community initiated opat services -...

COMMUNITY INITIATED OPAT SERVICES - ADMISSION AVOIDANCE

Sharon Bamber Dr John Cunniffe Clinical Scientist Consultant Microbiologist OPAT Service Manager OPAT Clinical Lead (Secondary Care)

Cunniffe – WUTH Clinical Lead Dr Paula Cowan – GP Clinical Lead

Wuth.nhs.uk @wuthnhs #proud #PROUD TO CARE

FOR YOU

THE WIRRAL (OPAT) WAY Sharon Bamber Dr John Cunniffe Clinical Scientist Consultant Microbiologist OPAT Service Manager OPAT Clinical Lead (Secondary Care)

Cunniffe – WUTH Clinical Lead Dr Paula Cowan – GP Clinical Lead

Wuth.nhs.uk @wuthnhs #proud #PROUD TO CARE

FOR YOU

#PROUD TO CARE FOR YOU


Case for Change •  Enhance existing service

•  Safe, standardised practice /compliance with BSAC good practice guidelines

•  Antimicrobial stewardship •  Extend scope of practice

•  Increased demand •  Admission avoidance •  Early discharge •  Clinical e.g. bacterial resistance

•  NHS Service Strategies •  5 year forward plan – integrated primary and acute care systems •  Patient focused


Vision – Wirral OPAT •  Shared Care - multi-organisational

•  Wirral University Teaching Hospital NHS Foundation Trust •  Wirral Community NHS Foundation Trust •  Wirral CCG

•  Seamless integrated service •  Primary/secondary care referrals

•  Quality driven •  BSAC good practice recommendations

•  Enhanced patient experience/choice


Barriers Overcome •  3 organisations

•  Separate budget/priorities •  Operating procedures •  IT

•  Multidisciplinary

•  Multiple clinical specialties •  Multiple NHS professions

•  Expertise •  Change to existing service

•  Short timescale

•  Weekly/monthly OPAT Steering

Group •  Key stakeholders •  Strategic management, governance

•  Recruitment of specialist operational

team •  Infection specialists •  IV access •  Pharmacy

•  Engagement with medical/nursing

teams

•  Phased implementation


What makes us different?

•  Broad range of infections treated •  Wide range of antimicrobials

approved for OPAT delivery (including tds and qds agents)


Range of conditions: • Secondary care initiation: Any patient fulfilling the inclusion/exclusion criteria, following discussion between ward team and OPAT core team

• Primary care initiation: Patients with a diagnosis of urinary tract infection, skin and soft tissue infection, or lower respiratory tract infection, fulfilling the inclusion/exclusion criteria, following discussion between GP and OPAT core team


Initiation by Primary Care (on the advice of OPAT team) • Flucloxacillin • Co-amoxiclav • Piperacillin and tazobactam

• Amoxicillin • Ceftriaxone

• Ceftazidime • Meropenem • Ertapenem • Temocillin • Teicoplanin


Discharge from Secondary Care (after OPAT team review) Also: • Daptomycin • Linezolid • Metronidazole


“Antibiotics not on the list but clinically indicated for a specific patient may be used if agreed by all relevant parties”



•  Microbiologist ‘gatekeeper’ at time of referral – antimicrobial stewardship; review of previous results; alert orgs; potential for oral option

•  Single access point for referral, with standard documentation

•  Whole health economy ‘buy-in’



•  Referring clinician retains patient care responsibility, or appropriate delegation (e.g. 2y care to 1y care)

•  Primary care initiation – GP retains clinical responsibility

•  Model revolves around delivery of care in patient home

•  Increased demand on service mitigated by revised administration of certain agents, and bias towards od and bd regimens where possible



•  Wirral OPAT service built on existing model delivered by Community Trust staff

•  OPAT nurses support and facilitate, and have significant role re line insertion and troubleshooting

•  Range of lines utilised •  OPAT nurses also cross-cover

hospital IV specialist nurse, and contribute to IV line surveillance



•  Clinical Scientist role as service manager

Clinical Scientist Role OPAT

•  Chair steering Group •  Strategic management, liaise with

key stakeholders •  Service Manager:

•  Staffing/recruitment/training •  Finances •  Develop policy/procedures •  Monthly Reports

