A hospital offering outpatient parenteral antimicrobial therapy to people from across the UK undertook a review of its long-distance service model to ensure it is safe
This article describes a review of the clinical and safety outcomes when discharging patients from a tertiary centre using a long distance model for the administration of outpatient parenteral antimicrobial service.
Citation: Crick K et al (2016) Reviewing a long-distance OPAT service model. Nursing Times; 112: 35/36, 19-21.
Authors: Katy Crick and Swee Hwa Chin are outpatient parenteral antimicrobial therapy (OPAT) clinical nurse specialists, Aliyah Undre is OPAT pharmacist and Amrit Shakon is antimicrobial pharmacist; all at The Royal National Orthopaedic Hospital, London.
- This article has been double-blind peer reviewed
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Administering intravenous (IV) antibiotic therapy in the community or outpatient setting is an alternative to inpatient care for those who need IV antibiotics but are otherwise medically stable. It can result in:
- Reduced length of stay;
- Admission avoidance;
- Less exposure to hospital-acquired infections;
- Improved patient experience as patients can return home and continue their daily routine (Matthews et al, 2007).
The Royal National Orthopaedic Hospital (RNOH) is the largest orthopaedic hospital in the UK and treats patients from across the country. Before 2011, if patients required a lengthy course of antibiotics, most remained in hospital until they had completed the course (on average six weeks). There was no criteria for assessing patients for discharge on IV antibiotics, or educating or monitoring patients and reviewing treatment outcomes. This meant few were considered suitable for discharge.
The outpatient service
Because patients are referred to the RNOH from across the UK, outpatient follow-up is rarely feasible. They may receive outpatient parenteral antimicrobial therapy (OPAT) for a range of conditions – mainly for prosthetic joint infections undergoing revision surgery, other orthopaedic implant infections and osteomyelitis. Our OPAT service has been developed using good-practice recommendations from the British Society of Antimicrobial Chemotherapy (Chapman et al, 2012). It uses a long-distance model in which:
- Line care and routine blood testing are provided by local healthcare services;
- Follow-up is provided by weekly RNOH clinical nurse specialist (CNS) telephone clinics and multidisciplinary team (MDT) discussion;
- A single physical review is carried out at the end of treatment.
RNOH patients are usually on a defined course of at least six weeks’ IV antibiotics before these are stopped or are replaced with oral antibiotics. The IV antibiotic course length is determined by the bone or joint infection being treated and its compatibility with a long-distance model.
The OPAT MDT comprises a consultant microbiologist, antimicrobial pharmacist, OPAT pharmacist and two OPAT clinical nurse specialists.
Preparing patients for OPAT
Fig 1 (attached) outlines the OPAT process. Potential patients are identified in the weekly OPAT MDT meeting or by the microbiologist during ward rounds. The microbiologist informs the team of the antimicrobial regimen; whenever possible this is a once-daily regimen, making it as easy as possible for patients to manage when they are at home. However, occasionally the organism being treated needs an antibiotic that requires more frequent administration. Patient suitability for OPAT is assessed by the OPAT CNS and patients must consent to be discharged under the care of the OPAT service.
OPAT patients are either taught to self-administer antimicrobials or referred to the local community nursing team (NHS or private) for administration.
We use a teaching plan to show patients how to self-administer antibiotics and give them written instructions. Before going home, OPAT nurses must assess whether the patients are competent to reconstitute and administer their medication at least twice. Some patients may need more support to develop the necessary skills so training is tailored to their needs. Those who do not pass competency assessments usually accept referral to community services in their local area to have their antibiotics administered. If this is not available, patients remain in hospital until they finish the course.
Discharge to community services
Most community teams to which we refer provide IV antibiotics in the community setting but, due to workload, some can visit patients only once a day. In some areas, IV administration is provided by specialist IV teams or private providers. Discharges are negotiated with the different teams to find a solution to these issues. If they cannot be solved, an alternative solution – such as using private providers or our partner nurse company at the RNOH – is sought.
Patients are usually discharged with a peripherally inserted central catheter (PICC). These are tolerated well by patients and can remain in place for the duration of treatment. Patients can decide to have a post-discharge follow-up locally or at the RNOH. Few are able to return to RNOH for follow-up due to the long-distance travel involved so a referral letter is sent to the community nurses to provide weekly PICC line care and blood tests.
All OPAT patients undergo a weekly full blood count, renal profile, liver function test and C-reactive protein (CRP) test. Depending on the antibiotic administered, they may need an antibiotic level or other markers. Instructions for weekly blood testing required by the GP are included in the electronic discharge summary.
Patients are given a booklet including:
- Information on their medication;
- PICC line advice;
- Contact numbers for the pharmacy and OPAT CNS at RNOH.
This has been developed in line with good-practice recommendations (Chapman et al, 2012). The RNOH retains responsibility for dispensing medication and delivers this by courier in two-week instalments.
All OPAT patients cases are discussed at a weekly virtual ward round attended by the MDT, which aims to:
- Discuss each patient’s progress and any treatment-related issues;
- Review their blood test results;
- Ensure follow-up appointments are made;
- Ensure there is a signed prescription for each patient for the next two weeks;
- Ensure that appropriate equipment is ordered for each patient.
Evaluating the service
Between April 2013 and March 2016, we undertook a service review to provide assurance that this model is a safe way to manage patients requiring OPAT. The review explored clinical and safety outcomes associated with discharging patients from a tertiary centre using the long-distance model.
