1. GUIDELINES & TOOLS for HOSPITAL DOTS LINKAGE (HDL)
TBCAP project C3 APA2
PPM Sub-group meeting, Cairo
Jan Voskens

3. 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 !!

4. 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

5. 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

6. 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

7. HDL Framework Hospitals GovernmentNTP Partners
COORDINATING
BODY: HDL team
Local Stop TB Partnership
GovernmentNTP
Partners
Districts
Health Centers
Hospitals
Health Office
Professional Organisations
Providers: Private, NGO’s,etc pp

8. Steps for HDL Planning Implement the external network
Implement the internal network
Monitoring and evaluation

9. 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

10. 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

11. 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

12. Planning and Implemen- tation
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

13. 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

14. 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’

15. Indicators: Confirmed sputum diagnosis rate: Successful referral 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)

16. 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)

17. Internal network PATIENT EMERGENCY ROOM SPECIALIZED CLINICS and
WARDS incl VCT/ART
GENERAL
WARDS Ho
spital DOTS
UNIT & DOTS
team
PATHOLOGY
LABORATORY
RADIOLOGY
HOSPITAL IEC
PHARMACY
MEDICAL RECORD
OTHER (i.e. SOCIAL
SERVICES)
Community
Others Health
Centre

18. 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

19. Public health functions of options 3 and 4 are variable
and are normally context –specific

20. Scaling up to assure QUALITY !!! Phased wise expansion
Supervision: monitor hospital performance continuously
to assure
QUALITY !!!

21. Thank you! Your comments and inputs on this draft are most welcome