The document outlines the benefits and risks of setting up an effective Outpatient Parenteral Antimicrobial Therapy (OPAT) service. It discusses components of an OPAT service including different delivery models like self-administered, infusion centers, and home-based care. Risks of OPAT include misdiagnosis, inappropriate treatment duration or location, and increased antimicrobial resistance. The document emphasizes the importance of multidisciplinary teams, appropriate patient selection, education and support to maximize benefits and safety of OPAT programs.

1. Setting up and running an
effective OPAT service
Linda Nazarko
Nurse Consultant
West London Mental Health NHS Trust
Hallam Conference Centre, London 14th
April 2016

2. Aims and objectives
To enable you to:
 Be aware of the benefits and risks of OPAT
 Be aware of how to tailor services to meet needs
 Be aware of the range of services provided
 Types of therapy S-OPAT, H-OPAT, C-OPAT
 Selecting patients and monitoring outcomes
 Understand the needs of those requiring short and long
term therapy
 Providing patient support and education
 Demonstrate benefits to commissioners
 And most importantly how to work together to care for
patients

3. OPAT, past present and future
 Outpatient Parenteral Antimicrobial Therapy (OPAT )
now used to describe IV therapy outside inpatient
settings
 Developed 1974, for children with cystic fibrosis
 First described UK early 1990s

5. Components of an OPAT service

6. The OPAT team
 Physician- IDT consultant
 Microbiologist
 Pharmacist with expertise in antibiotic
therapy
 Nurse specialist
 Community nurses
 Administration support

7. Service delivery models

8. Self administered outpatient
antibiotics therapy (S-OPAT)
 “Self-administration of intravenous
antimicrobial therapy, in selected
patients under the supervision of a
specialist team, is a safe and feasible
strategy” (Barr et al, 2012a)
 Between 38-53 percent of patients can
self administer

9. Infusion centres H-OPAT
 Cost effective
 Can be based in community hospitals, clinics
or acute hospitals
 Can be used to teach patients and staff,
deliver therapy, check bloods, monitor
patients
 Patient has to travel but less delay in waiting
for staff
 Drop in for problems

10. Home (community)– C-OPAT
 Around 70 percent of those treated in
hospitals suitable for OPAT in some form
 “OPAT was generally safe and effective, but
specific patient groups were identified with
more complex management pathways and
poorer outcomes” (Seaton et al, 2011)
 Specialist IV teams
 Community nurses
 Private companies

11. Types of therapy
 Antimicrobials.
 Chemotherapy.
 Bisphosphonates.
 Iron sucrose – but fall off in use some areas
 Immunoglobulins.
 Parenteral nutrition (PN);
 Blood products
 Intravenous fluid

12. Short and long term therapy

13. Working in partnership

14. Inclusion/exclusion criteria
(an example)

15. Suitable for OPAT?
 70 percent suitable – 30 percent not
 Generally safe but specific groups more
complex and have poorer outcomes
 26 percent re-admitted in 30 days
 Some patients three times more likely to
be re-admitted

16. Higher risk patients
 Complex pathways
 Older
 Co-morbidities
 Resistant organisms
 Number of non infective admissions last
year
 Endocarditis with cardiac or renal failure

17. Selecting patients
 Clinical judgment
 Do they meet local
criteria
 How often will
review be required
 Treatment regimes
 Suitable vascular
access

18. Emma’s story
Delivered by emergency caesarean
section and returned home with baby.
Developed post operative infection,
admitted and potentially separated from
her baby whilst having IV antibiotics.
Distraught and desperate to go home

19. Margaret’s story
Margaret is an 86 year old widow. She has a
confirmed diagnosis of vascular dementia
and has moderately severe problems with
cognition. Margaret lives alone and has a four
times daily package of care and support. She
was treated for pyelonephritis secondary to
renal calculi and discharged home with a PIC
line. Margaret was unable to consent to,
understand or adhere to treatment and
removed the PIC line. It was not possible to
deliver OPAT and she was re-admitted.

20. Marek’s story
Came to UK from Poland and is
supporting a wife and two children. Has
multidrug resistant TB. Needs oral
antibiotics plus daily IV antibiotic
therapy for at least six months. Keen to
S-OPAT but worried he will not
manage. Fearful that he will lose his
job if he is late or has a lot of time off

21. Meeting patient needs

22. Supporting patients
 Patients may be anxious, having IV antibiotics at
home can be scary
 Patients need:
 A leaflet giving information, advice and support
 Details of what to do if there are problems, who to
contact and where to go if problems occur.
 Patients are people and level of support needed
varies
 Weekly reviews and ongoing help and support

23. Community Initiated OPAT
 Partnership microbiology, IDT, pharmacy and
community to initiate and treat certain
conditions at home, e.g ESBL E.Coli
infections of urinary tract and cellulitis

