DOT's 'true believers' testify in North Carolina
DOT's 'true believers' testify in North Carolina
Good infrastructure the key to DOT increase
It may be hard to name the magic ingredient in North Carolina's approach to pushing the concept of directly observed therapy (DOT), but clearly, one does exist. The state has upped the percentage of active TB cases on DOT from 24% in 1990 to more than 85% for the first half of 1997, the most recent time period for which numbers exist.
"Our special trick?" asks Jim Jones, TB control program manager. "I think it's having nurse consultants who believe in DOT." Universal DOT at that, Jones adds: "I'd say one of the most effective ways to destroy the incentive to do DOT is to have staff people going and saying, 'Oh, this person's a doctor or a lawyer or a teacher, so they don't need DOT.' What you need are people who believe that absolutely everybody should be on DOT."
If an unerring belief in DOT is the foundation, the framework is a good infrastructure whose members all work as a team, says Mary Glynn Alligood, MAEd, health educator for the state's TB program. That infrastructure consists of 100 public-health nurses - all of whom, Alligood emphasizes, wear a lot of hats in addition to the one that says "TB nurse" - along with four nurse consultants, who oversee the state's four regions.
On paper, what the nurse consultants do is serve as a reliable source of support and guidance for the TB nurses. In practice, there's something more, too, says Alligood. "Our nurse consultants are right on the front lines," she says. "They know what's going on out there, because they've all worked at the local level, and so they know how many directions these TB nurses are being pulled in - immunology, general clinic, breast and cervical cancer projects, food-borne illness, you name it."
As a result, they also know that adding DOT to a nurse's already long list of duties is like telling them, "OK, now you have to learn how to fly," says one state nurse consultant. Certainly, adding DOT does make for extra work up front, says Alligood. But what state TB nurses have discovered is that in the end, it pays off, and in three ways: less acquired resistance to contend with; more cases completing within six months; and faster sputum conversion (which, in turn, translates to less transmission).
But how to get the word out on these benefits? One strategy that works well are testimonies given at twice yearly regional meetings by TB nurses who've adopted DOT as the standard for their counties. "It's kind of like at a religious service," says Jones. "People see a nurse in an adjoining county getting good results with DOT, and they decide that's something they want to try."
Conversely, when a nurse who's been slow to adopt DOT gets in trouble, the nurse consultant isn't above gently pointing out how the trouble might have been avoided. "It's what you might call a teachable moment," says Alligood.
Regional meetings accomplish other goals, too. Nurse consultants review completed cases from the six-month period that corresponds to the previous year, and gather data on current active and suspected cases. Most of the time, the review of completed cases offers no unpleasant surprises, since, in addition to communication that takes place at regional meetings, TB nurses and nurse consultants are constantly on the phone to one another between gatherings. "They always say, ask me now, not after a mistake's been made," says Alligood.
Despite the steady presence of a nurse consultant's guiding hand, TB nurses in the state enjoy a surprising degree of autonomy.
The decision whether or not to use DOT, for example, is entirely the nurse's call, and DOT is considered a nursing function, not a medical one.
In the same spirit, people who call the state TB control office in Raleigh with questions about their regimen, or about why they've been put on DOT, often are not referred to a physician, but instead back to the county TB nurse. "So you have so-and-so's phone number? She's your local TB nurse, and that's who you really to need to talk to about this," callers are told, according to Alligood.
Selling DOT to TB nurses is one thing, of course; selling it to patients is another. Sometimes, all it takes is the right incentive to get a patient to come into the clinic, says Jones. But in an urban center such as Raleigh, the bulk of the case load may consist of homeless patients and others who need to be painstakingly hunted down every day. Even so, DOT gives an edge, briskly moving patients who might otherwise never complete therapy through to completion.
Not quite everyone has bought into the DOT concept, Jones allows; some counties are still coming on board slowly. But the state is strict about one point: everyone on the twice-weekly therapy that usually succeeds the first two weeks of daily therapy gets DOT. Twice-weekly therapy, unlike daily therapy, is just too easy to forget, the reasoning goes. Thus, if a patient on twice-weekly therapy needs to take a business trip, for example, and can't make his appointed clinic visits, he's placed temporarily on daily therapy.
To make sure no patient falls through the cracks, another state law requires laboratories to report all cases of TB to the regional and state offices. That way, if a name pops up that a nurse consultant's not already familiar with, she can call the corresponding TB nurse to get the information.
Finally, there's Alligood herself, perhaps the only part of the state's formula for success that does have a name. As health educator for the program, Alligood acts as a sort of human glue that holds the rest of the pieces of the program together. "I fill in gaps,"she says. Her duties, nurse consultants say, consist of doing all the things that urgently need to be done but that no one else has the time to do. "I may be the only certified nurse educator out there working for a TB control program," she says. "But don't get me wrong. I'm just a peon."
As one who is trained in teaching community health at the school and community level, Alligood divides her time between tasks that include designing and producing supplies, maintaining a video lending library, organizing sessions in TB control, putting together video conferencing, and teaching local TB nurses how to requisition supplies. Recently, for instance, Alligood began to hear reports that nurses across the state were yearning for some easy way to make sure residents at the state's many teaching hospitals didn't make any missteps when they wrote prescriptions for their TB patients.
Alligood went right to work designing, costing out, and overseeing mass production of a drug card. The card, which is laminated and designed to fit into a front shirt pocket, seemingly manages to distill the principles of an entire textbook on TB treatment, including standard drug therapy, treatment information, a primer on TB skin testing, and instructions on what to do with positive skin tests. (There's also a handy millimeter rule thrown in on two edges of the card, for ascertaining induration, for good measure.)
"My wife, who's a nurse, tells me that drug card is one of the best things the department's ever produced," says Jones.
[Editor's note: For more information or to order the drug card, which is free, contact Mary Glynn Alligood at the North Carolina TB control office, at (919) 733-0391.]
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