Post on 20-May-2020
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TB Nurse Case ManagementAugust 20‐22, 2019San Antonio, Texas
ProvidingDOTLori Eitelbach, BSN, RN
August 21, 2019
• No conflict of interests
• No relevant financial relationships with any commercial companies pertaining to this educational activity
LoriEitelbach,BSN,RNhas the following disclosures to make:
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Providing DOTBY LORI EITELBACH, BSN, RN
AUGUST 21, 2019
Disclosures
No conflicts of interest.
No relevant financial relationships with any commercial companies
pertaining to this educational activity.
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Directly Observed Therapy (DOT) The 5 W’s
• What • Directly observing TB clients take their medications.• “Supervised swallowing” by trained health care worker.
• Who • All active TB disease clients.
• Why • Helps clients during their TB treatment.
• Provides clients someone to talk to about their treatment, i.e. side effects,
concerns, etc.
• Assists clients in taking their medications correctly.
• The most effective strategy to ensure adherence.
• Prevents drug resistance.
• When • Daily for the duration of TB treatment.
• Where • Time and place convenient for client because DOT is patient‐centered (home, work, park, school, clinic, parking lot, library, etc).
Polling InstructionsRespond to: PollEv.com/lorieitelbac884
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Text: LORIEITELBAC884 to 22333
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History of DOT in US
• DOT in TB treatment has become enshrined as “canon in a field long characterized by fervor in principle and practice” as in no other disease. First implemented in Madras and Hong Kong in the 1950s, DOT became globally endorsed in 1994 in the aftermath of a public health alarm created by an outbreak of multidrug‐resistant (MDR)‐TB in New York City (Bayer & Wilkinson, 1995).
• DOT has emerged now as the standard of care in the treatment of tuberculosis in the USA, in response to the dismal record of assuring that those with tuberculosis complete their treatment, the problems of tuberculosis in persons with HIV infection, and the public alarm that attended the emergence of multidrug‐resistant tuberculosis in New York (Metcalfe, O'Donnell & Bangsberg, 2015).
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Lessons from New York’s TB Epidemic• Late 1980s – dramatic epidemic of TB in New York city (NYC)
• By 1990 ‐ NYC had 3% of US population but 15% of country’s cases
• From 1984 to 1991 ‐ incidence increased from 23 to 50/100 000
• In central Harlem ‐ incidence rose from 90 to 220/100 000
• In 1991 ‐ among black men aged 35‐44, incidence was 469/100 000, almost 45 times national average
• Many reasons why this happened, but ultimately failure of treatment compliance was at heart of drug resistance epidemic
• By 1989 – treatment completion rates in NYC were only about 60% (and as low as 11% in some areas)
• “This allowed patients with infectious tuberculosis to remain a threat to others; relapse was frequent; and, worst of all, drug resistant strains flourished”.
Coker, R., 1998, Lessons from New York’s tuberculosis epidemicLerner, B., 1993, New York City’s Tuberculosis Control Efforts: The Historical Limitations of the “War on Consmption”
2016 Official American Thoracic Society/ Centers for Disease Control/ Infectious Diseases Society of America Clinical Practice Guidelines
DOT was significantly associated with:
improved treatment success (sum of patients cured and patients completing treatment)
with increased sputum smear conversion during treatment
compared with self administered treatment.
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DOT is used in over 180 countries in the world.
What is not DOT?
Permitting medical professionals to self‐administer their TB medications
Allowing family members to administer medications without the health care worker being present to observe.
Leaving TB medications at the hospitalized client’s bedside.
Allowing client to take TB medications without being observed; self‐administered treatment (SAT).
Direct observation of drug ingestion should not be the sole emphasis of DOT.
It should not be a blanket approach; instead it should be a process of negotiation & support, incorporating clients’ characteristics & choices.
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WHO REPORT ON THE TUBERCULOSIS EPIDEMIC 1997
Responsibility for Successful TreatmentSuccessful TB treatment is primarily the responsibility of medical providers and health care workers, not the patient.
It is strongly recommended that the initial treatment strategy utilize patient‐centered case management with an adherence plan that emphasizes direct observation of therapy (DOT).
DOT is significantly associated with improved treatment success (the sum of patients cured and patients completing treatment) and with increased sputum smear conversion during treatment, as compared to self administered treatment (SAT).
◦ Early recognition of adverse drug reactions
◦ Allow for establishing rapport with patients and families
◦ Addressing treatment complications expeditiously
◦ Remains standard practice in US and Europe
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DOT Tool KitIncidentals for yourselfID, pen, paper, CHARGED cell phone, cash, water, snack
Water and snack for client
Apple, banana, granola bar
Preparing/mixing tools
Food to prepare/mix medications in
Applesauce, pudding, Nutella
Client chart or DOT record
Itinerary
Respiratory Protection
Preparing/Mixing ToolsPill cutter
Pill crusher
Tongue depressor or spoon
Oral syringe
Small cup
Poly towel
Hand sanitizer
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Client Chart / DOT Log• HIPAA compliant
medical records transport bag
• Client’s prescription
• Dot log
• Progress Note
• Medications
ItineraryHave an itineraryBe sure to leave a copy with someone in the office
Helps keep you on track with your visits
Keep track of your mileage
Stick it on a clipboard
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Respiratory Protection•Be sure to have a supply of N95 masks that are fit for your face.
