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From its inception Outpatient Parenteral Antibiotic Therapy (OPAT) has been shown to be a safe and effective method of delivering healthcare
Administering parenteral antibiotics in an outpatient setting was first described in the United States in 1974 for the management of paediatric cystic fibrosis. Over recent decades this model of care termed Outpatient (or Home) Parenteral Antibiotic Therapy (O(H)PAT) has become a standard treatment option in North America, Australiasia, with Europeand especially the United Kingdom- looking to OPAT as an effective and efficient method of treatment.
OPAT involves the administration of intravenous or intramuscular anti-infective agent(s) without the patient having to stay overnight in hospital. Treating patients using OPAT has many advantages including increasing patients quality of life, reducing inpatient hotel costs- and avoiding cross transmission of Methicillin-Resistant Staphylococcus aureus and other resistant organisms to the patient or from the patient to other inpatients.
These advantages together with recent once daily anti-infectives and advancing line technology make OPAT an appealing option for medical institutions and patients alike.
This short article describes areas to consider when establishing an OPAT service within the United Kingdom.
Where to start?
One of the first tasks will be to establish who are the key stakeholders in a potential OPAT service in your organisation. Some of these individuals or groups will be instrumental in driving the service and identifying target patient populations. Others will be key in managing risk, costs, secondary-primary care interfaces and policies. The make up of this group will be dependant on the local needs of the service, however key
members to include in intial discussions are:-
The second area to consider is what type of patients the OPAT service is going to treat. Infections suitable for OPAT generally fall into three categories:
1. Short term therapy for example superficial skin infections (2-5 days).
2. Medium term therapy for example complicated urinary tract infections (10-14 days).
3. Long term therapy for example endocartitis, prothetic joint infection, diabetic foot infections, complicated skin and soft tissue infections and osteomyelitis (2-3 months or more).
A business case will generally rest on projecting a reduction in length of stay so examining this area is a good starting point. Hospital finance departments are critical in ensuring service income versus expenditure and any potential cost savings are properly evaluated.
Coding data can be a valuable source of information; extracting patient episodes coded with for example cellulitis or osteomyelitis as the primary diagnosis can give estimates for the average length of stay and the number of bed days that might be saved if an OPAT service were introduced.
An alternative might be to use data from existing OPAT services to draw conclusions about the potential in your own hosptial.
Figures 1 and 2 give a breakdown of treatment days (so potential bed days saved) and patient episodes by condition treated by our hospital’s OPAT service in 2008-09. The service takes both general medical referrals and referrals from tertiary care specialties such as oncology, orthopaedics, neurosciences and vascular surgery.
How can OPAT be delivered?
There are a variety of models used to deliver OPAT. The optimal format will depend on the local needs of the organisation, the demographics of the population and the availability and training of community nursing services. Almost without exception a clinical nurse specialist will be the appropriate person to have key responsibility for the service.
OPAT delivery models include:
With either model there is a choice of individuals
and mechanisms for delivering therapy. These include:
Moving the management of patients outside the confines of a ward setting strikes some as a risky practice. However, there is growing evidence that OPAT is safe and effective when properly organised even when patients practice self administration.-
A typical OPAT patient
OPAT is obvisouly not for everyone and each service will have their own inclusion and exclusion criteria. In general, a typical OPAT patient should:
Choosing which anti-infectives are suitable for OPAT?
Discussions surrounding suitable anti-infectives should take place between nursing, pharmacy and medical staff at an early stage as not all anti-infectives are appropriate for OPAT. Hospitals may need to consider making new applications to their local formularies for newer once daily agents which lend themselves to OPAT. In general OPAT agents should be:
The favoured antibiotic agents currently available in the
United Kingdom are:
ceftriaxone, ertapenem, tigecycline, and teicoplanin for which OPAT dosing guidelines were published earier this year. Meropenem is particuarly effective for patients who can self administer. Daptomycin has recently received a license for a 2 minute bolus which will aid OPAT treatment of gram positive infections.Other anti-infectives including antiviral and antifungals may be used when sensitivities dictate.
Short term therapy (less than seven days) is conveniently
accomplished with a peripheral cannula (often left for 3 days at a time) or butterfly needle (inserted for each infusion/bolus). For longer-term therapy peripherally inserted catheters with tip placement in the subclavian vein (midline) or in the lower third of the superior vena cava (peripherally inserted central catheter, PIC line) are ideal. These lines have an extremely low incidence
of complications including infections and can remain in situ for up to 12 weeks and one year respectively. Conventional tunnelled central venous catheters are an alternative when long term therapy is required.
Key documents to think about producing locally:
From its inception OPAT has been shown to be a safe and effective method of delivering healthcare. These services provide a much needed alternative for the many patients who are occupying a hospital bed solely in order to receive their intravenous antibiotics.
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20. Novartis Pharmaceuticals UK Limited. Daptomycin Summary of Product Characteristis May 2009.