Referrals

International Clinicians Course on TB Management

Dr Ndiviwe Mphothulo

MB CHB, Diploma in HIV Management, MPH, MBL, PHD (Public Health-Current)

Presentation Outline

• A case from Taung District Hospital’s TB ward

• Referral of a TB patient

• Elements of a functional referral system

• Referring a TB patient within the health system

• Discharging a TB patient

• Referring a TB patient outside the health system

• Providing Psycho-socioeconomic support

A case from Taung District Hospital’s TB ward

A case from Taung Hospital cont..

“Abject poverty is demeaning, is an assault on the dignity of those that suffer it. In the end it demeans all of us. It makes the freedom of all of us less meaningful”- Nelson Rolihlahla Mandela

“Our nights cannot but be nights of nightmares while millions of our people people live in degrading poverty, sleep cannot come easily when children get permanently disabled, both physically and mentally, because of lack of food’-Thabo Mvuyelwa Mbeki

A case from Taung District Hospital’s TB Ward

• A 26 years old lady has been brought to the TB unit by the Sub-District Defaulter tracer. She has been on TB treatment twice before and defaulted at continuation phase during the last TB treatment episode. She has been brought to the unit to receive treatment as an inpatient.

• Social History: She is an orphan who was raised by her aunt and uncle. She has never known her biological father and her mother passed away 18 years ago. She attended school until grade 2 and she depends on the remittances of her uncle.

• Reasons given for defaulting: She feels worthless because she does not have an Identification Document (ID), during harvesting season she feels obliged to go to seek employment at the surrounding farms, and anyway she always feel better at the end of 3rd month of TB treatment and stops the treatment.

A case from Taung District Hospital’s TB Ward

• Ward doctor called Taung Home affairs offices to inquire about procedures of obtaining an ID book for a person without a birth certificate

• Procedure explained: Home affairs requests an affidavit from a close relative of the applicant to confirm that they know her from birth, and she was born in South Africa. They also need her mother’s ID number, a clinic card or hospital file detailing the applicant’s birth details and/or letter from the local traditional authority as a testimony that the applicant’s parent(s) is/are known in the village.

• Challenges: Mother had no ID, there is no clinic or hospital records of birth (Home birth), relatives don’t know details of the father, uncle cannot read or write and has no money to travel.

A case from Taung District Hospital’s TB Ward

Plan:

Ward doctor to draft the affidavit detailing family history.

Uncle signs the affidavit and commissioner of oath certifies the affidavit.

TB tracer contacts the local chief for a supporting document.

Staff at TB ward donates towards transport for the uncle and the applicant’s transport.

Taung’s Home affairs offices accept the affidavit, and within 6 weeks she gets a birth certificate, and 3 weeks later she receives her ID book.

SASSA and Department of Social Development furnishes family with food parcels.

Patient applies for a Disability Grant (DG) using her birth certificate, temporary ID & receives 8 months DG.

Down referred to local clinic to continue with TB treatment.

Treatment outcome: Patient is cured of PTB.

Case Highlights

• Poverty is an obstacle in TB treatment and towards goal of ending TB.

• The role of clinicians in social support of TB patients.

• Multi stakeholders' relations in patient support (Department of Health, Traditional authority, Family, SASSA, DSD, Home affairs)

• Inter government collaborations.

• Referral of a TB patient from a clinic to a District Hospital (TB unit).

• Referral of a TB patient from a District Hospital to a clinic.

Elements of a functional referral system

Reviews by Murray et al 2001 and, Murray & Pearson 2006 on maternity referrals in developing countries identified several elements of a functional maternity ward referral systems:

A referral strategy that is informed by the population needs and local context ( disease patterns, cultural & ethnic diversity, economy etc.)

Strategy informed by health System capabilities.

Referral centers are adequately resourced.

There is collaboration in-between the referral centers.

There are protocols of the referral system.

A unified referral records system.

Referring a TB patient within the Health System

• Primary Health Care (PHC) center to District Hospital.

• Transfer from one PHC to another.

• District Hospital to Regional or Tertiary Hospital.

• Tertiary hospital/Regional hospital to District Hospital.

• Referral to TB hospital, and from TB Hospital to Tertiary hospitals.

• From any level to Drug Resistant TB Hospitals.

• Referral to other health care services: HIV, Mental health, Physiotherapy, occupational therapy, Dietician etc.

• Discharge from TB hospitals or District hospital to PHC.

Referring a TB patient within the health system cont..

• Referral to a TB hospital (Indication)

Medical reason for admission: When patients diagnosed with TB are too ill or too weak to go home, including severely emaciated TB patient without other complications.

Social or socio-medical reasons for admission: When clinic or community and care cannot be achieved, particularly in patients with alcohol or drug dependence, mental illness or previously noncompliant.

Patients medically stable (no acute illness).

Referring a TB patient within the health system cont..

• Conditions of admission from general hospitals to TB hospitals

TB diagnosis has been confirmed.

Patients with negative smears require a culture to confirm PTB.

Other conditions such as bacterial or viral pneumonia, congestive cardiac failure, asthma, COAD, bronchiectasis and bronchial carcinoma need to be excluded in the differential diagnosis.

TB patients with medical conditions such as diabetes mellitus, epilepsy and severe hypertension should be stabilized before referral.

Severely ill patients with extra-pulmonary TB (TB Meningitis, TB spine, TB pericarditis) need to be stabilized in general hospitals before transfer to TB hospitals.

Referring a TB patient within the health system cont..

• Criteria for referral from TB hospitals to district/regional hospitals

All severe complications of TB disease e.g. massive haemoptysis, TB meningitis.

Severe dyspnoea and empyema

Severe drug reactions e.g. acute liver failure, Steve Johnson Syndrome.

HIV related diseases that need specialized medical care e.g. cryptococcal meningitis

Discharging a TB patient

• Discharge from TB Hospital to PHC

The patient is medically stable (no dyspnoea, no haemoptysis, not severely emaciated and afebrile).

The patient should be able to care for self (has adequate family support or community-based care is arranged).

The patient is able to access treatment at a clinic and be monitored either at the clinic or community.

Discharge Process

• Within 2 weeks of admission a discharge plan must be completed which ensures:

Continuation of care (contact with the most accessible clinic, assigning a treatment supporter).

The patient knows about their TB management (how & when to take medication; duration of treatment; importance of compliance; attendance at nearest clinic for follow up, infection measures at home).

A formal link is established between the patient, the local clinic and treatment supporter).

Discharge Process Cont..

• Psycho-social support: A social worker needs to be involved to arrange the appropriate social support for patients in need.

• Completing the referral in detail with all the relevant information:

One copy is for the patient to take to the clinic ; one copy kept at the hospital, one copy to the referral clinic.

The green card patient card should be updated before the patient leaves the TB hospital, and the clinic or DOT supporter should keep it updated until the TB treatment is completed.

Referring a TB patient outside the Health System

• SA TB Guidelines (Section 10): “TB is a complex disease that has a biological, social, economic and cultural implications for the patient. Health care providers should be mindful of the strong impact that TB can have on all aspects of the patient’s life..”

• Psycho-Socio Economic support means you interact with a patient in a relationship that will improve coping, esteem, belonging for the patient. It includes financial support, informational support, emotional support and appraisal support.

• Treatment supporters/NGOs.

• TB patients have poor HRQol (Health Related Quality of Life).

• SASSA (DG), DSD (Food Parcels).

• Conversation with the employer: duration of leave, UIF, incapacity leave etc.

END

“No individual raindrop ever considers itself responsible for the flood”

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