Hospital Resource Utilization and Patient Outcomes Associated with Respiratory Viral Testing in Hospitalized Patients - Volume 21, Number 8—August 2015 - Emerging Infectious Disease journal - CDC

full-text ►

Hospital Resource Utilization and Patient Outcomes Associated with Respiratory Viral Testing in Hospitalized Patients - Volume 21, Number 8—August 2015 - Emerging Infectious Disease journal - CDC

Volume 21, Number 8—August 2015

Research

Hospital Resource Utilization and Patient Outcomes Associated with Respiratory Viral Testing in Hospitalized Patients

On This Page

• Methods
• Results
• Discussion
• Suggested Citation

Tables

• Table 1
• Table 2
• Table 3

Technical Appendicies

Downloads

• PDF[743 KB - 6 pgs]
• RIS[TXT - 2 KB]

Sunita Mulpuru , Shawn D. Aaron, Paul E. Ronksley, Nadine Lawrence, and Alan J. Forster

Author affiliations: Ottawa Hospital Research Institute, Ottawa (S. Mulpuru, S.D. Aaron, N. Lawrence, A.J. Forster); University of Ottawa, Ottawa, Ontario, Canada (S. Mulpuru, S.D. Aaron, A.J. Forster); The Ottawa Hospital, Ottawa (S. Mulpuru, S.D. Aaron, A.J. Forster); University of Calgary, Calgary, Alberta, Canada (P.E. Ronksley)

Suggested citation for this article

Abstract

Testing patients for respiratory viruses should guide isolation precautions and provide a rationale for antimicrobial drug therapies, but few studies have evaluated these assumptions. To determine the association between viral testing, patient outcomes, and care processes, we identified adults hospitalized with respiratory symptoms from 2004 through 2012 at a large, academic, tertiary hospital in Canada. Viral testing was performed in 11% (2,722/24,567) of hospital admissions and was not associated with reduced odds for death (odds ratio 0.90, 95% CI 0.76–1.10) or longer length of stay (+1 day for those tested). Viral testing resulted in more resource utilization, including intensive care unit admission, but positive test results were not associated with less antibiotic use or shorter duration of isolation. Results suggest that health care providers do not use viral test results in making management decisions at this hospital. Further research is needed to evaluate the effectiveness of respiratory infection control policies.

In 2003, the coronavirus responsible for the severe acute respiratory syndrome (SARS) outbreak infected 774 and killed 8,096 persons worldwide (1). It was quickly recognized that this virus spread between close contacts, because 21% of infected case-patients were health care workers caring for patients infected with the SARS coronavirus (1,2). During the outbreak, respiratory infection control policies were developed by clinical infectious disease and public health experts, and their use was mandated in all Canadian hospitals. These measures were attributed to the eventual control of the outbreak (3–6). As a result, infection control practices, including strict hand hygiene, viral testing of patient samples, and use of isolation precautions, quarantine rooms, and personal protective equipment, were mandated for routine use with all patients who sought treatment at emergency departments (EDs) with respiratory symptoms and fever (7,8).

National guidelines suggest that patients admitted to acute care hospitals with infectious respiratory symptoms should receive screening for viral infections by answering symptom-based questionnaires, and they should be placed under droplet isolation precautions until definitive evidence rules out a transmissible respiratory illness (7,9). Viral testing in this setting is carried out with a nasopharyngeal (NP) swab sample, which is processed by direct fluorescent antibody (DFA), PCR, or both to identify a viral pathogen. Viral testing in these patients should improve diagnostic clarity, reduce the number of subsequent diagnostic tests and procedures required, and prevent infection transmission to other patients and health care workers by guiding the use of isolation precautions. However, these outcomes can only occur if physicians and infection control practitioners assess the results of the viral test and feel confident ruling out viral disease on the basis of the results.

To date, whether respiratory viral testing in patients improves outcomes or care processes has not been proven in large studies. Two small studies demonstrated that knowledge of the viral test results did not affect length of stay and subsequent antibiotic use (10,11). However, 1 previous study demonstrated reduced length of stay, mortality, and cost when using viral testing (12). These studies were limited by the following: relatively small sample sizes; only single winter seasons being evaluated; and utilization of hospital resources, including isolation precautions, not being assessed (10–12).

To address this gap in evidence, we set 2 main objectives for this study. First, we aimed to determine the association between the use of viral testing and subsequent hospital resource utilization (antibiotic/antiviral drugs prescribed; radiology studies conducted; cultures and bronchoscopies performed), including the duration of isolation precautions. Second, we aimed to determine whether viral testing was associated with in-hospital deaths, admission to intensive care, and length of stay in the hospital.

Dr. Mulpuru is an assistant professor at the University of Ottawa and associate scientist at The Ottawa Hospital Research Institute. Her research interests focus on the efficacy of hospital infection control measures for febrile respiratory illnesses and transmission of respiratory infections in the hospital.

Acknowledgment

This work was supported by a research grant from the Patient Safety and Quality Committee of the Department of Medicine, University of Ottawa, Ontario, Canada. S.M. is supported by a research fellowship award from the Department of Medicine at the University of Ottawa, and a Cameron C. Gray Fellowship award from the Ontario Thoracic Society in Ontario, Canada. P.R. is supported by a postdoctoral fellowship award from the Canadian Institutes of Health Research. S.D.A. and A.J.F. are supported by career salary awards from The University of Ottawa, Department of Medicine.

