UpdatetoOPATGoodPracticeRecommendations

DrAnnLNChapmanBMBCh,FRCP,DTM&H,MSc(MedLeadership),PhD

ConsultantinInfectiousDiseasesandGeneralMedicine,NHSLanarkshireHonoraryClinicalAssociateProfessor,

UniversityofGlasgow

OPATGoodPracticeRecommendations(GPRs)

•  PragmaticguidanceonthedevelopmentanddeliveryofOPATservices

•  ToensurethatOPATservicesprovidehigh-quality,low-riskcare,whateverthehealthcaresetting

•  Ausefulresourceforteamsdevelopingnewservices

•  Apracticalsetofqualityindicatorsforexistingservices

Literaturereview

Requestedsearches Adult

Adults 1July2010–31July2017

Paediatric 1July2012–31July2017

Librariessearched CINAHL,Embase,Medline,WebofScience(sciencecitationindexexpanded),CochraneLibrary

SearchtermsAdult Paediatric

Outpatient/Homeparenteralantibiotic/antimicrobial/antifungal/antiparasiticantibacterial/antiviral/antiinfectivetherapy/treatmentHospitalinthehomeHomeinfusiontherapyANDantibacterial/antibiotic/antifungal/antiviral/antimicrobial/antiinfective/antiparasiticOPATOHPATAdulthomeparenteraltherapyprogram*ParenteralantibiotictherapyinthehomeHomeintravenous/IVantimicrobialserviceOutpatientintravenous/IVantibiotictherapy/treatmentOutpatientparenteralantibioticsOutpatientparenteraldrugdeliveryOutpatienttreatmentwithparenteralantibioticsNon-inpatientCommunity-basedHomeparenteraltherapy/treatmentHometreatment/therapy

Treatment/therapyathomeHome-initiatedtreatment/therapyHomedruginfusiontherapy/treatmentHomeintravenous/IV(+/-antibiotic)therapy/treatment(HIVAS)Intravenousantibiotictherapy/treatmentinanoutpatientsettingAmbulatoryantibioticinfusiondeviceDomiciliaryIVantibiotictherapy/treatmentCommunityintravenousantibioticservice(CIVAS)Self-administrationParentaladministrationAmbulatorycareCellulitis/SkinandskinstructureinfectionUTIOVIVA(oralversusintravenousantibiotics)AdmissionavoidanceEarlydischargeIVDUOutcomePalliative

Searchtermsasperadultwiththefollowingterms:Child*Paediatr*Pediatr*InfantPOPAT

Competencysearchterms

Requestedsearches

Dates 1Jan1970–31July2017

Librariessearched CINAHL,Embase,Medline,WebofScience(sciencecitationindexexpanded),CochraneLibrary

CompetencyrelatedsearchtermtobecombinedwithOPATrelatedsearchterm

CompetencyframeworkGoodpracticeSkillsdevelopmentCompetenceorcompetencesKnowledgeSkillsAttitudesBehavioursGuidelinesGeneric

Literaturesearchoutput

•  OPATSearches– Allreferences=2463

•  POPATSearches– Allreferences=544

•  Competency(OPATandPOPAT)– Allreferences=661

Literaturesearchoutput

2463

888conferenceabstracts

1195excludedoninitialscreen(duplicates,nonEnglish,not

relevant)388

1575

229

159excludedonspecialistscreen

Literaturesearchoutput

229

Servicestructure27

Patientselection22

Drugsanddevices53

Monitoringduringtherapy6Outcomemonitoringandclinicalgovernance30

OPATgeneral39OPATforspecificinfections52

1.Servicestructure

•  ImportanceofspecialistOPATservicewithIDinput

•  OPAT‘bundles’•  Community–basedservices

•  Telemedicine

1.1Clearmanagerialandclinicalgovernancelinesofresponsibility1.2Identifiableleadphysicianwithtimeinjobplan1.3CompositionoftheOPATMDT

1.4ManagementplanagreedbetweenOPATandreferringteams1.5ClinicalresponsibilitysharedbetweenreferringclinicianandOPATclinicianunlessotherwiseagreed1.6CommunicationbetweenOPATteam,GPandreferringclinician

OPAT‘bundle’•  Muldoonetal,2013;Madalineetal,2017

MDTOPATteamPatientdispositionscreeningPatientandfamilyeducationInpatientIDconsultationCaretransitionOPcareco-ordinationOPATprogrammeasures

EarlyphonecommunicationwithpatientOPappointmentwithin2weeksofdischargeElectroniccomprehensivetreatmentplanaccessibletoall

OPATtransitionofcare‘bundle’

•  ‘Highrisk’OPATpatients•  184patientspreinterventionvs146post•  30dayreadmissionsbeforeandafterintervention•  13%vs26%overall•  Sensitivityanalyses•  Hypothesisedthatadverseeventsdetectedearlierresultinginavoidanceofreadmission

