1. Dr Alison Rodger Royal Free Hospital, London 14 TH A NNUAL C ONFERENCE OF THE B RITISH HIV A SSOCIATION (BHIVA) 23-25 April 2008, Belfast Waterfront Hall, Northern Ireland, UK

2. Inpatient “snapshot” audit BHIVA 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. Demographics Number (%) SexMale Female Not stated 158 (62.0) 96 (37.6) 1 (0.4) Age16-18 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)

8. Timing of HIV diagnosis Number (%) 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.

9. 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.

10. Most recent CD4 by ART status at admission CD4 in cells/mm 3 On ART number (%) Not on ART number (%) Total number (%) 0-5018 (15.3)30 (27.8)53 (22.2) 51-10012 (10.2)20 (18.5)33 (13.8) 101-20023 (19.5)26 (24.1)51 (21.3) 201-35029 (24.6)17 (15.7)49 (20.5) >35036 (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.

11. Most recent VL by ART status at admission VL in copies/mlOn ART number (%) Not on ART number (%) Total number (%) 0-5064 (54.2)12 (12.1)81 (35.4) 51-40025 (21.2)9 (9.1)34 (14.8) 401-10008 (6.8)3 (3.0)12 (5.2) 1001-10,0005 (4.2)10 (10.1)16 (7.0) 10,001-100,00011 (9.3)29 (29.3)42 (18.3) >100,0005 (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.

12. Mode of admission to reporting hospital Number (%) of patients From A&E82 (32.2) From community80 (31.4) From outpatient or GUM clinic at reporting hospital 51 (20.0) From outpatient or GUM clinic elsewhere 10 (3.9) Transferred as inpatient31 (12.2) Not stated1 (0.4)

13. Working diagnosis/reason for admission Totals exceed 100% because some patients had multiple conditions.

14. 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.

15. 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.

16. 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).

17. Hospital types (self-defined) Number (%) of patients (Provider within an) HIV centre offering complex and inpatient care 183 (71.8) Hospital with outpatient HIV unit16 (6.3) Neither of above18 (7.1) Missing/not stated38 (14.9)

18. Distribution of patients by site 0 5 10 15 20 123456789101112131415161718192021222324252627 Number of inpatients/day patients per site audited Number of sites

19. Distribution of patients by site 0 5 10 15 20 123456789101112131415161718192021222324252627 Number of inpatients/day patients per site audited Number of sites

20. Distribution of patients by region

21. Beds occupied on review day

22. Beds occupied for AIDS-defining conditions

23. 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).

24. Duration of admissions Maximum time from admission to review* Number (%) of patients Up to a week62 (29.1) Week to a month64 (30.0) 1-2 months54 (25.4) 2-3 months17 (8.0) 3-12 months14 (6.6) >12 months2 (0.9) *For patients admitted via inpatient transfer, includes time at previous hospital. NB excludes 42 patients for whom data was missing.

25. Appropriateness of service use Respondents 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.

26. Reasons for delayed discharge Number of patients Lack of community social care9 No rehabilitation/nursing/ intermediate care bed available 8 Home circumstances not suitable 5 Immigration status/not legally resident in UK 3

27. 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.

28. 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

29. 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.

30. 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.

31. 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.

32. 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.

33. 14 TH A NNUAL C ONFERENCE OF THE B RITISH HIV A SSOCIATION (BHIVA) 23-25 April 2008, Belfast Waterfront Hall, Northern Ireland, UK