Retention of Clients Taking HAART in Care at Hospital/ART Clinc, West Nile, Uganda

 

Problem: 
 In West Nile Region. AHAP located in Arua regional Referral Hospital. It is also a site that offers services to HIV positive clients with complicated conditions such as cryptococcal meningitis; toxoplasmosis and clients with severe side effects of ARV medicines.
Intervention: 

-        To reduce client`s waiting time from over 4hrs to less than 45mins from entry to exit points.

-        Stable clients identified by review of files. Exit interviews conducted randomly for stable clients to establish the time taken and average time found. This was done by use of time recorder and the results are as below.

 

month
March
April
May
No of clients interviewed
23
19
25
Cumulative time taken
91
81.7
97.5
Average time/hrs to nearest whole number(4.06hrs)
4
4.3
3.9

 

The clinic team identified the above issue, as one of the factors causing a gap in client retention into care which reduces the efficacy of good ART program.
The QI site team planned activities to reduce the benching time and improve on clients’ appointment keeping, reducing the challenges of poor adherence to therapy and improving clients` clinical outcome.
 
CHANGES INTRODUCED
Pre-packing drugs
Drugs are pre-packed before the clinic day/before clients reach the dispensing widow i.e. every evening and early in the morning on each clinic day, to reduce time spent at pharmacy. The pre-packing is done by clinic Volunteers and nurses to ease the workload on the clinic day. This resulted in completion of clinic work by 4pm.
Task shifting
These include review of roles and responsibilities of the clinic team members. Files for clients for scheduled appointment days are retrieved on previous day, and triage team helps in sorting out the clients according to their stability (wellness).Nurses took on some clinician `s roles especially reviewing stable clients. This was implemented after Nurses were trained in clinical management of HIV positive stable clients, mentoring and regular support supervision by medical clinical offers and M/Os helped the team to perform their duties diligently. This change led to an improvement in reduction of client waiting time in the clinic.
Involving patients in quality improvement
The clinic team works closely with expert clients in the clinic. They are involved in giving daily health education on positive prevention attitudes to clients, tracing of clients who miss their appointment dates over 7 days as well as offering day care for the children. This brought a sense of relief and satisfaction on the part of the patients and improved patient-provider relations.
More than a months’ supply of ART
This was the most significant change that helped patients with transport and distant challenges. This change was applicable to stable clients, with good adherence to their therapies, no history of missed appointments and no chronic conditions such as Diabetics and hypertension. The success of this change has been attributed to availability of sufficient drug stocks.
Introduction of time –appointments:
Clients were given chance to discuss with the clinical team during consultation session to choose a convenient time to come to clinic, such that, they are booked for clinical consultation on that particular time, e.g. 10:00 am.3:00pm, this change worked well with working class patients to help them to reduce long  benching hours in the clinic , It has helped clients with high stigma to keep their appointment dates.
Results: 

Program Results.

 

Serial No
Interventions/Improvement changes introduced
Steps/Process
Comments/was the intervention effective
 
1
Pre-packing of drugs in the Pharmacy (Septrin, drugs for treating OIs,) time spent at pharmacy window has reduced from 1hour to 15minutes.
-        Involvement of expert clients.
-        Use of free time for pre packing drugs
Time spent at pharmacy window has reduced from 1hour to 15minutes.
 
 
2
-        Review of stable clients by Nurse Reviewer.
-        Longer appointments for refill (3months).
-        Time appointment for stable patients.
 
 
-        Review of stable clients files by MCO.
 
-        Retrieval of stable clients files for Nurse Reviewer to see.
 
-        Stable clients are seen after every 3 months.
 
-        Follow up of clients who miss up their appointments through phone calls.

 

Appointment keeping
 
Table showing number of clients on ART who kept appointment
 
MONTHS
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Number of clients on
ART who kept appointment
1905
2144
2288
2612
2655
2668
2680
3020
3581
5109
5539
Number of clients
on ART seen
2540
2680
2860
2902
2692
2890
2994
3300
3770
5421
5630
PERCENTAGE
59
82
80
90
99
92
89
91
95
94
98

 

 
Table showing data for clients’ time spent in the clinic
Months (June-Dec. 2011)
June
July
August
September
October
November
December
Average time spent in the clinic (in mins) for stable patients
240
180
120
60
45
30
30

 

Lessons: 

Application of principles of QI is a good process to implement the planned changes for improvement. A change has to be introduced one at a time so that its effectiveness is studied and appropriate action is taken according to the yield results

The team has a plan of spreading out forming QI team for chest clinic and PMTCT unit in order to apply the principles of quality improvement to introduce changes for improvement.

 

Countries: 
Report Author(s): 
Joyce Draru
Organization(s): 
Arua Hospital AIDS Programme
ASSIST publication: 
no
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