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The OPAT experience in Hampshire

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Presentation on theme: "The OPAT experience in Hampshire"— Presentation transcript:

1 The OPAT experience in Hampshire
Jorge Cepeda

2 Dr. J. Cepeda Consultant Microbiologist
Developing an OPAT service for HHFT Dr. J. Cepeda Consultant Microbiologist

3 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 How many beds per site?

4 Hampshire Hospitals

5 The OPAT Team Helen O’Horan OPAT Nurse Specialist Taryn Keyser
Antibiotic Pharmacist Dr. Jorge Cepeda Consultant Microbiologist Katie Bolam Pathology Manager ADD PIC of the Lyford Unit

6 Understanding the model
Care Pathway Referral Assessment (incl. VTE) Enrolment under OPAT IV line (peripheral/central) Treatment initiated Ongoing treatment, follow up and monitoring OPAT HOPAT 1 full time nurse, Microbiologist 1 afternoon session and ongoing recruitment and support to OPAT nurse, Antibiotic Pharmacist input and support Full support of Microbiology consultants and SpR 9-5 and out of hours. Weekly MDT Patient held records SOPAT Intravenous therapy under OPAT concluded

7 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

8 Activity Data April – September 2012
May June July Aug Sept Development of infrastructure Patient recruitment Data collection Annual leave Data analysis and report

9 Patient recruitment and ‘Marketing’
Letter sent to all heads of departments Trust wide 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 Prior to the pilot service Letter sent to all heads of departments, medical and nursing

10 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)

11 Demographics Mean age: 52

12 Who referred patients? 63% Surgical referrals

13 Infections suitable for treatment in OPAT
Cellulitis Pyelonephritis Osteomyelitis Diabetic foot Prosthetic joint infections Bronchiectasis Liver Abscesses CNS infections MDR-TB Endocarditis

14 What patients do we cater for?

15 Antibiotics used

16 Venous access

17 Complications Gout Hypokalaemia Hyponatraemia flare up PUD Dehydration
Suicidal ideation/panick attacck

18 Patients referred but not recruited
54% OF NON-RECRUITED PATEINTS COULD HAVE BEEN RECRUITED SHOULD WE HAD FULL STAFFING AND SERVICE WAS ABLE TO BE MORE FLEXIBLE AND ACCOMAODATE PATIENT’S NEEDS 29% OF REFERRED PATIENTS WERE NOT SUITABLE ACCORDING TO CRITERIA

19 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 In order to be able to recruit a higher number of patients we decided to explore alternatives for the service provision,

20 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 Using a feedback questionnaire developed by the OPAT advisory panel working on behalf of the British Society of Antimicrobial Chemotherapy (BSAC), we surveyed all discharged patients anonymously.

21 Challenges of delivering an OPAT pilot
Seven day service provision Out of hours cover Nursing time Communication Non attendance Funding

22 Service development 3.8 wte 5.2 wte 0.4 wte 0.5 wte 3.0 to 3.5 3.5
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 3.5

23 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

24 Conclusions 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 The next step after formally establishing the OPAT service at Basingstoke hospital, will be to provide the OPAT service to other areas of the trust As with any newly created service, there are still a number of difficulties that need to be overcome; these are predominantly due to the staffing of the service and the absence of a service manager. The service development will need careful consideration and involvement of finance, management, nursing, pharmacy and Microbiology to ensure that a suitable and robust model is developed and implemented.

25 Thank you Any questions?

26 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 Grand Total 507

27 Reduction in hospital stay
Condition Estimated No of Patients Length of IV Rx (days) Bed days saved Admission avoidance Potential savings (bed days) Cellulitis 140 (40% of the total) 3-5 420 Osteomyelitis 12 (50% of the total) 45-60 40-55 NA 540 Diabetic foot 1? ? 40 Prosthesis inf. 10 (20% of the total) 450 Septic arthritis 6 (50% of the total) 12-18 8- 12 48 Pyelonephritis 5 (50% of the total) 7-14 35 TOTAL 174 1533 It is very difficult to estimate the total number of patients who will be suitable for the service. Based on previous cellulitis audit and last two years cases:

28 Diabetic foot Pathway Referral A&E, AAU, Diabetic clinic (Admission avoidance if possible) Inclusion according to pre-agreed criteria VTE assessment PICC line insertion by Venous access Service / OPAT as a buffer service? First dose of antibiotics Transport arrangements HOPAT by district nurses / BUPA Weekly review at OPAT clinic to assess progress and diabetic clinic when required. Joint management Oral switch according to pre-agreed criteria Discharge from OPAT

29 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

30 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

31 Antibiotic usage OPAT UK
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

32 Good Practice Recommendations
OPAT team and service structure clear managerial and clinical governance lines of Responsibility should have an identifiable medically qualified lead clinician Patient selection Initial assessment for OPAT should be performed by a medically qualified clinician and a specialist OPAT nurse Patients should be fully informed about the nature of OPAT and consent to OPAT should be documented Antimicrobial management and drug delivery The infection treatment plan should be agreed between the OPAT team and the referring clinician before commencement of OPAT Monitoring of the patient during OPAT Weekly multidisciplinary meeting/virtual ward round to discuss progress Mechanism in place for urgent discussion and review of emergent clinical problems Outcome monitoring and clinical governance Data on OPAT patients should be recorded prospectively for service evaluation and audit Standard outcome criteria should be used on completion of intravenous therapy Risk assessment and audit of individual processes should be undertaken as part of the local clinical governance programme Regular surveys of patient experience should be undertaken in key patient groups

33 Patient Information

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