Reduction of client waiting time using task shifting in an anti-retroviral clinic at Specialist Hospital Bauchi, Nigeria

Abstract

Aiming to assess the impact of the intervention in reducing the patients' waiting time in the clinic, two surveys were conducted before and after task shifting intervention in an anti-retroviral (ARV) clinic at the Specialist Hospital, Bauchi, Nigeria in November 2008 and April 2009, respectively. Before the task shifting, six nurses from the clinic were trained on integrated management of adolescent and adult illness, as well as on the principle and guidelines for the anti-retroviral therapy, after which their schedule in the clinic was broadened to include seeing HIV patients presenting for routine refill and follow-up visits. In this study, fifty-six and sixty patients, respectively out of 186 and 202 who attended the clinic on the days of the pre- and post-intervention surveys, were randomly sampled. Data on patients' sex, age and marital status, whether patient a first timer or follow up visitor and the time spent in the clinic on that day as well as the number and composition of staff and equipment in the clinic was collected. The difference in waiting time spent between the first group before task shifting and second group after task shifting was statistically analyzed and significance tested using unpaired t-test. There was a reduction in the average waiting time for patients attending the clinic from 6.48 h before task shifting to 4.35 h after task shifting. The difference of mean was −2.13 h, with 95% CI: −2.44:−1.82 hours and the test of significance by unpaired t-test P<0.0001.

Introduction

Sub-Saharan Africa bears the largest burden of diseases per unit population,¹ and incidentally its the region in the world with the most pronounced crisis in human resources for health: 36 of the 57 countries that now face health worker shortages are in Africa.² Obviously, the situation becomes worst with persistence of HIV pandemic across the region.³

Much interest has recently been paid to how to streamline HIV care, both to offer high-quality care to patients and expand access to care.^4–6 One response to this shortage has been the reassignment of clinical roles by shifting tasks to different cadres of health workers, for instance nurses may become involved in prescribing drugs to particular group of patients,^2,7 counselors may get trained to test for HIV or patients may be engaged to take over some elements of their own care.^4,5

The potential for task shifting in HIV care was elaborated by the World Health Organization's 2004 publication of Integrated Management of Adult and Adolescent Illness guidelines, which recommended nurses and clinical aids be trained to provide primary care for HIV.⁸ In 2008, this potential was expanded and formalized by the WHO/UNAIDS/PEPFAR guidelines for the implementation of task shifting² as an immediate way to address staff shortages while delivering good quality care. The objective of task shifting is to mainstream HIV care by allocation responsibility across cadres of staff in facilities based patients' needs and the capacities of the staff while maintaining quality standards for patients and increasing access to interventions.^2,8–12

Bauchi state is located in the north-eastern geopolitical region of Nigeria in West Africa, with a population of about 4.6 million people¹³ and estimated HIV prevalence rate of about 3.8%,^14,15 which means about 175,000 people with HIV in the state. There are 7 anti-retroviral drugs treatment (ART) clinics in the State.

In these clinics, the practice is for doctors' initiate and monitor ART, while nurses provide adherence counseling for patients starting the ART regiment and those already enrolled when necessary.

It's observed that patients spent long time waiting to receive services in the clinic due to the high burden of patients per doctor. This observation could affect the health seeking behavior of patients in variety of ways.¹⁶ This situation therefore makes the idea of task shifting not only interesting but a necessity.

Materials and Methods

Aiming to assess the impact of the intervention in reducing the patients' waiting time in the clinic, two surveys were conducted before and after task shifting intervention in an ARV clinic at the Specialist Hospital, Bauchi, Nigeria in November 2008 and April 2009, respectively.

In this study, we randomly selected and sampled 56 and 60 patients, respectively out of 186 and 202 who attended the clinic on the days of the pre- and post-intervention surveys. Data on patients' sex, age and marital status, whether patient a first timer or follow up visitor and the time spent in the clinic on that day, as well as the number and composition of staff and equipment in the clinic was collected. The difference in waiting time spent between the first group before task shifting and second group after task shifting was statistically analyzed and significance tested using unpaired t-test. The number and quality of staff and equipment in the study have been controlled by ensuring that the same staff and equipment were available during both the pre- and post-intervention surveys. Ethical approval for this research was sought and granted by the appropriate ethical approval committee.

Setting

This study was conducted in Specialist Hospital, which is one of the ART sites in Bauchi State, Nigeria. About 4800 HIV+ patients are enrolled for ARV treatment in the facility as at 30 October, 2009. There are usually about 3–4 doctors, about 7–8 nurses, and about 3–4 support staff in the clinic, at any clinic day. The clinic attends to about 200 patients daily.

Patients waiting time before task shifting, t1

Fifty six patients were randomly selected from the pool of patients lined up to receive services at the clinic on 5 November 2008. Participants were informed on the study and their consents were sought and documented.

The time these patients came and joint the queue was asked and recoded (t1a).

Patients were then tagged and informed that at the end of the clinic session, he or she will be given a T-shirt as an incentive for participation in this study.

