Clinical Mentorship of Nurse-Initiated Antiretroviral Therapy in Khayelitsha, South Africa: A Quality of Care Assessment
Author: Ann Green annfordgreen@gmail.com
Green, Ann1; de Azevedo, Virginia2; Patten, Gabriela3; Davies, Mary-Ann4; Ibeto, Mary3; Cox, Vivian3 1University 4University
of Cape Town School of Public Health and Family Medicine; 2City of Cape Town Department of Health; 3Médecins Sans Frontières Khayelitsha; of Cape Town Centre for Infectious Disease Epidemiology and Research
Background South Africa’s National Strategic Plan calls for task shifting of HIV care from doctors to nurses by 2016 to increase access to antiretroviral therapy (ART). There is little research demonstrating sustainable success of competent HIV management by nurses after training and mentorship. In February 2011, Medecins Sans Frontieres (MSF) partnered with the City of Cape Town Department of Health to implement a nurse initiation and management of antiretroviral therapy (NIMART) mentorship programme and assess the quality of clinical care provided by nurses after mentorship.
Aims To describe the characteristics of ART initiations done by nurse graduates of the MSF NIMART mentorship programme; To measure the quality of nurse initiations and long term clinical management of patients continuing ART in Khayelitsha primary health care clinics.
Methods • A before-after study was conducted on nurses completing mentorship from February 2011 to September 2012. • Routine clinical data from 229 patient folders was collected to determine the following: • The number of patients initiated on ART by individual nurses; • The quality of ART management before and after mentorship, and the quality of ART initiations; • The patient characteristics for doctor and nurse ART initiations. • Data from self-administered questionnaires completed by 21 nurses was used to assess nurse confidence to initiate and manage ART. Indicator % Before % After ART start date recorded 100 98.8 Treatment plan documented for patients with viral load > 400 50 33.3 Creatinine clearance recorded 17.56 15.4 Documented result of most recent bloods 92.5 93.8 Last required bloods drawn 91.25 98.8 Tuberculosis symptom screen performed 82.89 91.9 Sexually transmitted infection screen performed 88.75 93.8 Family planning offered 58.93 67.3 Pap smear recorded /referenced 6.67 10.5 Clinical presentation entered 100 100 Problem list entered 41.25 45 Adherence assessed and documented 50 77.5 Stage entered 62.5 91.3 Stage correlates with known medical history 88 79.5 Treatment plan documented 72.5 82.5 Referred to doctor 1.25 2.5 Medication plan entered 100 100 ART dosing entered correctly 80 80 Cotrimoxazole prescribed 15 10 Table 1: Documentation of clinical indicators from patient folders (n=80) before and after primary care nurses completed the mentorship programme in Khayelitsha, South Africa, 2011-2012. Indicators in bold are those that differed significantly (p<0.05).
Results 300
90% 80%
250
70%
200
60% 50%
150
40%
100
30% 20%
50
10%
0
0%
# Nurse initiations
Total # Initiations
% nurse initiated
Figure 1: Total ART initiations and nurse initiations per month at City of Cape Town primary health care clinics in Khayelitsha, South Africa. 2011-2012.
• 21 nurses were authorized by one nurse mentor with one part-time medical officer support, resulting in nurses initiating 77% of eligible patients by August 2012. • Improvements in ART management were found for drawing required bloods (91% vs 99%, p=0.03), assessing adherence (50% vs 78%, p<0.001) and WHO staging (63% vs 91%, p<0.001) (Table 1). • Clinical indicators recorded at ART initiation were successfully completed by nurses for a majority of indicators evaluated (Table 2). • Family planning, creatinine clearance, cervical cancer screening and accurate cotrimoxazole prescription were poorly documented by nurses. • Doctors initiated more TB/HIV co-infected patients and those with WHO stage 3 or 4 disease than nurses; 24% of patients initiated by nurses were seen or discussed with a doctor in the month prior to initiation. • Nurse confidence in managing and initiating ART improved significantly, in particular for the management of HIV-infected children. Clinical indicators evaluated at ART initiation by nurses
% completion
Patient weight, baseline CD4 count, creatinine, haemoglobin, WHO staging, STI screening, accurate medication list, clinical presentation, ART initiation date, return date
>95%
Past medical history, prior ART history, treatment plan
90-95%
Patient body mass index, alanine aminotransferase (ALT), TB screening, family planning offered if eligible, problem list completed, correct ART dosing in treatment plan
70-90%
Creatinine clearance, correct cotrimoxazole prescription
50-60%
Pap smear documented
<30%
Table 2: Documentation of clinical indicators by nurses at the date of ART initiation after completion of the nurse mentorship programme.
Conclusions Implementation of a nurse mentor driven NIMART mentorship programme led to competent nurse initiation or referral of a majority of eligible patients. Mentorship can ensure the quality of nurse led HIV care and management with minimal resource allocation from ART programmes. This sub-district led, goal oriented approach is a successful pilot of translating NIMART policy into practice, and could serve other health programmes in resource limited settings.
Acknowledgements
MSF nurse mentors with City of Cape Town NIMART mentorship graduates during a feedback session on NIMART implementation in the clinics.
To Nikiwe Mkhosana and Nombulelo Raphahlelo for their tireless assistance in locating patient folders. To the dedicated staff at Khayelitsha City clinics involved in the study. To the NIMART nurses, for their dedication in providing high quality, accessible patient care to the people of Khayelitsha.