The OPAT experience in Hampshire Jorge Cepeda. Andover War Memorial Hospital Basingstoke and North Hampshire Hospital Royal Hampshire County Hospital

The OPAT experience in Hampshire

Jorge Cepeda

Andover War Memorial Hospital Basingstoke and North Hampshire Hospital Royal Hampshire County Hospital

Dr. J. Cepeda

Consultant Microbiologist

Developing an OPAT service for HHFT


Hampshire Hospitals

• Hampshire Hospitals NHS Foundation Trust serves a population of approximately 600,000 across Hampshire and parts of west Berkshire

– Basingstoke and North Hampshire Hospital (BNHH) – Royal Hampshire County Hospital (RHCH) – Andover War Memorial Hospital (AWMH) provides community and

hospital services


Hampshire Hospitals


The OPAT Team

• Helen O’Horan OPAT Nurse Specialist

• Taryn Keyser Antibiotic Pharmacist

• Dr. Jorge Cepeda Consultant Microbiologist

• Katie Bolam Pathology Manager


Understanding the model• Care Pathway

– Referral– Assessment (incl. VTE)– Enrolment under OPAT– IV line (peripheral/central)– Treatment initiated------------------------------------– Ongoing treatment, follow

up and monitoringSOPAT

OPAT

HOPAT

Intravenous therapy under OPAT concluded


What we have developed

• Patient pathways and on-call cover were devised and the following documents were developed for the OPAT service:– Operational framework– Eligibility criteria (inclusion and exclusion) included on

referral form (electronic)– Information for patients and clinicians – Patient record (electronic)– Discharge summary (electronic)– Patient feedback questionnaire


Activity Data April – September 2012

ACTIVITY April May

June July Aug Sept

Development of infrastructure

Patientrecruitment

Datacollection

Annual leave

Data analysis and report


Patient recruitmentand ‘Marketing’

• Letter sent to all heads of departments• Trust wide email was sent to all clinicians and nurses

to advertise the service• Advert published in a Trust newsletter and on the Trust

Intranet• Posters disseminated to key areas:

AAU, orthopaedic, surgical and medical wards• Pharmacists were asked to identify suitable patients• Active recruitment by all team members started on a

daily basis, lead by the Specialist Nurse


Service delivery

• Predominantly outpatient day case and patient/carer

administration models of antibiotic delivery

• All patients attend the local IV infusion unit daily to receive

IV antibiotic therapy on weekdays and the Acute

Assessment Unit at Basingstoke Hospital at weekends

• All patients reviewed daily by the OPAT Specialist nurse

and once a week by Infection Specialist

• Regular monitoring of infection parameters, liver and renal

function

• Weekly MDT (Virtual ward)


Demographics

Males, 14

Females, 10

Mean age: 52


Who referred patients?

10

5

9

0

2

4

6

8

10

12

Orthopaedics Other surgical specialties Medicine

63% Surgical referrals


What patients do we cater for?

6

1

5

2

3

2

1

2

1 1

0

1

2

3

4

5

6

7

Cellu

litis

Osteo

mye

litis

Septic

arth

ritis

Pre-p

atel

lar b

ursiti

s PJI

Soft t

issue a

bsces

s

Diabe

tic fo

ot inf

ectio

n

Liver a

bsces

s

Pyelo

nephr

itis

Infe

ctive

exa

cerb

atio

n COPD


Antibiotics used

Treatment episodes

9

4

5

6

0

1

2

3

4

5

6

7

8

9

10

Ceftriaxone Ertapenem Teicoplanin Daptomycin


Venous access

15

11

1

0

2

4

6

8

10

12

14

16

PICC line Cannula Midline


Complications

0

2

0 0 0 0

1

2

6

0

1

2

3

4

5

6

7

DVT

Infe

ctio

ns

Line b

lock

age

Line i

nfect

ion

C. diff

icile

S. aure

us infe

ctions

Antibio

tic a

llerg

ies

Readm

issio

n

Other


Patients referred but not recruited

N=217

5 5

3

1

0

1

2

3

4

5

6

7

8

Not suitable Transport OPAT on hold BD antibiotics Patient reluctance


How did we adapt the service?

• Transport arrangements were organized utilizing the trust transport service if appropriate

• Arrangements with district nurses for home administered antibiotics during weekends and some weekdays treatment were made for selected patients

• Extended working opening hours at the IV infusion unit for week day administration of antibiotics

• Training of selected patients for home self administered antibiotic therapy to facilitate weekend treatment and avoid trips to the hospital


Patient satisfaction

• 80% of all answers scored the service at the top of the score and there were no expressions of dissatisfaction

• In addition two patients were able to have an early return to work whilst on antibiotic therapy, in both cases they were young self employed individuals who benefitted from the flexibility provided by the OPAT service


Challenges of delivering an OPAT pilot

• Seven day service provision • Out of hours cover• Nursing time • Communication• Non attendance• Funding


Service development

Staff Single site Two sites Multi-site

Nurse 1.68 wte 3.8 wte 5.2 wte

Specialist pharmacist

0.2 wte 0.4 wte 0.5 wte

Infection specialist consultant

1.5 Clinical sessions

3.0 to 3.5 Clinical sessions

3.5 Clinical sessions


Conclusions 1

After 6 moths of pilot work :

• The OPAT service has enrolled 24 patients • Had 45 patients referred and reviewed• Saved 380 in-patient bed days • Inserted 11 PICC lines• Had 24 extremely happy costumers


We feel very proud of the service that we have created in such a short period of time with the limited resources provided and a number of very important milestones have been attained by developing the foundations of the OPAT service for HHFT

Conclusions


Thank you

Any questions?


