Outpatient parenteral antimicrobial therapy (OPAT) provides a method for keeping patients out of the hospital setting while allowing for treatment for serious infections. Here, a pharmacist with advanced training and experience in the area of infectious diseases discusses the topic.
Authored By: Krutika N. Mediwala, Pharm.D., BCPS
[Last updated: 26th August 2017]
In recent years Outpatient Parenteral Antimicrobial Therapy (OPAT) has experienced significant growth. This has been fueled by increased acceptance with patients and providers, availability of reliable resources, technological advances, once-daily antimicrobials, and cost-containment goals.
Benefits of OPAT can include readmission avoidance, reduced length of hospital stay (which results in increased inpatient capacity), reduction in health-care associated infections, improved patient-choice and satisfaction, and significant healthcare cost savings compared to inpatient care.
This article reviews the ins and outs of OPAT.
OPAT definitions from around the world…
The Infectious Diseases Society of America (IDSA) describes OPAT as the provision of parenteral antimicrobial therapy in at least 2 doses on different days without intervening hospitalization . Across the hemisphere, the United Kingdom classifies OPAT as a method of delivering intravenous antimicrobials in the community or outpatient setting, as an alternative to inpatient care . In Australia OPAT care is termed “hospital-in-the-home” and includes care that would otherwise have to be delivered in hospital, because of the nature of the patient’s medical or social condition .
A walk through OPAT history…
The impetus to develop OPAT programs in the United States actually came about in part due to gaps in medical insurance coverage. Going back to 1974, Rucker et al published on using OPAT therapy for their Cystic Fibrosis (CF) patients in order to improve the social aspects of their lives . Although they had only a 68% success rate, this paved the way for OPAT trials in various infections and populations.
IDSA published the Community Parenteral Antimicrobial Therapy (CoPAT) guideline in 1997 and identified healthcare teams, communication, and written policies and procedures as key elements of the program . During this year, the OPAT Registry was also initiated for monitoring, but was later discontinued in 2000 due to lack of support and funds. The 2004 IDSA OPAT guidelines changed the name to be all encompassing and added patient follow-up and outcomes monitoring to the initial key elements .
OPAT can be delivered in various settings, each of which has unique has pros and cons. The 4 most commonly utilized settings in the U.S. are summarized here in Table 1.
|Table 1. Delivery Settings for OPAT [5,7,8]|
|Infusion Center:||Supervised administration, readily available staff, “Day hospitals”||Travel requirement, overhead costs, maintenance|
|Visiting Home Service:||Home environment evaluation, medical supervision, patient independence||Costly, travel time, multi-dose regimen challenges|
|Self-administration:||Financial savings, patient independence||Appropriate training, refreshers, initial therapy monitoring|
|Skilled Nursing Facility:||Readily available staff, multiple co-morbidities, direct supervision||Costly, staff training, travel requirements|
Bundle it up! OPAT component review…
There are several important components that can help providers improve the reliability and delivery of OPAT and improve patient outcomes. These include patient identification, OPAT team consultation, patient-family education, transitions-of-care, outpatient monitoring, and OPAT program assessment. The key factors surrounding each component are discussed here:
1. Patient Identification
Patients identified for OPAT should have no clinical contraindication to hospital discharge, stable disease and no risk of sudden life-threatening changes in health. In addition to the severity of infection and appropriate inpatient therapy, a thorough assessment of abuse potential, caregiver support, home environment, and insurance details should be conducted.
The patient should have access to a telephone and other means of immediate communication and transportation in case of emergencies and to maintain appointments. In addition, resources should be identified for the elderly, those with dexterity problems, or those with multiple co-morbidities [1-3,9].
2. OPAT Team Consultation
IDSA and the UK Good Practices guidelines recommend a multidisciplinary team consisting of at least an Infectious Diseases (ID) specialist or medically qualified clinician, an antimicrobial stewardship/ID pharmacist, and an OPAT-trained nurse.
Several studies have shown that ID-service consult and antimicrobial stewardship can increase adherence to standards of care, decrease use of inappropriate therapy, improve patient outcomes and reduce readmissions, all while causing no significant delay in patient discharge [1,2,9-12]. Together, these team members can ensure appropriate patient identification, optimal therapy and duration, and proper education on parenteral therapy and devices.
Additionally, case managers, primary/referring physicians, and ancillary staff can ensure that the patient is equipped with suitable transitions-of-care referrals to guarantee successful treatment completion and defer hospital readmission. However, the most important members of the multidisciplinary team include the patient and their caregivers, as they will be replacing the traditional inpatient healthcare personnel and becoming active participants in their care [1,2,9,10,13].
3. Patient & Family Education
Even though little is published about patient and caregiver education, their consent, education and compliance can be extremely impactful in clinical success. They should be thoroughly educated about the infection, complications, treatment plans, potential problems, communication and expected outcomes. They must also be able to assume responsibility of maintaining infusion, vascular access and infusion site care, and report observations.
Training on sterile technique and administrations should comply with governing standards and be carried out by an OPAT team member. The healthcare team and the patient/family should ideally also document their satisfaction with this training [1,2,9,10].
As 30-day readmission rates are an important quality-of-care metric, successful care transition from hospital to home/alternative healthcare facility is important for the patient’s well being and limiting the financial impact of readmission.
Currently reported OPAT-related readmission rates have a wide range of 6-20%. To avoid these negative outcomes, clear communication between the inpatient and outpatient services is key. Follow-up appointment (preferably at an ID-clinic) should be made prior to discharge. The treatment plan, including safety labs, should be ordered and documented in the patient’s discharge summary. When these patients are discharged, the responsibility of some or all their care may also fall on family members or caregivers, which may bring its own stressors.
Interventions that include specific actions to empower and educate patients/caregiver, coordinate data flow, and facilitate follow-up within 7-10 days should be considered, as this can reduce readmissions as well as improve patient knowledge and understanding of their diagnoses and medications .
5. Outpatient Monitoring
Monitoring is not a “one size fits all” model and needs to be individualized with consideration to the OPAT model/resources, patient characteristics, severity of infection, and antimicrobial therapy.
The frequency of follow-up visits with supervising physician should be determined as part of the OPAT plan. Patients may need to be seen daily to once a week depending on the infection type and caregiver support. The IDSA guidelines stress that nurse and pharmacist monitoring are not substitutes for face-to-face physician evaluations. If there are transportation difficulties, care may be coordinated with local physicians.
Labs are usually drawn weekly, but depending on the antimicrobial agent, may need to be more frequent. Special attention should be paid to adverse drug events (ADEs) that may develop later in the therapy, such as blood dyscrasias. As always, patients should be made aware of various ADEs and instructed to seek medical attention should a complication arise. For example, potential ototoxicity with aminoglycosides can be monitored by patients using volume of conversation, tinnitus, vertigo, or a feeling of fullness in the ear. The patient’s understanding of these instructions should be documented clearly in the medical record and it might be beneficial to include the possibility of ADEs in the contract for OPAT that these pts will sign.
Depending on the access and device used, dressing changes, frequency of catheter flushes, site maintenance must be performed by protocol. Patient and healthcare personnel should monitor access daily or a few times a week. Specifically, it is important to monitor and educate about local phlebitis, erythema, tenderness, leakage, and induration.
In the case of tampering, malfunction, or infection the access line may need to be removed in a timely fashion. In addition to regular physician review, weekly multi-disc virtual ward rounds are recommended.
Regular and prompt communication with patient’s other healthcare providers is vital, but guidelines recommend that ID specialists lead the monitoring and responding to lab studies. After completion of OPAT, clinical cure should be documented and there should be a thorough evaluation to ensure that the patient did not suffer any ADEs [1,2,10].
6. OPAT Program Assessment
With the development of any service, systems should be put in place for thorough review and continuous quality improvement. Tools such as the Healthcare Failure Modes and Effects analysis (FMEA) can allow for identification of areas where potential harm and errors could occur and ultimately affect patient care. They also provide a framework for ongoing quality improvement.
Readmission rates for reasons such as ADEs, line infections, or worsening clinical status should be recorded and thoroughly evaluated. Given that OPAT is a method of hospital cost saving, it would be counterproductive to have early discharge with OPAT that resulted in high readmission rates.
A recent study evaluated readmission rates in patients receiving OPAT . Amongst the 20% readmissions, majority were secondary to infection recurrence or progression (33%) and adverse-drug reactions (24%). However, patients with follow-up were less likely to be readmitted.
Patient satisfaction is also an important measure and studies report that OPAT patients are highly satisfied and if able, are more likely to choose it again. Staff involved in OPAT care can also be surveyed for their perception of ease of transition.
Some of the best-studied OPAT outcomes indicators have been those related to cost-savings and financial analyses. These results may be useful for marketing and contracting with payors.
Joint Commission as well as the National Committee for Quality Assurance require outcomes measures as part of their certification process.
Table 2 describes important OPAT outcomes that were measured by the OPAT Registry [1,8,9].
|Table 2. OPAT-Related Outcomes|
|Clinical outcome||Improved/ Failed/ No change|
|Bacteriological outcome||No culture/ Culture-negative/ Persistent pathogen/ New pathogen|
|Program outcome||Completed/ Ended early/ Hospitalized/ Died|
|Antibiotic outcome||Completed/ ADE/ Clinical failure/ Resistant Organism|
|Adverse events||Rash/ Nausea, vomiting/ Fever/ Nephrotoxicity|
Pharmacist’s Role in OPAT
In 2000, the American Society of Health-System Pharmacists (ASHP) published guidance for the pharmacist’s role in home care . These can also be applied to OPAT patient care and are listed here:
- Preadmission assessment
- Initial patient database and assessment
- Selection of products, devices, and ancillary supplies
- Development of care plans
- Patient education and counseling
- Clinical Monitoring
- Communication with patient and caregiver
- Coordination of drug preparation, delivery, storage, and administration
- Standard precaution for employee and patient safety
- Documentation in the home care record
- ADE reporting and performance improvement
- Participation in performance improvement activities
- Policies and procedures
- Training, CE, and competence
In summary, OPAT is a viable option for continuation of antimicrobial therapy with significant cost benefits and positive patient outcomes. It has been shown to have positive outcomes in various populations including pediatrics, elderly and even in patient populations with severe infections (e.g., infective endocarditis).
Key elements of successful OPAT treatment include patient identification and selection, ID consultation, patient-family education, care transition, outpatient monitoring and program assessment. It is a viable option for most patient populations and an avenue of expansion for antimicrobial stewardship programs, but it should be undertaken with the appropriate cautions and supervision.
12. Fowler VG et al. Outcome of Staphylococcus aureus bacteremia according to compliance with recommendations of infectious diseases specialists: experience with 244 patients. Clin Infect Dis. 1998; 27: 478-86.
13. Heintz BH et al. Impact of a multidisciplinary team review of potential outpatient parenteral antimicrobial therapy prior to discharge from an academic medical center. Ann Pharmacother. 2011; 45: 1329-37.
15. ASHP guidelines on the pharmacist’s role in home care. Developed through the ASHP Council on Professional Affairs with the assistance of the Executive Committee and Professional Practice Committee of the ASHP Section of Home Care Practitioners and approved by the ASHP Board of Directors on April 27, 2000. Am J Health-Syst Pharm. 2000; 57:1252–7.
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