•Masks can be reused as long as they are stored in a paper bag, NEVER PLASTIC, and are not wet or dirty.
•Only use the same mask for the same client.
•Bring extra surgical masks in case your client has run out and needs more.
Our ClientsLITTLE ONES BIG ONES
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•Partnership with parent(s)
•0‐2 years old
•3‐6 years old
•7‐12 years old
•13 years and older
•Overcoming challenges
Providing DOT/DOPT to Children
Partnering with Parents•Have a plan in place that was developed with the support and input of the parents.
•Identify common terms that will be used by both you and the parents to identify symptoms.
•Discuss potential incentives for the child.
•Discuss concerns in private, away from the child.
•Involve parents in problem solving.
•Provide the nurse case manager’s phone number and advise family to call if child experiences any problems.
•Instruct caregiver when to seek medical evaluation or immediate medical attention.
•Be a team – show a united front.
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Methods to Deliver TB Medications
Liquids:
• INH suspension is available commercially in sorbitol – 10mg/ml
•Often associated with diarrhea.
•Unlikely to be tolerated in amounts greater than 10 mL to 15 mL (i.e., doses in excess of 100–150 mg)
Pills:
•Can be taken intact or in halves.
•Tip the head back to swallow pills and tip the head forward to swallow capsules
• Tablets SINK, Capsules FLOAT
•Pills fragmented (with a knife or commercial pill cutter) or crushed (by commercial pill crusher, mortar and pestle, spoon against spoon or bowl)
Capsules:
•Capsules can be opened and mixed in food.
Delivery Method◦ Syringe
◦Medicine dropper with larger tip
◦ Catheter tip syringe
◦ Baby bottle (may need to make hole larger)
◦ Special Rx MediBottle ‐ with internal sleeve for syringe
◦Medicine delivering pacifier (may need to make hole larger)
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0‐2 Years OldMedications can be:
•crushed and mixed with formula or breastmilk
•crushed and mixed with food or juice
•formulated into a liquid ‐ use as little as possible
Use pediatric medicine tools
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Remember…
Children may act out in hopes of not having to take medication. If this “works” and they succeed in sending you away for days, they will repeat this behavior every time you visit.
Children learn from and adapt to their situations.
When presented with something they do not want to do, they may cry or act out.
• If this “works” in their favor, they will repeat this behavior.
3‐6 Years Old
•Medications can be crushed and mixed with food or juice
•Talk to the child at the child's level of understanding
•Offer options not directives
•Let them be “in control” by offering options so they choose: “You choose ‐ you can take this in any kind of juice you pick, or you can swallow it with water and have a cookie after. What do you think would work best?”
•Provide visual reward
•Mix in small amounts of additives
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TIP
When working with the parent/guardian in selecting a food that will work best for the child, be sure to stress to the parent that this will work best if they refrain from giving the food to the child any time other than during the DOT visit.◦ Ex: Mixing meds with chocolate syrup, do not allow the child to have chocolate any other time.
Remember to praise the caregiver for a job well done too!
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Recipe for SuccessFood Choices: Drink Choices:
Chocolate saucePuddingFudge sauceIce creamJelly or marmaladeApple sauce or berry‐sauceMarshmallow creamNutella or peanut butterOreo cookie filling
Kool aidOrange juiceApple juiceSpriteSlushy
Overcoming Challenges:TB Medications are Yucky!•Crush and mix.
•Put a thin layer of soft food onto a spoon.
•Place the pill fragments or powder on top of the food layer and top with more yummy food.
•Give the child the dose of medication in this “sandwich.”
•Teach them to swallow it without chewing by practicing without the medication in place first.
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Important Reminders•Crushed or opened medication should be mixed with food or liquid immediately before administration.
•Suspend in a SMALL AMOUNT of food or liquid.
•The crushed pills have a strong flavor; small fragments of the pill taste better
•If the medication is not administered within 30 minutes after mixing, it should be discarded, and a new dose prepared.
•Never premix at the clinic. Medications when mixed with food begin to lose their efficacy, so it is important to mix and immediately administer the prescribed dosage.
7‐12 Years Old•Scored medications can be cut in half
•Medications can be crushed if necessary
•“I’m a grown‐up” approach
•Discuss symptoms
•Provide education
•Trick the tongue ‐ put the pill in back of throat to disguise taste
•Provide encouragement/praise
•Allow monitored independence, be supportive
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13 Years and Older•Medications can be taken whole
•Make them a part of the treatment plan
•Like adults
•Provide education
•Provide encouragement
•Provide praise
Adherence to Treatment
•Educate about TB.
•Most effective strategy is DOT.
•Offer incentives or enablers.
•Adherence can be difficult because many clients are reluctant to take several different medications for many months.