•  Importanceofrobustservicestructure,MDT,communication

Community-basedOPAT

•  Regan&Morgan,2015;O’Hanlonetal,2017–  trainedcommunitynursessupportedbyIVtherapynursespecialists

–  Importanceofcollaborativeworkingbetweenprimaryandsecondarycare

–  Issueofmedicalresponsibility–  Pathwaysforescalation– Gradualdevelopmentofexperienceandconfidence– Datacollection;reviewofoutcomestoidentifyproblemsanddevelopsolutions

Telemedicine

•  Limitedexperience:–  Patientmonitoring/consultations–  Distantnursetocheckmedicationspreadministration

•  ReducedLOS/admissionavoidance•  EarlierreturntoADLs•  BUTmaybelimitedbycost;technicalissues;patient,familyandphysiciananxiety

•  Possiblerolewithuseoflongactingantibiotics

2.Patientselection

•  Specificgroups–  IVDU– Homeless– Renaltransplants

– MDRinfections– Olderadults

•  Newindications– Prophylaxis– Palliation

2.1Responsibilityoftheinfectionspecialisttoagreeinfection-relatedinclusion/exclusioncriteria

2.2AgreedOPATpatientcriteria

2.3Initialassessmentperformedbycompetentmemberofteam2.4Patientsshouldbefullyinformedandabletoconsent/declineOPAT2.5Patientswhohavebeenonthromboprophylaxisasinpatientshouldcontinuethis

IVDU•  Hoetal2010:–  97%successrateincarefullyselectedIVDUwithclosesupervision,speciallinesecurityseals

•  Beieleretal2016:–  homelesspeopleinamedicalrespitecentre,53%currentIVDU:87%completedtreatment

•  Buehrleetal2017:–  only26of67IVDU(39%)completedOPATsuccessfully–combinationofclinicalandsocialfactorscontributingtofailure

3.Drugsanddevices

•  OralvsIV•  Newagents•  Continuousinfusions

TreatmentplanagreedbetweenOPATteamandreferringclinician

PharmacyinputminimumweeklyatMDTmeeting

CompliancewithRCNandlocalstandardsforantimicrobialuse,IVline,drugdeliverydevice,trainingpatientsorcarersAlladministereddosesshouldbedocumentedAdministrationoffirstdoseinasupervisedsetting

Continuousinfusions

Elastomericdevices Portableelectronicpumps

Advantages

EaseofoperationLightweightSilentDisposableNoneedforpowersupply

AdjustableflowratesAccurateflowratesBuiltinalarms

Disadvantages

FixedflowrateVariableactualflowratesAbsenceofalarmsLimiteddataonantibioticstability

MoredifficulttouseNoisyHeavier

4.Monitoringduringtherapy

•  Bloodtestmonitoringimportant

•  DescriptionsofADRs

•  Importanceofservicestructure

4.1DailyreviewofpatientswithSSTI4.2WeeklyMDTmeeting

4.3Weekly(orbimonthlyifstable)reviewsbyOPATnurse/physician.4.4Weeklybloodtests(orbimonthlyifOPAT>1month)4.5OPATteamresponsibleformonitoringclinicalresponse,investigationsandtreatmentplan4.6Pathwayfor24-houraccesstoadvice/review/admission

5.Outcomemonitoringandclinicalgovernance

•  Antimicrobialstewardship

•  Patientreportedoutcomes

•  Standardisedclinicaloutcomes

5.1Patientdatarecordedprospectively5.2Standardoutcomecriteriarecorded5.3Riskassessmentandauditofindividualprocesses

5.4Regularsurveysofpatientexperience5.5ResponsibilityforpersonalCPD

Antimicrobialresistanceandhealthcareassociatedinfection(ARHAI)

Patientreportedoutcomes

CommunityIntraVenousAntibioticStudy,2017:

– Qualitativestudyofpatients’perceptionsofOPAT– 7themes:

•  Meetingtheneedsofadiversepopulation•  Benefitsofandbarrierstodifferentmodelsofcare•  Effectivenessoftreatment•  Communication•  Reviewandaftercare•  Staffexpertise•  Impactonfamilyandfriends

Keydevelopments(withmassivehealthwarning...)

•  GPRsremainconsistentwithpublishedliterature•  Servicestructure:–  Communitybasedservices

•  Drugsanddevices:– OralvsIV– Newagents–  Continuousinfusions

•  Outcomemonitoringandclinicalgovernance:– OPATandantimicrobialstewardship

Nextsteps

•  Completereviewofallpapers•  Consultationprocess•  Publicationofupdate–combinedadultandpaediatricOPAT

•  OPATcompetencies:–  Literaturereview–  Furtherdevelopmentofcompetenciesthroughdatacollection,workinggroup,engagementofstakeholders

Thankyou

Acknowledgements:•  SanjayPatel•  AndrewSeaton•  MarkGilchrist•  CarolyneHorner•  VittoriaLutje•  Literaturereviewers