Reflexión y Arquitectura del Software

The sub-themes of the processes in the TB-STS that emerged from the interviews are summarised in Figure 35.

113

Decision-making processes

The interviews identified variation between the HPUs in the way the strain typing information is reviewed and stored, and the gathering of information that constitutes a cluster investigation.

In some areas, the strain typing information was reviewed thoroughly before decisions were made about cluster investigations. This process involved the CCDC lead, the Handbook, advice from colleagues (often including a TB nurse) and the advice of the cluster investigator (CI), and a handful of HPUs had monthly multi- disciplinary meetings where they discussed clusters. In contrast to this holistic approach, there were many HPUs where they relied more thoroughly on the advice of the CI. One HPU reported the involvement of the regional lead, who would review the clusters and give them guidance on the next steps.

“Use professional judgement, Handbook and the advice of the Cluster Investigator and other colleagues.” (CCDC, Low TB incidence)

“We follow the recommendation on the report.” (CCDC, Low TB incidence)

“We rely on a monthly meeting…we look at cases and clusters and see what we should prioritise.” (CCDC, Low TB incidence)

Because many HPUs followed the advice of the CIs, the thresholds for investigation were less relevant to them as they were not taking decisions about whether to investigate themselves. One respondent felt the thresholds, in terms of the number of cases, were appropriate but that the risk factors for early investigation were not. Others found that the thresholds were sometimes appropriate and sometimes inappropriate. Specifically, many low TB incidence areas reported investigating clusters under the threshold, whereas the high TB incidence areas followed the thresholds more closely. Similarly, some people found the Handbook a useful reference tool, whereas others did not use it at all as they would just follow the advice of the CI.

114 “I don't know if we've paid much attention to the thresholds. They haven't

necessarily impacted on what we've done because two [cases] in certain circumstances might be enough to trigger some action whereas if a cluster of four turns to five it might not be a difference.” (CCDC, Low TB incidence)

“We have the luxury to spend more time to have a quick look if they are potentially linked. We have a lower margin to look at it. We work it [the threshold] as appropriate in our area.” (Senior Nurse Specialist and Regional TB Lead, Low TB incidence)

“Strict about thresholds and liaise with [the CI]…unless we've already picked up some links ourselves through incident management.” (Nurse Specialist, High TB incidence)

“Actually we wait for [the CI]. I don't think we have used the guidelines as such.” (CCDC, Medium TB incidence)

Some of the HPUs that were more involved in the decision-making process had also developed a local cluster monitoring database. In these areas, the HPUs mirrored the role of the cluster investigator and carried out a preliminary cluster review by linking the cluster information to information held locally and on the ETS. This was not a widespread activity and tended to be only in low TB incidence areas.

“Even before we receive the report…we keep an eye on the VNTR and within the unit we create a spreadsheet…and then on an ad hoc basis we can look at it.” (CCDC, Low TB incidence HPU)

“[The London laboratory] sends out monthly spreadsheets. I look to see what is going on in the area. If there is a new cluster I will look at it, even if it is less than the Handbook threshold. I investigate connections between people using ETS, HPZone, ask TB nurses. I organise a meeting to see if we need to take public health action. The cluster report is generated…and I go through the same process.” (Health Protection Nurse and TB Lead, Low TB incidence HPU)

115

Information gathering

There were four main routes of information gathering and TB nurses were critical to them all:

1. Direct contact between the HPU and patients (sometimes through TB nurses);

2. Delegating the cluster investigation to TB nurses and asking them to liaise between themselves;

3. Through multidisciplinary cluster meetings; and

4. By changing contact tracing practices.

The most significant of these was the changing contact tracing practices so that the information that may eventually be required for a cluster investigation was collected when the patient was first diagnosed. Not many HPUs have attempted this change, but many see the value in gathering the information at the earliest possible moment. This change in practice came about in response to nurses being asked to complete cluster questionnaires after their patients had finished treatment, making it difficult to contact them and/or the contact being traumatic for the patient.

“Some of the TB nurse teams have already incorporated the content of the questionnaire into their normal screening process.” (CCDC and Regional TB Lead, Medium TB incidence)

The HPUs that took decisions at monthly meetings would gather some of the information at the meeting because the TB nurses, physicians, microbiologist and HPU are all present to fill in any information gaps.

“I circulate it to all my TB nurses so they all have a copy and I forward on to others as necessary. I ask them for feedback if there is anything pertinent to tell me, otherwise every other month we go through each report cluster by

116 cluster and if there is anything significant we will report it back.” (CCDC,

Medium TB incidence)

Where monthly meetings did not take place, communication with the TB nurses appeared to be either active or passive. Some HPUs spoke with nurses directly on the phone or arranged to go and see them to gather the information, whereas others “just pass it on to the TB nurses…and ask the TB nurse to liaise with the other areas”. There was a distinction between the willingness of HPUs and nurses to collect the information based on whether the TB patient was still on the books or whether they had finished their treatment and had been discharged. A strategy adopted by one HPU was to “email the nurse if the case if from a while ago and ask them to look at their notes to see if anything relevant sticks out…if the case is current I’ll ring straight up”.

“We have done quite a bit of work getting a standardised form for TB nurses to use so that they are collecting person, place and time information up front. They've adapted the questionnaire but I cannot give you assurance that it is being implemented properly. In my area the service doesn't see it as a priority. If the patients are still on the books and we think there is a cluster growing we'll ask them for details”. (CCDC, Low TB incidence)

The cluster questionnaire (used as a template to gather more information as part of a cluster investigation) was used in some areas and not others. It was deemed useful because it provided a framework for gathering more information and some areas had developed their own local questionnaire based on the cluster questionnaire provided. However, some people talked about the questionnaires being “sent out of the blue”, without any further communication or explanation so some nurses “didn’t know what to do with them”.