Initial results of BHIVA audit of HIV-related inpatient and day care in the UK
Simon Collins, HIV i-Base
Annual audits on a wide range of aspects of HIV care and management are one of the most valuable aspects of BHIVA programme of projects. Each year, they provide a snapshot of one or two evaluable areas, usually in reference recommendations in BHIVA guidelines and standards.
This year, Alison Rodger from the Royal Free Hospital presented preliminary results from an audit of inpatient care in the UK, which at outset was recognised as affecting a smaller percentage of patients compared to pre-HAART use. The audit looked at all adult inpatients and day patients attending participating sites during the week 5-11 November 2007. An initial summary of patient data was presented in Belfast with expanded results on service networks and referral pathways due for the BHIVA Autumn meeting.
115 sites contributed results from the centre and networks survey, 51 of which had no inpatients during the target week. Data on 255 patients was provided from 64 sites. The majority of sites (n=37) only contributed 1 or 2 patients with larger numbers of patients 7 larger clinics (9 to 27 patients each).
Only 30% of admissions occupied HIV-specific beds with another 20% occupying infectious disease beds and 20% general medical beds. Inappropriate bed use was highlighted as one of the early issues from the audit with some patients in general medical bed with pneumonia, sepsis, depression, lymphoma with complications because of limited availability in oncology or infectious disease wards.
Patient demographics include 62% men 37% women; most patients were over 30 (1% age 16-18, 13% age 19-29, 32% age 30-39, 33% age 40-49, 12% age 50-59 and 7% age 60 or over). Half the patients were seen in London clinics.
A quarter of patients were receiving care related to recent diagnoses (17% were diagnosed during the audit week, with 10% diagnosed during the previous 3 months). Almost half the patients admitted were already on HAART with a further 10% having started HAART during this episode of inpatient care.
There were a wide range of CD4 counts on admission, roughly evenly spread in each band (<50, 51-100, 101-200, 201-350 and >350 cells.mm3). A higher percentage of patients on HAART to be admitted at higher CD4 count (ie 30% vs 24% with CD4 >350), with higher percentage of patients not on treatment having lower CD4 (28% vas 15% with <50 cells/mm3).
Viral load was generally suppressed in patients on HAART but 14% of these patients had viral load >100,000 copies/mL. A surprising 20% of patients not on HAART had viral load <400 copies/mL). Approximately 30% of patients were admitted from each of A&E and community, with 25% admitted from outpatient or GUM clinics. 12% patients were transferred as inpatients from another hospital.
44% patients had an AIDS-defining illness (ADI), 47% had a non-AIDS illness and 10% were unclear. Approximately 10% of admissions were related to each of PCP, TB, psychiatric, neurological or hepatic/renal disease, with 30% related to other infections and 15% undefined. Approximately 5% of admissions were related to each of respiratory, abdominal, drug reactions (generally to OI rather than HIV drugs), KS, lymphoma and childbirth.
Only 10/47 patients admitted with CD4 >200 and suppressed viraemia had an ADI (including lymphoma, TB, KS and encephalopathy).
Duration as an inpatient (for the 200 or so patients with data) included 14 patients who had been hospitalised for over three months and two patients who had been in care for over one year. Approximately 30% of patients were seen for up to 1 week, 1 week to 1 month and 1-3 months.
Inappropriateness of service use was highlighted in the audit with 45 patients (175) judged to be receiving sub-optimal care: 25 were fit for discharge which was delayed for various reasons (including lack of community support, rehab beds, home circumstances and immigration status), 16 were in inappropriate beds and 4 were delayed from transfer to a different centre.
The presentation concluded that 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.
- 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.