Setting up and running an effective OPAT service

Linda Nazarko Nurse Consultant

West London Mental Health NHS Trust Hallam Conference Centre, London 14th April

2016

Aims and objectives To enable you to: Be aware of the benefits and risks of OPAT Be aware of how to tailor services to meet needs Be aware of the range of services provided Types of therapy S-OPAT, H-OPAT, C-OPAT Selecting patients and monitoring outcomes Understand the needs of those requiring short and

long term therapy Providing patient support and education Demonstrate benefits to commissioners And most importantly how to work together to care

for patients

OPAT, past present and future

Outpatient Parenteral Antimicrobial Therapy (OPAT ) now used to describe IV therapy outside inpatient settings

Developed 1974, for children with cystic fibrosis First described UK early 1990s

Components of an OPAT service

The OPAT team Physician- IDT consultant Microbiologist Pharmacist with expertise in

antibiotic therapy Nurse specialist Community nurses Administration support

Service delivery models

Self administered outpatient antibiotics therapy (S-OPAT) “Self-administration of intravenous

antimicrobial therapy, in selected patients under the supervision of a specialist team, is a safe and feasible strategy” (Barr et al, 2012a)

Between 38-53 percent of patients can self administer

Infusion centres H-OPAT Cost effective Can be based in community hospitals,

clinics or acute hospitals Can be used to teach patients and staff,

deliver therapy, check bloods, monitor patients

Patient has to travel but less delay in waiting for staff

Drop in for problems

Home (community)– C-OPAT Around 70 percent of those treated in

hospitals suitable for OPAT in some form “OPAT was generally safe and effective,

but specific patient groups were identified with more complex management pathways and poorer outcomes” (Seaton et al, 2011)

Specialist IV teams Community nurses Private companies

Types of therapy Antimicrobials. Chemotherapy. Bisphosphonates. Iron sucrose – but fall off in use some areas Immunoglobulins. Parenteral nutrition (PN); Blood products Intravenous fluid

Short and long term therapy

Working in partnership

Inclusion/exclusion criteria

(an example)

Suitable for OPAT? 70 percent suitable – 30 percent not Generally safe but specific groups

more complex and have poorer outcomes

26 percent re-admitted in 30 days Some patients three times more likely

to be re-admitted

Higher risk patients Complex pathways Older Co-morbidities Resistant organisms Number of non infective admissions

last year Endocarditis with cardiac or renal

failure

Selecting patients Clinical judgment Do they meet local

criteria How often will

review be required Treatment regimes Suitable vascular

access

Emma’s storyDelivered by emergency caesarean

section and returned home with baby. Developed post operative infection, admitted and potentially separated from her baby whilst having IV antibiotics. Distraught and desperate to go home

Margaret’s storyMargaret is an 86 year old widow. She has

a confirmed diagnosis of vascular dementia and has moderately severe problems with cognition. Margaret lives alone and has a four times daily package of care and support. She was treated for pyelonephritis secondary to renal calculi and discharged home with a PIC line. Margaret was unable to consent to, understand or adhere to treatment and removed the PIC line. It was not possible to deliver OPAT and she was re-admitted.

Marek’s storyCame to UK from Poland and is

supporting a wife and two children. Has multidrug resistant TB. Needs oral antibiotics plus daily IV antibiotic therapy for at least six months. Keen to S-OPAT but worried he will not manage. Fearful that he will lose his job if he is late or has a lot of time off

Meeting patient needs

Supporting patients Patients may be anxious, having IV antibiotics at

home can be scary Patients need: A leaflet giving information, advice and support Details of what to do if there are problems, who

to contact and where to go if problems occur. Patients are people and level of support needed

varies Weekly reviews and ongoing help and support

Community Initiated OPAT

Partnership microbiology, IDT, pharmacy and community to initiate and treat certain conditions at home, e.g ESBL E.Coli infections of urinary tract and cellulitis

Hospital Initiated OPAT Plan discharge early Consider likely duration therapy,

vascular access, discharge medication Consider midline access if staff are

not competent with central lines Be aware of constraints in community

in terms of capacity Give plenty of notice

Roles of rapid response Short sharp courses of treatment

e.g treatment ESBL UTIs requiring IV therapy and cellulitis

Bridging treatment to facilitate discharge and handover to long term IV services

Risks of OPATThe administration of intravenous

antimicrobial therapy is potentially hazardous. These are:1. Misdiagnosis and inappropriate treatment 2. Inappropriate OPAT therapy when oral

would be effective 3. Inappropriate duration of therapy 4. Inappropriate place of care 5. Increased anti-microbial resistance

Lower leg cellulitis- are we winning?