Discharged diagnosis BNHFT 01-04-2009 to 31-03-2010

Bronchiectasis 18

Cellulitis/Erysipelas 357

Diabetic Foot Infection 1?

Osteomyelitis 23

Prosthetic Joint Infections 21

Septic Arthritis 61

Pyelonephritis 13

Liver Abscess 13

Grand Total 507


Reduction in hospital stayCondition Estimated

No of

Patients

Length of

IV Rx

(days)

Bed days

saved

Admission

avoidance

Potential savings

(bed days)

Cellulitis 140 (40% of the total)

3-5 3-5 3-5 420

Osteomyelitis 12 (50% of the total)

45-60 40-55 NA 540

Diabetic foot 1? 45-60 40-55 ? 40

Prosthesis inf. 10 (20% of the total)

45-60 40-55 NA 450

Septic arthritis 6 (50% of the total)

12-18 8- 12 NA 48

Pyelonephritis 5 (50% of the total)

7-14 7-14 7-14 35

TOTAL 174 1533


Diabetic foot Pathway1. Referral A&E, AAU, Diabetic clinic (Admission avoidance if possible)2. Inclusion according to pre-agreed criteria 3. VTE assessment4. PICC line insertion by Venous access Service / OPAT as a buffer service?5. First dose of antibiotics 6. Transport arrangements7. HOPAT by district nurses / BUPA 8. Weekly review at OPAT clinic to assess progress and diabetic clinic when

required. Joint management9. Oral switch according to pre-agreed criteria10. Discharge from OPAT


Cellulitis Pathway Patients living within 10 miles / less than 1 hour trip

• A&E, AAU, Outpatients, GPs (Admission avoidance if possible)• Inclusion according to pre-agreed criteria • VTE assessment• Peripheral cannula (72 hour change)• First dose of antibiotics • Transport arrangements for daily attendance• Daily treatment review by OPAT nurse/doctor • Early oral switch• Discharged from OPAT


Resource development• District nurses IV skills

– Training programme– Competencies– Use existing ‘Venous Access Service’

• Antibiotic preparation/distribution– Antibiotics reconstituted and administered by district nurse– Antibiotics pre prepared at a IV infusion centre and delivered

• Transport• Patient support 24/7• Care pathways for specific conditions• Joint care with some specialities• Data collection


Antibiotic usage OPAT UKANTIBIOTIC No cases %

Ceftriaxone 1303 50

Teicoplanin 849 33

Vancomycin 161 6.8

Meropenem 139 5.8

Ertapenem 37 1.7

Clindamycin 25 1.0

Gentamicin 20 0.8

Flucloxacillin 15 0.6

Daptomycin 1 0.04

TOTAL 2614 100

5 published series


Patient Information



Development of an OPAT service at the HHFTJorge Cepeda. Microbiology Consultant. Hampshire Hospitals NHS Foundation Trust, UK

IntroductionOPAT: the start of a new patient centered service at Basingstoke

What is OPAT?

Outpatient parenteral antibiotic therapy (OPAT) refers to the administration of Intravenous antibiotic therapy in the community or outpatient setting and is

used to facilitate the discharge from hospital of patients requiring medium- or long-term parenteral antibiotic therapy and to avoid admission in those requiring shorter-term therapy.

DiscussionThe feasibility study

References1..2. I

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Why OPAT?From the patient’s perspective:

Allows patient choice and

preference, improves quality of life,

patients and relative find it more

convenient, saves patient/carers

time, brings the care closer to home.

and in some cases allows

earlier return to work.

From the Healthcare perspective:

One of the key drivers for the

Increased requirement for OPAT is

the rise in serious hospital-acquired

Gram-Positive infections, particularly

Infections such as complicated skin

and soft tissue infections , bone, joint

and prosthetic infections, line-related

sepsis, and C. difficile infections.

OPAT helps reducing the risk of

healthcare associated infection,

allows better use of resources by

freeing up essential beds, and lower

treatment costs.

Service Models

Funding and sustainabilityThe funding provided by the Prudence panel will allow us to develop the foundations for the OPAT service at Basingstoke, starting with a 6 month pilot period recruiting a full time nurse who will work with Microbiology to provide this service.The start date of the pilot is

In short OPAT is an alternative to inpatient care aimed to provide treatment that is equal to inpatient care, if not superior !

Potential risks of OPAT - Broad-spectrum antimicrobial regimens - IV catheter –related complications- Reduced medical follow-up- Difficult to arrange regular clinic appointments- Potential for Increased carer’s burden - Patient complianceRisks can be minimised or avoided by undertaking a risk assessment and devising a pathway of care with appropriate monitoring

Documents

The OPAT experience in Hampshire Jorge Cepeda. Andover War Memorial Hospital Basingstoke and North Hampshire Hospital Royal Hampshire County Hospital