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Linda Nazarko OBE discusses setting up and running OPAT services at todays IV Therapy Conference

Linda Nazarko OBE, Nurse Consultant at London North West Healthcare NHS Trust updated delegates today on setting up and running an effective OPAT service including competence and skills development. Linda is the OPAT lead in her organisation.

Fifteen years ago only a small minority of hospital inpatients were considered suitable for Outpatient Parenteral Antimicrobial Therapy (OPAT) services (Wiselka & Nicholson, 1997). Now almost 70 percent of those treated with intravenous antibiotics as hospital inpatients are considered suitable (Hitchcock et al, 2009). Now between 38 - 53 percent of those requiring OPAT are able to self administer (Hills et al, 2012). The demand for intravenous antimicrobial therapy is increasing and the way it is being delivered is changing.  This paper examines service models, setting up services and developing staff to enable them to deliver OPAT services.

Key words: IV therapy services: Community: Delivery models; Staff support

Introduction

Outpatient Parenteral Antimicrobial Therapy (OPAT) services were first described in 1974. They were developed to provide care and support to children with cystic fibrosis requiring intravenous antibiotics (Rucher & Harrison, 1974). The term OPAT originated in the US.  It originally referred to intravenous antibiotic therapy delivered outside of hospitals. It now appears to have been adopted as a universal term to cover all provision of IV therapy that is not delivered in patient hospital settings (Kayley, 2012). At present there is a huge diversity in relation to the level of services available and the type of services delivered (Kayley, 2011).

As healthcare becomes more complex there is a growing need to provide intravenous therapy in community settings.  This article aims to inform readers who are considering setting up or working in an OPAT service about the different service models, about setting up services, developing staff and auditing services.

Benefits of an OPAT service

OPAT services have developed globally over the last 30 years.  Services can reduce treatment costs, improve outcomes and enhance quality of care (Chapman et al, 2009: Wai et al, 2000).  In areas where OPAT services are not available people may remain in hospitals for prolonged periods so that they can receive intravenous therapy. OPAT services can be used to enable people to return home thus reducing length of stay and also in some cases to avoid the need for hospital admission.

Principles of setting up and running an IV therapy service

In the past only a few pioneering specialist centres in the UK ran OPAT services (Nathwani et al, 1999: Kayley et al, 1996).  They were considered to be suitable for a minority of patients.  Wiselka & Nicholson (1997) found that only two percent of patients admitted to their infectious disease unit were suitable for OPAT. Suitable patients were those who were medically stable and required prolonged intravenous antibiotics.  The number of people being treated by OPAT services is now increasing as clinicians have gained expertise in OPAT and new services are being developed.  Demographic, social and healthcare policy changes are now encouraging the development of OPAT services across the UK (Chapman et al, 2012: Kayley, 2011).  There are also factors inhibiting the development of OPAT services. Figure one (author’s own work) summarises the factors driving and inhibiting the development of services.

Figure one: Forces driving and inhibiting the development of OPAT services

OPAT services are delivered outside of hospital and this means that the person receiving OPAT receives less supervision than a person receiving inpatient care (Chary et al, 2006).  This means that the risks of delivering OPAT are potentially greater than inpatient therapy.  Services should be developed with care to ensure that risks to patients and staff are minimised (Gilchrist et al, 2009). Good practice recommendations suggest that these are addressed in relation to team and service delivery standards, patient section, antimicrobial and drug delivery, monitoring of the patient and monitoring of outcomes and clinical governance (Chapman et al, 2012). Figure two (author’s own work) illustrates this.

Figure two: Key components of an OPAT service (Based on Chapman et al, 2012)

The OPAT team

OPAT is best managed and delivered by a team. The composition of teams varies and team members may work for different organisations.  Those delivering the service on a day to day basis may work for an organisation providing community services and other team members may work in an acute NHS Trust. The team normally consists of a physician with expertise in antibiotic therapy. This is normally an infectious disease consultant.  In some areas a microbiologist provides this expertise. Some teams have a microbiologist and an infectious disease consultant.  Pharmacy input is considered of crucial importance.  Many acute hospitals and community service providers now employ pharmacists with specialist expertise in antibiotic therapy who provides expert pharmacy support.  The team should also have specialist nursing and community nursing input (Tice et al, 2004: Chapman et al, 2012).

