TB Patient Referrals From Hospitals To Clinics
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1 TB Patient Referrals From Hospitals To Clinics A Study at CH Baragwanath Hospital ME Edginton and Colleagues School of Public Health University of the Witwatersrand
2 The Weakest or Missing Link.?
3 The Continuum of Care Patient with suspected TB DIAGNOSIS Private HS Clinic Prov Hospital TREATMENT Clinic TB hospital
4 CH Baragwanath hospital
5 Baragwanath Hospital Largest in the world Almost 3000 beds Staff of 5000 Medical admissions over 3000 per month Serves the surrounding community in Soweto (about 2 million) and referrals from other level hospitals
6
7 Processes for TB Patients Drs complete notification & transfer form (referrals to local clinic) Notification office clerk collated forms Collected by local authority Patient education limited by time, skills, knowledge of staff and by patient capacity to absorb information
8 How Many Patients With TB?* Methods: Identify and document all diagnosed TB patients Medical and paediatric wards and OPDs 8-week period late 2001 * routinely measured only by notifications
9 Results 1291 patients (167 per week) 19% & 18% of all medcal & paediatric admissions respectively Three quarters were medical inpatients Mean and median age 32 and 33 years
10 More Results Source of patients 46% self-referrals (not from other health services) 29% referred from clinics in Soweto 15% from private drs 9% from other clinics, TB hospitals and prisons
11 Clinical Disease Pulmonary TB - 74% of adults HIV 76% tested 80% of those were positive
12 Outcome of Hospital Attendance Death in hospital 190 (19%) almost 20% of all adult medical deaths Referral to: TB hospital 209 (21%) Hospice/rehab. 12 (1%) Clinics outside Soweto 152 (15%) Soweto clinics 443 (44%)
13 Notification Process 31% not entered into hospital notification records No deaths notified Significance: *30% under-estimate of TB numbers *No copy of the transfer form for action for nonattenders at referral clinics
14 What Happened to Patients Referred to Soweto Clinics? Methods: Computer data system listed patients due at clinics Researchers visited clinics to check registers (and cards) Time allowed for attendance Other clinics checked
15 Results of 443 Patients Referred 25 known deaths 11 readmitted 407 expected at clinics
16 Attendance at Clinics 50% (203) within 2 weeks X X 29% (117) late - 64 after 3 wks - 53 after 4 wks 21% (87) never attended
17 Analysis Statistical relationship between late or no attendance and stated previous problems at clinics No association between attendance and stated knowledge about TB treatment duration of admission
18 Identifying and Interviewing Non-attenders Visits to addresses and neighbours 50 not found 37 found 19 Did not know about further treatment 12 Too sick to attend 6 Miscellanous reasons
19 Three Justifications for Action The size of the problem Education to patients at home visits had positive results ( 23 of the 37 subsequently attended a clinic) Pilot study with education and referral before hospital discharge proved that 81% of 48 patients attended
20 A System of TB Patient Care The TB Care Centre established by hospital management, clinicians and public health drs Supported by district authorities (LA and province)
21 Information, Education, Counselling, Discussion to ensure that patients reach facilities for their TB treatment
22 Documentation To ensure a complete and accurate record of each patient Notification Transfer forms TB register Electronic register (case finding)
23 Centre Staff Four professional nurses See patients for discharge at Centre Visit patients for transfer to TB hospitals in wards Two clerks Two doctors (director & public health registrar)
24 Results: From 12 Weeks of Operation 1675 patients with TB documented 1392 seen (25 per day) 298 deaths recorded (18% of total) Outcomes 981 (70%) referred to clinics 314 (23%) referred to TB hospitals 97 ( 7%) other places
25 Centre Evaluation For 949 patients referred to clinics in Jhb Metro district 85% attended the clinic to which they were referred All 1675 patients registered and notified in hospital database
26 Possible Model for Other Provincial Hospitals Scaled according to need and resources
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