Clinical Safety & EffectivenessCohort 22Team 9

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Outpatient Parenteral Intravenous Therapy (OPAT) Transitions of Care

DATEEducating for Quality Improvement & Patient Safety

The Team• Division

• Michelle Matheu, MD, ID Fellow (CS&E Participant)• Kristi Traugott, PharmD, BCPS (CS&E Participant) • Thomas Patterson, MD, FACP, FIDSA, ID Attending • Heta Javeri, MD, MPH, ID Attending• Ruth Serrano, MD, ID Fellow• Delilah Chandler, LVN• Brenda Reyes, MA• Ramon Gallegos Jr., MAA, BSN, RN• Sherry Martin (Facilitator)

• Sponsor Department• Jan E. Patterson, MD, MS; Jason Bowling, MD; • Division of Infectious Diseases, Department of Internal

Medicine 2

Our Aim Statement

Process aim: To improve the adherence to “standard of

care laboratory monitoring” for patients enrolled in the

Outpatient Parenteral Antibiotic Therapy (OPAT) Clinic at

University Health System from 11% to 80%, by May 24, 2018

Outcome aim: To improve the readmission rate from 37%

to 10% for patients receiving OPAT at UHS by 1/2020.

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What is OPAT and Why is it Important?Outpatient Parenteral Antibiotic Therapy

• Delivery of intravenous (IV) antibiotic (atb) therapy outside the hospital

• Home• Skilled nursing facility• Clinic• Infusion center

• OPAT has been shown to:• Reduce hospital LOS • Reduces readmissions• Reduce hospital morbidity• Increases patient satisfaction• Patients incorporate to society• Dramatically reduces overall

costs

4Tice AD., et al., Practice Guidelines for OPAT • CID 2004:38

Bone and Joint

InfectionsEndocarditis Bacteremia SSTI UTI Others

Key Elements For Success

Successful OPAT Therapy

Multidisciplinary Team

Appropriate Patient Selection

Defined Roles and

Responsibilities

Active Participation of

Patient and Caregiver

Effective 24h Communication

Close Monitoring

5Tice AD., et al., Practice Guidelines for OPAT • CID 2004:38

Standard of Care Monitoring in OPAT

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• ≥ 1 f/u prior to completion of therapy • Pertinent studies w/in 7 days

Clinical Monitoring

• Weekly• Based on antimicrobial prescribed

Laboratory Monitoring

• Weekly nurse or infusion clinic visits for care

VAD Monitoring

Tice AD., et al., Practice Guidelines for OPAT • CID 2004:38

Impact of Close Laboratory Monitoring on Readmission Rates

Outcome Tests not available (n = 109)

Tests available(n = 291)

OR (95% CI)

P value

Readmitted while on OPAT 34 (31) 48 (16) 2.29 (1.33 – 3.93)

0.001

Seen at an ID follow-up office visit

37 (34) 212 (73) 0.19 (0.12 – 0.32)

< 0.001

Premature discontinuation of OPAT due to antimicrobial adverse events

1(1) 18 (6) 0.14 (0.003 – 0.91)

0.03

Actual OPAT duration (days), median (Q1 – Q3)

11 (7 – 19)

20 (11 – 35)

-9.42 (-12.44 - -6.39)

< 0.001

7Huck D, et al., J Antimicrob Chemother 2014; 69: 228–233

8Composite Standard of Care Monitoring: 4%

Standard of Care Elements n=27 Percentage

Complications from OPAT 5 19%Appropriate lab monitoring 3 11%Pre-clinic studies available at f/u 6 22%Therapy completed 15 56%Seen prior to completion of therapy 6 22%No-show 11 41%

Unknown 6 55%Lost to follow-up 2 18%In hospital 1 9%Non-compliance 1 9%In jail 1 9%

Readmissions 10 37%Infection 5 50%PICC problem 3 30%Other 2 20%

Baseline OPAT Clinic Data (10/2017 – 12/2017)

Baseline Data, Pareto Chart

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Pre-Intervention Flowchart

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INAPPROPRIATE FOLLOW UP

COMMUNICATION

SCHEDULING

MONITORING AND ORDERS

TRANSITIONS OF CARE

LACK OF SUPPORTING STAFF

PATIENT ISSUES

Lack of clinical summary to transition to clinic

No direct contact clinic providers

No inpatient to outpatient point of contact

No established protocol of handoff to clinic

Clinic unable to reach physicians for acute issues

No OPAT education for patients or clear discharge instructions

No dedicated pharmacist

No dedicated CM in clinic

# of patients is too high for clinic capacity

Need nursing staff to assist with orders

Patients scheduled after therapy completed

Lack of system and patient registry to monitor labs

No pre-clinic labs availableduring follow up

No system to input orders to start or change atb

No priority slots available

Clinic is overbooked andhigh no show rate

No pharmacy support to verify HH orders

Difficulty reminding patients at SNF

Lack of OPAT education

Non-compliance

Inefficient scheduling through call center

Fishbone Diagram

Data Measurement

Process measure: “Standard of Care Laboratory Monitoring”

# of patients with weekly labs obtained # total number of patients

• Weekly labs are tracked through our Excel registry. Data will be collected weekly by registry and EMR audit.

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Goal Primary Drivers Interventions Measure Responsible

To im

prov

e th

e a

dhe

renc

e to

“st

anda

rd o

f car

e la

b m

onito

ring”

for p

atie

nts

enro

lled

in O

PAT

Clin

ic a

t UHS

from

11%

to 8

0%, b

y M

ay 2

4, 2

018

Lack of transition of care from inpatient to outpatient.

ID fellow will write a “Transition note” using an acronym expansion and forwarded to the clinic staff using SHM. (March 1st)(RS 3)

No measure ID fellows

IT will create a standard document for the “Transition note” with specified elements and fields. This will replace the acronym expansion. All ID fellows will be responsible of writing this note. (May 1st)(RS 4)

No measure IT team

Establish an OPAT registry: once notified of patient through SHM, clinic staff to add patients to excel file (ongoing) (RS 2)

No measure LVN, OPAT physicians

IT will create a “Patient list tag for OPAT” order. This will be activated inside the “Transition note”. This will allow us to create an automated registry in the EMR active patients. (May 7th)(RS 4)

No measure IT team

Lack of lab monitoring resulting in many patient safety issues

LVN and assigned MA will be given protected time weekly to follow up with HH and outpatient pharmacist to obtain labs (ongoing).

% compliance with standard of care lab monitoring.

LVN

Documentation of weekly lab monitoring in the chart (ongoing)

OPAT physician

Twice a week meeting with clinic staff to discuss issues with patients

OPAT physician and LVN

Inability to monitor OPAT program

Create an automated registry in EMR by using “Patient tag” (May 1st) (RS 4)

Accurate Readmission rate

IT Team

Inappropriate follow up

Develop a strategy to prioritize appointments. (Future project)

No show rate OPAT physician and Clinic leadership

Driver Diagram

Intervention: Transition of CareCreating a “Transition to OPAT” note

ID Diagnosis:

Antibiotic Regimen:Duration of therapy:Start date:End date:

Safety labs:Appointment:

The OPAT clinic is located at the Robert B. Green campus, 3rd floor. Please fax labs to clinic fax number: 201-358-5945, attention to ID Clinic. The number for the clinic is 210-358-3555.

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Forward to clinic using SHM

Intervention: Patient registry

Intervention: Education and Communication

• Meetings with UHS leadership

• Creation of SOP for all processes

• Weekly audit and feedback with clinic staff

• Frequent follow up with fellows on service

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Proposed Post-Intervention Flowchart

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Intervention Implemented and isin process of change/improvement

Intervention Implemented

Our Progress So Far…

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0.3733 CL

0.6152 UCL

0.000

0.100

0.200

0.300

0.400

0.500

0.600

0.700

0.800

0.900

Prop

ortio

n of

pat

ient

s w

ith

Lab

com

plia

nce

Weeks

Lab compliance

May 21 –

May 24

May 14 –

May 18

May 7 –

May 11

Apr 30 –May 4

Apr 23 –Apr 29

Apr 16 –Apr 22

Apr 9 Apr 15

Apr 2 –Apr 8    

Mar 26 –

Mar 30

Mar 19 –

Mar 23

OPAT ROI - Why OPAT is Needed?Expenditure No OPAT OPAT

Cost of Hospitalization $34,231,680 $5,705,280

Cost of Home Health/Day $0 $3,074,400

Cost of 0.88 FTE OPAT MD + benefits $0 $189,000

Cost of 0.22 FTE OPAT Medical Director + benefits $0 $50,000

Cost of 0.75 FTE LVN + 25% $0 $42,186

Cost of 0.75 FTE Medical Asst + 25% $0 $30,000

TOTAL (current state) $34,231,680 $9,090,866

DIFFERENCE $25,140,814

0.5 FTE Pharmacist + 25% 0 $72,500

0.25 FTE LVN + 25% 0 $14,062

0.25 FTE Medical Asst + 25% 0 $10,000

TOTAL (with added resources) $34,231,680 $9,199,972

DIFFERENCE $25,031,708

OPAT ROI Why Laboratory Monitoring is Important?

Expenditure No Monitoring MonitoringReadmissions 31% 16%Number of patients/year 149 77Cost/Readmission $13,857,000 $7,161,000DIFFERENCE $6,696,0000.5 FTE Pharmacist + 25% 0 $72,5000.25 FTE LVN + 25% 0 $14,0620.25 FTE Medical Asst + 25% 0 $10,000TOTAL (with added resources) $13,857,000 $7,257,562DIFFERENCE $6,599,438

Huck D, et al., J Antimicrob Chemother 2014; 69: 228–233

Lessons Learned

• Support of leadership is key• Close follow up and guidance/coaching, show progress• Frequent feed back sessions• Implementation is challenging and keeping an open

mind and room for change is key for success. • Not all hesitation to change is due to unwillingness to

change, some ideas may just not be the right ones• It is not only about achieving the metric, it is about

sustainability and learning through the process

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Future Interventions and Sustainability

• IT changes• Standardized document for “Transition to OPAT”• OPAT order tag Automated patient list • Clinical summary view • Ambulatory flow sheet Outside lab entry

• Prioritize scheduling • Urgent slots available• Capacity to schedule patients prior to completion of therapy

• Having dedicated OPAT staff• Clinical pharmacist• Full time LVN and MA• ID fellow and attending

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Thank you!

Educating for Quality Improvement & Patient Safety