•Treatment for TB disease lasts longer and requires more drugs than treatment for most other infectious diseases.
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Enablers Incentives
Interventions to assist the client in completing therapy Interventions to motivate the client, tailored to individual client wishes and needs and, thus, meaningful to the client; rewards
Transportation vouchers Snacks and meals
Clinic personnel who speak the languages of the populations served
Assistance in finding or provision of housing
Reminder systems and follow‐up of missed appointments Clothing or other personal products
Social service assistance (referrals for substance abuse treatment and counseling, housing, and other services)
Books, coloring books, stickers, stamps, kids' meal toys, meals for adults, movie passes
Outreach workers (bilingual/cultural prn); i.e. DOT, sputum collection, educational reinforcement
Stipends
Integration of care for tuberculosis with care for other conditions
Patient contract
Enablers and Incentives
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Importance of Monitoring AdherenceNonadherence to treatment can lead to serious consequences
•acquired drug resistance
•more severe illness
•ongoing TB transmission
•death
Why are some clients non‐adherent?Improved or no symptoms
Lack of knowledge
Cultural beliefs
Language barriers
Lack of access to healthcare
Work schedule conflicts
Lack of transportation
Poor relationship between client and healthcare worker
Competing priorities
Family obligations
Legal issues
Homelessness
Alcoholism
Stigma
Mental Health
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Detecting Problems
We cannot predict who will take their TB medications
correctly!
You should notify your program manager, nurse case manager, or the designated point of contact as soon as
you suspect issues.
Determine why the client is not willing to take medications and begin strategies that will help the client finish treatment before legal measures are taken.
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Things to Be Aware of
• Some tricks: “cheeking” or hiding pill under tongue, keeping pill in hands, hiding in furniture, promising to take later, answering the phone, picking up a child.
• If you have a strong suspicion client isn’t swallowing medication, consider asking the client to open his/her mouth.
Strategies to Address Barriers to Adherence
Create
• ... an adherence agreement
Help
• … clients keep appointments
Use
• … incentives and enablers to improve adherence
Encourage
• … the client to seek support
Give
• … TB drugs in easy‐to‐take preparations
Coordinate
• … other services
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Teaching PointsAttempt to have regularity
◦ Same nurse or DOT worker
◦ Same time of day
◦ Same location
Attempt to make interactions positive
◦ Use praise
◦ Use positive reinforcement
◦ Always end the visit on a happy (positive) note
Anticipate problems
◦ Research ahead of the visit
◦ Learn from each visit
◦ Have new ideas ready to go
◦ Try something new if what you are doing is not working – ask for help!
Any questions?
E.g., What if the child spits out the meds? Should I re‐dose?
NO! You do not know how much has been absorbed. Make a notation in your DOT log that the child spit out the dosage and be sure to communicate with the nurse.
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THANK YOU!
ReferencesBayer, R., & Wilkinson, D. (1995). Directly observed therapy for tuberculosis: History of an idea. Lancet, 345(8964), 1545. Retrieved from https://www.thelancet.com/journals/lancet/article/PIIS0140‐6736(95)91090‐5/abstract
CDC. Treatment of tuberculosis. American Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR 2003; 52 (No. RR‐11). Retrieved from www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm
Coker, R. (1998). Lessons from New York’s tuberculosis epidemic: Tuberculosis is a political as much as a medical problem—and so are the solution.. BMJ : British Medical Journal, 317(7159), 616–620. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1113831/
Lerner, B. (1993). New York City’s Tuberculosis Control Efforts: The Historical Limitations of the “War on Consumption”. American Journal of Public Health, 83(5). 758‐766. Retrieved from https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.83.5.758
Metcalfe, J. Z., O'Donnell, M. R., & Bangsberg, D. R. (2015). Moving beyond directly observed therapy for tuberculosis. Plos Medicine, 12(9), e1001877. doi:10.1371/journal.pmed.1001877
Nahid, P., Dorman, S.E., Alipanah, N., Barry, P.M., Brozek, J.L., Cattamanchi, A., Chaisson, L.H., Chaisson, R.E., Daley, C.L., Grzemska, M., Higashi, J.M., Ho, C.S., Hopewell, P.C., Keshavjee, S.A., Lienhardt, C., Menzies, R., Merrifield, C., Narita, M., O’Brien, R., Peloquin, C.A., Raftery, A., Saukkonen, J., Schaaf, H.S., Sotgiu, G., Starke, J.R., Migliori, G.B., Vernon, A. Executive Summary: Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug‐Susceptible Tuberculosis. Clin Infect Dis 2016; 63 (7): 853‐867. doi: 10.1093/cid/ciw566
Yee, D., Valiquette, C., Pelletier, M., Parisien, I., Rocher, I., Menzies, D., & ... Menzies, D. (2012). Incidence of serious side effects from first‐line antituberculosis drugs among patients treated for active tuberculosis. American Journal Of Respiratory & Critical Care Medicine, 185(1), 1472‐1477. Retrieved from https://www.atsjournals.org/doi/full/10.1164/rccm.200206‐626OC
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