Wessex BASHH regional audit 2008

Dr Emma Rutland

HIV positive patients needing inpatient care should be ordinarily admitted to an HIV centre

If diagnosed (HIV+) during the course of an acute medial inpatient admission, advice must be sought immediately from a consultant qualified to provide HIV inpatient care.

Consider in all general medical admissions where local prevalence >2 in 1000 population

Clinical indicator diseases including suspected primary HIV infection

Aim Describe patterns of service use Identify issues with inpatient care

Conclusions Most in/day patients managed appropriately AIDS defining conditions still account for a sizeable

proportion of inpatient work Some inappropriate service use highlighted

◦ Delayed discharge (social)◦ Inappropriate bed use◦ Delayed transfer to another centre

Most patients in larger HIV centres, but many smaller sites are providing IPT care for small numbers, potentially raising questions of governance, risk and cost effectiveness

Aim Describe patterns of service use Particular reference to

◦ time to diagnosis of HIV infection, ◦ presenting illness including HIV clinical indicator

diseases◦ length of stay

Identify any issues with inpatient care

‘compare’ with the national audit data

Method Retrospective case note review of all HIV positive

patients (known or newly diagnosed) admitted to and completing inpatient stays in the Wessex region over 1 year period (Sept 07-Aug 08)

For the purpose of the audit Wessex region described as all Trusts represented by members of Wessex regional BASHH group (Basingstoke, Bournemouth, Isle of Wight, Portsmouth, Salisbury, Southampton, Weymouth and Winchester)

Patients identified by hospital coding records

5 out of 9 centres returned data

Data were received for 169 patient episodes

52 episodes in 21 patients were readmissions however the majority of these were elective

35% were for elective procedures

Acute admissions (n=108)

Patient Demographics

◦ Majority (69%) male

◦ Majority (71%) Caucasian (25% Black African, 4% Asian)

◦ Majority (71%) aged 30-50 years old (range 22-70yrs)

The majority were known HIV-positive (87%) 14 patients were newly diagnosed during their

admission Of these 12 had symptoms suggestive of HIV, almost

all of which (92%) were AIDS defining diagnoses ◦ 5 PCP◦ 1 cerebral toxoplasmosis◦ 1 NHL & CMV retinitis◦ 2 HIV dementia◦ 2 TB (extrapulmonary)◦ (1 viral meningitis)

Median time to HIV diagnosis was 4 days (1-24) Median time to HIV specialist referral 1 day (0-8)

In all acute admissions 31 patients (29%) received a new AIDS defining diagnosis during their admission◦ PCP - CMV colitis & retinitis ◦ extrapulmonary / miliary TB - Oesophageal

candidiasis ◦ NHL - Cerebral Toxoplasmosis ◦ cryptococcal meningitis - Kaposis Sarcoma ◦ HIV dementia - disseminated MAI

Well controlled HIV:There were 44 patients who had CD4 >200 and VL <50

when last measured, of whom 2 had AIDS-defining conditions:◦ Non hodgkins lymphoma & cryptococcal meningitis

CD4 On ARV(58)

Not on ARV(44)

Total

<50

5% 50%

25%

51-100 2% 9% 5%

101-200 10% 23% 12 %

201-350 39% 20%

26 %

>350 44% 14% 30%

CD4 On ARV(58)

Not on ARV(44)

Total

<50 5% 50% 25%

51-100 2% 9% 5%

101-200 10% 23% 12 %

201-350 39% 20%

26 %

>350 44% 14% 30%

CD4 On ARV(58)

Not on ARV(44)

Total

<50

5% 50% 25%

51-100 2% 9% 5%

101-200 10% 23% 12 %

201-350 39% 20%

26 %

>350 44% 14% 30%

Viral load was undetectable in the majority (79%) taking ARV

Median length of stay for acute admissions was 4 days (range 1-110 days)

Median length of stay for elective admissions was 1 day (range 1-5 days)

Amongst acute admissions mortality was low with 5 deaths;◦ NHL with neutropenic sepsis◦ CMV colitis and Staph A Pneumonia◦ Probable disseminated MAI◦ Kaposis Sarcoma ◦ Motor Neurone Disease

4 acute patients were transferred to tertiary centres 5 acute patients were from ‘out of area’ 1 patient not referred to HIV services for follow up All other acute patients had appropriate follow up

arranged with the local HIV team

Results: no relation between time to diagnosis and length of stay

Delayed discharge – awaiting residential placement

Diagnosis / clinical issues:◦ PCP/HIV suspected day 2. Septrin not started till HIV

result day 4◦ ‘probably needs HIV test’ written on admission, not

done till 6 days later

Prescribing errors:◦ lost to follow up patient. Not discussed with GUM.

ARV prescribed by QAH - wrong doses!!◦ prescription error in hospital = zidovudine only not

combivir

Incomplete data; coding, difficulty accessing notes, interpretation of notes

AIDS-defining diagnoses still account for a sizable proportion of inpatient work.

High level AIDS diagnoses in newly diagnosed patients

Few non-AIDS diagnosis in patients diagnosed during acute admissions; continued lack of awareness of HIV indicator illnesses amongst general physicians?

Ongoing problems with delay in diagnoses and appropriate management

Delay in notification of HIV specialist in some cases of new diagnoses

Recommendation that smaller units transfer patients to an HIV centre with an HIV consultant who has regular contact with inpatients – unable to assess with current data setRegional experience supports national reports of poor clinical outcomes when not following above recommendationA case for strengthening / maintaining regional network

Data very similar to National Audit data which included the larger centres with regards to :◦ Patient demographics◦ Proportion diagnosed during the acute admission◦ Proportion on ARV◦ CD4 results◦ Reason for admission / working diagnoses◦ (Duration of admission)

Larger proportion of AIDS related conditions in National data set (44% vs 29%)

Continued effort to raise the awareness of HIV testing amongst non HIV specialists

Measures to minimise delay to informing HIV specialist about new diagnoses

Timely start of ARV to reduce AIDS diagnoses / HIV related illness in known patients

Maintenance of clinical networks to ensure acute inpatients in smaller units are transferred to larger centres as appropriate

 

Ige:

  Sex: Male Female    Ethnicity:   Country of origin:   Date admitted:   Team admitted under:   Presenting symptoms: (brief description)    Known HIV positive? YES NO    Time to HIV diagnosis: (days)   cd4 count:   VL:    Time to first discussion with GUM / HIV specialist once HIV diagnosis known:(days)

                     

 Any opinions sought from other HIV centres?  YES NO Specify:    Other specialist reviews during care? YES NO Specify:    Symptoms suggestive of HIV? (see attached form BASHH guidelines on testing for HIV)

Yes NO Specify:    AIDS defining diagnosis?: YES NO Specify:  Other diagnoses:    All treatments received during hospital stay (including initiation of ARV):    Length of inpatient stay  Outcome: ongoing follow up Transfer Death

Other (specify)    Appropriate follow up arrangements made: YES NO N/A    Any other comments: