Abstract
Background: We are an interdisciplinary team from ULSA and our project arose from the identification of a need to improve the coordination of care on the part of hospital care - Infectious Diseases Service that admits patients diagnosed with TB and Primary Health Care - the CDP (Pneumological Diagnostic Center) that monitors patients diagnosed with TB and their relatives in an outpatient clinic - Access for TB patients to primary/differentiated healthcare (without wasting time). This project is based on the pillars: Health needs of the population and local context, carried out based on the four-step management methodology - PDCA (PLAN - DO - CHECK - ACT).
We started by measuring the current situation (baseline):
-TB patients followed at the CDP, when they needed hospitalization, were admitted through the Emergency Department, increasing waiting time and risk of contagion.
-As for TB patients admitted to the hospital, cohabitants/family members were lost to screening, we found a lack of systematization in the teaching given to patients and family members and patients were discharged without scheduling an appointment.
Approach:
Improvement objectives, indicators, solutions and monitoring plan for 6 months:
-Improve the circuit for patients diagnosed with TB, referred from the CDP to hospital care, increasing the number of direct admissions to 100%, without the need to go to the emergency department.
-Improve the identification and referral circuit of cohabitants for screening of patients admitted to hospital care, providing an increase in screenings carried out.
-That all patients admitted with a diagnosis of TB demonstrate knowledge about the disease until discharge.
-That all patients admitted with a diagnosis of TB, at the time of hospital discharge, have their first nursing appointment scheduled at the CDP within 72 hours.
Strategies used: creation of a direct communication channel (telephone and email), preparation of protocols, systematization of procedures, use of Guidelines, information leaflets, definition of roles and existence of a case manager and team training. An action plan was defined using regular monitoring strategies.
Results:
In 6 months:
-All patients referred by the CDP for hospital care were admitted directly to the Infectious Diseases service.
-All patients hospitalized with a diagnosis of TB, at the time of discharge, had a nursing appointment at the CDP scheduled in less than 72 hours.
-All patients admitted with a diagnosis of TB and lack of knowledge about the disease showed an increase in knowledge at the time of discharge.
-All people living with TB patients identified during hospitalization and referred to the CDP undergo screening.
-This project included 12 hospitalized patients and 18 cohabitants who were screened. 10 positive cohabitants were identified, people who started treatment early, interrupting the transmission of the disease.
Implications: The path was one of growth and learning, understanding that there are several fundamental strategies for the successful implementation of a project, namely the importance of listening to the people to whom we direct our projects and care and always working towards continuous improvement.
This project resulted in health gains for the patient, family and community.