24. Hospital Initiated OPAT
 Plan discharge early
 Consider likely duration therapy,
vascular access, discharge medication
 Consider midline access if staff are not
competent with central lines
 Be aware of constraints in community in
terms of capacity
 Give plenty of notice

25. Roles of rapid response
 Short sharp courses of treatment e.g
treatment ESBL UTIs requiring IV
therapy and cellulitis
 Bridging treatment to facilitate
discharge and handover to long term IV
services

26. Risks of OPAT
The administration of intravenous antimicrobial
therapy is potentially hazardous. These are:
1. Misdiagnosis and inappropriate treatment
2. Inappropriate OPAT therapy when oral
would be effective
3. Inappropriate duration of therapy
4. Inappropriate place of care
5. Increased anti-microbial resistance

27. Lower leg cellulitis- are we winning?
 In 2012 over 93,000 admissions, over 407,000 bed days.
Cost £259-175 million
 Admissions increased 88 percent in nine years now falling.
Why?
 Diverting a quarter would save 100,000 bed days and
around £64 million

28. Misdiagnosis & inappropriate treatment
 1/3 of those with
cellulitis misdiagnosed
 Misdiagnosis of UTI
common
 Oral might work just as
well
 IDT approval of
OPAT requests

29. Inappropriate duration
 Cellulitis – 3-4 days parenteral therapy
– nurse review and switch
 Osteomyelitis may be exposed to
prolonged therapy with little evidence
benefit past 6 weeks
 Review by specialist team to mitigate
risks

30. Inappropriate place of care
 Tighter control over who can request
OPAT
 OPAT approval by IDT
 Education and review to reduce risk of
inappropriate discharge

31. Antimicrobial therapy
 Third generation cephalosporins
 High risk C. Difficile in hospital but not in community –
however 60 percent C. diff now developing in non
hospitalised.
 Daily or occasionally twice daily therapy

32. Antimicrobial stewardship
 “We could be close to reaching a point where
we may not be able to prevent or treat
everyday infections or diseases” (DH &
DEFRA, 2013).
 ‘Every antibiotic expected by a patient, every
unnecessary prescription written by a doctor, every
uncompleted course of antibiotics, and every
inappropriate or unnecessary use in animals or
agriculture is potentially signing a death warrant for a
future patient. (Donaldson, 2008)

33. Antimicrobial stewardship (2)
 25,000 deaths in Europe in 2007 because of
antibiotic resistance.
 Fifty percent of antibiotics prescribed
unnecessarily
 Take time and diagnose properly
 Prescribe prudently, narrow spectrum safer
 Say “no” when not clinically indicated
 Use right dose, right time, right route and
right duration

34. Identifying and reducing OPAT risks

35. Developing and supporting staff
 Staff training in IV
therapy
 Learn how to use
VADs used in OPAT
 RCN Standards
guidance
 Nurse specialist and
OPAT team support

36. Delivering a comprehensive service
 Use existing services
 But don’t overwhelm them
 Build on services
 Tailor services to meet needs
 Community for housebound,
rapid response for short
interventions and infusion
centre to enable and empower
those needing long term
OPAT

37. Business case and KPIs
British Society for Antimicrobial Therapy (2011).
Outpatient and Parenteral Antimicrobial
Therapy
(OPAT) Toolkit for Developing a Business Case
for OPAT Services in the UK. BSAC,
Birmingham.
http://e-opat.com/wp-
content/themes/pmix/Business_case_toolkit_
PDF.pdf

38. Evaluate outcomes
 Use existing
information routinely
gathered
 Quality tools
 Additional
questionnaires,
interviews, audits

39. What to evaluate
 Clinical and patient outcomes
 Service specific e.g. number of
admissions prevented, bed days saved
 Improvements in functional status
 Patient satisfaction
 Productivity and efficiency
 Staffing indicators

40. Why evaluate
 Services change over time and we may be too busy
to notice
 We need to learn what we can improve
 We may identify gaps and opportunities to develop

41. Cost effective services
 Get accurate costs of services
 Not just cost but also:
 Accessibility, care closer to home
 Timely – no long waiting lists
 Relieving pressure on traditional
services
 Meeting or exceeding quality indicators

42. Being excellent is not enough
You need to be seen to excellent
 Be visible
 Evaluate and innovate
 Disseminate
 Move forward
 You are stars – let your light
shine brightly

43. Final tips
 Up to 70 percent of inpatients could benefit from OPAT
 Around half of those having OPAT could self administer OPAT
can be community or hospital initiated and can be used to avoid
admissions or reduce length of stay.
 OPAT can enable people requiring parenteral therapy to remain
at home or to go home sooner. This enhances quality of life.
 OPAT once a highly specialist service is entering the
mainstream
 It is vitally important that staff from acute and community and
across disciplines form a team to minimise risk and maximise
benefit

44. Thank you for listening
Any questions?
Check out profile for useful downloads
https://uk.linkedin.com/in/linda-nazarko-
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