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Transition from Hospital to Home Outpatient Parenteral Antimicrobial Therapy (OPAT)

Transition from Hospital to Home Outpatient Parenteral Antimicrobial Therapy (OPAT). Karri A. Bauer, PharmD , BCPS Specialty Practice Pharmacist Infectious Diseases January 16, 2013. Objectives.

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Transition from Hospital to Home Outpatient Parenteral Antimicrobial Therapy (OPAT)

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  1. Transition from Hospital to HomeOutpatient Parenteral Antimicrobial Therapy (OPAT) Karri A. Bauer, PharmD, BCPS Specialty Practice Pharmacist Infectious Diseases January 16, 2013

  2. Objectives • Understand combined benefits to provider and patient of outpatient parenteral antibiotic therapy (OPAT) • List key components of a successful OPAT program • Review OSUWMC data regarding transition of patients from hospital to home on OPAT • Discuss the potential role of an infusion center at OSUWMC

  3. Background • 1970s- Outpatient parenteral antimicrobial therapy introduced • Minneapolis-Canada • Community hospital reported successful treatment of > 150 patients with invasive infections • 1998- 250,000 people treated, generates $2 billion in revenue • Growth rate > 10% annually • Emphasis on cost containment • Availability of antibiotics administered once or twice daily • Advances in vascular access • Increased acceptance • Increased availability of structured services

  4. Background • Facilitate early discharge • Avoid hospital readmission • Provide safe, effective, and cost-effective therapy • Improve hospital throughput • Improve patient satisfaction • Numerous studies have confirmed the safety with appropriate antimicrobial selection and monitoring

  5. Key Components • Medical director/advisor • Defined roles • Physician, nurse, pharmacist, and patient • Standards • Physician, nurse, and pharmacist • Accreditation or certification (JCAHO) • Experience • Policies • Reporting of laboratory results • Willingness to share local quality assurance and outcomes • Willingness to share charge/cost information

  6. Key Elements Patient

  7. Delivery of OPAT • Infusion centers • Visiting nurse • Self or caretaker • Long term care facility

  8. Selection of Outpatient Antimicrobials • Dosage schedules • Long-term toxicity • Drug stability • Drug half-life • Patient population • Anticipated duration of therapy • Patient tolerance • Low incidence of side effects • Cost effectiveness

  9. Home IV Antimicrobial Infusion Therapy • 205 patients discharged from a VA • Outpatient IV infusion team • July 2000-December 2003 • 230 courses of IV antimicrobials • Most patients ≥ 60 years of age • DM, CAD, PVD • IV therapy team verified that patients could perform infusion at home and provided instructions • Osteoarticular (52%), bacteremia (14%), and skin and soft tissue infections (13%) • Mostly PICCs Cox Am, Malani PN, Wiseman SW, Kauffman, CA. Home intravenous antimicrobial infusion therapy: a viable option in older adults. J Am Geriatr Soc 2007; 55:645-650.

  10. Home IV Antimicrobial Infusion Therapy • Vancomycin (46%) and cefazolin, ceftriaxone, and ertapenem used for other infections • Nephrotoxicity observed in 10 courses (4.3%) • PICC complications common • Failures: • 9 cases (8%) in patients ≥ 60 years of age and • 7 (6%) of patients < 60 years of age • Overall, 70 (65%) courses in patients ≥ 60 years of age and 89 (72%) courses in patients < 60 years of age resulted in stable or improved infections Cox Am, Malani PN, Wiseman SW, Kauffman, CA. Home intravenous antimicrobial infusion therapy: a viable option in older adults. J Am Geriatr Soc 2007; 55:645-650.

  11. OPAT Outcomes Registry • Provided information regarding treated infections, pathogens, and antibiotics • Allowed sites to compare programs and experience • 24 contributing US sites- >8000 patients, >11000 courses • Osteomyelitis • Vancomycin • Most patients (93%) did not have repeat cultures • 266 patients analyzed • 3 experienced therapy failure • 4 showed no change • Overall adjusted failure rate of 2.5% Tice A. The use of outpatient parenteral antimicrobial therapy in the management of osteomyelitis: data from the Outpatient Parenteral Antimicrobial Therapy Outcomes Registries. Chemotherapy 2001;47(Suppl 1): 5-16.

  12. Economics of OPAT • IV antibiotic treatment is ~$1000-2500,compared with $200-300 for OPAT/day • Benefits • Ability to return to work • Reduction in cost of nosocomial infections • ~5% of hospitalized patients develop an infection during hospitalization • Estimate total cumulative cost of >$2 billion annually • Outpatient care may reduce expenses, morbidity, and mortality

  13. Antimicrobial Stewardship at Transition of Care • Retrospective study 2/14/10-5/14/10 • Cleveland Clinic CoPAT Registry • Structured data entry form (CoPAT form) • No patient can leave the hospital on OPAT without CoPAT filled out • Electronic form requesting ID consultation • CoPAT request • CoPAT approved in 72% and avoided in 28% • 17% oral antibiotics; 11% no antibiotics • No significant differences in ED visits or readmissions when comparing CoPAT avoided vsCoPAT approved Shrestha NK, Bhaskaran A, Scalera NM, et al. Antimicrobial stewardship at transition of care from hospital to community. Infect Control Hosp Epidemiol 2012; 33:401-404.