What type of therapy is suitable for OPAT

A wide range of IV therapies can be delivered outside of hospitals (Kayley, 2011). These include:

  • Antimicrobials.
  • Chemotherapy.
  • Bisphosphonates;
  • Iron sucrose;
  • Immunoglobulins;
  • Parenteral nutrition (PN);
  • Blood products
  • Intravenous fluid.

OPAT services have two main aims, to support discharge and to avoid admissions.  This has led to the development of services that aim to enable people requiring long term IV antibiotic therapy for soft tissue infections to be discharged home and services that aim to treat simple infections such as cellulitis without the person being admitted to hospital (Seaton et al, 2005: Barr et al, 2012b).

Referral pathways and caseloads

OPAT is delivered in many different ways throughout the UK. It is essential that any OPAT service has clear pathways, policies and procedures (O’Hanlon et al, 2008).  These should have clearly defined inclusion and exclusion criteria. They should also make it clear that the patient remains the responsibility of the referring organisation until formally accepted by the OPAT service.

The issue of caseloads is seldom referred to in the literature.  In hospitals capacity is determined by availability of beds, theatre slots and outpatient appointments. In the community there is sometimes the assumption that capacity is unlimited. This is not the case and community nurses may worry about how they will manage to deal with additional workload. If setting up a service it is good practice to set a capacity limit. This can be increased as the service develops.

Selecting and monitoring patients and outcomes

Although the threshold for referring patients to OPAT has changed dramatically in the last 15 years not everyone is suitable for OPAT services.  The service should have clear inclusion and exclusion criteria.   These criteria may be specific to a particular condition or may be service specific. Figure four provides a generic example.

Figure four: An example of generic inclusion and exclusion criteria

Short term and long term therapy

There are two distinct types of patients those requiring short term therapy and those requiring long term therapy. In the past OPAT tended to concentrate on supporting the discharge of people likely to require long term OPAT but this is changing (Seaton & Barr, 2013).  OPAT has the potential to provide a service for both those requiring short term therapy and those requiring long term therapy.

People likely to require short term therapy are those with cellulitis, urinary tract infection not amenable to oral therapy and those with surgical wound infections.  People likely to require long term therapy are those with osteomyelitis diabetic foot infections and increasingly multi-resistant tuberculosis. Their needs for care and support are very different. Figure five illustrates these different types of patients.

Short term case history

Emma is 32 years old and had her much longed for first child by emergency caesarean section.  She went home and all seemed well however a few weeks after surgery she developed a severe wound infection.  Emma was admitted to a general ward and was separated from her baby. She required IV antibiotics and medical staff assured her that she’d be able to leave after a few days of IV therapy.  Emma became distraught and was desperate to return home and be re-united with her baby.  Fortunately her medical team assessed her as suitable for OPAT and she was able to return home to her baby within 24 hours.

Around 25 percent of all women give birth by caesarean section in UK and around 5 percent will develop a surgical site infection (Ghuman et al, 2011).  Clearly offering an OPAT service can make a real difference to people like Emma.

Long term case history

Marek is 35 and came to the UK from Poland two years ago.  He has multi-drug resistant TB and will require oral and daily IV antibiotics for at least six months. Marek has a wife and two children in Poland and they depend on his income.  Marek is worried about having time off work or being late for work as he fears he could loose his job.  Marek is keen to learn how to give his own IV antibiotics but is worried that he will not be able to manage.  He has arranged to finish early one day a week so that he can be seen in clinic.

Tuberculosis rates are falling across Western Europe, except in the UK. IN the UK 9,000 cases are diagnosed annually, 40 percent of cases are in London.  The number of cases diagnosed in London rose by almost 50 percent between 1999 and 2009 (Zumla et al, 2013).

