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
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
Government
NTP
Partners
Local Stop TB Partnership
Health
Providers:
Office
Professional
Private,
Organisations COORDINATING NGO’s,etc
BODY:
HDL team
Districts
pp
pp
pp
Hospitals
pp
pp
Health Centers
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Steps for HDL
I.
II.
III.
IV.
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 HDL
external 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  Baseline assessment tool
 Hospital Implementation Plan
Implemen Referral mechanism
tation
 Adapted NTP modules and training curricula (SOP, TB/HIV
Human
coordination, laboratory EQA)
resource
development  Training of trainer modules
Monitoring
and
evaluation


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



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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
Coordinator
SMS,
phone
Referring hospital
‘A’
Referral
register
Phone
directory
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
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 NTPhospital MOU
• Establish Hospital DOTS Unit (DOTS
executive room)
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Internal network
GENERAL
CLINICS and
WARDS
PATIENT
SPECIALIZED
CLINICS and
WARDS incl VCT/ART
LABORATORY
EMERGENCY
ROOM
PATHOLOGY
RADIOLOGY
Hospital DOTS
UNIT & DOTS
team
PHARMACY
MEDICAL RECORD
HOSPITAL IEC
Community
Others Health
Centre
OTHER (i.e. SOCIAL
SERVICES)
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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
Clinical functions
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
Public health functions
Recording and reporting of cases
Follow-up on defaulters
Training to hospital staff
Supervision of networks
Laboratory EQA
Monitoring and evaluation
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
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