•  Core Operational team: •  Day to day management of OPAT

nursing team/referrals •  MDT •  Trouble shooting •  R+D: IV access (ECG line

placement)

Infection Control:

•  IPORT – Infection Prevention Operational Reporting Team

•  Water Safety Committee •  Epidemiology/Outbreaks •  Line surveillance/IV access

Microbiology Laboratory: •  Development/Clinical Business cases •  Board Member

Service Development • Key aspects:

•  team & service structure •  patient selection •  antimicrobial management &

selection •  patient monitoring •  outcome monitoring and

clinical governance


Outcomes: From April 2015 - March 2016 •  Secured funding beyond pilot

•  Excellent clinical outcomes - 81% cure and 11% improved

•  Improvements in Quality & Safety

•  Increased activity & ease of access to service

•  Financially efficient

•  Established good working relationships with Community Foundation Trust


Outcomes •  Measured

•  BSAC database utilised •  Data submitted to the

National OPAT Outcomes Registry (NORS)

•  Activity: •  Number of referrals •  Bed days saved/AA/ED •  Patient outcomes •  Clinical data

•  Patient feedback surveys

•  Full Service Audit


Outcomes: From April 2015 - March 2016 Audit demonstrated 97% compliance with BSAC OPAT Good Practice Recommendations (compared to 23% prior to introduction of specialist OPAT team)


OPAT Activity


Outcomes: From April 2015 - March 2016 •  >4000 hospital bed days saved, with 339 patient episodes incl 285 recorded

cases of admission avoidance + 283 cases of early discharge from secondary care This would have cost >£1,100,000 to provide this service in secondary care#

#Financial Impact based on: Hospital excess bed days saved x £303* per day (treatment days on OPAT).Outpatient admissions £114* per case (admission avoidance for blocked line/line removal/GP referral) * Pricing updated based on Department of Health Reference Costs 2014-2015

£70,632 £82,689

£140,451

£88,059 £85,869 £91,323 £87,273

£136,674

£0

£20,000

£40,000

£60,000

£80,000

£100,000

£120,000

£140,000

£160,000

May June July Aug Sept Oct Nov Dec

OPAT Treatment days + Day case admission avoidance

Financial Impact without OPAT Service Monthly OPAT budget


OPAT: The GP viewpoint Dr Paula Cowan GP and Primary Care lead for OPAT

•  Streamlined referral process: clinical discussion with Consultant Microbiologist and once regime agreed; referral made via SPA (Single Point of Access)

•  Hub pharmacies: 4 pharmacies across Wirral facilitates patients and relatives

accessing antibiotics •  Updated referral form: can be self populated from GP system and referral form

includes diluents and flushes : very useful!!

•  Most importantly : •  Patients cared for at home •  Reduced risk hospital acquired infection •  Reduced risk of immobility and muscle decompensation from extended length

of stay

Integrated care between Primary & Secondary care improves care to patients (RCP/RCGP, Patient care : a unified approach 2016)


Service User Feedback The OPAT service at WUTH is

excellent! The team enables me to treat diabetic patients with

complicated soft tissue & bone infection with parenteral antibiotics at

home. Use of OPAT has reduced hospital admissions, inpatient length

of stay and most importantly improved outcomes (& patients love

it!).

Dr Srinivas Diabetic Consultant WUTH

“The OPAT service at WUTH is excellent! The team enables me to treat diabetic patients with complicated soft tissue & bone infection with parenteral antibiotics at home. Use of OPAT has reduced hospital admissions, inpatient length of stay and most importantly improved outcomes (& patients love it!).”


Patient Story - Cynthia

“The OPAT service has just been brilliant, I am always kept in the loop and get far more feedback from OPAT than my own GP. I am really well monitored and I feel that I don’t have to worry about myself. The OPAT team are always there if I need anything and always sort me out, I am so pleased I am in such safe hands.”

•  59 yrs old

•  Lives alone

•  Chronic rheumatoid arthritis

•  Multiple prosthetic joint replacements

•  MRSA +ve

•  Multiple care providers

•  Needs lifelong antimicrobial suppressive therapy


Patient Feedback

“Excellent service - wonderful concept to keep people in their own homes”

“OPAT were great, they arranged my PICC line

insertion and helped me get a very quick

discharge.”

“I was so happy that I could continue with my study thanks to OPAT. Many thanks”

“I was very impressed with how

professional and informative the staff

were”

“I was very impressed with the service and how it

enabled me to stay at home with my new born

baby. Thanks OPAT”

“Very happy to receive my treatment at home as my husband had

dementia and I would have worried leaving

him”

“Thanks to this service I managed to avoid hospital admission. Many

thanks”

Patient satisfaction surveys: 97% of patients STRONGLY AGREE that OPAT was preferable to inpatient treatment. 98% would opt for OPAT again


Sharing •  Locally – WUTH/WCT/WCCG

•  Recruit externally from neighbouring trusts

•  Quality Improvement Champions

Group •  Healthcare Science Transforming

Patient Care Case Studies

•  Poster BSAC national conference

•  National Registry (NORS)

•  CSO Conference & Advancing Healthcare Awards


And now...

The interactive bit!


Question:

Nurse competencies • Community Nurse • OPAT Nurse


Question:

• What about anaphylaxis? • Antibiotic knowledge


Community Nurse competencies: •  IV antibiotic administration is part of mandatory training program for all teams (annual update)

• OPAT specialist nurse included in community teaching • Central administration of IV antibiotics SOP (community document)

• Overarching (combined WUTH & community document) document in progress – covers all aspects of the service, including governance of referral process

• Phlebitis scoring and daily patient observations mandatory daily data entry on ‘System One’


OPAT nurse competencies • Training includes minimum 3 month initial training period with specialist IV access nurse, followed by regular rotation (1 in 4 month rotation) with IV access service to maintain skills required for PICC/midline insertions

• (OPAT/IV access team provide specialist training updates for secondary care staff)


Question:

Microbiologist competencies • ?


Question:

Service manager competencies • Clinical scientist role


Question:

GP competencies • ?


Question:

Patient selection


Inclusion criteria (All must apply) • Medically stable and fit for discharge (as assessed by medical team, registrar or above) or medically stable and fit to remain within community setting (as assessed by GP)

• Able to understand and consent to OPAT • Safe and appropriate IV access • Registered with a GP on the Wirral • Age >18 yrs • Definitive diagnosis known


Exclusion criteria (Any one will exclude the patient) • History of allergy to agent being administered or related agent

• Known risk of sudden death •  Immunocompromised / neutropenic • Septic (i.e. 2 or more of the following; heart rate >90bpm, temp >38.3oC or <36 oC, respiratory rate >20 breaths per minute, WCC >12x109/L or <4 x 109/L, or new altered mental state

• Unable to communicate / confusion •  Intravenous drug misuser


•  Individuals outside these criteria may still be accepted into the service after agreement of the patient management plan with senior medical team review including the Consultant Microbiologists and GP. E.g. patients receiving ‘End of Life’ care

• Note – if WCC not available at time of assessment, and any one of the other SIRS criteria are met, OPAT can only be met if arrangements are made for same day FBC. If this is not possible, or the result is outside the recommended range, OPAT is not appropriate

• Caution: patients with a history of anaphylactic reaction from causes other than the agent being administered should be risk assessed prior to referral


Rejection issues: • Sepsis • Undrained collection • IV drug use? • Infusion >30mins • (Home environment)


Grey area: • End of life care • Pre-agreed care plan with involvement of all stakeholders


Question: Where are the gaps?:

• Daily patient review / de-escalation • Confirming referring clinician retains involvement, or there is appropriate delegation of responsibility

• Patients with multiple teams involved


Question: Where are the gaps?:

Teicoplanin – turnaround time; responding to abnormal levels (chicken vs egg...)

Patients with no positive microbiology


Problematic infections: • IE, septic arthritis, OM, bacteraemia • Bronchiectasis • Recurrent UTI


Problematic patients...


Question: Confirming quality; assuring safety:

• BSAC database – outcome data • NORS registry • Clinical reviews / Service review

• Treatment failure - ?preventable • Drug reactions • Line infections • Alert organisms • Learning / feedback!


Question: Responding to feedback

• Patients • Clinicians (Service ‘users’) • Team members


Question: Responding to feedback

• Patients – self administration • Clinicians – fine tuning referral process; on-call

• Team members – elastomeric pumps


Thank you!

community initiated opat services -...

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