Outpatient Parenteral Antibiotic Therapy (OPAT) Service Operational Procedure
Author(s) – Job titles / Rashida Goswami (OPAT/Vascular Access Nurse
Victoria Longstaff (Infection Control Nurse Consultant )
Version / 1
Version Date / September 2014
Implementation/approval Date / DRAFT
Review Date
Reviewing Committee
Policy Reference Number
Version Control
Version Number / Date / Author (Job Title) / Reason / Ratification required?1 / 16/09/2014 / OPAT/Vascular Access Nurse / New service / Yes
1 Scope-
The standard Operation Procedure applies to all healthcare professionals involved in direct or indirect care of patients requiring delivery of Outpatient Parenteral Antibiotic Therapy
2 Objectives of the OPAT service:
· To facilitate the discharge of a selected group of patients by providing an OPAT service.
· To provide specialist advice in the care of the OPAT patient.
· Audit the activities of the OPAT service.
· Champion the OPAT service both within the hospital and community.
3 Principles of the OPAT Service at HUH:
OPAT team at Homerton University Hospital includes Clinical Nurse Specialist, Consultant Microbiologists/ID, and Antimicrobial Pharmacists. Microbiology/ID SpR available for clinical advice/support as required and Infection Control Nurses to assist in service cover.
It has been agreed by the OPAT team;
· The referral for OPAT will be made by the patient’s clinical team using the appropriate referral form (Appendix 1) and contacting the team to discuss the case; the team may already be aware of the patient through multidisciplinary team Microbiology/Infectious diseases meetings (MDT). The OPAT team may have already placed a vascular access device, (VAD) at the request of the clinical team.
· Clinical responsibility will remain with the clinical team; a consent document (Appendix 2) to this effect will be signed by the clinical team and the patient prior to discharging the patient. This document outlines the responsibilities of the clinical team and patient. This document sits with the OPAT patient held notes (Appendix 3). The patient held notes stays with the patient for the duration of therapy and are then is filed in the patients main medical records
· Before discharge all OPAT patients will have been discussed at the weekly MDT meetings (virtual ward round). At other times to facilitate early discharge the OPAT nurse will consult with either the ID/Microbiology consultant to discuss appropriateness of antimicrobial regimes.
· The discharge pathway is outlined in Appendix 4; this is meant as a guide only and any part of the pathway can occur at varying times depending on the individual patients and their needs. All patients follow this pathway irrespective of clinical condition, including those patients accepted from outpatient clinics and A&E areas.
· Exclusion/inclusion criteria,
o This service is for adult patients,
o All patients will be assessed individually by the OPAT nurse regarding the appropriateness of OPAT using OPAT Suitability Assessment Form Appendix 5
o Appropriate antimicrobial therapy that can be delivered in the outpatient/community setting safely.
4 Roles and Responsibilities –
Patient’s Designated Team
Clinical responsibility will remain with the consultant discharging the patient from hospital. Team must complete OPAT referral form available on trust intranet site. A full suitability assessment will be carried out by the OPAT CNS. Consultant Microbiologist will review the patient once accepted by the OPAT CNS.
The Team responsible for the patient care must prescribe intravenous antibiotics on TTA’s for the duration until patient is reviewed by the Consultant Microbiologist in outpatient clinic. The OPAT nurse will co-coordinate further supplies.
The responsible team for patient must complete and sign consent form.
The OPAT medication administration chart must be completed for all patients before discharge.
All patients must have a minimum of one dose of their OPAT medications in hospital before their discharge.
OPAT consultant
There will be a designated Micro/ID consultant responsible for the OPAT service at all times.
· The OPAT consultant will initially review patient as an inpatient and devise patient management plan prior to discharge.
· Outpatient clinic review for weekly OPAT management plan including response to treatment and monitoring for potential adverse effects.
· Request and review any investigations e.g. bloods tests including therapeutic drug monitoring.
· Communicate with the referring consultant/GP and other MDT members as required
· Lead MDT virtual ward weekly
OPAT Nurse
· The role of the OPAT nurse includes the following:
· Assess patient and carer suitability.
· Patient and carer education and support.
· Coordinate with ward pharmacist regarding discharge planning and ongoing outpatient supplies of IV antimicrobials.
