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National Collaborating Centre for Chronic Conditions (UK); Centre for Clinical Practice at NICE (UK). Tuberculosis: Clinical Diagnosis and Management of Tuberculosis, and Measures for Its Prevention and Control. London: National Institute for Health and Clinical Excellence (UK); 2011 Mar. (NICE Clinical Guidelines, No. 117.)

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Tuberculosis: Clinical Diagnosis and Management of Tuberculosis, and Measures for Its Prevention and Control.

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4Aims and principles of tuberculosis care

Created: .

In 2005, the Chief Medical Officer's TB Action Plan, Stopping tuberculosis in England,{2} set out essential tasks for reversing the increase in tuberculosis incidence and ensuring high-quality care and public health. The very first task in the action plan is the production and wide availability of information and educational materials on tuberculosis, and it specifies that they should be ‘multi-lingual and culturally appropriate’. The GDG enthusiastically support this, and therefore this guideline recommends the availability of such information and materials throughout the NHS, tailored to meet the needs of different languages and cultures.

As part of the action for ‘excellence in clinical care’, the action plan calls for a named key worker assigned to every patient, and that they should work closely with other agencies such as housing and social services to achieve improved outcomes. The GDG acknowledged the great importance of achieving a care plan which makes the successful completion of treatment of active or latent TB as easy as possible for the person receiving the treatment, and so this guideline has provided recommendations to support these aims and those of the Chief Medical Officer.

Where scientific evidence supports it, the parts of this guideline addressing prevention and control (chapters 1113) include recommendations for aspects of service organisation as well as for individual teams of healthcare professionals. The guideline attempts to focus NHS resources where they will effectively combat the spread of TB, and in some sections deals with high-and low-incidence areas separately.

The GDG acknowledge the importance of honest and positive communication concerning TB in overcoming stigma, poor concordance and misinformation about the condition and recognising socio-economic factors. Healthcare teams caring for people with, or at risk from, TB will need to work with non-NHS agencies to ensure a seamless service that promotes detection, concordance and cure.

4.1. Current service organisation

The review of current services (see Appendix G for more details) identified four basic service models in use.

Centralised

In this model TB nurses are based in a central unit, usually the health protection unit (HPU), and are responsible for all TB services including contact tracing and screening in a defined area. This model is used in areas with high and low incidence. It allows all TB services in the area to be coordinated and standardised. A variant which resembles the specialist hospital-based model (see below) is seen in some low-incidence small geographical areas, where a few nurses based in local hospitals or community clinics can achieve high volumes of specialisation.

Central with satellites

This is a variation of the first model; there are nurses at HPU level and other clinics alongside such as specialist new entrant and screening clinics. It may include generalist clinics in hospitals. In some cases the HPU nurse may coordinate all TB services, including contact tracing using satellite clinics. In this model, the HPU nurse may identify and send individuals for contact tracing to non-specialist health visitors in the community. It allows for coordination of services in areas of large geographical distance.

General hospital/community model

General respiratory nurses see people with TB in this model, sometimes with an additional nurse led clinic for contact tracing, BCG or new entrant screening. This model is used in areas of lowest incidence. Nurses may also be based in the community, and may run screening clinics.

Specialist hospital-based model

TB nurses are based in clinics in local hospitals or specialist community screening units but have functions for the surrounding community. There may a larger HPU-based network connecting these nurses. This model is seen in London and other areas with a relatively high TB incidence.

Staffing levels

The review aggregated staffing levels across HPUs to account for apparent imbalances between different types of clinic within each local area. The scatter plot of notifications against whole time equivalent (WTE) nursing staff (Figure 1) shows a clear correlation (Spearman's ρ =0.85), which is perhaps an indication that services are now in line with the British Thoracic Society (BTS) code of practice's{6} recommendations. These stated that nursing staff should be maintained at one WTE nurse (or health visitor) per 50 notifications per year outside London, and 40 per year in London. The review reflects a development in TB services since the audit conducted in 1999.{7} However, notification rates continue to increase in England and Wales, and it would seem that the challenge for those planning TB services is to see this increase in resources targeted effectively at those activities for which the evidence demonstrates benefit. This guideline aims to inform those decisions wherever possible.

Figure 1. Staffing levels of nurses/health visitors vs notified cases of TB.

Figure 1

Staffing levels of nurses/health visitors vs notified cases of TB. The line represents one whole time equivalent per 40 cases

Across HPUs, the WTE rate is roughly 1 per 40 notifications. London HPUs have the highest caseload and hence the highest WTE.

Other information on current services

The following aspects of the review of current services are reported in this guideline (details of the methods employed are given in Appendix G):

4.2. Communication and patient information

During the development of the guideline, patient and carer representatives on the GDG highlighted these suggestions:

  • a single national source of high-quality TB information in relevant languages, and formats for vision- or hearing-impaired people
  • TB services to assess local language and other communication needs, and accordingly make information from the national source available locally
  • clear discussion between healthcare professionals, people with (or at risk from) TB and their carers about tests, treatment, contact tracing and infection control measures, to enable understanding
  • people with both HIV and TB to be provided with information about the different specialties who may provide care during and after their treatment for TB
  • contact tracing explained and handled sensitively to avoid misunderstanding and stigma
  • information set out so as not to medicalise the patient
  • TB services providing each patient completing anti-tuberculosis treatment with clear ‘inform and advise’ information

The first task for improving TB services to be named in the Chief Medical Officer's TB Action Plan{2} is to ‘produce multilingual and culturally appropriate public information and education materials for national and local use and make them widely available’. See also section 2.5 above, for details of the National Knowledge Service.

Communication and information provision are an important part of efforts to successfully reverse the increase in TB incidence in England and Wales. Information resources for TB address the following aims:

  • achieving earlier diagnosis through general public awareness of symptoms
  • combating stigma and myths, which may delay presentation and impede contact tracing
  • helping to achieve concordance and treatment completion through awareness of different treatment options, awareness of side effects, and the importance of adhering to the treatment regimen
  • relieving anxiety about infection control measures in healthcare settings, family life and the workplace.

Recommendations are therefore given under section 6.2.

4.3. HIV co-infection

This guideline discusses risk assessments for HIV, and gives recommendations for treatment of active and latent TB in co-infected people. However, the specialised guidelines in the UK, at the time of going to press, are those from the British HIV Association,{8} and readers should be aware of these when considering care of any patient who is known to be, or is possibly, co-infected.

Copyright © 2006, Royal College of Physicians of London.

For 2006 original guideline text, no part of the content may be reproduced in any form (including photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally to some other issue of this publication) without the written permission of the Royal College of Physicians of London. Applications for the Royal College of Physicians of London's written permission to reproduce any part of this publication should be addressed to the publisher.

For 2011 updated text, the material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of NICE.

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