Implementation of effective screening for tuberculosis at Birmingham Prison. A tool was developed that was systematic and methodical. The tool was shared by two diverse stakeholders: healthcare staff and prison security staff.
This example was originally submitted demonstrating implementation of NICE guideline CG117. The example has been assessed by the team and remains in line with the updated NICE guideline NG33.
Aims and objectives
Aims and Objectives:
- To provide screening for Mycobacterium tuberculosis according to NICE guidance, leading to earlier treatment for Mycobacterium tuberculosis (M. tuberculosis). I also referred to NICE Public Health Guidance 37 (March 2012).
- To address a marked and understandable difference between the priorities of the prison and those of the healthcare staff. Prison staff and Healthcare staff may have different criteria for health conditions. Infection Prevention & Control Guidance may be poorly understood by prison staff.
- To address the prison regime does not allow for time to do the most thorough assessments on admission.
- To address that transfer of prisoners is often made suddenly with little warning, or their destination is not initially disclosed for security reasons.
Reasons for implementing your project
Healthcare services at the city prison are provided by the local Primary Care Trust in partnership with the local Mental Health Trust. Birmingham Prison has capacity for 1500 prisoners: short & long term (remanded and convicted).
Prison populations have a higher incidence of Mycobacterium tuberculosis than the general population including multiple risk factors for Mycobacterium Tuberculosis e.g. drug use, smoking, alcohol, poor living conditions, chaotic lifestyle, poor nutrition, ethnicity, immigrants (sometimes illegal), mental illness, HIV infection. Importantly, Tuberculosis symptoms may be masked by lifestyle. In-addition a prisoner's compliance with medication may be poor. There is a higher incidence of poor compliance in the prison population than the general population. Poor compliance may be related to the prisoner's risk factors Prisons are closed institutions. This promotes the time of close contact between individuals and increase the risk of transmission of infection from one person to other persons in the building.
A baseline analysis found the following problems:
- Assessment of Prisoners health needs: Limited time to assess prisoners on admission, often due to the amount arriving at the same time & the lateness in the day. Late in the day arrivals (from court) may have problems with prescribing & obtaining medication.
- Computerised record not always flagged to indicate possible infection risk.
- Very restricted times for dispensing of medication on wings. Prisoners may miss doses of medication if they are away from the area. Directly observed therapy (DOT) is advised but some prisoners see this as taking away a piece of their remaining independence. Visits to respiratory specialist / chest clinic may be difficult due to constraints of prison regime.
- Prisoners may be known to the community TB team, but use different names.
- Some prisoners are economical with the truth, and may state they have symptoms of MTB when this is not actually the case.
- Problems with continuing treatment on release. Transfers out may be made suddenly with little warning making discharge planning challenging. Prisoners may give unreliable information & be inconsistent with taking medication or attending follow up appointments.
How did you implement the project
A formal implementation of this section of NICE guidance took place in 2011-12.
From NICE NG33, specific recommendations:
- Section 1.1.1 - and relevant sub sections
From PH37 - Recommendations 9 & 10 Identifying/managing active TB in prisons or immigrant removal centres.
We ensured that all of these guidelines were included in our initial screening & follow up.
A review of the current admission procedure and screening questionnaire was undertaken. A gap analysis was carried out to highlight weaknesses in the current system. A review of the computerised medical records and a meeting with the Health Protection Unit and other staff took place. There was further development of the trust guidelines for Mycobacterium tuberculosis. Although these already contained a section specifically for the prison, further guidance was developed to try to ensure that appropriate screening and referrals always happen despite a limited time frame. Methods of communication were examined and areas for improvement highlighted and acted upon.
Birmingham Prison-Birmingham Community Healthcare:Tuberculosis Screening Questionnaire:
1). Is the inmate currently on treatment for:
(i) TB disease?
(ii) Latent TB infection
2). Check for presence of the following symptoms:
- Cough for more than 3-4 weeks
- Coughing up blood
- Night sweats
- Recent loss of weight without trying
- Poor energy
- Loss of appetite
3). Is the inmate from a high incidence country or has the inmate been in a high incidence country for more than three months in the last year?
4. Has the inmate had TB in the past? (get details when, treatment received etc)
5. Has the inmate had contact with anybody with TB in the last 5 years?
6. Has the inmate had a history of street homelessness at any stage?
7. Has the inmate a history of drug abuse?
8. Has the inmate a history of alcohol abuse?
9. Is there a history of previous imprisonment? (When & which prison?)
10. Has the prisoner a history of mental health issues?
Guidelines were reviewed to include more specific guidance for prison healthcare staff. A Standard Operating Procedure was developed to further assist the screening process. The computerised health record system and the Inmate Medical Record (IMR) are now flagged to alert any Mycobacterium tuberculosis.
Information (screening, results, treatment, etc). This has resulted in a reduced risk of delayed diagnosis and improved follow up of admissions, transfers and discharges in to the community. It is recognised that this is very much a work in progress. Continued efforts will be made by the multi-disciplinary team to further improve communication with all parties.
Close work with the prison staff and the combining of prison and healthcare aims and objectives will further improve care of prisoners with Mycobacterium tuberculosis and hopefully improve compliance with treatment. It is hoped that creating increased prisoner and prison staff awareness will further assist in prompt diagnosis and successful treatment.
Closer liaison with the staff of the Birmingham Specialist Tuberculosis Nursing Team is planned to form robust guidelines regarding the length of time that prisoners are isolated in Healthcare and when it is appropriate for prisoners to return to the main wings of the prison.
For further evaluation information please see the supporting material.
Key learning points
- NICE guidance provides an accessible template for service transformation, in this case, screening for tuberculosis in Birmingham Prison.
- A methodological service transformation approach (NHS Institute) enables the guidance to be embedded.
- The effective legacy of implementing the guidance are new systems and tools (e.g. flagging on I.T systems and tuberculosis screening tool).
- Engaging all stakeholders in a series of transformation meetings reduced implementation barriers and led to improved working relations generally and for other specific projects.