Dr Alison Rodger Royal Free Hospital, London 14 TH A NNUAL C ONFERENCE OF THE B RITISH HIV A...
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Transcript of Dr Alison Rodger Royal Free Hospital, London 14 TH A NNUAL C ONFERENCE OF THE B RITISH HIV A...
Dr Alison Rodger
Royal Free Hospital, London
14TH ANNUAL CONFERENCE OF THE BRITISH HIV ASSOCIATION (BHIVA)
23-25 April 2008, Belfast Waterfront Hall, Northern Ireland, UK
Inpatient “snapshot” auditBHIVA Clinical Audit Sub-Committee:
J Anderson, M Backx, G Brook, P Bunting, C Carne, G Cairns, A De Ruiter, S Edwards, K Foster, A Freedman, P Gupta, M Johnson, M Lajeunesse,
C Leen, N Lomax, C O’Mahony, E Monteiro, E Ong, K Orton, A Rodger, C Sabin, C Skinner, E Street, I
Vaughan, R Weston, E Wilkins, D Wilson, M Yeomans.
Description
A review of all adult inpatients and day patients with HIV at participating hospital sites on one day during the week 5-11 November 2007.
Accompanied by a survey of clinical networks and arrangements for care – full results to be presented in the autumn.
Aims
To describe inpatient and day patient care “as it happens”
To identify patterns of service use To identify any issues e.g. with transferring or
discharging patients.
Participation
Data were received for 255 eligible patients from 64 sites:
As was anticipated, many sites had no inpatients/day patients during the week of the audit.
Accordingly 51 sites completed the centre and networks survey questionnaire but did not submit patient data.
Thus 115 sites took part overall.
Interpretation
Caution is needed because: Respondents may not have known of eligible
patients, especially those admitted for reasons unrelated to HIV.
Data is as perceived on the day of review, during the admission. Some diagnoses are presumed/provisional and may subsequently have been revised.
DemographicsNumber (%)
Sex Male
Female
Not stated
158 (62.0)
96 (37.6)
1 (0.4)
Age 16-18
19-29
30-39
40-49
50-59
60 or over
Not stated
1 (0.4)
34 (13.3)
82 (32.2)
85 (33.3)
32 (12.5)
18 (7.1)
3 (1.2)
Timing of HIV diagnosisNumber (%) of
patients
During current inpatient/day patient episode
44 (17.3)*
Less than 1 month before admission
7 (2.7)
1-3 months before admission
14 (5.5)
More than 3 months before admission
190 (74.5)
*Includes 10 diagnosed at another hospital prior to transfer as inpatients.
ART status
120 (47.1%) patients were on ART when admitted to hospital, of whom 5 were reported to have stopped during the admission.
A further 28 (11.0%) patients had started ART during the admission and before the day of review.
Most recent CD4 by ART status at admission
CD4 in cells/mm3
On ART number (%)
Not on ART number (%)
Total number (%)
0-50 18 (15.3) 30 (27.8) 53 (22.2)
51-100 12 (10.2) 20 (18.5) 33 (13.8)
101-200 23 (19.5) 26 (24.1) 51 (21.3)
201-350 29 (24.6) 17 (15.7) 49 (20.5)
>350 36 (30.5) 15 (13.9) 53 (22.2)
Patients without CD4 data are omitted. Row totals do not add because ART status data was missing for 13 patients with CD4 data.
Most recent VL by ART status at admission
VL in copies/ml On ART number (%)
Not on ART number (%)
Total number (%)
0-50 64 (54.2) 12 (12.1) 81 (35.4)
51-400 25 (21.2) 9 (9.1) 34 (14.8)
401-1000 8 (6.8) 3 (3.0) 12 (5.2)
1001-10,000 5 (4.2) 10 (10.1) 16 (7.0)
10,001-100,000 11 (9.3) 29 (29.3) 42 (18.3)
>100,000 5 (4.2) 36 (36.4) 44 (19.2)
Patients without VL data are omitted. Row totals do not add because ART status data was missing for 12 patients with VL data.
Mode of admission to reporting hospital
Number (%) of patients
From A&E 82 (32.2)
From community 80 (31.4)
From outpatient or GUM clinic at reporting hospital
51 (20.0)
From outpatient or GUM clinic elsewhere
10 (3.9)
Transferred as inpatient 31 (12.2)
Not stated 1 (0.4)
Working diagnosis/reason for admission
Totals exceed 100% because some patients had multiple conditions.0% 5% 10% 15% 20% 25% 30%
Pneumocystis pneumonia
Tuberculosis
Other infection
Neurological
Hepatic or renal
Psychiatric
Lymphoma
Kaposi's Sarcoma
Other malignancy
Adverse drug reactions
Haematological
Childbirth
Abdominal symptoms
Respiratory symptoms
Other or ill-defined
AIDS-defining conditions
112 (43.9%) patients had actual or suspected AIDS-defining conditions
121 (47.5) had non-AIDS defining working diagnoses
For 22 (8.6%) the working diagnosis was not clear enough to say.
Non-AIDS defining conditions may still have been HIV-related. “Other pneumonia” (ie not PCP) and sepsis were considered non-AIDS defining.
Patients with well-controlled HIV
There were 47 patients who had CD4 >200 and VL <50 when last measured, of whom 10 had AIDS-defining conditions:
4 lymphoma 2 TB (unconfirmed for 1) 1 PCP 1 KS 1 unconfirmed encephalopathy/dementia 1 with encephalopathy had developed non-
PCP pneumonia.
