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