The World Health Organization (WHO) estimates that there were 650,000 cases of multidrug resistant tuberculosis (MDR-TB) in 2010. Multi-drug resistant TB is defined as strains that are resistant to at least isoniazid (INH) and rifampicin (RIF) (Daley and Caminero, 2013) .

Meeting patient needs

There are two components to meeting patient needs these are ensuring patients are reviewed regularly, treated effectively and receive support whilst undergoing IV therapy.

Reviews

People receiving OPAT should have regular reviews.  The frequency of review will be determined by conditions treated.  A person with cellulitis will for example receive daily reviews to ensure treatment is effective and that a switch from intravenous to oral antibiotics can be made at the appropriate time.  The person on longer term antibiotics to treat a condition such as osteomyelitis may be reviewed weekly at a virtual ward round and fortnightly in a clinic.  People who are self administering are normally reviewed weekly by a nurse and fortnightly in clinic.

 

Support and education

Not everyone who is receiving OPAT is ill and some people who are receiving OPAT may be working. Its important for staff to support people in their efforts to work and to educate and enable people to complete their treatment.  Toczek and colleagues (2013) carried out an analysis of 75 studies examining why patients with MDR TB do not continue their treatment. They found that 14.8 percent of patients did not continue treatment.  They found that supporting and educating patients improved treatment compliance.

Treatment regimes

Sometimes colleagues working in acute settings are unfamiliar with treatment regimes used in OPAT.  In acute hospitals for example cellulitis is treated with four times daily antibiotics, in the community once daily therapy, normally ceftriaxone 1g is used (Nazarko, 2012).  In hospital settings, ceftriaxone and other cephalosporins should be avoided because of the risk of Clostridium difficile (Regional Drug and Therapeutics Centre, 2009). Cephalosporins should not generally be used in community settings (Health Protection Agency, 2010); however, the risk of patients who are prescribed ceftriaxone developing C. difficile infection in the community appears to be extremely low (Matthews et al, 2007). Duncan and colleagues (2012) conducted a review of the use of ceftriaxone in OPAT and found that it had an excellent safety profile and in contrast to the inpatient setting, liberal use of ceftriaxone in OPAT has not been strongly linked to clostridium difficile infection (CDI), suggesting additional patient and environmental factors may be important in mediating CDI risk. Its important to establish what antibiotics can be given at home and how often they can be delivered. Many services normally only accept patients who require daily or exceptionally twice daily therapy. There are however reports of some services delivering four times daily therapy and this must be disruptive to patients and negate some of the benefits of OPAT.

Service delivery

There are three main ways to deliver OPAT. These are self administered outpatient antimicrobial therapy known as S-OPAT, therapy delivered in an infusion centre delivered known as H-OPAT and home based services delivered by staff known as C-OPAT. Infusion centres can be based in the community or in acute hospitals. Figure three (author’s own work) illustrates the diversity of OPAT services.

 

Figure three: OPAT service delivery models

Self administered outpatient anti-biotic therapy

At present there is limited published information about the safety of differing models of OPAT therapy.  The risks of S-OPAT include potentially higher risks of adverse effects such as venous access device infection and other line complications because therapy is being administered by people who are not healthcare professionals. Barr and colleagues (2012a) carried out a large study of OPAT and examined S-OPAT as part of the study.  They found that

 

“there is no evidence that self-administration of OPAT is associated with higher rates of venous access device complications after controlling for confounding variables”

 

Matthews and colleagues (2007) carried out an analysis of 13 years of OPAT therapy including people self administering. They found no excess complications or hospital re-admission in the S-OPAT group and concluded that

“Self-administration of intravenous antimicrobial therapy, in selected patients under the supervision of a specialist team, is a safe and feasible strategy”.

The number of people who have the ability to self administer intravenous therapy is probably much greater than most professionals realise. In Nottingham 38 percent of people with infections secondary to orthopaedic problems and 53 percent of people with diabetes related infections were able to self administer (Hills et al, 2012).

The literature is clear that it is important to ensure that people who self administer are carefully checked and supported to ensure that they have the skills and abilities to self administer. The OPAT team provide support and visit at least weekly to ensure that all is well.

