Implementing an OPAT service in the UK. Graeme Jones, Consultant in Medical Microbiology, Southampton, England

Transcription

1 Implementing an OPAT service in the UK Graeme Jones, Consultant in Medical Microbiology, Southampton, England

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3 University Hospital Southampton UK 1200 beds (60 wards) 150,000 in-patients seen ,000 bed days Secondary care to 650,000 pop. Full range of tertiary care to 3 million population in Southern England Large tertiary paediatric service 9,000 staff Turnover 695 million

4 The Southampton OPAT Service Acute Medical Unit 2000 PGD nurse-driven cellulitis service Local admission avoidance Adult Infection Specialists + Home Healthcare Company Nurses 2010 Individualised therapy Wider early discharge Paediatric Assessment Unit 2011 Medical generalist-driven service Local admission avoidance Paediatric OPAT 2012 Individualised therapy Regional early discharge Infection specialist + OPAT nurse + Other

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6 UHS OPAT overview 1999 Phase 1: establishing a service New Acute Medical Admissions Unit with capacity for Ambulatory Care Block contract: Trust trying to close medical beds to save money Financial incentives available to hospitals to develop ambulatory care pathways Outpatient DVT service to manage patients in community recently established and staff looking for additional workload Audit of cellulitis to identified ~150 cases pa and potential LOS savings OPAT cellulitis service proposed to reduce costs, earn income and save beds

7 Implementing an OPAT infusion centre model transport Same site as specialists for review 24 hour help line Identify physical space Waiting area Designated nursing staff pharmacy Lead clinician

8 Staffing Issues One designated nurse per shift algorithms for out-ofhours referrals 7 day access for patients Clerical support Review dates Who(Dr), where, when Lead clinician to take responsibility

9 Generalist OPAT model Examples: Infection is simple to manage and common Antibiotic choice is stereotyped Emergency Department Acute Medical Unit Specialist OPAT Service Cellulitis Cellulitis Cellulitis OPAT is central intervention and is of short duration. Daily review on acute unit Antibiotics administered by nurse at infusion centre Aim is admission avoidance Patient selection may be physician or nurse-led via PGD. Complicated patients are excluded

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11 Infection Specialist OPAT model Infections managed are complex and varied Infection specialist (GIM Physician) OPAT Nurse OPAT pharmacist Specialist OPAT Service AMU IDU Stand alone clinic Other Antibiotic choice is customised and driven by specialist expertise. OPAT is central intervention and may be of long duration. Antibiotics administered by: -Nurse at infusion centre -Community practitioner -Patient Patient selection is by referral Aim is early discharge Regular review in OPAT unit

12 Nurse-led OPAT management of cellulitis Nurse-led protocol management:114 cases Traditional medical review: 230 cases No difference in clinical outcome, complications or readmission rate Duration of iv therapy fell from 4 to 3 days Physician review fell from 100% to 19% Seaton RA JAC :

13 Example of PGD cellulitis algorithm GP refers patient to designated nurse Patient is assessed by nurse YES Fit for ambulatory care? NO Assessment by nurse via PGD 1g ceftriaxone via PGD Wait 20 minutes ADMIT Review after 24 hours re: ambulatory care Home Return for review mane

14 Ambulatory Medical Care OPAT cellulitis service 2013 Nurse-led PGD-driven service Support from Acute Medicine Physician 136 patients treated OPAT days Average 3.7d on OPAT

15 The Southampton OPAT Service Acute Medical Unit 2000 PGD nurse-driven cellulitis service Local admission avoidance Adult Infection Specialists + Home Healthcare Company Nurses 2010 Individualised therapy Wider early discharge Paediatric Assessment Unit 2011 Medical generalist-driven service Local admission avoidance Paediatric OPAT 2012 Individualised therapy Regional early discharge Infection specialist + OPAT nurse + Other