Over the review period of three years, 467 patients received treatment by the OPAT service, resulting in 15,759 OPAT days. Their average age was 59 years (range 9-84) and the most common conditions treated were:
- Prosthetic joint infections (76%);
- Spinal infection (6%);
- Osteomyelitis (6%);
- Other orthopaedic infections (12%).
Of the sample, 36% patients self-administered their antibiotics, 56% used district nurses, 4% used Medihome (a private community nurse provider) via hospital contract, 3.75% used private companies, and 0.25% used another method, such as a GP or local unit.
In total, 434 (93%) patients successfully completed their OPAT course as planned. Reasons for failure were usually related to the underlying condition rather than complications from OPAT, such as insufficient surgical debridement of infected bone in osteomyelitis. Fig 2 (attached) shows complications by year.
Line occlusion, the most common complication, can be resolved by changing position as the PICC line can migrate to the vessel wall. However, most incidents are resolved by RNOH or local OPAT nurses administering a dose of urokinase into the line. Occlusion occurred twice when the PICC line had not been flushed immediately after blood sampling, so the patient booklet now covers this. When IV antibiotics were reviewed, 50% of line occlusions occurred in patients receiving teicoplanin, 25% ceftriaxone and 14% other antibiotics. This is consistent with the most common antibiotics prescribed. The type of antibiotic did not affect the occlusion rate.
Line migration occurs when either line securement dressings cannot adhere due to allergy or perspiration, or the line is accidentally pulled out during dressing changes by health professionals – though incidences of this have been reduced by changing our line securement device. When migration is reported to the OPAT service, the line position is checked on a chest X-ray at RNOH or locally, if the patient prefers to establish whether the line can still be used.
Only six patients developed line infections; one had often developed such infections in the past and has undergone investigation elsewhere to ascertain the cause. No pattern of infection was evident in the other five patients as three self-administered and two had medication administered by a community nurse.
Care of patients with line-related DVT was reviewed by the anaesthetic lead for vascular access device insertion – again, no patterns were evident. Over the review period a total of 12 lines were replaced; seven of these were due to occlusion, four due to migration and one due to infection.
There were 37 (8%) medication-related events over the review period, including:
- Allergies: n = 7 (19%);
- Cytopaenia: n = 5 (14%);
- Other: n = 25 (68%).
Reactions were identified through patient reporting, weekly telephone clinics and weekly review of blood test results. All reactions are discussed with the consultant microbiologist as soon as they are discovered to determine the a course of action. Patients may be continued on therapy – and closely monitored – the antimicrobial dose may be reviewed, side-effects may be managed or the patient may be switched to an alternative antimicrobial for the remainder of the course.
OPAT complication rates range from 0-5% for line infections and 0-17% for other line complications (Barr et al, 2012). Line infection rates are also calculated per 1,000 catheter days – RNOH’s rate is 0.3 per 1,000 catheter days. Published data for line complications can vary between 0.6 and 1.9 per 1,000 catheter days on OPAT (Barr et al, 2012) and 0.4-4.7 per 1,000 catheter days in other settings – for example, inpatient hospital care (Pikwer et al, 2012).
Analysis of the data shows there does not appear to be any particular trend related to the adverse reactions identified. All the reported reactions indicate known side-effects for the antimicrobials but some are more common than others. In some cases, incidence of an adverse effect was higher in our patients than reported levels. However, the doses used to treat bone infections are often much higher and used for longer periods than those reported in general, which can account for an increased likelihood of adverse effects in our patient cohort. The numbers and types of adverse effects have not caused concern to date as they have always been managed promptly and successfully without harm to the patient or any clear, repeated patterns.
Some bone or joint infections remained despite the full treatment course, but this was usually due to the underlying condition rather than complications from OPAT, and the outcome is likely to have been the same in an inpatient setting. These patients were referred back to the orthopaedic team for further surgical management.
We are looking into using pre-filled infusers as this will remove the need for patient reconstitution and will mean more patients can self-administer medication.
A long-distance model appears to be as safe and effective as alternative models for medically stable patients, although longer-term follow-up would be beneficial. Our data shows outcomes and complication rates are consistent with published studies and clinical outcomes are favourable at six weeks. Further work is required to explore causes of line complications and reduce these by improving education for patients and health professionals.
- Outpatient parenteral antimicrobial therapy (OPAT) is a safe alternative to inpatient care
- OPAT patients are managed using a multidisciplinary approach
- An OPAT management plan should be agreed upon with patients
- Patients are given written information and contact details for the OPAT service
- Treatment plans and patient progress are reviewed by the multi-disciplinary team at weekly virtual ward rounds
Barr DA et al (2012) Self-adminstration of outpatient parenteral antibiotic therapy and risk of catheter-related adverse events: a retrospective cohort study. European Journal of Clinical Microbiology and Infectious Diseases; 31: 10, 2611-2619.
Chapman AL et al (2012) Good practice recommendations for outpatient pareteral antimicrobial therapy (OPAT) in adults in the UK: a consensus statement. Journal of Antimicrobial Chemotherapy; 67: 5, 1053-1062.
Matthews PC et al (2007) Outpatient parenteral antimicrobial therapy (OPAT): is it safe for selected patients to self-administer at home? A retrospective analysis of a large cohort over 13 years. Journal of Antimicrobial Chemotherapy; 60: 2, 356-362.
Pikwer A et al (2012) Complications associated with peripheral or central routes for central venous cannulation. Anaesthesia; 67: 1, 65-71.