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

Implementation of the RAFT clinic led to a 78% reduction in the time to assessment by ambulatory tropical medicine, and this enabled febrile returned travellers to be followed closely during the critical first few days of illness during which clinical deterioration can occur. That we did not have any patients requiring admission following assessment in the RAFT clinic supports that such an ED algorithm and programme can be implemented safely. For the two patients with P. falciparum malaria, the RAFT algorithm was followed and those patients were appropriately referred to the Infectious Diseases consultation service for evaluation, prior to being sent to RAFT by the Infectious Diseases team. Conversely, the benign, self-limited nature of many travel-acquired illnesses was reiterated by the number of patients seen in the EDs and referred to RAFT, but who felt better by the following day and declined the appointment. Since no additional resources are committed to running the RAFT programme as patients are accommodated into the regular schedule, the impact of 'no shows' on clinic operations is negligible. Averaged over a year, our results suggest that implementation of a RAFT programme can avert ∼72 repeat ED visits and 288 hours of ED bed-usage for a second malaria screening, thereby enhancing patient care and reducing workload in the ED. Our RAFT algorithm was derived from national guidelines on the approach to febrile returned travellers. 6 Yet adherence to the recommended minimum blood work was variable, with excellent adherence to malaria screening, CBC, electrolytes and creatinine, and lesser adherence to tests such as hepatic transaminases and urinalysis. Liver function tests are often perturbed in febrile returned travellers with diagnoses such as dengue, enteric fever, Epstein-Barr virus (EBV), cytomegalovirus (CMV), leptospirosis and the viral hepatitides, even in the absence of overt jaundice. Furthermore, hyperbilirubinaemia is one of the diagnostic criteria for severe malaria. 7 The pattern of abnormality of liver tests can be useful in refining the differential diagnosis. For instance, predominant elevation of hepatic transaminases occurs in arboviral infection, enteric fever, EBV, CMV and viral hepatitis. Conversely, a more cholestatic picture is suggestive of leptospirosis, biliary obstruction and even viral alcalulous cholecystitis. Thus, hepatic transaminases and bilirubin should be collected on all febrile returned travellers in order to inform the differential diagnosis, even in the absence of right upper quadrant pain and overt jaundice. Urinalysis, independent of urine culture, is also helpful in refining the differential diagnosis and may be abnormal in those without frank urinary symptoms, but with common travel-related diagnoses such as pyelonephritis (often occurring in the setting of traveller's diarrhoea), STIs including chlamydia and gonorrhoea, and leptospirosis, which leads to significant proteinuria. Conversely, the temptation to perform urine culture on febrile returned travellers without signs or symptoms of bacterial cystitis or pyelonephritis should be resisted in order to avoid inappropriate antimicrobial treatment of asymptomatic bacteriuria. Even in the absence of a dedicated RAFT programme, we advise adherence to the national guidelines for assessment of febrile travellers, though, as demonstrated in this analysis, adherence overall was quite good. Respiratory tract infections are the third most commo