TechNet-21 - Forum

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  1. Narayana Holla
  2. Service delivery
  3. Sunday, 12 January 2020

Dear techNet community viewers

Greetings from KVG Medical Coillege team.

We wish to share the following on going success story with the viewers for further contribution and also a PPT is attached on the same. Hope you will enjoy.

What is the innovative practice: Established “nursing station” for administering tuberculin as per CDC / RNTCP guidelines. Since tuberculin is an antigen, inducing / detecting cell mediated immunity, supplied in multi dose vial like Injectable Polio Vaccine for which Open Vial Policy is applicable; meant for administering to different beneficiaries, CDC recommends establishment of a “nursing station” for providing quality service for obtaining reliable result1.

Margaret Good expressed that developing a “better” test or “better” test reagent remains a perpetual challenge for the scientists, till such time administering tuberculin with potency will remain the most widely used means of determining the Mycobacterial infection2.      

“Knowledge is of no value unless you put it into practice, Practice till you are the best, Practice to remain the best.” Our innovation is to strengthen RNTCP by religiously practicing existing guidelines regarding Mantoux test [Tuberculin Skin Test –TST]. Senior chairpersons in the ZTF aptly called End TB stakeholders to get involved proactively. TST needs to be “approached with respect, administered with care, read with deliberation, interpreted with sentient discrimination”. Once a “Demo-Site” is established, replication for acceleration is much easier through cross learning visits and regular retro visits for sustenance.        

What is happening: Proactively and opportunistically, we found a few good practices of dedicated skilled persons administering tuberculin and designated Doctor reading the test result with minimal loss to follow-up deserving felicitation. Though TST is in practice since 1907, many avoidable programmatic errors are occurring in all the thematic areas from cold-chain to documenting, reading and interpreting the results in all the institutions (>20) in four states visited by the author in the last two years. These may grievously affect decision making [Picture2]. Charity begins at home. We established nursing station, operationalized standard guidelines, totally eliminated programmatic errors through hands on training and sustaining through supportive supervision till date.

How established: On appraising Medical Director regarding ongoing programmatic errors, we were asked to rectify. In response, author studied CDC / RNTCP guidelines and product specific manufacturer’s notes in depth. All the CDC rights to be observed while administering vaccines are applicable to tuberculin also3, in addition two more are added:

  1. the do’s and don’ts by the beneficiary and
  2. ii) ensuring reading of the test between 48 and 72 hours without fail by the team. Through “learning; both by doing & working together approach”,

We developed a comprehensive job-aid including standard operating procedure, indications / contraindications / limitations / interpretation of results with scientific discrimination, displayed in the nursing station as a ready reckoner [Picture1]. This is used for educating the nursing students, medical students, interns bringing the case for testing, post graduates, faculties, visiting faculties from other institutions, shared with the inviting medical colleges for release in the CMEW on TST as a public health event for similar purposes in their institution [Pictures 2 to 15]. 

We also developed the following TST specific novel form / format and tool:

  1. A) Supportive Supervision checklist for multiple purposes of concurrent recording of existing practices, hands-on training for capacity building, instant cessation of wrong practices, on the spot initiation of right practices, capacity building of key personnel for long term sustenance – [Appenix1]
  2. B) Universal register for adequate and uniform documentation – [Appendix 2]
  3. C) The tool for capturing related core data for deriving specific indicators for submitting along with monthly report, facilitating operational research. [Appendix 3]

We regularly shared our progressive experiences with End TB stakeholders from local to global viewers for additional inputs.

       We are blessed; establishing nursing station was a cake walk in our institution as we are already running dedicated vaccination clinic as per WHO/GOI guidelines, taking care of all the “rights”. To this we added 2 more “rights”, one comprehensive job-aid and a novel form of supportive supervision, a format for standard register for documenting and a tool providing denominator, recording numerator for deriving the indicators. We have the right cold-chain equipment – the Ice-lined refrigerator for keeping tuberculin. Recently H&FW department fixed temperature logger which displays temperature between 2.50C and 40C. [Picture11] In the regular Academic Society Meeting and the RNTCP core committee we presented the Standard Operating Procedure [SOP] for valuable suggestions and additional inputs which we incorporated and started functioning since April 2017. We won the hearts of all clinical departments through quality service including no lost to follow-up case. This is the nodal learning centre for nursing students, medical students, interns, Post Graduates, faculties and even the external examiners.                                                                           

       Impact: Referral for TST from the clinical departments has drastically increased. Lost to follow-up greatly reduced to almost zero except a death before 48hrs. We regularly shared our experiences with End TB stakeholders up to global viewers through techNet-21. For the Medical Colleges of home district we arranged two workshops. After disseminating our experience on 7th June 2019 in the State Task Force meeting with RNTCP nodal officers of medical colleges of Karnataka, till date six Medical Colleges organized CMEW for sensitizing on “The Diagnostic role and the rights to be observed with TST” – in short TST workshop, others will hopefully follow.

              Currently, DTO invited the author to conduct workshops for the lab technicians of Dakshinakannada district in two batches, first batch held on 19th Dec 2019.

  Thus we not only identified the problems but eliminated and replicating the elimination in a wider area across the state with stakeholder’s support, hoping to replicate across the country.         

In 2018, India shared 27% incidences of TB & MDR/RR-TB, 11.2% of TB-HIV co-infection and 35.48% deaths of Global TB burden4.

Director General WHO iterated that Elimination of TB from the world is a social justice. India is committed; eradicated polio and got the certificate on 2th March 2014, a milestone public health event5. India advanced the goal of End TB by 5 years aiming to lower prevalence, incidence, mortality of TB from ~300/L; 199/L; 32/L of 2018 to 65/L, 44/L, 3/L respectively and zero catastrophic cost by 20256. GoI has also committed to screen ~250 million less than 18 year population both for TB & Leprosy and to put them on treatment if required7. As per WHO, BCG vaccination and effective curative services are the two important areas of TB prevention.   In this regard Mantoux test has a definite role to play as a diagnostic adjunct in early diagnosis.

        Way forward: Uniform and universal all time practicing of CDC / RNTCP guidelines for administering tuberculin in all service delivery points, both in public and private sectors by establishing standard “nursing station” and regular retro-visits (monthly once for 4 consecutive months, quarterly once thereafter) by KVG team for reinforcement to sustain right practices through sustained supportive supervision, hands on training, especially to the “non viable” testers.

       Acknowledgement: With government support, this nursing station can be upgraded to TST Clinic; making it a hub for the effective implementation of newer tests / vaccine on introduction, additional TB related activities like quality newborn BCG vaccination, active case search for early diagnosis, piloting any new innovative interventions, Advocacy Communication Social Mobilization [ACSM], follow-up for treatment adherence both in the college and attached RHTC / PHCs, hand in glove with the government for attaining and sustaining “Zero TB” area.

Best wishes

Holla n Team

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