Transcript Management of HIV inpatients

Wessex BASHH regional audit 2008
Dr Emma Rutland
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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.
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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
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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
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‘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
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5 out of 9 centres returned data
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Data were received for 169 patient episodes
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52 episodes in 21 patients were readmissions however
the majority of these were elective
35% were for elective procedures
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Acute admissions (n=108)
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Patient Demographics
◦ Majority (69%) male
◦ Majority (71%) Caucasian (25% Black African, 4% Asian)
◦ Majority (71%) aged 30-50 years old (range 22-70yrs)
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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
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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)
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In all acute admissions 31 patients (29%) received a new
AIDS defining diagnosis during their admission
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PCP
extrapulmonary / miliary TB
NHL
cryptococcal meningitis
HIV dementia
-
CMV colitis & retinitis
Oesophageal candidiasis
Cerebral Toxoplasmosis
Kaposis Sarcoma
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
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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%
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Viral load was undetectable in the majority (79%) taking
ARV
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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
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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
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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
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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
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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
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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 set
Regional experience supports national reports of poor
clinical outcomes when not following above
recommendation
A case for strengthening / maintaining regional network
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Data very similar to National Audit data which included
the larger centres with regards to :
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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%)
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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
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I
ge:
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)
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Any opinions sought from other HIV centres?
YES
NO
Specify:
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Other specialist reviews during care?
Specify:
YES
NO
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Symptoms suggestive of HIV? (see attached form BASHH guidelines on testing for HIV)
Yes
NO
Specify:
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AIDS defining diagnosis?:
YES
Specify:
Other diagnoses:
NO
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All treatments received during hospital stay (including initiation of ARV):
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Length of inpatient stay
Outcome:
ongoing follow up
Other (specify)
Transfer
Death
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Appropriate follow up arrangements made:
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Any other comments:
YES
NO
N/A