Tuberculosis - RNOH/GIRFT review: national report

6 Summary of Recommendations

Please note that all the recommendations in this report are listed in this section for your reference. We have identified who we think should have responsibility for implementation of each recommendation using the key below.

Key

P: Provider (TB Service)

HB: Health Boards (Territorial)

N: National (This applies to the various national organisations involved in supporting TB services, including the Scottish Government, Public Health Scotland, and other Special Health Boards. Bodies responsible for implementing these recommendations will be identified during the implementation process).

Table 1: All Recommendations by Section

Recommendations: Epidemiology

1. Continued entry of information into surveillance systems is important to support planning for future services and understand local and national epidemiology. Administrative support is required to enable timely and complete data entry.

P, HB

Recommendations: Workforce Issues in the Management of Tuberculosis

2. TB clinicians and teams should be encouraged and supported to participate in research and other academic activities which include teaching (as in workforce specific sections) production of guidelines etc.

P, HB, N

Recommendations: Medical Workforce

3. Each TB service should have a recognised lead who is named, with responsibility for maintaining policies and overseeing Health Board education. This is dedicated lead SPA time and is generally the same for most services as even those with few notifications still need to deliver these general aspects of the TB service.

P, HB

4. The clinical lead should deliver all, or the bulk of TB medical care and should have sufficient DCC time in their job plan for this to take place.

P, HB

5. Depending on the size of the service, time for a clinical deputy and/or support needs to be included. There are advantages of this being from a different speciality, especially in managing co-infection with HIV.

P, HB

6. In all job plans, appropriate SPA time for providing education and self-continuing professional development (CPD) should be included together with DCC time for service delivery. This should include, not only clinic activity, but time for regular local and Health Board or National MDTs and clinical administration.

P, HB

7. Cohort reviews should be re-established with time in job plans to attend, with the lead clinician acting as a reviewer for other Health Boards. To support data collection for such reviews, there needs to be administrative time, and such reviews should be a feature of job plans for all individuals i.e. medical, nursing, pharmacist. A formal report with actions should be generated, hence the need for administrative time.

P, HB

8. For some services such as CYP, non-tuberculous mycobacteria, where there may be a Health Board or National lead role, time needs to be allocated in the individual Lead’s job plan for this work. Such networks need to be agreed and funded at Health Board or at National level.

P, HB

Recommendations: Nursing Workforce

9. Services should review their nursing workforce to ensure they are not doing tasks which could be done by lower banded staff i.e. ensuring senior qualified staff are working at ‘top of licence’.

P, HB

10. There are excellent examples of nurses where they run their own clinics and prescribe and request radiographs. These nursing options should be explored in each TB service.

P, HB

11. There should be sufficient senior nursing time to manage the TB service.

P, HB

12. All nurses, as part of their re-validation process, should ensure they are up to date with current TB practices and where training is required should have access to funds for such education, at whatever level is appropriate.

P, HB

Recommendations: Admin and clerical workforce

13. On a pro rata basis, Admin & Clerical support at Band 3 or Band 4 should be available in a dedicated role to support the TB service, acting as the focus for the service. This role would develop reports, collate information for MDTs and cohort reviews and facilitate data entry and general communication, informing all parties involved in TB care of decisions and outcomes.

P, HB

Recommendations: Policy

14. Regular meetings between management in acute providers, which would also include Health Protection, Public Health and the Health Board, are an important way of maintaining the profile and supporting funding. Based upon the number of notifications and preventative therapy, these meetings should take place at least on a quarterly basis.

P, HB

15. TB services should meet internally with their management team to discuss practical service delivery issues, the frequency dictated by activity. This time should be built into job plans.

P, HB

Recommendations: Data Management

16. National Services Scotland should consider the development of other data platforms, which would be helpful for in patient management and communication and would feed into national surveillance databases.

N

17. Inputting data into such databases is an essential part of surveillance work and this needs to be appropriately resourced with administrative staff, of which there seems to be few in Scotland, as noted in the workforce section 7. This needs to be reviewed and properly resourced for each service, noting the benefits of accurate data entry and freeing up clinical staff.

P, HB

18. Development of TB Service Analysis Reports, which can influence and support TB development at Health Board level, should be considered and developed by all TB services for Health Board level use.

P, HB

Recommendations: Diagnostics

19. Services should have both protocols and the option for negative pressure facilities if they feel induced sputum is a technique they wish to use for obtaining respiratory samples.

P, HB

20. All IGRA results (or just positives, depending on the service) should be notified to the TB lead, with the opportunity to ensure no positives are missed. This also gives an opportunity, working with pathology, to ensure there are not excessive and inappropriate requests from some speciality services.

P, HB

21. Discussion between speciality services requesting IGRA and pathology departments should take place to ensure appropriate funding.

P, HB

Recommendations: Outpatient settings

22. Ideally nurses and medical staff should run joint clinics, with nurses also having their own nurse-led clinics. For CYP services, nursing time should be made available.

P, HB

23. Infrastructure needs to be in place for efficient running of clinics which includes ready access to clinic rooms when needed, supported by clinic booking staff or ideally TB administration staff to contact the patient.

P, HB

24. Phlebotomy services in clinics should be available without the need for qualified nursing staff to be involved.

P, HB

25. For patients living at a distance from the TB service, alternative models of Liver Function Tests (LFT) surveillance should be explored.

P, HB

26. Infection prevention issues should be explored for Outpatient Departments (OPDs) in all TB services to minimise the risk to all parties. This should include a clear understanding of clinic air exchanges per hour and mitigation of potential risks, documented in a formal protocol or SOP. The output from the review above will help inform discussion.

P, HB

27. To understand clinic activity and the procedures undertaken, data collection should be considered at a national level, possibly linked to a payment process.

P, HB, N

Recommendations: Inpatient activity

28. Clinical teams should review the patient discharge letters to ensure they are accurate and where relevant discuss with the coding team to ensure that patients are correctly coded.

P, HB

29. Clinical teams and Health Boards should review the reasons why some patients have a long length of stay, defined as beyond 28 days, to address remediable factors. Such patients should be discussed at cohort reviews.

P, HB

30. All patients with tuberculosis need to be under a named TB physician if either outpatient or in patient, recognising TB patients may be admitted for other reasons. On such occasions the TB physician should be informed the patient is admitted, review them as an inpatient and provide ongoing advice.

P, HB

31. Patients admitted with proven TB should be reviewed by a TB nurse during their inpatient stay and ideally an interested pharmacist should review medication during the patients stay and /or prior to discharge.

P, HB

Recommendations: Delays in management

32. For individuals, where there are significant delays in both symptom onset to clinical review, and to treatment, a detailed review of the reasons should be undertaken and modifications to the service made to address the issues. These notifications should also be included in cohort reviews.

P, HB

33. Clear policies for managing TB should exist within the Health Board and acute providers, supported by regular multi-professional managerial meetings.

P, HB

34. There should be regular updates for primary care staff, at least bi-annually to general practitioners and primary care staff as part of their formal CPD program.

P, HB

35. The updates to Health Protection staff, as part of their training, as noted in the good practice should continue.

P, HB

36. Awareness of TB in the acute provider is essential in identifying patients promptly and therefore there should be at least an annual grand-round, or equivalent, in the acute provider with specific bi-annual education to staff in the acute portals.

P, HB,

Recommendations: DOT and VOT

37. A standardised tool to assess who would benefit from ECM should be used. This will allow consistency if patients move to different Health Boards’ TB services.

P, HB

38. DOT: Where DOT is required, appropriate staffing needs to be available i.e. using potentially lower banded staff. A risk assessment should always be performed to determine the number of staff required.

P, HB

39. DOT: Community pharmacists, who are appropriately reimbursed are an alternative source of staff, where staffing or travel times limit nurse delivered DOT.

P, HB, N

40. VOT: A platform should be available throughout Scotland to allow VOT to be delivered. This needs appropriate governance, and must be effective and easy to use for both patients and clinical staff.

N

41. VOT: VOT seems to have a low use despite its potential advantages in rural areas of minimising staff travel. This may relate to the patient case-mix, lack of staff or availability of infrastructure or a platform. Each service should consider the benefits of VOTs when appropriately supported.

P, HB

Recommendations: Treatment

42. All services should strive to achieve 12-month treatment outcomes of 'Treatment Success' for over 85% of culture-confirmed pulmonary tuberculosis cases and where they fail to do so, a root cause analysis as part of a cohort review, should take place.

P, HB

43. Patients on treatment for TB (and those receiving preventative therapy) require ongoing support that is tailored to them. This should include information in different formats (written, spoken) and different languages.

