An enhanced level of case management (ECM) is recommended by NICE for those deemed ‘hard to reach’ and should be provided where risk/needs assessment demonstrates that the patient has clinically and/or socially complex needs. NICE recommends one TB nurse for every 20 such cases so knowledge of their numbers is integral to workforce planning.
The Aim of this project was to identify and quantify those qualifying for ECM in an inner city TB cohort.
Methodology All 170 cases notified with TB in Central Manchester were retrospectively identified from department records for 01/2010 to 12/2010. Data were collected using a standard proforma from clinic letters and TB specialist nurses documentations. Standard case management was defined as per the RCN document ‘Tuberculosis case management and cohort review’.
Only 60/170 (35%) were identified as standard management cases in which 7/60 (11%) had other co-morbidities and 4/60 (6%) had a language barrier. 14/60 (23%) were excluded for diverse reasons (e.g. death before diagnosis).
Results 96/170 (56%) were identified as ECM cases which subdivided according to their requirements into either:
Medical needs, which comprised 12.5% (12/96) of cases including patients with dual pathology and recurrent hospital admissions.
Nursing needs which comprised 12.5% (12/96) of cases in which majority (8/12) of these did not attend clinics as required and the rest (4/12) had anti-TB treatment side effects demanding more home visits.
Both medical as well as nursing needs were present in 75% (72/96). In which 52% were paediatric, 11% had resistant organism, 6% were HIV +ve, 4% of patients declined treatment, 3% were on DOT, 3% had complications due to TB infection and 21% of cases had prolonged treatment due to CNS/bone involvement, interaction with other non TB treatment, immune compromised patients and overlap with others (HIV patients, Drug resistant organism, patients on DOT had prolonged treatment).
Conclusions The reasons for ECM are many and diverse and often multiple. In our practise more than half of patients could be classified as requiring such management. This has implications for TB nurse manpower planning.