update to opat good practice recommendationse-opat.com/.../2017/12/opat2017-day02-annchapman.pdf ·...
TRANSCRIPT
UpdatetoOPATGoodPracticeRecommendations
DrAnnLNChapmanBMBCh,FRCP,DTM&H,MSc(MedLeadership),PhD
ConsultantinInfectiousDiseasesandGeneralMedicine,NHSLanarkshireHonoraryClinicalAssociateProfessor,
UniversityofGlasgow
OPATGoodPracticeRecommendations(GPRs)
• PragmaticguidanceonthedevelopmentanddeliveryofOPATservices
• ToensurethatOPATservicesprovidehigh-quality,low-riskcare,whateverthehealthcaresetting
• Ausefulresourceforteamsdevelopingnewservices
• Apracticalsetofqualityindicatorsforexistingservices
Literaturereview
Requestedsearches Adult
Adults 1July2010–31July2017
Paediatric 1July2012–31July2017
Librariessearched CINAHL,Embase,Medline,WebofScience(sciencecitationindexexpanded),CochraneLibrary
SearchtermsAdult Paediatric
Outpatient/Homeparenteralantibiotic/antimicrobial/antifungal/antiparasiticantibacterial/antiviral/antiinfectivetherapy/treatmentHospitalinthehomeHomeinfusiontherapyANDantibacterial/antibiotic/antifungal/antiviral/antimicrobial/antiinfective/antiparasiticOPATOHPATAdulthomeparenteraltherapyprogram*ParenteralantibiotictherapyinthehomeHomeintravenous/IVantimicrobialserviceOutpatientintravenous/IVantibiotictherapy/treatmentOutpatientparenteralantibioticsOutpatientparenteraldrugdeliveryOutpatienttreatmentwithparenteralantibioticsNon-inpatientCommunity-basedHomeparenteraltherapy/treatmentHometreatment/therapy
Treatment/therapyathomeHome-initiatedtreatment/therapyHomedruginfusiontherapy/treatmentHomeintravenous/IV(+/-antibiotic)therapy/treatment(HIVAS)Intravenousantibiotictherapy/treatmentinanoutpatientsettingAmbulatoryantibioticinfusiondeviceDomiciliaryIVantibiotictherapy/treatmentCommunityintravenousantibioticservice(CIVAS)Self-administrationParentaladministrationAmbulatorycareCellulitis/SkinandskinstructureinfectionUTIOVIVA(oralversusintravenousantibiotics)AdmissionavoidanceEarlydischargeIVDUOutcomePalliative
Searchtermsasperadultwiththefollowingterms:Child*Paediatr*Pediatr*InfantPOPAT
Competencysearchterms
Requestedsearches
Dates 1Jan1970–31July2017
Librariessearched CINAHL,Embase,Medline,WebofScience(sciencecitationindexexpanded),CochraneLibrary
CompetencyrelatedsearchtermtobecombinedwithOPATrelatedsearchterm
CompetencyframeworkGoodpracticeSkillsdevelopmentCompetenceorcompetencesKnowledgeSkillsAttitudesBehavioursGuidelinesGeneric
Literaturesearchoutput
• OPATSearches– Allreferences=2463
• POPATSearches– Allreferences=544
• Competency(OPATandPOPAT)– Allreferences=661
Literaturesearchoutput
2463
888conferenceabstracts
1195excludedoninitialscreen(duplicates,nonEnglish,not
relevant)388
1575
229
159excludedonspecialistscreen
Literaturesearchoutput
229
Servicestructure27
Patientselection22
Drugsanddevices53
Monitoringduringtherapy6Outcomemonitoringandclinicalgovernance30
OPATgeneral39OPATforspecificinfections52
1.Servicestructure
• ImportanceofspecialistOPATservicewithIDinput
• OPAT‘bundles’• Community–basedservices
• Telemedicine
1.1Clearmanagerialandclinicalgovernancelinesofresponsibility1.2Identifiableleadphysicianwithtimeinjobplan1.3CompositionoftheOPATMDT
1.4ManagementplanagreedbetweenOPATandreferringteams1.5ClinicalresponsibilitysharedbetweenreferringclinicianandOPATclinicianunlessotherwiseagreed1.6CommunicationbetweenOPATteam,GPandreferringclinician
OPAT‘bundle’• Muldoonetal,2013;Madalineetal,2017
MDTOPATteamPatientdispositionscreeningPatientandfamilyeducationInpatientIDconsultationCaretransitionOPcareco-ordinationOPATprogrammeasures
EarlyphonecommunicationwithpatientOPappointmentwithin2weeksofdischargeElectroniccomprehensivetreatmentplanaccessibletoall
OPATtransitionofcare‘bundle’
• ‘Highrisk’OPATpatients• 184patientspreinterventionvs146post• 30dayreadmissionsbeforeandafterintervention• 13%vs26%overall• Sensitivityanalyses• Hypothesisedthatadverseeventsdetectedearlierresultinginavoidanceofreadmission