In 2012 over 93,000 admissions, over 407,000 bed days. Cost £259-175 million

Admissions increased 88 percent in nine years now falling. Why?

Diverting a quarter would save 100,000 bed days and around £64 million

Misdiagnosis & inappropriate treatment

1/3 of those with cellulitis misdiagnosed

Misdiagnosis of UTI common

Oral might work just as well

IDT approval of OPAT requests

Inappropriate duration Cellulitis – 3-4 days parenteral

therapy – nurse review and switch Osteomyelitis may be exposed to

prolonged therapy with little evidence benefit past 6 weeks

Review by specialist team to mitigate risks

Inappropriate place of care Tighter control over who can

request OPAT OPAT approval by IDT Education and review to reduce

risk of inappropriate discharge

Antimicrobial therapy

Third generation cephalosporins High risk C. Difficile in hospital but not in

community – however 60 percent C. diff now developing in non hospitalised.

Daily or occasionally twice daily therapy

Antimicrobial stewardship “We could be close to reaching a point

where we may not be able to prevent or treat everyday infections or diseases” (DH & DEFRA, 2013).

‘Every antibiotic expected by a patient, every unnecessary prescription written by a doctor, every uncompleted course of antibiotics, and every inappropriate or unnecessary use in animals or agriculture is potentially signing a death warrant for a future patient. (Donaldson, 2008)

Antimicrobial stewardship (2) 25,000 deaths in Europe in 2007 because

of antibiotic resistance. Fifty percent of antibiotics prescribed

unnecessarily Take time and diagnose properly Prescribe prudently, narrow spectrum

safer Say “no” when not clinically indicated Use right dose, right time, right route and

right duration

Identifying and reducing OPAT risks

Developing and supporting staff

Staff training in IV therapy

Learn how to use VADs used in OPAT

RCN Standards guidance

Nurse specialist and OPAT team support

Delivering a comprehensive service

Use existing services But don’t overwhelm them Build on services Tailor services to meet

needs Community for housebound,

rapid response for short interventions and infusion centre to enable and empower those needing long term OPAT

Business case and KPIsBritish Society for Antimicrobial Therapy

(2011). Outpatient and Parenteral Antimicrobial Therapy

(OPAT) Toolkit for Developing a Business Case for OPAT Services in the UK. BSAC, Birmingham.

http://e-opat.com/wp-content/themes/pmix/Business_case_toolkit_PDF.pdf

Evaluate outcomes Use existing

information routinely gathered

Quality tools Additional

questionnaires, interviews, audits

What to evaluate Clinical and patient outcomes Service specific e.g. number of

admissions prevented, bed days saved Improvements in functional status Patient satisfaction Productivity and efficiency Staffing indicators

Why evaluate

Services change over time and we may be too busy to notice

We need to learn what we can improve We may identify gaps and opportunities to

develop

Cost effective services Get accurate costs of services Not just cost but also: Accessibility, care closer to home Timely – no long waiting lists Relieving pressure on traditional

services Meeting or exceeding quality

indicators

Being excellent is not enough

You need to be seen to excellent Be visible Evaluate and innovate Disseminate Move forward You are stars – let your light

shine brightly

Final tips Up to 70 percent of inpatients could benefit from OPAT Around half of those having OPAT could self administer OPAT

can be community or hospital initiated and can be used to avoid admissions or reduce length of stay.

OPAT can enable people requiring parenteral therapy to remain at home or to go home sooner. This enhances quality of life.

OPAT once a highly specialist service is entering the mainstream

It is vitally important that staff from acute and community and across disciplines form a team to minimise risk and maximise benefit

Thank you for listening

Any questions?

Check out profile for useful downloadshttps://uk.linkedin.com/in/linda-nazarko-

1952a746