Quality Improvement is a useful process of improving health care – it is a process through which a problem is identified and possible solutions are explored, implemented and assessed. It is widely used in health care and is therefore part of the learning process and learning tasks of students in the SIC District Health block. Each group of students has to do a Quality Improvement Project (QIP) as part of their portfolio of learning. To improve the impact of the QIPs, the Department of Family Medicine selects a topic that is relevant and doable, and let students work on that issue in different sites and over a period of time. TB, and specifically linkage to care, was the topic chosen for the last group of SIC students in Tshwane in 2017.

The importance of TB and linkage to care and the results of the QIPs warranted a TB Symposium, organised by Dr Bac. The symposium took place on 17 November 2017 and was accredited two CPD points. An introduction was done by Dr Bac and the students presented their QIPs. After this followed a discussion of the findings by the participants which resulted in a set of recommendations for 2018.

Although the topic was TB and linkage to care, each group researched a different aspect of the topic, depending on the hospital or clinic they were placed at.

Students at Olievenhoutbosch Clinic looked at TB contact tracing and IPT (Isoniazid preventive therapy) practice. They found that the tracing of contacts of smear positive TB cases was inadequate. Working with Community Health Workers (CHWs) to trace the contacts of smear positive TB patients improved the number of high risk (HIV patients and children below five years) contacts screened and put on prophylaxis therapy or referred for TB workup. Their conclusion was that homes for contact tracing should be prioritized and communicated with Ward Based Outreach Teams.

Students in the inner city assessed the rate of defaulting on TB treatment at FF Ribeiro Clinic and their conclusion was that talking to patients is crucial to identify obstacles to adherence and to plan for improvement.

At Eersterust Clinic, students evaluated the use of the AitaHealth application for TB case-finding and follow-up. They found that the screening of TB on the AitaHealth app was nonspecific and flagged unnecessary patients. They suggested that the specificity of the TB screening tool on AitaHealth be improved, as well as improving the relationship between the WBOT and the clinic.

Students at the Kameeldrift Clinic looked at TB screening in newly diagnosed HIV patients and IPT. Their study showed that there was poor adherence to prophylactic protocols in HIV positive patients, e.g. IPT and cotrimoxazole. The clinic staff, however, was willing to improve and learn. A clear protocol was displayed in each consultation room which greatly improved adherence to protocols.

At Stanza Bopape II Clinic, students investigated TB case-finding by CHWs using the AitaHealth application and a mouth swab. Their findings were that CHWs can do home swabbing of TB suspects. However, none of the TB suspects that were referred to the clinic went. The students recommended that patients be better educated about the dangers of TB and that a ‘fast queue’ be created at clinics for TB suspects.

After looking at the TB 90:90:90 statistics at Folang Clinic, students decided to focus on improving the screening rates in Folang. This was because only 39.6% of patients seen at Folang Clinic was screened for TB, while the treatment rate was 93.6% and the percentage of completed medication courses was at 82.6%. Of all the interventions implemented, the TB screening stamp had the highest impact on TB screening and was successfully introduced in all the departments.

The students at Tembisa Tertiary Hospital did a follow-up study on MDR-TB to determine the number of patients with MDR-TB, their management, adherence to treatment, and what the outcome of the treatment was. They did this using the 2016 results. They found that 82 patients had MDR-TB. Of the 60 traceable patients, 50% were cured, 21.7% defaulted, 16.7% were deceased and 11.7% were still on treatment. They concluded that outpatient treatment of MDR-TB is difficult.

At East Lynne Clinic the students looked at TB management in Tshwane District Hospital and experiences with Synaxon and referrals. They found that about a third of the patients referred to the clinics from Tshwane District Hospital was unaccounted for. The pilot with Synaxon to improve the tracing of referrals was unsuccessful and the system was not user-friendly. The suggestion was made for Tshwane District Hospital to phone the clinics on a specific schedule to find out if patients were seen.

The students placed at Nellmapius Clinic investigated the down-referral of TB patients from Steve Biko Academic Hospital. There were 173 TB cases in 2017 (January to September). Of the randomized sample, 64% were not reachable. Of those that were reached, 62% were following up at the local clinic. The conclusion was that little is known about the TB patients discharged from Steve Biko Academic Hospital. The students suggested a national TB database which can be accessed from both hospitals and clinics, as well as a smartphone application for a TB patient referral database, such as AitaHealth. Linkage to care should be prioritized.

The following recommendations were made based on the outcomes of all the QIPs:

1. Display and implement the new guidelines for prophylactic IPT treatment in HIV.
2. Improve linkage to care after discharge from hospitals and also between clinics and homes.
3. Improve TB screening by focussing on high risk populations and using the TB screening stamp.
4. Collect sputum at patients’ homes via CHWs.
5. Do contact tracing in conjunction with WBOTS at high priority homes of smear positive TB patients.
6. Explore new technology e.g. WhatsApp, AitaHealth and TB Geomapper.
7. Start a TB task team consisting of AitaHealth, HAST, Public Health, Microbiology and Family Medicine.
8. Circulate a monthly dashboard of achievements in TB – number of new patients put on treatment, cure rates, IPT, and MDR.
9. Repeat a similar QIP cycle in 2018.

The students did valuable research and, as can be seen from the results, managed to make good improvements and suggestions for improvement.

With the repetition of a similar set of QIPs next year, we can monitor progress and create a quality improvement spiral for TB management in Tshwane. An annual TB Symposium with greater participation and contribution should be planned at the end of the rotation of the final group of SIC students. Master’s students in Public Health, Family Medicine and Microbiology should be encouraged to collaborate with SIC students in data collection.