Audit klinik untuk evaluasi kualitas penatalaksanaan TBC di Rumah Sakit Pusat Angkatan Darat Gatot Subroto

KOMARIAH, Oom, dr. Adi Utarini, M.Sc.,MPH.,Ph.D

2008 | Tesis | S2 Ilmu Kesehatan Masyarakat (Manaj. Rumah Sakit)

Latar belakang : Tuberculosis adalah penyakit yang mudah menular dan merupakan masalah kesehatan di dunia. Tahun 1995 WHO mencanangkan strategi DOTS adalah strategi yang paling cost effective. Di Indonesia, baru 29% dari seluruh rumah sakit yang telah menerapkan strategi DOTS. Meskipun rumah sakit telah menyatakan menerapkan strategi DOTS, akan tetapi belum sepenuhnya menerapkan strategi ini bagi seluruh penderita TBC. Tujuan : Untuk mengevaluasi kualitas penatalaksanaan TBC, kualitas diagnosis, kualitas pengobatan, kualitas tanggung jawab kesehatan masyarakat, mengukur pencapaian indikator program TBC di RSPAD Gatot Soebroto dengan audit klinik dan untuk menjelaskan kaitan antara hasil audit klinik dengan pencapaian indikator program TBC. Metode : Merupakan penelitian studi kasus eksplanatori. Instumen penelitian menggunakan check list audit klinik menurut Pedoman Penanggulangan TBC dar Depkes 2006, Standar ISTC dari Hopewell 2002 dan Clinical Pathways for Ambulatory Care Case Management dari Howe 1996; serta panduan wawancara. Hasil Penelitian : Kriteria ketepatan diagnosis penyimpangan tertinggi aspek identifikasi faktor risiko HIV (95%) dan penyimpangan terkecil aspek klasifikasi penyakit (11%). Untuk kriteria kesesuaian pengobatan penyimpangan terbesar dan terkecil masing-masing adalah edukasi TB, risiko dan pengobatannya (100%) dan pemantauan hasil pengobatan melalui LED (4%), dan untuk kriteria kesesuaian terhadap kesehatan masyarakat, penyimpangan pemeriksaan keluarga 100%, serta penyimpanganlaporan ke Dinkes 43%. Pencapaian indikator program TBC strategi DOTS di RSPAD Gatot Soebroto periode Januari sampai Juni 2006 adalah : proporsi pasien TBC BTA positif diantara semua pasien TB Paru tercatat 41,8%, conversion rate 43,75%, error rate tidak dapat dihitung karena tidak pernah dilakukan cross check pemeriksaan laboratorium, treatment success rate 94,45% dan DO rate 0. Antara hasil audit klinik dengan pencapaian indikator program TB hasilnya ada yang tidak sesuai yaitu TSR dengan jenis dan dosis OAT; dan DO rate dengan aspek mangkir. Mekanisme penulisan rekam medis yang tidak sempurna dengan fenomena ”dilakukan tapi tidak ditulis” dan rekam medis pojok DOTS yang terpisah menjelaskan hubungan hasil audit klinik dengan hasil indikator program. Kesimpulan : Hasil audit klinik menunjukkan penyimpangan yang cukup besar dan indikator program juga berada di bawah standar. Terdapat ketimpangan antara hasil audit dengan indikator program. Penanganan TBC strategi DOTS di RSPAD Gatot Soebroto hanya diterapkan di pojok DOTS, namun tidak secara keseluruhan.

Background: Tuberculosis is a highly contagious disease and has become the world’s health issue. In 1995 WHO had established the DOTS strategy which was considered as the most cost effective strategy. In Indonesia, only 29% of hospitals in Indonesia had fully applied the DOTS strategy. Even though those hospitals have confirmed the application of DOTS strategy on a regular basis, this strategy has not been fully employed to every TB patient. Objectives: the aim of this study is to evaluate the quality of TB management, diagnosis, treatment, public health responsibilities, and to measure the achievement of TB program indicator at the RSPAD Gatot Soebroto by means of clinical audit and to find possible explanation regarding the relationship between the outcomes of the clinical audit and the achievement of TB program indicator. Methods: This is an explanatory case study. The instruments are check lists of clinical audit based on the Guidelines of TB Management from The National Health Department (2006), ISTC standard from Hopewell (2002), and Clinical Pathways for Ambulatory Care Case Management form Howe (1996), and also personal interview. Results: The greatest deviation for diagnosis was the identification for HIV risk factor (95%) and the least deviation was found on the classification of the disease (11%). For the criteria of treatment, the greatest and the least deviation were of the TB counselling (100%), and monitoring of the outcomes of treatment through LED (4%) and for the criteria of public health responsibilities, contact tracing deviation was 100% and report to Dinkes deviation was 36%. The achievement of TB program indicator through DOTS strategy at RSPAD Gatot Soebroto January to June 2006 period were as follows: the proportion of BTA positive TB patients accounted for 41,8% among other TB patients, conversion rate was 43,75%, error rate was unable to be calculated due to the lack of cross checking of the laboratory examinations, treatment success rate was 94%, and DO rate was null (0). The outcomes of the clinical audit and the achievement of the TB program indicator had revealed a discrepancy, there were the TSR and treatment completion and dosage; also DO rate and default. The poor mechanism regarding the phenomenon “we done it but we don’t write it down” upon completion of the medical records and the separation of medical records of DOTS Corner had explained the discrepancy observed between the findings presented in the outcomes of the clinical auditand the result observed in the program indicator. Conclusions: The results of the clinical audit demonstrated a great deviation, and the program indicator was considered to be below standard. There was a discrepancy between the findings of clinical audit and the program indicator. DOTS strategy used in the management of TB at the RSPAD Gatot Soebroto was only employed in the DOTS Corner, but has never been fully applied to all TB patients.

Kata Kunci : Tuberkulosis,Penatalaksanaan Rumah Sakit,Strategi DOTS, Tuberculosis, clinical audit, explanatory case study