OPAT Debbie Cumming - Antimicrobial Pharmacist Amanda Wilson – Lead OPAT Nurse St Mary’s Hospital, Isle of Wight

OPAT – What is it? Outpatient / home parenteral antimicrobial therapy Patients who are otherwise clinically well / stable but who need intravenous antimicrobials may be suitable for treatment in their own home (or clinic) Risk assessment essential Needs to be cost effective Patient choice / preference Needs tight clinical governance

OPAT – Advantages in the Community Alter potential for acquiring HCAI Patient advantages …….. Cost effective (Chapman et al paper) Professional development and job satisfaction But what can go wrong?

Mrs A from St Elsewhere Phone call Friday pm (if you are lucky!) Mrs A on way home and needs iv antimicrobials for another 6 weeks for “an infection” No other information available! No info re antibiotic, dose, frequency, how many doses have they had already, what is the microbiology, are the infection markers improving / getting worse, do they have any other major co-morbidities, do they live alone, are their social circumstances appropriate for OPAT (e.g. dementia), what kind of line do they have, is there appropriate follow up, who is going to maintain clinical responsibility????

So how …. does it / can it / should it work? What can a nurse do to help a pharmacist? What can a pharmacist do to help a nurse? What can we both do to get the best out of the multi-disciplinary team (Consultants – surgeons or physicians or microbiologists, GPs, junior doctors referring hospitals), and the patient / family? What can we both do to help a patient?

What are our …. Professional Standards? Nurse Pharmacist The code (NMC 2015) 1. Prioritise people 2. Practice effectively 3. Preserve Safety 4. Promote professionalism and trust. 1. Make patients your first concern 2. Use your professional judgement in the interests of patients and the public 3. Show respect for others 4. Encourage patients and the public to participate in decisions about their care 5. Develop your professional knowledge and competence 6. Be honest and trustworthy 7. Take responsibility for your working practices.

The aim is to have… A clinical pathway which is… Safe and effective… yet …. With the ability to have appropriate medical input when necessary ...... And delivers the best patient experience. Autonomous within a perfect MDT!

How to achieve? The right patient – referral form The right paperwork … from pre OPAT to post OPAT The right engagement from the clinician pre, during, post OPAT The right delivery of service (pharmacist / nurse) The right ability to recognise need and to escalate before necessary Excellent communication across the MDT

The Right Paperwork - Hospital Referral form

The Right Paperwork - ED / GP Referral form

The Right Paperwork – St Elsewhere Referral form

The Right Patient - Risk Assessment The OPAT team accepts referrals from.... Our Hospital …. Our ED / GPs or …..St Elsewhere Must include Social, drug history, infection, points of contact, monitoring regime, antibiotic regime (po and iv) interactions, line choice, location of service delivery, patient consent, VTE prophylaxis, self administration? Engagement with patient: rules and responsibilities….

The Right Paperwork - Risk assessment Current medications, Antibiotics Social History Past Medical History Non medical prescribing

The Right Access Device Cannula Mid lines PICC Other Considerations: dementia, visually impaired, IVDU, poor circulation, needle phobia, length of treatment, and anatomy of insertion site.

The H in OHPAT The H in OHPAT stands for home! But we can also deliver care in Residential homes Nursing homes Intermediate care beds Non-weight bearing beds Poppy unit (NHS hospital ward in a Nursing home)

The Right Delivery of Service Daily observations – clinical Daily observations – quality of life score out of 10 Delivery of antimicrobial – if all good to go..... Drug charts / drug administration (location of delivery)

The Right Delivery of Service

Quality of Life score

VIP score

The Right Drug chart

The Right Drug Administration Chart

Monitoring and Communication Monday OPAT team meeting (0800) Tuesday Blood results table sent to MDT Wednesday Virtual ward round with Consultant Medical Microbiologists (1200) Wednesday New / changed prescriptions written at VWR by Pharmacist (NMP) Weekly patient review sent to referring clinician Monday to Friday CMM and Pharmacy trawl for patients on WR

The Right Safety Nets! 111: 24 hour telephone line Adastra – Flags up patient as OPAT when patient rings 111 OPAT nurse mobile phones OPAT clinic telephone during working hours 7day service District Nurse communication template – for out of hours if problem with intravenous access device GP admission letter – keeps GP informed of patient journey Re-admission via Emergency Department if needed Buddy system with District Nurses as lone workers

The Right Discharge Line removal Patient questionnaire / Friends and Family test Discharge summary to referring clinician Completion of entry onto local database Completion of entry onto national database GP discharge letter Sending the bill (if from elsewhere) Ensuring activity logged to gain appropriate reimbursement Audit, audit, audit paperwork, outcomes, environment

What problems could we face? Being firm with referring physician to give complete information – or don’t accept Importance of risk assessment as patient on their own for 23 hours Being firm with patient about roles and responsibilities Concept of clinical governance in a MDT More than one person in the team – all need to have same standards / concept of OPAT Concept of immaculate line care Lots of paperwork – but necessary!!! Lots to audit – to assess service – keep on top of it! Don’t forget to get paid!

Infections treated under OPAT

Conclusion – Does OPAT work?

Conclusion - Patient feedback Were you satisfied that the treatment met the standards you expected? 98.3% (2013 – 2014), 98% (2014 – 2015) Would you be happy to choose this form of therapy again if the need arose? 99.0% (2013 – 2014), 98.8% (2014 – 2015) Were you happy with the support as an out-patient? 98.9% (2013 – 2014), 98.8% (2014 – 2015) Were you happy with the supplies service? 99.3% (2013 – 2014), 99% (2014 – 2015) If a family member was involved, were they happy with the service? 99.2% (2013 – 2014), 99.7% (2014 – 2015)

Anything Else? Yes... Education, and more education Communication Line insertion Drug Bugs Standard operating procedures Audit – rationale

Anything you’ve still left out? We are now OHPIT not OHPAT or OPAT So patients can be... OHPittable Or OHPattable Thank you...

Hopefully yes!!!! Questions????? Have we met our brief? Hopefully yes!!!! Questions?????

Questions Conditions not treated? Self administration? Other devices to allow multi dose regimes? OPAT and Antimicrobial stewardship? OPAT and C-Diff? OPAT in the terminally ill? OPAT and drug users? Range of Nurses delivering OPAT? Best thing we’ve done?

Gilchrist and Seaton Checklist

Useful References: Chapman, A. L. N., Dixon, S., Andrews, D., Lillie, P. J., Bazaz, R., Patchett, J. D. (2009) Clinical efficacy and cost-effectiveness of outpatient parenteral antibiotic therapy (OPAT): a UK perspective. Journal of antimicrobial chemotherapy. 64 (6) pp 1316 – 1324. Chapman, A. L. N., Seaton, R. A., Cooper, M. A., Hedderwick, S., Goodall, V., Reed, C., Sanderson, F., Nathwani, D. (2012) Good practice recommendations for outpatient parenteralantimicrobial therapy (OPAT) in adults in the UK: a consensus statement. Journal of antimicrobial chemotherapy. 67 pp 1053 – 1062. Jones, G. R., Cumming, D. V., Honeywell, G., Ball, R., Sanderson, F., Seaton, R. A., Healy, B., Hedderwick, S., Gilchrist, M. (2015) How is income generated by outpatient parenteral antibiotic treatment (OPAT) in the UK? Analysis of payment tariffs for cellulitis. Journal of antimicrobial chemotherapy. 70 (4) pp 1236 – 1240. Gilchrist, M., Seaton, R. (2015) Outpatient parenteral antimicrobial therapy and antimircrobial stewardship: challenges and checklists. Journal of antimicrobial chemotherapy. 70 pp 965-970.