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OPAT April 2016

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Linda Nazarko

The document outlines the benefits and risks of setting up an effective Outpatient Parenteral Antimicrobial Therapy (OPAT) service. It discusses components of an OPAT service including different delivery models like self-administered, infusion centers, and home-based care. Risks of OPAT include misdiagnosis, inappropriate treatment duration or location, and increased antimicrobial resistance. The document emphasizes the importance of multidisciplinary teams, appropriate patient selection, education and support to maximize benefits and safety of OPAT programs.

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Setting up and running an effective OPAT service Linda Nazarko Nurse Consultant West London Mental HealthNHS 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
OPAT April 2016
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
Emmas story Delivered 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
Margarets story Margaret 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.
Mareks story Came 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 OPAT The 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 贈259-175 million Admissions increased 88 percent in nine years now falling. Why? Diverting a quarter would save 100,000 bed days and around 贈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 dont 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 KPIs British 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 downloads https://uk.linkedin.com/in/linda-nazarko- 1952a746

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OPAT April 2016

  • 1. Setting up and running an effective OPAT service Linda Nazarko Nurse Consultant West London Mental HealthNHS Trust Hallam Conference Centre, London 14th April 2016
  • 2. 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
  • 3. 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
  • 5. Components of an OPAT service
  • 6. The OPAT team Physician- IDT consultant Microbiologist Pharmacist with expertise in antibiotic therapy Nurse specialist Community nurses Administration support
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. Types of therapy Antimicrobials. Chemotherapy. Bisphosphonates. Iron sucrose but fall off in use some areas Immunoglobulins. Parenteral nutrition (PN); Blood products Intravenous fluid
  • 12. Short and long term therapy
  • 15. 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
  • 16. Higher risk patients Complex pathways Older Co-morbidities Resistant organisms Number of non infective admissions last year Endocarditis with cardiac or renal failure
  • 17. Selecting patients Clinical judgment Do they meet local criteria How often will review be required Treatment regimes Suitable vascular access
  • 18. Emmas story Delivered 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
  • 19. Margarets story Margaret 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.
  • 20. Mareks story Came 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
  • 22. 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
  • 23. 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
  • 24. 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
  • 25. 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
  • 26. Risks of OPAT The 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
  • 27. Lower leg cellulitis- are we winning? In 2012 over 93,000 admissions, over 407,000 bed days. Cost 贈259-175 million Admissions increased 88 percent in nine years now falling. Why? Diverting a quarter would save 100,000 bed days and around 贈64 million
  • 28. 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
  • 29. 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
  • 30. Inappropriate place of care Tighter control over who can request OPAT OPAT approval by IDT Education and review to reduce risk of inappropriate discharge
  • 31. 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
  • 32. 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)
  • 33. 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
  • 35. 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
  • 36. Delivering a comprehensive service Use existing services But dont 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
  • 37. Business case and KPIs British 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
  • 38. Evaluate outcomes Use existing information routinely gathered Quality tools Additional questionnaires, interviews, audits
  • 39. 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
  • 40. 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
  • 41. 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
  • 42. 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
  • 43. 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
  • 44. Thank you for listening Any questions? Check out profile for useful downloads https://uk.linkedin.com/in/linda-nazarko- 1952a746