Patients were subsequently tracked and immediately after been attended to, time was recorded (t1b).

The total time spent during visit (waiting time) is equal to: t1= t1b – t1a.

Task shifting

A two weeks training was organized and sponsored by the Bauchi State Agency for the control of HI, Tuberculosis and Malaria (BACATMA) for the ART clinic nurses (6 nurses from the Study clinic) on the Integrated Management of Adolescent and Adult illness (IMAI), and during this training, they were introduced to the HIV/AIDS National ART principles and guidelines. After this training, the schedule for nurses in the ART clinic was broadened from providing only adherence counseling to include seeing patients on follow-up visits without any clinical complaint, normally coming in for refill with CD4 count of 350 or higher. All new patients and those with complaints or a CD4 count less than 350 were followed by doctors. A triage nurse, who is also the clinic manager, screens patients to filter based on patients' weight, other vital signs, the CD 4 count and whether patient is coming in with any complaint or not. Patients are subsequently asked to join the appropriate queue.

Patients waiting time after task shifting, t2

Sixty patients (30 from nurses queue and 30 from doctors queue) were randomly selected from the pool of patients lined up to receive services at the clinic on April 2, 2009. Participants got informed on the study and their consents were sought and documented. The time these patients came and joint the queue was asked and recorded (t2a). Patients were then tagged and informed that at the end of the clinic session, he or she will be given a T- shirt as an incentive for participation in this study. Patients were subsequently tracked and immediately after been attended to, time was recorded (t2b). The total time spent during visit (waiting time) is equal to: t2= t2b − t2a.

Analysis

The average ‘waiting time’ for patients before (t1) and after task shifting (t2) was calculated. The difference between these values was calculated, and the statistical significance of this difference was tested by unpaired t-test. ScienceDirect statistics software was used for this analysis.

Results

Pre-intervention survey

About 16% (9) of the patients were first timers, 84% (47) follow up patients, 45% (25) were female and 55% (31) male, 36% (20) were married, 13% (7) were either divorced or separated, and 17% (10) were widows or widowers, and 34% (19) were single.

Patient's average waiting time was estimated at about 6.48 h (range 2.50–9.9 h, SD 1.87).

Post intervention survey

About 18% (11) of the patients were first timer and 82% (49) follow up patients, 50% (30) were female and 50% (30) male, 45% (27) were married, 10% (6) were either divorced or separated, 10% (6) were either widows or widowers and 35% (21) were single. Patient's average waiting time was estimated at about 4.35 h (range 2.50–6.0 h, SD 1.23) (Table 1).

Table 1. Comparison of the pre- and post-intervention sample population and observed waiting time.

	Pre-task shifting survey	Post-task shifting survey
Study population (n)	56	60
Total patient population (N)	186	202
First timers % (number)	16% (9)	18% (11 patients)
Follow ups patient % (number)	84% (47)	82% (49 patients)
Female % (number)	5% (25)	50 % (30 patients)
Male % (number)	55% (31)	50% (30 patients)
Married % (number)	36% (20)	45% (27)
Divorced or separated % (number)	13% (7)	10% (6)
Either widows or widowers % (number)	17% (10)	10% (6)
Single patients % (number)	34% (19)	35% (21)
	34% (19)
Average waiting time % (number)	6.48 h	4.35 h
	(2.50–9.9 h, SD 1.87 h)	(2.50–6.0 h, SD 1.23 h)

Impact of the intervention

There was a reduction in the average waiting time for patients attending the clinic from 6.48 h before task shifting to 4.35 h after task shifting. The difference of mean was −2.13 h with 95% CI: −2.44:−1.82 h and the test of significance by unpaired t-test gave a P<0.0001.

Discussion

The main findings in this study is a 2.13 h (which is about 2 h, 8 min) ‘task shifting’ attributable reduction in the ‘waiting time’ for HIV patients attending ARV clinic, and a P<0.0001 suggesting a strong statistical significance for this finding.

These findings means task shifting by redistribution of responsibilities from doctors to nurses without necessarily compromising quality of care could be time and resources saving for both patients and staff.

These results add evidence to the calls for adoption of task shifting towards a nurse-centered HIV care rather than the popular physician centered model as an effective approach to alleviate the severe physician shortages that currently hinders HIV treatment scale-up in many resource limited settings.^4,10,17,18

Some earlier studies reported the potentials of task shifting as not only cost effective but a cost saving approach to achieve universal access to care by HIV patients.^6,7,10,19,20

The potential confounders in this study are social and individual factors, such as the time spent by some patients discussing non relevant issues with the attending, thereby prolonging consultation time for him/herself and others, and also bias by the attending, been conscious of the study taking place.

Conclusions

Task shifting is an effective approach for addressing shortages of doctors in HIV treatment settings. It offers opportunity for quality care to more patients than the popular physician-centered model of ARV treatment. However, the main challenge is in ensuring proper training for the nurses before stating the new task.