Management of HIV inpatients

1. Management of HIV inpatients Wessex BASHH regional audit 2008 Dr Emma Rutland

2. Background: 1. Standards for HIV clinical care, March 07 • 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.

3. Background: 2. UK national guidelines for HIV testing 2008 • Consider in all general medical admissions where local prevalence >2 in 1000 population • Clinical indicator diseases including suspected primary HIV infection

4. Background: 3. BHIVA national inpatient “snapshot” audit 2008 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

5. Background: 3. BHIVA national inpatient “snapshot” audit 2008 • 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

6. Wessex BASHH regional audit of HIV inpatients 2008 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

7. Wessex BASHH regional audit of HIV inpatients 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

8. Results • 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

9. Number of inpatient episodes by site

10. Elective procedures

11. Results: Patient demographics • 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)

12. Results: HIV diagnosis • 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)

13. Results: AIDS defining diagnoses • 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

14. Results: Trend in CD4 in newly diagnosed and known HIV positive inpatients

15. Most recent CD4 by ART status at admission

16. Most recent CD4 by ART status at admission

17. Most recent CD4 by ART status at admission

18. Results: virological control on ARV • Viral load was undetectable in the majority (79%) taking ARV

20. Results: outcomes • 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

21. Results: outcomes • 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

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

23. Results: Service provision issues -comments • 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

24. Conclusions: General • 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

25. Conclusions: Testing • 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

26. Conclusions: Standards of care • 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

27. Conclusions: ‘comparisons’ to national data • 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%)

28. Recommendations • 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

29. QUESTIONS ?????

30. 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)

31.  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: