Delivery of an integrated OPAT

service in Buckinghamshire

Marie Coward

Delivery of an integrated OPAT service in BuckinghamshireMarie Coward – IV specialist Nurse / OPAT lead

April 2012 BSAC

Buckinghamshire Healthcare trust (BHT)

• BHT – vertical integration approx18 months ago (merger of community and acute trusts)

• 2 acute hospital sites (Stoke Mandeville and Wycombe)

• 6 community hospitals and 7 localities for

Adult Community Healthcare Teams (ACHTs).• Buckinghamshire is a long narrow county

(50miles) with a population of around 530,000.

History & background• Originally, ad hoc service from Wycombe hospital

(south county) in 2007.• Increasing opportunities for OPAT from Stoke

Mandeville site in the north put service under pressure as only manned by 1 nurse.

• In 2009 a 6 month pilot was commenced with a team of nurses using the integrated service model. The pilot was successful & reduced length of stay/ bed days saved and patient acceptability.

• Unfortunately the pilot was not continued at this time but went on to inform the business case that was subsequently re presented.

Service development• The proposed business case was approved by the PCT

and the service was established using SIRF (Service improvement reform fund) money for the first year and is now embedded in the community division of the trust.

• 4 nurses (1 band 7 & 3 band 6) plus funding for antibiotics and start up equipment.

• The service was officially re launched in September 2010 with the service only reaching its full manpower & working capacity in Dec 2011.

• Part of the service development was to show innovation and new ways of working with the integration of the 2

trusts.

Service Design

• We are predominantly a nurse led service• 4 microbiologists plus the 4 specialist

nurses form the OPAT team – each consultant supporting the OPAT service on a weekly basis

• Dr Kathy Cann is the clinical lead for service development.

• The service was predominantly to support Early supported discharge(ESD) and to phase in Admission Avoidance (AA).

Service Design • ESD is well established with our core work

coming from orthopaedics, plastics and cardiology.

• Cellulitis AA pilot commenced in November 2011 from A & E at Stoke Mandeville only.

• GP Locality Leads are supportive and service now embedded to be delivered for both main hospital sites as from April12.

Service Design• We have established policies endorsed by BHT

governance process.• Clinical governance is paramount:-

-ESD - the team shares care with the referring clinician

-AA - the team shares care with the patient’s GP. • We operate from 08.30 – 5 (Mon – Fri. incl. bank holidays)

and have an on call service at weekends, which all the specialist nurses cover.

• We manage most of our patients in their own homes or daily return to our discharge lounge if possible.

• We are supported by the ACHTs who are just establishing

24 / 7 working.

The ModelWe operate as an MDT.• 1. Referral

ESD - referral form with telephone discussion

We also attend a weekly orthopaedic ward round .

AA - phone calls from GP or A&E

We also visit A&E areas daily to find patients.• 2. Assessment

Inclusion / exclusion criteria but also assess on an individual basis.

Generic paperwork for all referrals and have dedicated authorisations for IV administration in the community.

Includes vascular access assessment and referral

Includes assessment for self administration with competency assessment.

• 3. Care plan

Agree antibiotic regimen with consultant microbiologist.

Prescribing by the referring team/A&E plus authorisations for community administration

ESD- Facilitate discharge date /equipment / pharmacy

AA -template prescription sheet for rapid turn around

All patients

Adrenaline is prescribed to take home in all cases.

Liaison with ACHTs to support a 1st visit with the patient.

Hand held notes for the home setting

THE MODEL

4. Follow up and monitoring

Most IV administration by ACHTs

Daily VIP & EWS on all patients.

Clinical checks appropriate to condition

Weekly bloods -monitor results at weekly virtual ward round with the microbiology consultant.

Outpatient review at 2 weeks for long courses

We attend specific OPA’s with patients to ensure treatment plans are followed or problems discussed as we don’t have our own clinics. Often give IV’s when they attend.

Our oral follow on patients get monitored at 2 weeks and if stable discharged from the service.

5. Communication• Template GP letter on discharge from acute setting and end of IV

treatment with conversion to oral antibiotics .

Activity and outcomes• Data from Sept 2010 to end Feb 2012 (17

months)• Referrals (inc repats) :169• Accepted patients(inc repats): 137• Bed days saved (exc repats): 1952

• We audit outcomes from guidance paper:

C.L. Mackintosh et al JAC(2011).• ESD – 4 weeks from discharge, 6 months, 1 yr

& 2yrs• AA – 4 weeks only

Do we fulfil the BSAC good practice guidelines?

• Good practice guidelines:

1, OPAT Team & Service.

2, Patient Selection.

3, Antimicrobial management & drug delivery.

4, Monitoring of the patient.

5, Outcome monitoring & clinical governance.

YES.

How are we developing?• We are called the “IV Service” rather than just OPAT we

aim to give more than IV antibiotics.• We support Nursing home / Residential home patients. • We support our community hospitals to give patients IV

therapy / antibiotics.• Provide inpatient care for any CVAD on a weekly review.• Key IV training role in the Trust including venepuncture.• Clinical lead in procurement of IV therapy equipment.• Learning points: • Introduced thermometers/adrenaline• To establish guidelines/ governance.• To develop good communication systems.

The Future• PICC / Midline inserters – expand the teams skills and

variety of VADs• Non medical prescribing / advanced assessment courses

being attended.• Trust still going through reconfiguration and our model will

constantly change for this.

Biggest problem• Repatriation of patients from neighbouring Trusts –

endless problems where there is no OPAT service or a different model -? expand BSAC guideline.

• Governance arrangements need to be clear.

The Team