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

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 !!

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

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

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

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

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

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

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

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

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

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

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’

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)

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)

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

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

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

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

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