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

population constitutes a potential medical emergency warranting immediate exclusion of life-threatening travel-acquired infections. One to two Canadians are reported to die each year due to delayed diagnosis or treatment of malaria, 2 and many more become critically unwell and require admission to intensive care. 3 However, most febrile returned travellers will have more benign aetiologies, such as traveller's diarrhoea (TD) or respiratory tract infections; 1 4 yet there is no standardised 'system' for close follow-up and monitoring of such patients in the critical first few days of their illness, when deterioration may occur or a serious diagnosis may declare itself. Thus, many patients are either admitted to hospital for observation, or are discharged from the ED with ambulatory infectious diseases follow-up, days to weeks later. This gap in care translates into overutilisation of acute care, such as the ED and general medicine inpatient service, and also leads to underprovision of care for those who present early in their potentially serious illness with more benign appearing clinical parameters. 5 National Canadian guidelines on the assessment of febrile returned travellers have been published, 6 and we have adapted these guidelines into an ED decision-algorithm to standardise the evaluation and disposition of such patients, through creation of the 'Rapid Assessment of Febrile Travelers' (RAFT) Programme. The RAFT algorithm triages patients to either hospital admission, in the case of unstable vital signs, significant laboratory derangements, volume depletion or Plasmodium falciparum malaria, or to same-day referral to the RAFT Clinic in the Tropical Disease Unit (TDU) of Toronto General Hospital, if patients fail to fulfil admission criteria (figure 1). In addition, the RAFT algorithm provides management advice and diagnostic stewardship to the participating EDs. The RAFT Programme aims to fill the identified care gap and, in the process, improves patient flow, utilisation and delivery of service and clinical outcomes. We herein report our primary and secondary outcome measures of quality and performance at 10 months postimplementation of the RAFT programme.