VOL: 97, ISSUE: 38, PAGE NO: 62
JENNIFER DEAGLE, SRN, is a sister, hospital at home services, Southampton General Hospital
It is established practice in the UK to treat patients with chronic illnesses requiring intravenous antibiotics at home. Many patients with cystic fibrosis or cytomegalovirus have learnt how to mix and administer drugs while monitoring their own condition and caring for infusion lines (Kayley et al, 1996).
In the USA outpatient therapy at home (OPAT) has become a standard mode of therapy for severe localised and systemic infections (Lawrence, 2001). The guidelines for an OPAT service recommend that a senior microbiologist should supervise the service, with the referring surgeon or physician retaining clinical responsibility. A nurse experienced in OPAT care should give the first dose of antibiotic and oversee the treatment, with pharmacy support. The physician, microbiologist and OPAT nurse should review the patient on a regular basis. If administration of care is passed to a second provider they must meet the same standards in delivering and monitoring care as the initial OPAT provider, with an OPAT trained nurse involved in the transfer of care. The treatment outcomes must be as good as those for patients treated in hospital (Williams et al, 1997).
Recent practice in Southampton
In June 1999 the medical directorate started an OPAT pathway to treat selected patients with an acute episode of cellulitis (soft tissue infection). Southampton patients are asked to return to the hospital on a daily basis. The intravenous antibiotics used are ceftriaxone, gentamycin and teicoplanin. Patients who are in a lot of pain or are vomiting or feel unconfident about coping at home are admitted for 48 hours and then reassessed for OPAT. In 12 months 78% of patients with cellulitis (138 people) were successfully treated via an OPAT pathway.
Expansion of service.
OPAT pathways can be used to treat other conditions, such as osteomylitis, joint infections, endocarditis, resistant urine infections, MRSA-infected wounds and respiratory infections, but many patients requiring six weeks’ intravenous therapy would not want daily visits to the hospital (Williams et al, 1997). Other options were considered: to involve the patient’s community nurse, to teach the patient to self-administer or to involve a private nursing agency.
Benefits to the patient and hospital
Patients benefit from an OPAT pathway because they receive care from a focused team and are not exposed to hospital-acquired infections. Antibiotics can be prescribed to OPAT patients that are not appropriate for hospital patients. Clindamycin is an example of an effective antibiotic for treating osteomylitis, which cannot be used in hospital because the drug alters the gut flora, making patients susceptible to bacteria from other hosts - for instance, Clostridium difficile.
What other hospitals are doing
A literature search using Medline, the internet, the hospital library and verbal recommendations from colleagues revealed that medical staff working in Minneapolis, USA, wrote the best practice guidelines for OPAT (Williams et al, 1997). OPAT pathways in Europe are underdeveloped and the pioneering work in the UK is being done in Dundee (Nathwani and Davey, 1996). The International OPAT Registry (www.opat.com) audits the pathways.
I visited four hospitals. Dundee University Hospitals NHS Trust uses a nurse practitioner (NP) to run its OPAT service. Patients requiring more than seven days’ intravenous antibiotics have a long line (PICC) placed by the NP, who also teaches them how to self-administer their drugs. At weekends patients who do not wish to self-administer come to the ward for treatment. The NP estimates that 50% of community nurses would need to be trained in each GP practice to provide seven days a week cover for patients, a level of service unavailable in Dundee.
A mixture of private and public programmes funds the US health service (Koperski, 2000). Hennepin County Medical Hospital in Minneapolis is a government-funded hospital that uses a private health care organisation to deliver an OPAT pathway. The hospital finds it cheaper to pay a commercial organisation than to keep the patient in a bed.
Methodist Hospital is a private hospital which runs OPAT through an infusion clinic. Patients either return daily or are taught how to self-administer, as some health insurers will not pay for a daily home nurse.
Fairview Homecare Services is a mutual assurance programme which provides nurses to visit patients in their home to insert lines, administer antibiotics and teach self-administration. These patients have health insurance that pays for a home nurse. All patients had access to a 24-hour helpline.
All four hospitals were funded and managed in different ways but each hospital had very similar policies and procedures covering OPAT pathways. All nursing staff were registered nurses, with senior staff having a degree or Masters degree in nursing. Staff were required to work in an extended role, with competencies defined for line insertion, dressing changes, administration of drugs and teaching of patients. Training programmes used videos, practice sessions on dummy arms and supervised practice. Each unit had an audit system looking at numbers of patients treated, adverse events, failure of treatment and outcomes.
I was able to observe one elderly patient having his PICC line inserted in hospital, visit him at home the next day and observe his wife give him his antibiotics. Another, a young man, was recovering at home after a road accident. His wounds required a longer course of antibiotics, so a PICC was inserted in his home and he continued self-medicating.
I spoke to 23 patients receiving OPAT treatment whose ages ranged from 22 to 87. All preferred OPAT to an extended stay in hospital. These conversations count as anecdotal evidence. It would have been impossible for me to devise a questionnaire suitable for this purpose and submit it to four different health organisations within my short visits. The strength of the evidence lies in the fact that one person asked the same question each time and that I was viewed as separate from the providing health care system.
I went on this study tour convinced that I would have to build links with community nurses or a commercial organisation in order to treat more people via OPAT. I was unprepared for the ease and rapidity with which patients learnt how to self-administer. The experience has altered my expectation of how patients can be treated via an OPAT pathway.
Expanding OPAT in Southampton
Although intravenous administration of drugs has been available for 30 years, the skill is still considered to be an extended role, with registered nurses required attending additional training. Many community nurses in Southampton are now trained to give chemotherapy in the community but are not considered competent to administer antibiotics. When community nurses are able to administer IVs their workloads limit the time they can spend with a patient and only bolus or 24-hour infusions can be given.
Southampton has decided to expand OPAT by teaching the majority of patients how to self-administer.
Issues to be addressed when implementing OPAT
- Training: the nurses working in the clinic are all experienced registered nurses with further education. All staff are trained (ENB 998) in teaching and assessing and have experience in teaching other patients how to self-medicate and are trained in intravenous administration. No further training is required;
- The line manufacturer has provided PICC insertion training with supervised practice and assessment by the trust’s intravenous nurse practitioners;
- Operational pathways have been written and agreed by the microbiologists, clinical directorates, pharmacy, nursing and risk management. Patient-held notes have been developed with detailed agreements on how, when and by whom the patient should be reviewed;
- Out of hours advice, 18.00-08.30: Patients can ring the emergency medical unit for advice. An algorithm guides the nurse in deciding whether the patient needs to attend A&E for immediate assessment by a doctor, or should return to the clinic the next day;
- Patient information leaflets on self-administration have been written;
- Pharmacy has costed the provision of a central intravenous service, where antibiotics are prepacked under sterile conditions and delivered to the patient’s home. This is not essential; patients in Dundee are taught how to mix their own drugs;
- A safe, inexpensive ambulatory pump, the sidekick infuser, has been identified for home use;
- Audit: all patients will be registered on the OPAT International Registry.
OPAT pathways staffed by nurses experienced in OPAT care provide an effective service to the majority of patients requiring intravenous antibiotic therapy. Large numbers of people can benefit from OPAT if they learn self-administration and undergo a weekly review by an OPAT nurse.
The training and competencies of nurses working within OPAT pathways needs to be uniform to promote the safe transfer of care from acute to community trust, public to private provider.
Intravenous administration is now a very common therapy. Student nurse training courses should include the theory and practice of intravenous drug administration through all types of lines in the last six months of training, with assessment on their first post-registration placement. Separate post-registration courses should not be necessary.
- The study was funded by the Florence Nightingale Foundation Travel Scholarships