Adverse drug reactions
10 (3.9%) patients had ADRs (with or without other conditions):
3 hypersensitivity (2 cotrimoxazole, 1 dapsone or efavirenz)
2 renal toxicity (tenofovir including 1 confirmed Fanconi’s syndrome)
2 peripheral neuropathy (1 isoniazid/vincristine, 1 ART unspecified)
1 hepatotoxicity (?azithromycin) 1 collapse (octreotide) 1 diarrhoea/nausea/vomiting/myalgia (?Truvada).
Hospital types (self-defined)Number (%) of
patients
(Provider within an) HIV centre offering complex and inpatient care
183 (71.8)
Hospital with outpatient HIV unit 16 (6.3)
Neither of above 18 (7.1)
Missing/not stated 38 (14.9)
Distribution of patients by site
0
5
10
15
20
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Number of inpatients/day patients per site audited
Num
ber
of s
ites
Distribution of patients by site
0
5
10
15
20
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Number of inpatients/day patients per site audited
Num
ber
of s
ites
Distribution of patients by region
0 20 40 60 80 100 120
East Midlands
East of England
London
North East
North West
South Central
South East Coast
South West
West Midlands
Yorks & Humberside
Wales
Scotland
Beds occupied on review day
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0%
Dedicated HIV IP
Dedicated HIV day
Dedicated ID
Negative pressure room
Other isolation
Psychiatric
Obstetric/delivery
ITU/HDU
Surgical
Renal unit
Oncology
Other day
Neurosurgical
Haematology
Rehabilitation
Admission/assessment unit
Medical
Not stated
Beds occupied for AIDS-defining conditions
0 5 10 15 20 25 30 35
Dedicated HIV IP
Dedicated HIV day
Dedicated ID
Negative pressure room
Other isolation
ITU
Oncology
Haematology
Psychiatric
Renal unit
Obstetric
Other day
Medical
Not stated
Number of patients
AIDS-defining malignancy
AIDS-defining infection
All AIDS-defining
Inappropriate bed use examples
In general medical bed with pneumonia, sepsis, depression, lymphoma with complications. “No beds available in oncology/ID.”
“Should have been in a psychiatric bed but nurses on the psychiatric unit unable to cope with her” (UTI, psychiatric illness, in rehab bed).
Duration of admissions
Maximum time from admission to review*
Number (%) of patients
Up to a week 62 (29.1)
Week to a month 64 (30.0)
1-2 months 54 (25.4)
2-3 months 17 (8.0)
3-12 months 14 (6.6)
>12 months 2 (0.9)
*For patients admitted via inpatient transfer, includes time at previous hospital.
NB excludes 42 patients for whom data was missing.
Appropriateness of service useRespondents considered that service use was sub-optimal for 45 (17.6%) of patients:
25 were fit for discharge from acute care on the review day, but this was delayed.
4 would have benefitted from transfer to a different hospital, but this was delayed/not happening.
16 were in beds which were not most appropriate to clinical need.
Discharge and transfer were proceeding normally for a further 55 and 5 patients respectively.
Reasons for delayed discharge
Number of patients
Lack of community social care 9
No rehabilitation/nursing/
intermediate care bed available
8
Home circumstances not suitable
5
Immigration status/not legally resident in UK
3
Complex issues and needs
“Patient is newly deaf / blind and will need considerable further rehab” (cryptococcal disease).
“Patient admitted from detention facility. Asylum seeker. Prison officers guarding bed.”
“… small community with no access to HIV support services” – discharge delayed, DOT being arranged.
Conclusions
While most inpatients/day patients are appropriately managed, some issues emerge:
AIDS-defining diagnoses still account for a sizable proportion of inpatient work
Some patients have very complex needs, and lack of rehabilitation/intermediate or community-based care often delays discharge from acute care
Conclusions, continued
Most patients were in larger HIV centres, but many sites are providing inpatient care for small numbers of patients, potentially raising questions of governance, risk and cost effectiveness
There are issues about support for smaller units, and the appropriateness of supporting patient choice to receive care locally in isolated areas.
Proposal to change audit protocol
To date, clinic/centre identities have been blinded during analysis so in theory the BHIVA audit coordinator (H Curtis) cannot match data to any participating site.
Blinding is becoming problematic to maintain, and inhibits analysis of data by clinical networks/groups of neighbouring sites. In practice, sites often identify themselves voluntarily when discussing queries about their data.
Proposal to change audit protocol, continued
In a poll as part of the 2007 centres and networks survey:
52 respondents favoured unblinding for future audits
29 favoured continued blinding.
Accordingly the BHIVA Audit & Standards Sub-Committee proposes that in future site identities should be unblinded during audit analysis, from the Autumn 2008 audit of TB co-infection onwards.
Implications of this change
The audit co-ordinator and some members of the committee will be able to match data to named clinics/centres, while analysing audit data.
BHIVA will NOT publish or release data which identifies clinics/centres. As now, sites may choose to release their own data, and some commissioners may require this.
BHIVA will NOT collect information which identifies individual patients.
14TH ANNUAL CONFERENCEOF THE
BRITISH HIV ASSOCIATION (BHIVA)
23-25 April 2008, Belfast Waterfront Hall, Northern Ireland, UK