I was pleased to be runner-up in the Respiratory Nurse of the Year category of the BJN Awards 2021. The following are some of the initiatives I have implemented during 2019/2020.
TB screening at hostels and homeless shelters
People who use hostels and homeless shelter are some of the hardest to reach client groups who are high risk of tuberculosis (TB) activation due to their lifestyle. Their health is not their main priority. The TB team, which consists of six trained nurses and one outreach worker, goes out to these areas, undertakes teaching sessions on TB signs and symptoms, offers testing for staff and patients, and a weekly dose of rifapentin, or a daily dose of rifinah. Medications are delivered to the hostel by the TB team and all patient reviews take place there to improve compliance.
A 40% positivity rate for latent TB was found in staff and 30% in clients. The screening has raised awareness of TB signs and symptoms, and ensured the TB team are well-known to this patient group, which enables trust to be built.
Implemented flag 4 data at Refugee and migrant centre
Flag 4 data is a database that Public Health England keeps of all new GP registrations for new entrants. These data were not previously shared with the TB team in Wolverhampton. A data sharing agreement was set up and these data were analysed in order to see how many patients the TB team had contact with using current systems. The GP locations were analysed in order to choose the best locations to undertake the TB screening to ensure good attendance. When the data were analysed, the TB team were previously only making contact with around 10% of new entrants to Wolverhampton via the refugee and migrant centre (RMC) model. Clinics were set up at two other hospital sites around Wolverhampton and patients were offered screening appointments at these two sites in addition to the RMC. The TB team called all patients on the flag 4 database of new GP registrations in the UK to offer them appointments at three sites around Wolverhampton to be screened. We looked at which GPs had the most registrants and obtained sites near these GPs in order to get good attendance at these clinics.
Infection control net alert system
All patients who do not attend (DNA) screening appointments are added on to this system. If they are admitted to hospital the TB team get an alert and the patient is offered screening as an inpatient. If a patient declines treatment and in the future is admitted to hospital, a member of the TB team will visit the patient. If the patient has respiratory symptoms then the TB team member will obtain sputum samples to ensure a prompt diagnosis. Often, hard to reach groups have multiple health problems and TB can be difficult to diagnose. The TB team can ensure that these patients who are known to have had contact with infectious TB get prompt X-rays and sputum samples sent to improve length of time to diagnosis and reduce the risk of spreading the infection to other hard-to-reach patients.
Improvement in DNA rates
Nurses were often sitting in clinics and no patients would attend. DNA rates nationally in TB clinics are between 20 and 40%. In Wolverhampton, the DNA rates in 2018 were 35%. In order to improve DNA rates, the TB team ensured all patients are sent a text message the week before their appointments and then a phone call the day before to ensure they are planning to attend. Non-English speaking patients are sent a text message as well as a phone call and telephone interpreters are used if required. The team also liaises with the RMC staff, who provide assistance and interpreters for new entrants. If there are cancellations other appointments are brought forward if patients agree to ensure time is used effectively. DNA rates improved from 35% to 12%, which is below the national average.
Huge increase in latent TB numbers
By implementing all of the above schemes, the TB team tripled the number of latent TB patients found during 2019. In order to reduce the number of active TB cases in Wolverhampton, the TB team need to find and treat latent TB in order to prevent it from becoming active TB and becoming a public health risk.
National Institute for Health and Care Excellence (NICE) guidelines (2016) state that people younger than 65 years old from underserved groups should be tested for TB. This guideline was met by the TB team during 2019 and continued during 2020.
Underserved groups include:
- Homeless people
- People who misuse substances
- Prisoners
- Vulnerable migrants.
The NICE (2016) guidelines also recommend that TB teams should identify and support ongoing TB education programme for local professionals in contact with the general public and at-risk groups in particular. Examples include, hostels, prisons, substance misuse services, GPs, primary care staff and people who support migrants.
In 2019, the TB team visited four sites run by P3, a homeless charity, in Wolverhampton, screened clients and staff in these areas and found between 30% and 50% positivity rate in this cohort. They have also undertaken screening events at women's refuges and the RMC, including the staff who work there. The team actively look for patients with drug dependency, and current (or a history) of homelessness.
This has continued since September 2020 with the team regularly visiting the Good Shepherd homeless shelter and Solace hostel. Over 70 clients have been screened at Solace hostel with a positivity rate of 48% for latent TB and 3 active TB cases found.
In 2018 there were 104 latent TB cases in Wolverhampton and this number increased to 292 in 2019.
Reduction in active TB cases
Due to a huge increase in treating latent TB patients, active TB numbers decreased by 38.5% over the period April 2019 to March 2020. In recent years, the highest rates of TB have been observed in Coventry, Wolverhampton, Birmingham, Sandwell and Walsall upper tier local authorities (UTLAs). The UTLA with the highest estimated rate for 2020 is Sandwell (23.2 per 100 000), followed by Walsall (21.2) and Stoke-on-Trent (18.8). Solihull, with no cases (April 2019 to March 2020), has the lowest estimated rate at 0 per 100 000. Of UTLAs with more than 15 cases in 2019, Walsall has the largest estimated increase in rate compared to the previous year (+114.3%; 2019: 9.9 per 100 000, 2020: 21.2). Wolverhampton has the largest decrease (-38.5%; 2019: 19.8 per 100,000, 2020: 12.2). (Rowley et al, 2020).
Hospital walk around
Once or twice a week the TB team go around the Royal Wolverhampton Hospital and offer screening to homeless people and known drug users so that treatment can be started in hospital and any side effects managed to improve compliance once discharged. Discharge would not be delayed; if patients are ready to go home then the TB team would follow them up as an outpatient and undertake a home visit. The TB team also provide education and training to ward staff
Rifapentin weekly dose
We introduced the use of Rifapentin in hard-to-reach patients such as those in prisons, hostels and homeless shelters. This medication, requires only a once-a-week dose rather than a daily dose, which has led to improved completion rates for this difficult client group, with more patients agreeing to treatment, especially in the prison population.
Work during the pandemic
During February 2020, I was asked to manage a new ward that opened for COVID-19 patients. I had to manage staff from all over the hospital who did not know each other and were from a variety of backgrounds with very few of them having ward experience. There were around 10 new overseas nurses who had arrived in the UK in January 2019 and this was their first experience of UK nursing. I brought the team together and provided lots of teaching sessions for the staff. I wanted to give the new nurses a positive impression of UK nursing and ensure they had skills to take back to their own areas and improve patient care all around the hospital. I had a one-to-one with every staff member and came up with an action plan in conjunction with them for all the things they could learn while on the COVID-19 ward. I received lots of positive feedback from staff. Some of their comments are below:.
‘You've pushed me to learn and do more and I appreciate the effort and time you have dedicated to enabling me to progress.’
‘You have such high standards for patient care and actively encourage and share your enthusiasm for learning and improving with all of us.’
‘I will miss being part of such a closely knit team, it's been something that should have been a difficult time but was made wonderful by the support from everyone.’
‘You have been the most supportive manager guiding us all through the most difficult of times.’
Team effort
I am proud of the initiatives the TB team has carried out over the past few years and especially during the stressful time of the pandemic and pleased to have this recognised at the BJN Awards.