P, HB,N

Recommendations: Medicines Management

44. All services should have a robust prescribing system to minimise drug errors,

P, HB

45. Pharmacist and pharmacy technician time is essential in TB services, providing advice, support to clinicians and patients, tracking medication use and advising around drug shortages. Attendance at TB MDTs and cohort reviews should be part of their job plan. Staff of appropriate seniority and experience / knowledge should support the service on a pro rata basis, depending upon the size of the service. All services should review their pharmacy infrastructure and support as needed.

P, HB

46. Consider the setting up of a ‘Scottish pharmacy network’ to support TB, including CYP, and NTM, providing advice and support for the use of less commonly prescribed drugs, potential interactions when patients are taking anti TB drugs for long periods and to help manage TB drug shortages.

P, HB, N

Recommendations: NTM

47.

Infrastructure should be developed to comply with the national NTM guidelines.

P, HB

48. Services should be developing a business case, as noted above, to support these patients.

P, HB

49. A funded national NTM advice service which is multi-professional and includes pharmacist and administration time should be developed with a fortnightly MDT that individuals can refer into along the lines of the BTS MDR service.

N

Recommendation: Inclusion health

50. It is important to acknowledge the changing epidemiology and patient groups who will have issues of inclusion health, especially around substance misuse and homelessness. Services need to be in place to address these social risk factors.

P, HB

Recommendations: CYP

51. Health Boards should recognise the need for appropriate staff numbers, with time in their job plans, and access to training for managing CYP TB and any associated preventative treatments that occur after contact tracing.

P, HB

52. A multi-professional Scotland CYP TB network needs to be established and funded.

P, HB, N

53. If Scottish Government decides to develop a preventive strategy for latent TB, a specific infrastructure needs to be in place for CYP and unaccompanied adults.

N

Recommendations: Preventative strategies

54. A formal preventative strategy needs to be developed for Scotland, encompassing all groups who may be eligible, but also recognising that some populations may have more numbers identified from a screening exercise and some may have a greater benefit from preventative therapy.

N

55. There is wide variation in the practice of initiating and reviewing treatment for latent TB, including checking liver function and the nature of any follow up. NHS Health Board TB Services should develop a more uniform practice based on best evidence.

N

Recommendations: Contact Tracing

56. There is an element of inconsistency regarding who is screened in pulmonary and extra-pulmonary disease, which reflects a lack of current guidance. A standardised approach, based on best practice, may be helpful in maximising the use of resources.

P, N

57. Services should look to identify 5 or more contacts per index case with active disease, which most services appear to be doing already. However, there is wide variation in the number of individuals screened, which merits a review by the service and a discussion during cohort reviews.

P, HB

58. The reasons for variation in self-reported attendance of individuals for screening needs to be explored by each service. To address low attendance rates. Services should seek to learn from colleagues who have better attendances.

P, HB

59. Services should explore why there is variation between the identification of individuals who should start preventative treatment, and those who appear not to do so, or fail to complete treatment. Some of this may relate to contact tracing procedures and support during therapy, as noted previously. Cohort reviews have a role here.

P, HB

Recommendations: BCG

60. BCG vaccination for neonates is an effective way of reducing the risk of developing TB, so a model that works for each service provider and Health Board is essential. With the potential for more babies to receive BCG, due to the evolving population, sufficient infrastructure needs to be in place. Health Boards need to keep the workload and delivery model under review.

P, HB

Recommendations: Occupational health screening

61. A robust screening process needs to be in place due to staff from high prevalence areas being recruited into delivering health care.

P, HB

62. There appears to be an increasing volume of work for occupational health services, for pathology services who perform the IGRA, and for TB services involved in delivering preventative therapies. This activity should be reviewed by Health Boards to ensure there is sufficient capacity to deliver a prompt service.

P, HB

63. Consideration needs to be given to screening for TB in other workers involved in health care beyond acute providers’ e.g. social care.

P, HB

Recommendations: Screening for biological therapies

64. There should be discussion between pathology departments and specialist services regarding the increasing cost burden of IGRA tests (As in the diagnostics section 8.3,) so this is managed appropriately within the Board/service.

P

65. TB services and pathology departments should be aware of the volume of requests for IGRA before biological therapies and to ensure current guidelines are followed, for example, that there are not unnecessary repeat tests requested.

P