References

1. World Health Organization Global Alert and Response. Summary of probable SARS cases with onset of illness from 1 November 2002 to 31 July2003 [cited 2014 May 22]. http://www.who.int/csr/sars/country/table2004_04_21/en/
2. Lapinsky SE. Epidemic viral pneumonia. Curr Opin Infect Dis. 2010;23:139–44. DOIPubMed
3. Ontario Ministry of Health and Long Term Care. Preventing respiratory illnesses: protecting patients and staff. Recommended infection control and surveillance standards for febrile respiratory illness (FRI) in non-outbreak conditions [cited 2014 May 22].http://www.health.gov.on.ca/fr/public/programs/emu/sars/reports/dir_122303_acute_care_nonoutbreak.pdf
4. Dwosh HA, Hong HHL, Austgarden D, Herman S, Schabas R. Identification and containment of an outbreak of SARS in a community hospital. CMAJ.2003;168:1415–20 .PubMed
5. Shaw K. The 2003 SARS outbreak and its impact on infection control practices. Public Health. 2006;120:8–14. DOIPubMed
6. Bridges CB, Kuehnert MJ, Hall CB. Transmission of influenza: implications for control in health care settings. Clin Infect Dis. 2003;37:1094–101.DOIPubMed
7. Public Health Agency of Canada. Routine practices and additional precautions for preventing the transmission of infection in healthcare settings,2012 [2014 May 22]. http://www.ipac-canada.org/pdf/2013_PHAC_RPAP-EN.pdf
8. Centers for Disease Control and Prevention. Seasonal influenza [cited 2014 May 22]. http://www.cdc.gov/flu/about/disease/us_flu-related_deaths.htm#how-many-die?
9. Public Health Ontario. Best practices for infection prevention and control programs in Ontario in all health care settings. 3rd ed. 2012 [cited 2014 May 22]. http://www.publichealthontario.ca/en/eRepository/BP_IPAC_Ontario_HCSettings_2012.pdf
10. Hernes SS, Hagen E, Quarsten H, Bjorvatn B, Bakke PS. No impact of early real-time PCR screening for respiratory viruses on length of stay and use of antibiotics in elderly patients hospitalized with symptoms of a respiratory tract infection in a single center in Norway. Eur J Clin Microbiol Infect Dis. 2014;33:359–64. DOIPubMed
11. Oosterheert JJ, van Loon AM, Schuurman R, Hoepelman AI, Hak E, Thijsen S, Impact of rapid detection of viral and atypical bacterial pathogens by real-time polymerase chain reaction for patients with lower respiratory tract infection. Clin Infect Dis. 2005;41:1438–44. DOIPubMed
12. Barenfanger J, Drake C, Leon N, Mueller T, Troutt T. Clinical and financial benefits of rapid detection of respiratory viruses: an outcomes study. J Clin Microbiol. 2000;38:2824–8 .PubMed
13. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36:8–27. DOIPubMed
14. van Walraven C, Austin PC, Jennings A, Quan H, Forster AJ. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care. 2009;47:626–33. DOIPubMed
15. van Walraven C, Escobar GJ, Greene JD, Forster AJ. The Kaiser Permanente inpatient risk adjustment methodology was valid in an external patient population. J Clin Epidemiol. 2010;63:798–803. DOIPubMed
16. Escobar GJ, Greene JD, Scheirer P, Gardner MN, Draper D, Kipnis P. Risk-adjusting hospital inpatient mortality using automated inpatient, outpatient, and laboratory databases. Med Care. 2008;46:232–9. DOIPubMed
17. Public Health Agency of Canada. FluWatch Canada, 2013 [2014 May 22]. http://www.phac-aspc.gc.ca/fluwatch/13-14/index-eng.php
18. Abad C, Fearday A, Safdar N. Adverse effects of isolation in hospitalised patients: a systematic review. J Hosp Infect. 2010;76:97–102.DOIPubMed
19. Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA. 2003;290:1899–905. DOIPubMed
20. Bonner AB, Monroe KW, Talley LI, Klasner AE, Kimberlin DW. Impact of the rapid diagnosis of influenza on physician decision-making and patient management in the pediatric emergency department: results of a randomized, prospective, controlled trial. Pediatrics. 2003;112:363–7.DOIPubMed
21. Iyer SB, Gerber MA, Pomerantz WJ, Mortensen JE, Ruddy RM. Effect of point-of-care influenza testing on management of febrile children. Acad Emerg Med. 2006;13:1259–68. DOIPubMed
22. Wishaupt JO, Russcher A, Smeets LC, Versteegh FGA, Hartwig NG. Clinical impact of RT-PCR for pediatric acute respiratory infections: a controlled clinical trial. Pediatrics. 2011;128:e1113–20. DOIPubMed
23. Özkaya E, Cambaz N, Coşkun Y, Mete F, Geyik M, Samanci N. The effect of rapid diagnostic testing for influenza on the reduction of antibiotic use in paediatric emergency department. Acta Paediatr. 2009;98:1589–92. DOIPubMed
24. Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49:1373–9 . DOIPubMed

Tables

• Table 1. Baseline characteristics of hospitalized adults admitted with respiratory symptoms, Ottawa, Ontario, Canada, 2004–2012
• Table 2. Outcomes for hospitalized adults seeking treatment with respiratory symptoms, Ottawa, Ontario, Canada, 2004–2012
• Table 3. Laboratory, prescription, radiology, and procedure use among hospitalized patients with positive and negative NP swab samples, Ottawa, Ontario, Canada, 2004–2012

Technical Appendix

• . 4 tables showing the following: odds of death and ICU admission among hospitalized adults for whom an NP swab sample was analyzed, in a subgroup of hospitalizations in which the... 98 KB

Suggested citation for this article: Mulpuru S, Aaron SD, Ronksley PE, Lawrence N, Forster AJ. Hospital resource utilization and patient outcomes associated with respiratory viral testing in hospitalized patients. Emerg Infect Dis. 2015 Aug [date cited]. http://dx.doi.org/10.3201/eid2108.140978

DOI: 10.3201/eid2108.140978