16 UHS OPAT overview 2010 Phase 2: A home infusion service UHS identified as site for development of a major trauma centre Inadequate T&O capacity to meet additional need Innovative schemes to reduce LOS Early supported discharge (ESD) scheme developed Opportunity identified to develop OPAT service as part of ESD using iv-trained home healthcare nurses Business case grafted onto existing ESD business case T&O trial to develop system Model rolled out to other areas

17 Home infusion OPAT model Infections managed are complex and varied Infection Specialists OPAT Pharmacist OPAT Nurse Home infusion nurses Specialist OPAT Service Home infusion Daily nurse r/v Weekly OPAT r/v Adhoc ward r/v Planned specialist r/v Antibiotic choice is customised and driven by specialist expertise. OPAT is central intervention and may be of long duration. Antibiotics administered by: -Nurse at home Patient selection is by referral Active recruitment via consults Aim is early discharge

18 Aspergillosis Brain abscess surgically related bronchiectasis Cellulitis CF infective episode Cholangitis Discitis/vertebral oesteomyelitis metalwork Empyaema Endocarditis Malignant Otitis Externa Non tuberculous mycobaterial abscess Osteomyelitis non surgical Osteomyelitis surgically related Prosthetic joint infection UTI 12 Q OPAT data: 44 episodes 43 patients n OPAT days 2 0

19 The Southampton OPAT Service Acute Medical Unit 2000 PGD nurse-driven cellulitis service Local admission avoidance Adult Infection Specialists + Home Healthcare Company Nurses 2010 Individualised therapy Wider early discharge Paediatric Assessment Unit 2011 Medical generalist-driven service Local admission avoidance Paediatric OPAT 2012 Individualised therapy Regional early discharge Infection specialist + OPAT nurse + Other

20 UHS OPAT overview 2012 Phase 3: Paediatric OPAT services UHS plan to expand tertiary paediatric services Inadequate capacity to meet additional need Plan to build new children s hospital Innovative schemes to reduce LOS now Increasing numbers of complex patients Appointment of PID physician Innovative schemes to fund post Development of paediatric OPAT to build on successful UHS experience of adult OPAT

21 Generalist Paediatric OPAT model Infection is simple to manage Antibiotic choice is stereotyped Paediatric Medical Assessment Unit Paediatriciandriven patient selection Based on condition and home support OPAT is central intervention and is of short duration. Daily review on acute unit Antibiotics administered by nurse on unit Aim is admission avoidance

22 Specialist Tertiary OPAT model Infections managed are complex and varied Infection specialist OPAT Nurse OPAT pharmacist Specialist OPAT Service Stand alone clinic Antibiotic choice is customised and driven by specialist expertise. OPAT is central intervention and may be of long duration. Antibiotics administered by: -Community practitioner -Another hospital -Patient Patient selection is by referral Aim is early discharge Regular review in OPAT unit

23 BSAC OPAT Initiative Outpatient and Parenteral Antimicrobial Therapy (OPAT) Toolkit for Developing a Business Case for OPAT Services in the UK The OPAT initiative will support, guide and encourage the establishment of standardized OPAT services throughout the UK Support for the development of a business case is central to this development Available free as an online interactive tool from or to download as a hardcopy pdf at

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25 The BSAC Business Case Toolkit Drop in text sections for editing Background rationale for OPAT Antimicrobial requirements for OPAT Checklist of costs to include Worked examples of costs Interactive sections to reflect local needs Criteria for evaluating an OPAT service Analysis of different models of OPAT service provision Cost analyses

26 Interactive Cost Model

27 Who are your stakeholders and how best to engage with them? Identify how OPAT will generate income for provider Identify how OPAT can help achieve existing organisational goals Development priorities of funders & stakeholders Funding streams Engage with funder early to discuss best approach Gauge likely support and recruit champions Discuss novel funding arrangements Develop business case in partnership

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29 Summary Different models for OPAT services can be adopted Patient needs will influence choice of model Use existing facilities to provide safe care Business case must fit with wider organisational goals