· Co-ordinate OPAT clinic review.
· Co-ordinate monitoring of response to OPAT and any drug toxicity.
· PICC line insertion after appropriate training.
· Administer intravenous antibiotics to patients using the hospital attendance model.
Community nurses
· Intravenous antibiotics may only be administered by registered nurses with the necessary knowledge and skills in preparing and administering intravenous antibiotics and evidence that they are confident and competent to carry out this practice.
· Nurses involved in any aspect of administration of intravenous antibiotics have a responsibility to acquire and maintain the necessary knowledge and clinical skills.
· It is the responsibility of nurse to administer prescribed intravenous antibiotics as per trust policy.
· Assess patients’ home environments for suitability for OPAT and contact OPAT team if any concerns
Antimicrobial Pharmacist:
· Hospital Antimicrobial Pharmacist can be contact for advice. On discharge hospital pharmacy will provide patients with prescribed intravenous antibiotics, diluents and flushes till their first follow up appointment with Microbiology Consultant at outpatient clinic.
· Hospital Antimicrobial Pharmacist will periodically review all reconstitution and administration instructions listed on the OPAT drug chart. Any changes will be communicated to all relevant parties.
· Pharmacy will coordinate further supplies with OPAT nurse and consultant microbiologist.
6 Antimicrobial Therapy:
The decision regarding outpatient parenteral antimicrobial therapy is a joint decision made by the clinical team after advice is sought from Consultant Microbiologist/ID Consultant. Apart from sensitivities of the bacteria the following criteria are taken into consideration when deciding therapy.
· Once daily antimicrobial therapy is the first choice
· BD antimicrobial therapy is chosen if the clinical condition of the patient enables BD therapy or if this is the drug of choice and this can be facilitated in the community or the Medical Day Unit. (NB not all community teams can facilitate BD regimes and this is considered a limiting factor in some situations).
· Intermittent infusions longer than 30 minutes or antibiotics that require frequent monitoring cannot be facilitated in the community and would require daily outpatient appointments by the patient. (Drugs in this category include gentamicin and amikacin )
· Length of treatment is agreed by clinical team in discussion with the OPAT team.
· Conversion to oral therapy if appropriate will occur at the end of IV therapy and this is managed by the OPAT CNS in consultation with the clinical team and Microbiologist attached to the referring clinical team.
· District Nurse administration in the patients home is the preferred method of administration, other options include daily visits to the MDU where the VAN/OPAT CNS would administer the antimicrobials
· All patients will receive the first doses of antimicrobial therapy in hospital. The hospital will supply all antibiotic, diluents and flushes for the duration of the therapy.
· In some certain situations the OPAT team may be asked to supply other consumables for patients by community teams. This is funded by the OPAT service as are all consumables required for self-administration.
Drugs primarily used in OPAT are:
Ceftriaxone, Teicoplanin & Ertapenem. Other drugs used include Amikacin, Gentamicin, Ceftazadime, Meropenem, and Daptomycin.
6 Referrals:
Referrals to the service are completed using the OPAT referral form available on the Intranet and emailed to . See Appendix 1 for referral process and referral form
Clinical conditions that will be considered for the service include:
Osteomyelitis
Cellulitis
Soft tissue/wound infections
Joint Infections
Endocarditis
Any other conditions that require long-term antibiotics will be considered after review.
Those patients who live in the Hackney CCG will have the option of home administration by District Nurses or attending the MDU daily. Patients living outside Hackney CCG will be arranged on a case-by-case basis.
All patients will be reviewed on a weekly basis by the OPAT Specialist nurse and/or consultant, which includes a full review including blood tests.
Transport can be arranged but we would prefer them to make their own way to hospital.
Before they can be considered for the service they must be:
1. Fully assessed medically which needs to include relevant swabs/blood cultures for microbiology.
2. Requiring once daily IV Antibiotic regime e.g. ceftriaxone (a bd regime may be considered on a case by case basis)
3. Clinical responsibility remains with the relevant team who will be contacted for follow-up. Conversion to oral therapy if appropriate will occur at the end of IV therapy and this is managed by the OPAT CNS in consultation with the clinical team and Microbiologist
4. IV Antibiotics need to be written as a TTA. Drugs will be stored in the MDU and those to be administered by the District nurses will be supplied directly to the patient on discharge and at each outpatient clinic appointment. IVDU – patients with a history can be accepted onto the service after an individual history is taken and it is agreed by the OPAT team, this is on a case-by case basis. They will be managed with either a daily cannula injection; once again this is on a case by case basis after discussion with the OPAT team.
