Role of the TB Clinical Nurse Specialist in Tuberculosis Care and Treatment

Written by Lorraine Dolan, TB CNS, Respiratory Assessment Unit, St James’s Hospital

St James’s Hospital TB referral centre has a team which consists of Consultants, Registrar, TB Clinical Nurse Specialist (CNS), senior pharmacist and secretary. The TB CNS is an integral part of this team. The role is wide-ranging and involves been an advocate for the patient, maintaining continuity of care, supporting and educating the patients. This is in addition to also educating those involved in the patient’s care. A holistic approach is important as each patient differs in the level of support/needs required therefore care and support must be patient centred. Most patients diagnosed with active TB are treated in the ambulatory care setting. The TB CNS is the link for the patient between community care and the hospital TB team.

The TB team works in conjunction with other MDT members and hold’s twice weekly MDT meetings. Our MDT members consist of Microbiology colleagues from the Irish Microbiology Reference Laboratory (IMRL) and Public Health. The IMRL updates the team on the identification type of TB and sensitivities so that treatment is tailored accordingly. Our TB MDT offers clinicians from around the country the opportunity to discuss their patients also when they are seeking our expert input and advice. All MDT outcomes are documented on our Electronic Patient Record (EPR) system by the TB CNS. The TB service holds weekly outpatient clinics, twice weekly ward rounds and a fortnightly Nurse Led Latent TB clinic. We also offer urgent walk in reviews outside of clinic times.

Adherence

Building strong relationships with the patient is vital in order to promote adherence to treatment. Adherence to TB medication is paramount to a successful treatment outcome. Non-adherence can occur for many reasons. E.g. stigma, side effects of medications, chaotic lifestyle, denial of the TB diagnosis and lengthy treatment course. Treatment duration for active TB can be for a minimum of 6 months but in the case of Multi Drug Resistance TB can be 18 months.

Having a point of contact for each patient ensures that there is always someone available to answer questions/concerns. Each patient is given contact details of the TB CNS and are encouraged make contact if issues arise. Non-adherence to TB treatment may result in onward transmission, ill health, preventable death and drug resistance. Therefore, it is important that any issues are resolved promptly in order that the patient continues taking their medications. Our TB service offers patients urgent reviews outside of routine clinic times to facilitate this.

To ensure adherence some patients (as per Health Protection Surveillance Centre Guidelines 2010) require Directly Observed Therapy (DOTS). This involves the TB CNS referring the patient to the Public Health Nurse (PHN). PHN will observe the patient taking their TB medication each day. In this instance the TB CNS in collaboration with the PHN promote adherence.

Patient Monitoring and Follow up

Due to the potential hepatotoxicity of TB medications, patients require frequent blood monitoring. This is done at baseline and 4-6 weekly intervals. TB CNS monitors these results and decisions are made if patient’s need to temporarily hold TB medications or requires a change in medications. As hepatotoxicity can occur at any time point of the treatment course. So close blood monitoring is continued for duration of treatment. Some patients require therapeutic drug monitoring (TDM). This involves taking numerous blood tests at certain time interval’s throughout the day, which the TB CNS carriers out. TBM is important if a patient fails to improve as expected (and nonadherence is not an issue) or there is a question of malabsorption. Other side effects such as nausea/ vomiting, peripheral neuropathy, rash can also occur which require prompt evaluation.

Patients are encouraged to not miss any of their clinic appointments as our TB medications are dispensed from clinic. Any patient who fails to attend will get a phone call from the TB CNS and another appointment is facilitated as soon as possible. This ensures adherence to treatment.

Education

All patients with a new diagnosis of active TB/Latent TB meet the TB CNS and receive education on their diagnosis and treatment plan. Often, they request that family members are spoken with, which is beneficial to the patient as family members are an important support network. Patients are encouraged to contact the TB CNS with any questions.

Lectures and education session are also given by the TB CNS to other health care professionals who may be involved in the care of pts with TB. This includes other hospitals, community colleagues and also University’s. Stigma is still evident in relation to a TB diagnosis in Ireland and many of our patients have reported been ostracized from family and friends. Only through awareness and continued education will this be eliminated. One positive to arise from the Covid pandemic is that the wearing of face masks has been normalized. Prior to this our patients would have felt very vulnerable and self-conscious with wearing masks when there was potential of onward transmission of TB.

Advocacy

There is a requirement for the TB CNS to regularly advocate on patients behalf. This can arise due to issues with employment and sick leave, accommodation or financial issues. The TB CNS has close links with social work department, Inclusion health, safety net and other agencies in order to advocate on behalf of the patients if required.

Research

Audit and research is an integral part of the TB CNS role to ensure that we provide the best possible service to our patients. Currently the TB CNS is principal investigator on a research study into Video Observed Therapy (VOT) and comparing it to DOTS. VOT is the use of a mobile app for patients to record themselves taking their medication to ensure treatment compliance. This research study will therefore be conducted over two years.

TB is a complex disease and requires expert input in order to have a successful outcome. Therefore the TB CNS along with MDT colleagues play a vital role in ensuring that only the highest standard of care is afforded to the patient and that all patients receive the most appropriate TB investigation’s, treatment and support.

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