarily by nurses and nursing assistants, was operating as a stand-alone unit within the hospital and had minimal clinical-decision support. There was no linkage between the TB clinic and the Infectious Disease Clinic (IDC) providing chronic care services to HIV-positive clients, and links to the district health team and medical ward were limited to drug supply and occasional supportive supervision. In addition to the human resource limitations, the patient information recorded in the Ministry of Health (MOH) patient management information system, including the TB registries and patient-held cards, was often inaccurate or incomplete. Patient information systems also lacked contact information for proactive client follow-up, and the clinic had no mechanisms in place for tracking clients who failed to return for routine clinical review and prescription refills of anti-TB drugs.
With support from the Strengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN) project, the health workers at Gulu RRH identified and initiated a package of interventions in October 2011 to improve the quality of care for clients with TB and to increase treatment completion rates.
Established a focal TB care team: Clinicians from the IDC and the TB care team (predominately nurses and nursing assistants) agreed to work together to enhance decision support for TB care and management of TB-HIV coinfected patients. The clinicians from IDC rotated to the TB clinic and medical wards to routinely review TB clients and provide mentoring and supportive supervision to the TB care team.
Improved Data Management and Review: The TB care team participated in monthly review of TB data and reported TB indices during performance review meetings.
Established Proactive Client Follow-up and Transfer: Mechanisms were established for active client follow-up, including: introduction of patient mapping and appointment registries; recording of client contact information when available; and follow-up by phone and home visits. The hospital Community Health Department (CHD) and TB care teams are jointly responsible for coordinating follow-up efforts. To increase accessibility of services, TB clients whose conditions have stabilized are transferred to lower-level healthcare facilities for follow-up appointments and prescription refills.
Built Capacity: Hospital-based continuing medical education sessions, as well as training in Integrated Management of Adult and Adolescent Illness (IMAI) and TB-HIV comanagement, were conduced to enhance staff skills.
Improved Collaboration for HIV and TB Services: Appointments were coordinated for clients with TB and HIV coinfection. The hospital management plans to establish a chronic care clinic to further improve linkages between the HIV and TB clinics; this clinic, which will require improved infrastructure for infection control, will be completed next year.
TB treatment completion rates improved from 27.7% in July to September 2011 to 54.3% in October to December 2011 following the intervention. Despite national stock-outs of TB medicines, a completion rate of 51% was maintained in January to March 2012. Further improvements were noted in April to June 2012, with a treatment completion rate of 64%.
Figure 1: Quarterly TB Treatment Completion Rates at Gulu Regional Referral Hospital, January 2011 to June 2012
Establishment of a focal TB care team, including clinicians and nurses, greatly improved documentation and quality of care and provides a foundation for future TB-HIV collaborative activities.
- Monthly review of patient management data not only informs quality improvement efforts but also improves quality of documentation.
- Training of providers enhanced the implementation of the other interventions, ensuring that healthcare workers had the requisite skills to provide quality care.
- Formal integration of TB-HIV activities strengthens all TB-HIV collaborative interventions.
- Community linkages efforts play a central role in attaining desired TB treatment success targets.
Overall, the provision of decision support for TB care, proactive TB patient follow up, and improved documentation significantly increases TB treatment completion rates.