Infusion centres

Infusion centres are centres based in acute or community hospitals or in community clinics. People requiring intravenous therapy come to the clinic and have therapy delivered in the clinic. People requiring IV therapy can be taught how to deliver their own therapy in the centre may have blood tests at the centre and can be reviewed by a visiting consultant Hills et al, 2012). Infusion centres can be more efficient and cost effective than nurses attending a person’s home. The nurse delivering the infusion can attend to more than one patient at a time (Tice, 2005).  People requiring OPAT have to travel to the centre but it can be easier for staff to organise and keep to appointment times.

Home delivery

OPAT is not suitable for all patients. Some people requiring intravenous therapy require hospital treatment. Hitchcock and colleagues (2009) found that around 30 percent of people required hospital treatment and around 70 percent were suitable for OPAT.  In fifteen years OPAT has moved to being suitable for a small minority of patients to being suitable for a majority of patients.  OPAT is associated with lower rates of infection than hospital delivered therapy. Seaton and colleagues (2011) found that the population being treated with OPAT was changing and more patients co morbidities were being treated.  They concluded that

“OPAT was generally safe and effective, but specific patient groups were identified with more complex management pathways and poorer outcomes”

A number of models are used in the UK to deliver C-OPAT. These include specialist IV therapy teams based in the community, community nurses delivering IV therapy as part of their day to day practice and the use of private companies to deliver IV therapy (Kayley, 2008).

Providing a comprehensive service

What I’ve learnt over the last few years is that the best way to provide a comprehensive service is to use different teams to deliver different components of the service.  One size does not fit all.

Community nurses can provide C-OPAT to those who meet the criteria for community nursing i.e they are “housebound”.

Rapid response or intermediate care teams who have a time limited input can provide C-OPAT to people who require a time limited intervention such as people who have cellulitis or a urinary tract infection that requires IV antimicrobials.

Infusion centres can enable and empower people who are mobile to take control of their condition, provide support and serve as education centres where nurses can gain confidence and competence in IV therapy.

Developing and supporting staff

Community based staff may be unfamiliar with intravenous therapy.  They may not have given intravenous therapy in years and may be unfamiliar with vascular access devices used for medium and longer term intravenous therapy.  Staff will require training to ensure that they have the necessary theoretical and practical skills and competencies to carry out intravenous therapy in the community.  The Royal College of Nursing (2010) has developed comprehensive guidance on training education and skills.  Staff should also have access to the support of a nurse specialist and the OPAT team.

Demonstrating outcomes benefits and cost savings to commissioners

OPAT is sometimes delivered by community nurses however community nursing services are funded to deliver services to housebound patients. Many people requiring OPAT are not housebound and therefore do not fall within the remit of traditional community nursing services.  Those who wish to obtain additional funding to develop enhanced services are usually required to develop a business case for commissioners.  The British Society for Antimicrobial Therapy produces a tool kit for developing a business case (BSAC, 2011).  The business case will lead to the development of key performance indicators for the service. These generally include number of bed days saved or admissions avoided.

Conclusion

OPAT services are safe and cost effective. They enable people who would otherwise have been hospital inpatients to return home or to remain at home.  This reduces infection rates and improves quality of life for people requiring OPT. As our population ages and healthcare advances continue the demand for OPAT is set to rise.  Our challenge is to provide services the meet the changing needs and expectations of our population in the twenty first century.

Learning points

  • The term OPAT is being adopted as a universal term to cover all IV therapy outside of in patient hospital settings.
  • OPAT can be provided in three ways, self administered outpatient antimicrobial therapy known as S-OPAT, delivered in an infusion centre known as H-OPAT and home based services delivered by staff known as C-OPAT.
  • Infusion centres can be based in the community or in acute hospitals
  • OPAT is generally delivered giving once a day third generation cephalosporins
  • There is no indication that these increase the risk of C. difficile infection
  • OPAT is safe cost effective and enables people to return home from hospital or to avoid hospital admission.

 

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29 January 2015

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