Decentralisation of MDR-TB care in rural South Africa: Overcoming the challenges through quality improvement

Introduction: As the management of MDR-TB expands and is decentralised to resource-limited settings, ensuring that patients are managed in line with country guidelines optimises the chances of cure, and minimises transmission and development of further resistance. We aimed to develop sustainable quality MDR-TB services in a rural South African district hospital clinic. Methods: Four areas requiring improvement were identified: a poorly trained MDR-TB clinical team, recording of the nutritional status of patients, monitoring patients' response to treatment and drug side-effect monitoring. Changes were implemented over Plan-Do-Study-Act cycles over three months. Interventions included identifying and training nursing staff, creating a body mass index (BMI) measurement area, and introducing drug monitoring guidelines. Results: Improvements were noted across all areas. The number of MDR-TB-trained clinic nurses increased over three months (from 20% to 90%). Increases were also seen in the proportion of patient BMIs recorded (0% to 87%) and of appropriate dietician referrals (0% to 75%). The proportion of smear results available, visual acuity tests and ECGs performed, prior to doctor review, increased over the 3-month period from 0% to 68%, 31% to 94%, and 75% to 89% respectively. Conclusion: Through multidisciplinary collaboration and iterative changes, it was possible to develop a strong clinical team and improve care of MDR-TB patients. Lessons learnt can be applied to similar challenges facing district hospitals caring for complex patients.