• Importanceofrobustservicestructure,MDT,communication
Community-basedOPAT
• Regan&Morgan,2015;O’Hanlonetal,2017– trainedcommunitynursessupportedbyIVtherapynursespecialists
– Importanceofcollaborativeworkingbetweenprimaryandsecondarycare
– Issueofmedicalresponsibility– Pathwaysforescalation– Gradualdevelopmentofexperienceandconfidence– Datacollection;reviewofoutcomestoidentifyproblemsanddevelopsolutions
Telemedicine
• Limitedexperience:– Patientmonitoring/consultations– Distantnursetocheckmedicationspreadministration
• ReducedLOS/admissionavoidance• EarlierreturntoADLs• BUTmaybelimitedbycost;technicalissues;patient,familyandphysiciananxiety
• Possiblerolewithuseoflongactingantibiotics
2.Patientselection
• Specificgroups– IVDU– Homeless– Renaltransplants
– MDRinfections– Olderadults
• Newindications– Prophylaxis– Palliation
2.1Responsibilityoftheinfectionspecialisttoagreeinfection-relatedinclusion/exclusioncriteria
2.2AgreedOPATpatientcriteria
2.3Initialassessmentperformedbycompetentmemberofteam2.4Patientsshouldbefullyinformedandabletoconsent/declineOPAT2.5Patientswhohavebeenonthromboprophylaxisasinpatientshouldcontinuethis
IVDU• Hoetal2010:– 97%successrateincarefullyselectedIVDUwithclosesupervision,speciallinesecurityseals
• Beieleretal2016:– homelesspeopleinamedicalrespitecentre,53%currentIVDU:87%completedtreatment
• Buehrleetal2017:– only26of67IVDU(39%)completedOPATsuccessfully–combinationofclinicalandsocialfactorscontributingtofailure
3.Drugsanddevices
• OralvsIV• Newagents• Continuousinfusions
TreatmentplanagreedbetweenOPATteamandreferringclinician
PharmacyinputminimumweeklyatMDTmeeting
CompliancewithRCNandlocalstandardsforantimicrobialuse,IVline,drugdeliverydevice,trainingpatientsorcarersAlladministereddosesshouldbedocumentedAdministrationoffirstdoseinasupervisedsetting
Continuousinfusions
Elastomericdevices Portableelectronicpumps
Advantages
EaseofoperationLightweightSilentDisposableNoneedforpowersupply
AdjustableflowratesAccurateflowratesBuiltinalarms
Disadvantages
FixedflowrateVariableactualflowratesAbsenceofalarmsLimiteddataonantibioticstability
MoredifficulttouseNoisyHeavier
4.Monitoringduringtherapy
• Bloodtestmonitoringimportant
• DescriptionsofADRs
• Importanceofservicestructure
4.1DailyreviewofpatientswithSSTI4.2WeeklyMDTmeeting
4.3Weekly(orbimonthlyifstable)reviewsbyOPATnurse/physician.4.4Weeklybloodtests(orbimonthlyifOPAT>1month)4.5OPATteamresponsibleformonitoringclinicalresponse,investigationsandtreatmentplan4.6Pathwayfor24-houraccesstoadvice/review/admission
5.Outcomemonitoringandclinicalgovernance
• Antimicrobialstewardship
• Patientreportedoutcomes
• Standardisedclinicaloutcomes
5.1Patientdatarecordedprospectively5.2Standardoutcomecriteriarecorded5.3Riskassessmentandauditofindividualprocesses
5.4Regularsurveysofpatientexperience5.5ResponsibilityforpersonalCPD
Antimicrobialresistanceandhealthcareassociatedinfection(ARHAI)
Patientreportedoutcomes
CommunityIntraVenousAntibioticStudy,2017:
– Qualitativestudyofpatients’perceptionsofOPAT– 7themes:
• Meetingtheneedsofadiversepopulation• Benefitsofandbarrierstodifferentmodelsofcare• Effectivenessoftreatment• Communication• Reviewandaftercare• Staffexpertise• Impactonfamilyandfriends
Keydevelopments(withmassivehealthwarning...)
• GPRsremainconsistentwithpublishedliterature• Servicestructure:– Communitybasedservices
• Drugsanddevices:– OralvsIV– Newagents– Continuousinfusions
• Outcomemonitoringandclinicalgovernance:– OPATandantimicrobialstewardship
Nextsteps
• Completereviewofallpapers• Consultationprocess• Publicationofupdate–combinedadultandpaediatricOPAT
• OPATcompetencies:– Literaturereview– Furtherdevelopmentofcompetenciesthroughdatacollection,workinggroup,engagementofstakeholders
Thankyou
Acknowledgements:• SanjayPatel• AndrewSeaton• MarkGilchrist• CarolyneHorner• VittoriaLutje• Literaturereviewers