3. Clinical Services
3.1 Clinical services relate to the treatment, care and management at an individual level of those infected with TB. This relates to the critical role of TB clinicians (whatever clinical speciality) and TB specialist nurses but also to those who contribute to the management of patients through associated services.
3.2 Clinical care of patients with TB can increasingly involve management of complex issues such as treatment of drug resistant strains of the bacteria or clinical care for those co-infected with HIV or with other serious co-morbidities.
3.3 The Scottish Health Protection Network guidance Tuberculosis: Clinical diagnosis and management of tuberculosis, and measures for its prevention and control in Scotland, published in 2009, underpins approaches to clinical management of TB patients in Scotland. The document is available at: http://www.documents.hps.scot.nhs.uk/about-hps/hpn/tuberculosis-guidelines.pdf
3.4 The Clinical Services Subgroup considered a range of current issues in respect of treatment, care and management of patients, and provided advice to the TB Action Plan Working Group.
3.5 The incidence of TB varies across Scotland. In NHS Boards that have fewer cases of TB there has to date often been less of a clear focus on TB, both clinically and organisationally, than has occurred in some of the larger cosmopolitan Boards. However, it is vital to ensure that the quality of care that is delivered is of a high standard throughout Scotland, irrespective of the size of the Board or the number of TB cases seen per annum. Agreed systems and structures should be in place in all Boards, with an emphasis on multidisciplinary team-working, quality, audit, and shared TB learning on local, regional and national basis.
3.6 The Working Group felt strongly that TB should be a Board priority for those areas in Scotland with the highest incidence of cases. Other Boards with lower incidence of TB should however also review their response to TB in line with recommendations in this report.
Improving clinical management
3.7 A key aim of this Action Plan is to improve the consistency and quality of care for TB patients across Scotland, removing inappropriate variation as far as possible in line with the Quality Strategy. Informal TB networks exist in most Boards, but the Clinical Services Subgroup agreed that a more formal multidisciplinary approach - of the kind that has been shown to be very successful in other complex clinical areas, such as cancer care - should now be universally adopted by TB services in Scotland. Several Boards have already successfully introduced a multidisciplinary approach to TB care. This approach recognises that TB is a complex, multi-dimensional condition and that care of patients needs to take account of a range of clinical, social, occupational and other needs to ensure the best clinical outcomes.
3.8 Multidisciplinary approaches involve regular scheduled meetings to review every TB patient being treated. Meetings review the clinical and public health management of TB patients and so have a wider focus than traditional x-ray review meetings. Multidisciplinary team membership includes, as a minimum, every clinician treating TB in the geographic area covered by the team (including infectious disease, paediatric and respiratory specialists); every TB nurse in the area; public health nurses involved in caring for TB patients; Consultants in Public Health Medicine with TB lead; microbiologists and pharmacists.
3.9 The multidisciplinary team has a local leadership role, being responsible for developing local protocols based on national guidance, for supporting clinical audit of treatment, contact tracing activities, and for monitoring local morbidity and mortality. Multidisciplinary teams also have a role in promoting and supporting local continuing professional development ( CPD) in respect of TB to ensure staff involved in patient care have up-to-date knowledge and skills.
3.10 GPs have a key role in the early detection and treatment of TB and a primary care representative should be a member of local multidisciplinary teams.
3.11 The view of the TB Action Plan Working Group is that the multidisciplinary team model of clinical care should be adopted across Scotland. In practice this means that no TB patient should be treated by a single consultant without the involvement or oversight of a multidisciplinary team. Evidence shows that treatment of TB should be initiated by a specialist and supervision of management should be as part of an multidisciplinary team, including primary care.
3.12 GPs and primary care teams (including pharmacists) have a crucial role in the early detection of TB and, in collaboration with others, the overall care and treatment of their patients.
3.13 All TB patients in Scotland should have their care plans reviewed by a TB multidisciplinary team. In patients with suspected TB, initiation of anti- TB therapy should be discussed with a TB specialist to ensure optimal investigation and management.
3.14 For those NHS Boards with a high incidence of TB it would be expected that multidisciplinary teams could be limited to NHS Board geographic areas. However, in Boards with lower TB incidences it may be more beneficial for two or more Boards to come together to form a single multidisciplinary team covering their areas. This would ensure sufficient clinical throughput for the maintenance of expertise.
Sharing Best Practice
3.15 The role of multidisciplinary teams can promote and ensure best quality care within the geographic area of that team. However there is a recognised need for professionals from different parts of the country to come together to share best practice, to jointly undertake training and development, and to inform future policy. The Scottish Government should ensure that a national network of multidisciplinary team staff/leads is supported and facilitated.
3.16 Recognising the key role of TB Nurses, the Scottish Government should also ensure that the national TB Nurses Network is supported and facilitated.
