Delivery of an integrated OPAT service in Buckinghamshire Marie Coward Delivery of an integrated OPAT service in Buckinghamshire Marie Coward

Delivery of an integrated OPAT service in Buckinghamshire Marie Coward – IV specialist Nurse / OPAT lead April 2012 BSAC

Buckinghamshire Healthcare trust (BHT) BHT – vertical integration approx18 months ago (merger of community and acute trusts) 2 acute hospital sites (Stoke Mandeville and Wycombe) 6 community hospitals and 7 localities for Adult Community Healthcare Teams (ACHTs). Buckinghamshire is a long narrow county (50miles) with a population of around 530,000.

History & background Originally, ad hoc service from Wycombe hospital (south county) in Increasing opportunities for OPAT from Stoke Mandeville site in the north put service under pressure as only manned by 1 nurse. In 2009 a 6 month pilot was commenced with a team of nurses using the integrated service model. The pilot was successful & reduced length of stay/ bed days saved and patient acceptability. Unfortunately the pilot was not continued at this time but went on to inform the business case that was subsequently re presented.

Service development The proposed business case was approved by the PCT and the service was established using SIRF (Service improvement reform fund) money for the first year and is now embedded in the community division of the trust. 4 nurses (1 band 7 & 3 band 6) plus funding for antibiotics and start up equipment. The service was officially re launched in September 2010 with the service only reaching its full manpower & working capacity in Dec Part of the service development was to show innovation and new ways of working with the integration of the 2 trusts.

Service Design We are predominantly a nurse led service 4 microbiologists plus the 4 specialist nurses form the OPAT team – each consultant supporting the OPAT service on a weekly basis Dr Kathy Cann is the clinical lead for service development. The service was predominantly to support Early supported discharge(ESD) and to phase in Admission Avoidance (AA).

Service Design ESD is well established with our core work coming from orthopaedics, plastics and cardiology. Cellulitis AA pilot commenced in November 2011 from A & E at Stoke Mandeville only. GP Locality Leads are supportive and service now embedded to be delivered for both main hospital sites as from April12.

Service Design We have established policies endorsed by BHT governance process. Clinical governance is paramount:- -ESD - the team shares care with the referring clinician -AA - the team shares care with the patient’s GP. We operate from – 5 (Mon – Fri. incl. bank holidays ) and have an on call service at weekends, which all the specialist nurses cover. We manage most of our patients in their own homes or daily return to our discharge lounge if possible. We are supported by the ACHTs who are just establishing 24 / 7 working.

The Model We operate as an MDT. 1. Referral ESD - referral form with telephone discussion We also attend a weekly orthopaedic ward round. AA - phone calls from GP or A&E We also visit A&E areas daily to find patients. 2. Assessment Inclusion / exclusion criteria but also assess on an individual basis. Generic paperwork for all referrals and have dedicated authorisations for IV administration in the community. Includes vascular access assessment and referral Includes assessment for self administration with competency assessment.

THE MODEL 3. Care plan Agree antibiotic regimen with consultant microbiologist. Prescribing by the referring team/A&E plus authorisations for community administration ESD- Facilitate discharge date /equipment / pharmacy AA -template prescription sheet for rapid turn around All patients Adrenaline is prescribed to take home in all cases. Liaison with ACHTs to support a 1 st visit with the patient. Hand held notes for the home setting

THE MODEL 4. Follow up and monitoring Most IV administration by ACHTs Daily VIP & EWS on all patients. Clinical checks appropriate to condition Weekly bloods -monitor results at weekly virtual ward round with the microbiology consultant. Outpatient review at 2 weeks for long courses We attend specific OPA’s with patients to ensure treatment plans are followed or problems discussed as we don’t have our own clinics. Often give IV’s when they attend. Our oral follow on patients get monitored at 2 weeks and if stable discharged from the service. 5. Communication Template GP letter on discharge from acute setting and end of IV treatment with conversion to oral antibiotics.

Activity and outcomes Data from Sept 2010 to end Feb 2012 (17 months) Referrals (inc repats) :169 Accepted patients(inc repats): 137 Bed days saved (exc repats): 1952 We audit outcomes from guidance paper: C.L. Mackintosh et al JAC(2011). ESD – 4 weeks from discharge, 6 months, 1 yr & 2yrs AA – 4 weeks only

Do we fulfil the BSAC good practice guidelines? Good practice guidelines: 1, OPAT Team & Service. 2, Patient Selection. 3, Antimicrobial management & drug delivery. 4, Monitoring of the patient. 5, Outcome monitoring & clinical governance. YES.

How are we developing? We are called the “IV Service” rather than just OPAT we aim to give more than IV antibiotics. We support Nursing home / Residential home patients. We support our community hospitals to give patients IV therapy / antibiotics. Provide inpatient care for any CVAD on a weekly review. Key IV training role in the Trust including venepuncture. Clinical lead in procurement of IV therapy equipment. Learning points: Introduced thermometers/adrenaline To establish guidelines/ governance. To develop good communication systems.

The Future PICC / Midline inserters – expand the teams skills and variety of VADs Non medical prescribing / advanced assessment courses being attended. Trust still going through reconfiguration and our model will constantly change for this. Biggest problem Repatriation of patients from neighbouring Trusts – endless problems where there is no OPAT service or a different model -? expand BSAC guideline. Governance arrangements need to be clear.

The Team