1. a African Comprehensive HIV/AIDS Partnership b Department of Public Health (MOH), c CDC Atlanta, d CDC Botswana
Botswana has a high TB incidence (455 cases/100 000 population
in 2011) and nosocomial transmission of TB in clinical settings is of
great concern. Despite availability of comprehensive infection
control guidelines and didactic trainings for health workers since
2009, translating knowledge to practice has remained a challenge.
In February 2012, Botswana piloted a training package developed
by CDC in 10 health facilities. The package included didactic
lectures, slides, video, hands-on site assessments tools and coaching
to develop facility-specific infection control plans. Follow-up
supervisory, support and mentorship visits were built into the
program including feedback on progress to facility staff using a
simple dash board matrix. Status of implementation on key
infection control interventions were identified at baseline and at 6-
month follow-up on the color-coded dashboard: RED was “not
being done”; GREEN “being done and documented”, BLUE “being
done but not documented” or YELLOW “not applicable”.
The pilot program demonstrated positive change in infection control practice in facilities at 6 months after initial training using the CDC package. A simple
dashboard was useful in tracking implementation and providing timely feedback to staff for continuous quality improvement. Botswana is considering rolling out
this model to national scale.
A Continuous Quality Improvement Approach to
Implementing TB Infection Control in Botswana
a Moshe Y, b Ncube RT, a Garekwe M, b Jibril HB, c Emerson C, c Lipke V, d Lanje S, c Nakashima AK
BACKGROUND
INTERVENTION
RESULTS
An average of 65% of the 37 key infection control interventions
were flagged RED for all facilities at baseline; after 6 months an
average of 19% were designated RED. Notably, 9 of 10 facilities
were actively triaging patients and fast tracking coughers for early
TB diagnosis and treatment initiation. Facilities were also actively
monitoring daily interventions such as opening of windows to
ensure adequate ventilation in waiting areas / exam rooms in
outpatient clinics. Nine of 10 facilities actively screened healthcare
workers for TB and provided N-95 respirators to protect them from
acquiring TB.
CONCLUSION
TBIC Indicators
Gaborone Mahalapye
PMH
(Baseline)
PMH
(At 6 mo)
Nkoyaphiri
(Baseline)
Nkoyaphiri
(At 6 mo)
Tlokweng
(Baseline)
Tlokweng
(At 6 mo)
MPH
(Baseline)
MPH
(At 6 mo)
Airstrip
(Baseline)
Airstrip
(At 6 mo)
IC Policy available
Designated IC Officer in place
IC Committee in place
Written IC plan in place
Endorsed facility IC plan
TB IC risk assessment done annually
Facility design & patient flow assessed
TB patients managed on DOTS
TB IC measures monitored daily
Reporting system for TB in place
TB IC training for all staff done
TB IC IEC material available
Evident Operations research on TB IC
Staff wellness program in place
Patients screened for cough at entry
Coughing patients "fast tracked"
Designated Cough Monitors in place
Signage for cough etiquette in place
KEY: Done, desired outcome Not done or not right Not applicable Done but no documentation
Fig.1 Status of Dashboard Matrix at 6 months, selected TB IC indicators in selected pilot health facilities, Botswana, 2012
Fig.2 Crowded indoor waiting area at baseline,
Palapye Primary Hospital
Fig.3 Waiting area moved outdoor, at 6 months,
Palapye Primary Hospital
Fig.4 Active triaging of coughers noted at 6
months, Kideretswe clinic
Fig.5 Outdoor coughing spot, built by
community noted at 6 months, Masego clinic
80%
60%
10%
20% 20%
10%
100%
90%
80%
100%
60%
80%
70%
0%
20%
40%
60%
80%
100%
120%
Designated
IC Officer in
place
IC
Committee in
place
Written IC
Plan in place
TBIC
measures
monitored
daily
TBIC
training for
all staff done
TBIC IEC
material
available
Wellness
program in
place
Patients
screened for
cough
Coughers
fast tracked
Designated
Cough
Monitor
%FacilitiesimplementingTBICmeasures
Comparison of implementation of TBIC measures at baseline & 6 months
Baseline At 6 months