3.17 To ensure that clinicians from across Scotland working in the field of TB have the opportunity to meet and discuss issues, the Scottish Government should ensure an annual national meeting of all health professionals involved in treatment and management of the disease is funded and facilitated. This should include all clinical staff (including from the multidisciplinary team and TB Nurses networks) as well as public health leads.
Access to Negative Pressure Facilities
3.18 The Health Protection Network guidance on the management of TB, published in 2009 (see paragraph 3.3), states that there should be adequate arrangements in place for provision of suitable negative-pressure rooms for all NHS Board areas for treating respiratory and suspected respiratory TB. This is partly in the context of the challenges posed by immunocompromised patients in all areas of hospitals and the increasing incidences of multi-drug resistant TB for infection control
3.19 The TB Action Plan Working Group supports this guidance. To this end, every NHS Board should have documented arrangements in place to ensure access to negative pressure facilities where these are required. Individual circumstances may make this challenging but at a minimum single rooms should be used where required for the period that any patient would be considered to be infectious.
3.20 Patients with MDR/ XDR- TB should be managed in negative pressure facilities with en-suite facilities without exception. All patients with suspected MDR/ XDR- TB, should be managed in a negative pressure room with en-suite facilities pending microbiological results.
3.21 These arrangements should be understood by all relevant staff involved in patient management and should, for example, form a core part of multidisciplinary team operational documentation.
3.22 The above recommendations do not mean that every NHS Board is required to have their own facilities, but rather that they should have ready access to such facilities elsewhere in the country if required.
TB and HIV/ AIDS
3.23 The relationship between TB and HIV infections is an important one. TB is an AIDS defining condition and there is significant incidence of TB and HIV co-infection in other parts of the world. According to the World Health Organisation 5% of all TB cases globally have co-infection with HIV.
3.24 Co-infection does occur within Scotland with associated clinical implications for both conditions. Early recognition of HIV infection in TB infected patients is important as initiation of anti- HIV therapy during the course of TB therapy has been shown to reduce mortality. There are also important treatment-limiting and potentially life-threatening drug interactions which need to be anticipated in co-infected patients. In order to ensure best possible clinical outcomes for patients concerned it is vital that both conditions are diagnosed as quickly as possible.
3.25 The Chief Executive of the NHS in Scotland issued guidance in 2007 asking that all TB patients (amongst others) should be screened for HIV. (Chief Executive Letter 15(2007) http://www.sehd.scot.nhs.uk/mels/CEL2007_15.pdf). We know from the stocktake of services undertaken by Health Protection Scotland that less than half of NHS Boards offer and advise HIV screening for all TB cases. The TB Action Plan Working Group recommends that this existing guidance should be implemented routinely across Scotland, and health professionals should be reminded of this guidance. Moreover multidisciplinary teams should ensure that HIV screening has been carried out during patient reviews.
3.26 Patients co-infected with HIV and TB should be directly managed by a physician with expertise in the management of both conditions. Ideally this should be an adult or paediatric trained infectious diseases physician.
3.27 At the same time, Health Protection Scotland will initiate a population based study (an anonymised data linkage exercise) to improve our evidence base around dual TB/ HIV infection and associated risk factors in Scotland. This work will commence in 2011.
National guidelines for TB control
3.28 As detailed in paragraph 3.3 above the Scottish Health Protection Network published guidance in March 2009 on the clinical management of patients with TB. The view of the Action Plan Working Group is that these guidelines should not be a static document. Given the public health importance of TB in Scotland and globally, and recent epidemiological trends, our ambitions are such that we should constantly ensure we are operating on the basis of the most up to date evidence and experience. National guidelines should therefore be reviewed for Scotland at a minimum of every 3 years. The Scottish Health Protection Network should lead these reviews.
Drug Resistant TB
3.29 Reports have indicated that multi-drug resistant TB ( MDR- TB) and extensively drug resistant TB ( XDR- TB) are becoming more common in some foreign countries. These include countries in the former Soviet Union and parts of Asia and Africa. The Scottish Health Protection Network TB guidance (see paragraph 3.3) recommends that the risk of MDR- TB or XDR- TB must be assessed for every TB patient at diagnosis. The Working Group supports this guidance.
3.30 This assessment should include TB exposure in high risk countries, as well as previous, possibly failed, TB treatment. As stated in paragraph 3.21 patients with suspected MDR/ XDR- TB should be managed in a negative pressure room with en-suite facilities, pending microbiological results.
The Public Health (Scotland) Act 2008
3.31 The Public Health (Scotland) Act 2008 has enabled NHS Boards to respond more actively in cases (fortunately relatively uncommon) where an individual with active TB and known to be infectious fails to comply with treatment and presents a significant public health risk to others in the community. "Competent persons", with defined qualifications and experience, designated by the NHS Boards are able to use powers available within the Act. These include the ability to restrict or exclude an individual from places or activities which put others at significant risk. It also includes the power to detain and individual in hospital. The use of such powers must always be justified within the law by a Competent Person acting on behalf of the NHS Board.
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