OPAT service will:
1. For patient requiring administration of intravenous antibiotics at home OPAT CNS will liaise with District Nursing Team to arrange for the administration of prescribed antibiotics and fax/email DN referral form and confirm fax has been received.
2. Patients attending hospital for intravenous antibiotic administration will be seen by the OPAT CNS or ICT nurse covering OPAT CNS on the Medical Day Unit.
3. Monitor clinical condition and recommend any antibiotic changes.
4. Refer back to the relevant clinical team for any necessary follow-up.
5. Provide patients with supply of intravenous antibiotics.
Patients who require longer than a 6-day course of treatment will be considered for a midline or PICC line; otherwise they will be managed with peripheral cannulae.
Referrals can be made by completing the referral form and emailing it to the
7 Discharge process and Information:
Once a patient is accepted on to the OPAT service and method of administration has been decided the following information sent to the district/community Nurse team.
· Referral to District Nurses
· Vascular access device information, including tip position if relevant.
· Contact numbers including out of hours number.
· Copy of discharge summary.
· At least one week’s supply of the drug, diluents and flushes are given to the patient on discharge from HUH with instructions for storage in the home. At weekly review the patient is supplied with further supplies.
For patients on OPAT, the OPAT team will request their medical notes from medical records and an entry made detailing that the patient is currently part of the OPAT program.
Separate OPAT patient held records will be held by patient.
The GP will be sent a copy of the discharge summary regarding their patient informing them of the treatment plan for their patient. If appropriate other letters will be sent by OPAT team throughout the course of therapy if the need arises. At other times it may be necessary to write to consultants of OPAT patients informing or significant changes to treatment as decided due to clinical or environmental need, (e.g. drug reactions, non-compliance), this is copied to GP and /or District Nurse team as appropriate.
8 Vascular Access:
The patient will have an appropriate VAD inserted to facilitate OPAT. This decision is made by the CNS in discussion with the patient.
Devices that are used are:
· Peripheral cannula, (primarily for daily OPAT patients requiring short courses of treatment). If the patient is being discharged into the community with a peripheral cannula it is important to check with the relevant community/DN team that they will accept a patient with a peripheral cannula and if so there is a clear pathway for re-insertion should this be required out of hours.
· Midline cannula:
1. Leaderflex midline, which can stay insitu for 4 weeks, this has a much smaller gauge catheter and is more suitable for short courses of treatment.
· PICC - suitable for all drug administration. The tip of this line sits in the lower third SVC. (Available in both single and double lumens)
· Skin tunnelled catheter e.g. Hickman line– suitable for all drug administration and should be considered when a PICC is unable to be inserted.
All documentation will be kept within the patients records.
9 Review:
All OPAT patients will be reviewed according to clinical need, (minimum of once weekly) by the CNS and/or ID/microbiology consultant, whom will care for the vascular access device, take blood test as determined by the clinical condition of the patient and follow-up the results, informing the clinical team/OPAT team as required. Any other requirements of the patient, e.g. transport, assistance with dressings, further investigations will be done at the discretion of the CNS, liaising with clinical teams as required.
For patients on OPAT, the OPAT team will request their medical notes from medical records and an entry made detailing that the patient is currently part of the OPAT program.
Separate “Patient held” OPAT records will be held by patient.
10 Discharge:
On completion of therapy the patient will be discharged back to the relevant clinical team and/or the GP for follow-up. The timing of this is determined by the patients’ clinical condition and any on-going treatment plan.
11 SOP Review – Mandatory: This policy will be reviewed in 3 years’ time. (Normal review period for a policy is 3 years) Earlier review may be required in response to exceptional circumstances, organizational change or relevant changes in legislation or guidance.
12 Monitoring/Audit –
In order to examine the quality OPAT service programme, an annual service review report will be produced at the end of every financial year which will include: