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

2. 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

3. 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?

4. 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????

5. 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?

6. 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.

7. 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!

8. 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

9. The Right Paperwork - Hospital Referral form

10. The Right Paperwork - ED / GP Referral form

11. The Right Paperwork – St Elsewhere Referral form

12. 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….

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

14. 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.

15. 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)

16. 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)

17. The Right Delivery of Service

18. Quality of Life score

19. VIP score

20. The Right Drug chart

21. The Right Drug Administration Chart

22. 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

23. 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

24. 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

25. 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!

26. Infections treated under OPAT

27. Conclusion – Does OPAT work?

28. 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)

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

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

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

32. 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?

33. Gilchrist and Seaton Checklist

34. 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