  14. Impact of a Multidisciplinary Team Review of Potential OPAT • 2000- Multidisciplinary OPAT team • Independent from ASP • Review antibiotic care plans at hospital discharge • ID physicians, ID pharmacists, and case managers • Receive therapy at a variety of non-acute care settings • Interventions provided and documented • Patient safety • Regimen simplification • Clinical efficacy • Decreased healthcare expenditures Heintz BH, Halilovic J, Christensen CL. Impact of a multidisciplinary team review of potential outpatient parenteral antimicrobial therapy prior to discharge at an academic medical center. Ann Pharmacother 2011; 45:1329-1337.

  15. Impact of a Multidisciplinary Team Review of Potential OPAT • Analysis of impact of OPAT between 7/1/09-6/30/10 • 613 bed academic tertiary care hospital • Electronic form requesting ID consultation • Safety, efficacy, and complexity • Economic benefits (total number of hospital days avoided) Heintz BH, Halilovic J, Christensen CL. Impact of a multidisciplinary team review of potential outpatient parenteral antimicrobial therapy prior to discharge at an academic medical center. Ann Pharmacother 2011; 45:1329-1337.

  16. Impact of a Multidisciplinary Team Review of OPAT • Interventions • Regimen safety- 56.1% • Simplification- 40.6% • Efficacy- 28.6% • OPAT was avoided in 13.2% referrals Heintz BH, Halilovic J, Christensen CL. Impact of a multidisciplinary team review of potential outpatient parenteral antimicrobial therapy prior to discharge at an academic medical center. Ann Pharmacother 2011; 45:1329-1337.

  17. Impact of a Multidisciplinary Team Review of Potential OPAT Heintz BH, Halilovic J, Christensen CL. Impact of a multidisciplinary team review of potential outpatient parenteral antimicrobial therapy prior to discharge at an academic medical center. Ann Pharmacother 2011; 45:1329-1337.

  18. Impact of a Multidisciplinary Team Review of OPAT Heintz BH, Halilovic J, Christensen CL. Impact of a multidisciplinary team review of potential outpatient parenteral antimicrobial therapy prior to discharge at an academic medical center. Ann Pharmacother 2011; 45:1329-1337.

  19. Impact of a Multidisciplinary Team Review of OPAT • Discharge delays avoided • 6.2% referrals, resulting in total of 228 days (mean 6.5 days) and $366,000 in hospital bed cost savings • CVC placement prevented in 48 referrals, represents an additional $58,080 in cost savings • $424,080 of direct inpatient care-related costs was avoided over 1-year study period • Mean 27 minutes of ID pharmacist time was required Heintz BH, Halilovic J, Christensen CL. Impact of a multidisciplinary team review of potential outpatient parenteral antimicrobial therapy prior to discharge at an academic medical center. Ann Pharmacother 2011; 45:1329-1337.

  20. Transition from Hospital to HomeOutpatient Parenteral Antimicrobial Therapy (OPAT) Karri Bauer, PharmD, BCPS Jessica Johnston, MSPH Debbie Goff, PharmD, FCCP OSUWMC and University Optioncare

  21. Background • Audit in 2009 completed by Jen Severing, PharmD, BCPS • Evaluate home regimens of nafcillin and piperacillin • Patients discharged with incorrect or ambiguous orders • 30% of nafcillin orders; 24% of piperacillin orders • 26% readmitted for suspected or confirmed ongoing infection

  22. Background • At OSUWMC, approximately 200 patients per year are discharged to University Optioncare on OPAT • Currently, not every patient discharged on OPAT is seen by an ID physician or ID pharmacist • Collaboration between ID specialists at OSUWMC and pharmacists at University Optioncare provides an unique opportunity to study outcomes • Relationship provides a method for prompt identification of patient care issues and improved access to communication

  23. Methods • All patients who received inpatient antimicrobial therapy and were discharged on OPAT (ertapenem +/- additional antibiotic) through University Optioncare between 1/1/11-12/31/11 • Patients < 18 or > 89 years of age, prisoners, and pregnant females were excluded • Data obtained from the electronic medical record and University Optioncare database • IRB approved for all patients discharged on OPAT through University Optioncare

  24. Results *Top 5 services presented Data presented as % unless otherwise stated

  25. Results *Top 5 diagnoses presented Data presented as % unless otherwise stated

  26. Results *1 patient had MRSA identified as the only organism **8 patients had E coli; 6 patients had ESBL E coli; 6 patients had K pneumoniae #30 patients received combination therapy

  27. Results *1 patient elevated liver enzymes; 1 patient elevated vancomycin level **Median time to readmission was 50 days (11-133) Data presented as % unless otherwise stated

  28. Results • 20 patients did not achieve a clinical cure • 19 patients had an infection-related readmission

  29. Results • 20 patients could have potentially received oral antibiotics • 17 patients- no ID consult • 3 patients- ID consult • 3 patients could have potentially received ceftriaxone instead of ertapenem • 3 patients- no ID consult

  30. Conclusions • Currently, there is a great emphasis on methods to improve hospital throughput and patient satisfaction while minimizing health care-associated costs • Administration of IV antimicrobials on an outpatient basis has been shown to be safe, efficacious, practical and cost-effective • Future direction of the study is to complete review of all patients discharged on OPAT through University Optioncare and economic analysis • OPAT presents a future direction for OSUWMC and “Create the Future Now”

  31. Transition from Hospital to HomeOutpatient Parenteral Antimicrobial Therapy (OPAT) Karri A. Bauer, PharmD, BCPS Specialty Practice Pharmacist Infectious Diseases January 16, 2013

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