The Atlas of Shared Learning

Case study

Outpatient parental antibiotic therapy at Whittington Health NHS Trust

Leading change

The Lead Outpatient Parenteral Antibiotic Therapy (OPAT) Nurse at Whittington Health NHS Trust led on the development and implementation of new pathways and services, to reduce unwarranted variation by ensuring patients could be discharged home safely and still receive their antibiotic therapy as recommended. This has led to better outcomes, experiences and use of resources.

Where to look

Outpatient parenteral antibiotic therapy (OPAT) is widely used in most developed countries, providing considerable opportunities for improved cost savings (Minton et al 2017). Noteworthy, the specialist nurse service model is reportedly the most effective implementation method as well as most optimal for both short and longer treatment courses (Minton et al 2017).

The OPAT team at Whittington Health NHS Trust operate out of the Ambulatory Emergency Care department and include a Lead OPAT nurse, a Microbiology Consultant, a microbiology registrar and a pharmacist. The OPAT nurse and team identified unwarranted variation in the numbers of patients remaining in hospital due to antibiotic therapy alone who could have been effectively and safely delivered at home.

What to change

Prior to establishing the OPAT service pathways, only patients who had a central intravenous line in place (type of catheter placed in a large vein) and were bed/housebound could receive IV antibiotics in the community. This was due to limited specialist skills available in the community, which meant an over reliance upon District Nursing Services who themselves had active caseloads and patients with other needs.

Once the service had been established, the Lead OPAT nurse identified that they could offer this service more widely and comprehensively to benefit patients. Through staff education, advice and development of a clinical pathway to support a new model of care in the community, the team hoped to reduce unnecessary admission rates and reduce lengths of stay as well as improved outcomes for patients who access Whittington services.

How to change

The Lead OPAT Nurse, utilised NICE guidance which outlined which patient groups were safe to receive antibiotic therapy in the community, to develop procedures and practice pathways. The nurse developed a programme to support the referral of patients to the OPAT team and avoid or reduce admissions. This was rolled out across services within the Trust. To support the embedding of these new processes, the OPAT nurse and multidisciplinary team (MDT) developed strong relationships with the District Nursing teams, to support the referral of patients directly to the OPAT rather than into hospital.

Each patient signposted to the new OPAT pathway is provided with a bespoke care plan which is tailored to their needs. The Lead OPAT nurse also considered the impact on patients who were admitted to hospital and were receiving antibiotics. The nurse developed an internal process to identify patients suitable for home antibiotic therapies. They began working with wards to facilitate the safe, early discharge of patients from hospital when they are well enough to be at home.

The Lead OPAT Nurse supported by other nursing leads developed a working group to support the MDT in producing service specification, mapping training, reviewing patient care and ongoing governance of the service. More specifically, the group:

  1. Supported service design and delivery by identification and utilisation of existing community facing teams to administer the required medications;
  2. Ensured training was in place for the provision of safe clinical service delivery;
  3. Educated ward staff on availability of non-inpatient services to manage and treat acute illness by working in collaboration with the patients;
  4. Supported staff in OPAT, District nursing and in-hospital to change culture and practice;
  5. Created and developed a self-administration programme which gives the patient the key role in the improvement of their own health;
  6. Developed systems for referrals and ensured robust communication with community and in-hospital services to support recognition of patients and timely referrals;
  7. Established comprehensive digital databases for patients referred into the service;
  8. Established a vascular access group to support competency in venous access and to monitor practice.

The Lead OPAT nurse, along with the wider OPAT team also established a weekly review of all patients under the care of Whittington Health who were receiving Intravenous antibiotics in the community. This enabled the team to ensure oversight of patient caseloads and effective management of systems and processes centrally. This established a process whereby all patients receive senior nursing review and remote monitoring, to ensure highest standards of care are adhered to.

Adding value

Better outcomes – The service directly facilitates the discharge of patients from hospital to their own homes where they can receive the care they require. Furthermore, care is under constant review by senior decision makers including the Microbiology Consultant and the Consultant whose care they are under for their medical/surgical condition.

Better experience – The service has been well received by patients and feedback has included:

Staff make you feel at ease, are pleasant and calm. They explain what they are going to do. Clinic atmosphere is very calm and pleasant. Keep doing what you are doing.

Very thorough assessment & treatment. All staff very kind & courteous.

Staff appear expert and competent.

Focussed attention to detail and very clear explanations of symptoms & treatment and patient friendly attitude.

Very friendly service, they give you all the care you need. Best service in your own home

Staff have also responded well to the service reporting:

Excellent service. As a physician in acute medicine, the OPAT service allows me to discharge patients home to receive their care by senior nurses and allows for the safe handover of complex patients with complex health needs.

Better use of resources – In 2017, a total of 3093 bed-days were saved through the Whittington OPAT service. The cost of delivering the OPAT service was estimated to be £550,000 compared to £930,000 for inpatient stay of the same cohort of patients, resulting in an estimated savings of least £300,000. The savings were associated with the reduction in patients’ utilisation of healthcare services and also exposure to healthcare-associated infections.

Challenges and lessons learnt for implementation

Services can be underutilised even when you think they are being used effectively, so reviewing data and information is important to understand what is working.

Visible hands-on help with transferring care from inpatient to community is imperative.

A Multidisciplinary Team approach to a service such as this is key to success, as well as safety.

The support of ward staff and our community colleagues is paramount to the effectiveness of the service and education. Similarly, visible leadership instils confidence in staff to refer to the service.

Effective partnership working is vital to change culture and practice.

Find out more

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