Evaluation of a programme for ‘Rapid Assessment of Febrile Travelers’ (RAFT): a clinic-based quality improvement initiative

Jazuli, Farah; Lynd, Terence; Mah, Jordan; Klowak, Michael; Jechel, Dale; Klowak, Stefanie; Ovens, Howard; Sabbah, Sam; Boggild, Andrea K

The several limitations of this analysis should be acknowledged. First, owing to limitations in the scope and funding of the study, we do not have the full range of hospital administrative ED data that would permit quantification of economic savings; thus, an economic analysis was neither planned nor performed. Although we cannot apply a dollar value to the economic savings of an ED visit averted for fever after travel, owing to the variability of this metric, we believe that our programme offers a systems-level improvement in care as most patients appreciate timely definitive management and avoidance of ED visits if possible. Second, illnesses with very short incubation periods, such as influenza and URTIs, may be over-represented and erroneously attributed to travel. We cannot definitively exclude the possibility that some cosmopolitan causes of fever in this group of returned travellers were locally acquired. Third, our ability to comment on the full spectrum of aetiological illness in this population is limited by the application of specific diagnostic tests deemed to be clinically relevant to the patient. Our goal was not to more precisely define the spectrum of illness encountered, but to reduce time to diagnosis, as we assume this leads to better outcomes and to a more efficient use of hospital resources. In 19 patients, 'non-specific viral illness' was the final diagnosis, and in three patients the diagnosis remained unknown, although symptoms resolved uneventfully and without specific therapy. Understanding the full spectrum of aetiological illness in such a population would require additional sophisticated and investigational diagnostics. Finally, we did not have a system by which to capture febrile returned travellers who may have fulfilled algorithm criteria but not sent to RAFT. We mitigated the risk of failure to capture all febrile returned travellers by frequent in-services and reminders to ED staff, as well as posted RAFT signage and binders in the ED. All fellows on-call overnight for the Infectious Diseases service had RAFT pocket cards and signage in their reviewing room. Similarly, we do not have a system that forces a general travel history, though with triage protocols mandating the collection of travel history to specific geographic regions such as the Middle East (due to Middle East Respiratory syndrome coronavirus) and West Africa (due to Ebola virus), we believe that travel history is most likely requested from all febrile patients entering the ED. At present, nurses are automatically prompted at triage to document a travel history within 21 days should a patient present with fever, cough, dyspnoea or diarrhoea; thus, we feel that the likelihood of missing travel-acquired illness in our EDs is low.