Cootauco, M.B. (2008) Nurse-led rapid diagnosis and management of TB. This is an extended version of the article published in Nursing Times; 104: 32, 28-29.
This article describes how a nurse-led rapid access clinic was developed with the aim of reducing new infections, providing high-quality treatment and maintaining low levels of drug resistance. It explains how it has reduced the waiting list for medical TB clinics. The clinic accepts urgent referrals that can be seen on the same day.
Maricel BombioCootauco, BSc Nursing, Dip Psychology , is TB specialist nurse, Chest Clinic, St George's Healthcare NHS Trust, London.
Tuberculosis (TB) is a public health issue in the UK. In the 1850s, one in four deaths was attributed to it. TB rates steadily declined through most of the 20th century and infections reached their lowest incidence in 1987 with 5,086 notified cases (Davies, 1996). However, cases are increasing again. Frequent travel and migration have made a major contribution to this increase. In 2006, 8,497 new cases were diagnosed in the UK, and the London region accounted for 44.8% of these cases (HPA, 2007). Most TB cases occur in non-UK born young adults who may be slow to access care (HPA, 2007).
The World Health Organization has set up global targets to reduce the prevalence of and deaths due to TB by 50% relative to figures from 1990 by 2015 and to eliminate TB as a global health problem by 2050 (WHO, 2006).
To achieve these goals, TB services aim to reduce new infections, provide high-quality treatment for all and maintain low levels of drug resistance.
Establishing the clinic
In 2005 it was evident that there was a continuous rise in the number of people being referred to the medical TB clinic at St George's Hospital in London. A quarter of patients seen by the doctors were new patients who required TB investigations.
This increase has led to a long waiting list in the medical TB clinic and caused delay in investigations and diagnosis. It was decided to change the structure of the TB service to meet these demands but this had to be achieved with the current staffing and without additional cost.
A nurse-led rapid access TB clinic was established in August 2005 under the supervision of the lead TB consultant.
Referrals to the clinic
Patients can be referred by:
The health protection unit;
The local prison;
The radiology department;
Mobile X-ray unit;
The clinic is staffed by two TB clinical nurse specialists who organise appointments directly with patients.
There is a weekly nurse-led clinic but urgent referrals are seen immediately so that diagnosis is not delayed. These urgent referrals are patients who are highly likely to have open TB that is infectious. They usually present with abnormal findings on their chest X-ray, such as cavitating lesions. Patients who are found to have acid-fast bacilli in their sputum under microscopy are also seen as urgent cases as this is a diagnostic sign of infectious TB.
[sub] Management of patients
A medical history is obtained from the patient at the first appointment, along with the assessment of symptoms of TB such as cough, fever, night sweats, loss of appetite and weight loss. Investigations to either diagnose or rule out latent or active tuberculosis are also carried out. These are listed in Box 1.
Box 1. TB investigations
All cases and individual care management plans are discussed with the lead TB consultant during the regular weekly case meeting. The multidisciplinary team is also involved; for example a radiologist may be asked to discuss the results of a CT scan. Patients are kept informed throughout this process and the healthcare professional who made the referral is informed of the outcome of the investigations.
The TB nurse specialists give patients information about the disease, prevention of the spread of the disease, possible side-effects of the TB drugs and the importance of adhering to treatment. A TB information sheet, which is available in different languages, and the TB clinic contact numbers are also provided.
Patients are entered on database. The database record serves as the patient's personal file and the case is entered onto the London TB register (WHO, 1998).
Every case of clinically diagnosed TB, whether or not microbiologically confirmed, needs to be notified to the local health protection unit. When a case of TB is identified, it is important to screen the close contacts (NICE, 2006). The local health protection unit is involved in tracing the contacts of people who have open TB disease in the community.
The TB nurses use a risk assessment tool to assess potential problems that could interfere with adherence to treatment. These include factors such as homelessness, language difficulty, history of non-adherence and substance misuse. It also helps determine whether the patient meets the criteria for a directly observed therapy (DOTS). Patients who receive DOTS are seen daily or three times per week to take their medication in the presence of a TB nurse. This guarantees that the patient is taking the medication correctly. Those who self-medicate are seen less frequently but have a regular follow-up to check compliance, side-effects, review of the dosage of medication and liver function tests.
To review the effectiveness of this service innovation, a two-year audit of the nurse-led rapid access TB clinic was carried out. All data was gathered from the time patients were referred, seen and the outcome of the investigations.
A total of 462 patients were referred to the clinic with most referrals coming from GPs (Fig 1). Of the 462 referrals, 438 patients were seen in the clinic, 17 missed their appointments and seven declined to be seen.
Patients who missed their appointments were followed up by the TB nurse specialists. Phone calls, repeat appointments and domiciliary visits were carried out as necessary. Most of these patients were new entrants to the UK with abnormal chest X-rays at their port of entry and who had provided incorrect addresses. Of those who declined the appointment, some requested to be seen in another clinic and others returned to their home country for investigation and treatment.
Forty per cent (175) of patients seen in the clinic showed no evidence of latent or active TB and were discharged. One-third of these were referred for screening to rule out TB. Others were referred as a routine procedure prior to starting treatment for other conditions, for example anti-TNF therapy for patients with rheumatoid arthritis. This therapy can result in immunosuppression and patients with latent TB are at risk of developing an active infection (NICE, 2006).
