Nagata Yoko, Urakawa Minako, Kobayashi Noriko, Kato Seiya
Kekkaku. 2014 Apr;89(4):495-502.
A directly observed treatment short course (DOTS) trial was launched in Japan in the late 1990s and targeted patients with social depression at urban areas. Based on these findings, the Ministry of Health, Labour and Welfare established the Japanese DOTS Strategy in 2003, which is a comprehensive support service ensuring the adherence of tuberculosis patients to drug administration. DOTS services are initially provided at the hospital to patients with infectious tuberculosis who are hospitalized according to the Infectious Diseases Control Law. After being discharged from the hospital, the patients are referred to a public health center. However, a survey conducted in 2008 indicated that all the patients do not receive appropriate DOTS services at some hospitals. In the present study, we aimed to evaluate the protocols and workload of DOTS at hospitals that are actively involved in tuberculosis medical practice, including DOTS, to assess whether the hospital DOTS services were adequate.
We reviewed a series of articles on hospital DOTS from a Japanese journal on nursing for tuberculosis patients and identified 25 activities regarding the hospital DOTS service. These 25 items were then classified into 3 categories: health education to patients, support for adherence, and coordination with the health center. In total, 20 hospitals that had > 20 authorized tuberculosis beds were selected--while considering the geographical balance, schedule of this survey, etc.--from 33 hospitals where an ex-trainee of the tuberculosis control expert training program in the Research Institute of Tuberculosis (RIT) was working and 20 hospitals that had collaborated with our previous survey on tuberculosis medical facilities. All the staff associated with the DOTS service were asked to record the total working time as well as the time spent for each activity. The data were collected and analyzed at the RIT.
The working times for each activity of the DOTS service for nurses, pharmacists, ward clerks, head nurses, and doctors were 100, 90, 87, 86, and 63 min, respectively. For other professions, including medical social workers, nursing aids, nutritionists, and physical therapists, the working times for each activity of the DOTS service were 31, 18, 10, and 8 min, respectively. The professionals who spent a longer time on health education, support for patient adherence, and coordination with the health center were pharmacists, doctors, and head nurses; nurses, pharmacists, and doctors; and head nurses, doctors, and ward clerks, respectively.
Aging of tuberculosis patients was associated with problems on adherence in many patients, including patients who were not suited for a standard regimen, patients whose activity of daily life had deteriorated due to senile dementia, patients with diabetes mellitus, etc. Smoking cessation and mental care for cases of multi-drug resistant disease are new challenges in tuberculosis patient care. The present study clearly indicated that activities including patient education, support for patient adherence, and coordination with the health center--essential components of the hospital DOTS service according to the Japanese DOTS Strategy--were performed by a team of professionals including doctors, nurses, pharmacists, medical social workers, etc., depending on the features and roles that they serve and the needs of each patient. For good practice of hospital DOTS, it is essential to not only provide DOTS, but also effectively provide individual or group health education and coordinate with health centers, thus aiming towards a better community DOTS service after patient discharge.
20世纪90年代末，日本启动了一项直接观察短程治疗（DOTS）试验，目标是城市地区患有社交性抑郁症的患者。基于这些研究结果，厚生劳动省于2003年制定了日本DOTS战略，这是一项全面的支持服务，可确保结核病患者坚持服药。DOTS服务最初在医院为根据《传染病防治法》住院的传染性结核病患者提供。患者出院后，会被转介到公共卫生中心。然而，2008年进行的一项调查表明，一些医院并非所有患者都能获得适当的DOTS服务。在本研究中，我们旨在评估积极参与结核病医疗实践（包括DOTS）的医院中DOTS的方案和工作量，以评估医院的DOTS服务是否充足。
我们查阅了一本日本结核病患者护理杂志上一系列关于医院DOTS的文章，确定了与医院DOTS服务相关的25项活动。然后将这25项内容分为3类：对患者的健康教育、对依从性的支持以及与卫生中心的协调。总共从33家结核病研究所（RIT）结核病控制专家培训项目的前学员所在的医院以及20家曾与我们之前关于结核病医疗设施调查合作的医院中，考虑地理平衡、本次调查的时间安排等因素，挑选出20家拥有超过20张核定结核病床位的医院。所有参与DOTS服务的工作人员都被要求记录总工作时间以及每项活动所花费的时间。数据在RIT收集和分析。
护士、药剂师、病房办事员、护士长和医生在DOTS服务每项活动上的工作时间分别为100分钟、90分钟、87分钟、86分钟和63分钟。对于其他职业，包括医务社会工作者、护理辅助人员、营养师和物理治疗师，DOTS服务每项活动的工作时间分别为31分钟、18分钟、10分钟和8分钟。在健康教育、支持患者依从性以及与卫生中心协调方面花费时间较长的专业人员分别是药剂师、医生和护士长；护士、药剂师和医生；以及护士长、医生和病房办事员。
结核病患者的老龄化与许多患者的依从性问题相关，包括不适合标准治疗方案的患者、因老年痴呆导致日常生活活动能力下降的患者、糖尿病患者等。戒烟以及对耐多药病例的心理护理是结核病患者护理中的新挑战。本研究清楚地表明，根据日本DOTS战略，患者教育、支持患者依从性以及与卫生中心协调等活动——医院DOTS服务的重要组成部分——由医生、护士、药剂师、医务社会工作者等专业人员团队根据他们所服务的特点和角色以及每个患者的需求来执行。为了做好医院DOTS工作，不仅要提供DOTS，还必须有效地提供个体或团体健康教育并与卫生中心协调，从而在患者出院后实现更好的社区DOTS服务。
