Tuberculosis Control Project - Knowledge and Integrated Care.

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.