Twenty-seven per cent (118) of patients were followed up in the medical TB clinic for further medical assessment and investigations including CT scans and bronchoscopy; 7% (32) were diagnosed with latent TB infection and commenced three-month preventative treatment. Latent TB is diagnosed when an individual presents with a positive tuberculin skin test and reactive interferon gamma assay but reports no TB symptoms and their chest X-ray is normal.
A small number of patients (3%; 13) showed no evidence of TB but had other respiratory pathology and were seen in other respiratory clinics. The remaining 23% (100) were diagnosed with active TB and commenced treatment within one week of referral. These patients were followed up regularly in the medical and nurse-led TB clinic. Half of these were diagnosed with pulmonary TB and seven cases proved to be infectious.
Darbyshire (1995) and the WHO (2008) state that TB rates continue to increase globally due to several factors such as the HIV pandemic, human displacement, poverty and drug resistance.
The disease can affect any part of the body, the most common site being the lung. It can affect any individual, regardless of social status, gender or age, although some groups are at increased risk (Box 2; Pratt et al, 2005).
Box 2. High-risk groups
Source: Pratt et al (2005)
Mayho (2006) described TB as a social disease, and a patient diagn, 2005)sed with infectious TB may need to be isolated to prevent spread. Although the disease is contagious, the risk of infection through casual contacts is slim.
Generally, two weeks after commencing medication without interruption of treatment, an infectious patient will convert to a non-infectious state (BTS, 2000). Good adherence to treatment is essential to effectively treat the disease.
Burnett and Fassil (2000) have stated that 'how, when and what people present to health workers will be influenced by culture and beliefs'. The majority of patients receiving TB treatment were not born in the UK (HPA, 2007). There is often stigma attached to the disease and the TB nurses play a key role in helping to lift the barrier of stigma by stressing to patients that it can be treated and is no longer considered to be a fatal disease. These specialist nurses are committed to providing support planned individually for each patient and aim to ensure that treatment is completed.
Establishing a nurse-led rapid access TB clinic has made a huge impact on the overall TB service. Patients who may have TB are seen immediately and investigations, treatment and contact tracing can be carried out without any delay. Since its introduction, waiting times for the TB medical clinic have reduced; patients who are not urgently referred are seen within a week and, for those diagnosed with TB, treatment commences a week after their first appointment.
Most patients have gone on to self-medicate and are seen regularly in the nurse-led follow-up and medical TB clinics. One patient died a few weeks after commencing TB treatment due to other pathology, with TB contributing to death. Nobody has relapsed and treatment success rates for those who commenced on full TB treatment are over 90%.
Since the service started the number of reported cases in the hospital and community has fallen.
This service has made a positive response to meeting the targets set out by the World Health Organization (WHO, 2006) and national government (DH, 2004).
Innovation in TB service structure has created a positive approach towards meeting the global TB targets as set out by the World Health Organization. Effective utilisation of the TB clinical specialist nurses' knowledge and skills has provided patient-centred expert care within a multidisciplinary setting. Empowerment of these specialists has enabled them to further develop their skills, thereby promoting excellence in patient care. Developing strong relationships between patients and the TB team has promoted compliance which has ensured successful treatment.
In 2006 Miss Yettle was seen in the nurse-led rapid access TB clinic following referral by her GP. She is a 20-year old black African student born in Somalia and emigrated to the UK in 1995 along with her family.
The TB clinical nurse specialist immediately made an appointment for her to be seen at the rapid access clinic. She presented with two months' history of cough, fever, loss of appetite, excessive sweating at night and weight loss. She had received a BCG vaccination as a child and a scar from the vaccination was seen on her arm. Several years ago, Miss Yettle was screened following contact with TB through household exposure. She was diagnosed with latent TB infection but she did not adhere to treatment.
TB investigations including chest X-ray, three spontaneous sputum specimens, Mantoux test, and routine blood tests (inflammatory markers, full blood count, Vitamin D, renal and baseline liver function tests) were carried out at her first appointment. Her chest X-ray showed a large pleural effusion, left-sided cavitating lesion and consolidation within both upper zones. Her Mantoux reaction was highly positive and all sputum tests were microscopy smear positive (indicating open TB). Pulmonary tuberculosis was confirmed and standard TB treatment was commenced within one week of referral.
The case was notified for epidemiology and surveillance purposes. The health protection unit, GP, another TB service and her college were informed of the case. An incident meeting was called and contact tracing was carried out.
People in Miss Yettle's household were screened by the TB nurse specialists and people with close and prolonged exposure to her from the college were referred to another TB clinic for screening. Tables 1 and 2 show the results of the contact screening.
Miss Yettle was advised to stay indoors and avoid going to college and other public places until she converted to a non-infectious state. Due to previous history of non-adherence to treatment, she was seen three times a week to receive DOTS. She was also followed up in the medical TB clinic until she has completed nine months of TB treatment for extensive pulmonary TB disease. The TB clinical nurse specialists were able to build a good and strong relationship with Miss Yettle and her family. Compliance of everyone on TB treatment was monitored and support was provided throughout treatment.
This case study showed that through the nurse-led intervention, TB was rapidly diagnosed, immediate treatment and screening were carried out, and potential spread of the disease was prevented.
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