Outpatient parenteral antibiotic therapy (OPAT) refers to the approach by which intravenous (IV) antimicrobials are administered in the outpatient setting or community (Chapman et al, 2012). In the UK, until recently, OPAT delivery was limited to a few specialist centres led by enthusiastic individuals (Chapman et al, 2012). OPAT is now an increasingly used, safe and effective model of care in the UK, endorsed by the Department of Health and Social Care as a key antimicrobial-prescribing decision within an antimicrobial stewardship programme (Barr et al, 2013). Community nursing teams aim to provide a multidisciplinary and integrated approach between care in the hospital and community, complementing the services provided by the secondary and primary care sectors and community service providers.
Community nursing services administer a variety of IV medications to treat infections such as cellulitis, exacerbation of chronic obstructive pulmonary disease (COPD), community-acquired pneumonia and urinary tract infections (UTIs) (National Institute for Health and Care Excellence (NICE), 2012). These treatments are administered safely and effectively in community clinics or at home for housebound patients, often without the need for hospital admission. Referrals for these services are received from GPs to prevent the need for hospital admissions, and from secondary care, to support earlier discharge of patients who would otherwise need to remain in hospital until their treatment was completed.
By helping prevent hospital admission and supporting earlier discharge from acute hospitals, community IV therapy clinics can provide significant benefits to both patients and the NHS (Owen, 2016). The benefits to patients include a reduction in the risk of healthcare-associated infection as well as improved patient choice, quality of life and satisfaction (Chapman et al, 2012). The benefits to the NHS and to wider local health economy are that an increased number of bed days are saved, which, in turn, provides significant cost-savings compared with inpatient care (Chapman et al, 2009). This links strongly with the NHS Long Term Plan (NHS England, 2019), which discusses providing patients with the choice of where they receive their treatment.
As discussed above, OPAT has become a routine recommendation for many infections. At the authors' trust, the aims of setting up nurse-led IV clinics were to:
- Increase the capacity within the community nursing service to allow more patients requiring IV antibiotic therapy to be treated at home or in the community
- Increase collaborative working with secondary care to improve the patient journey for those requiring this treatment
- Improve the patient journey for non-housebound patients
- Improve placed-based care and integrated working.
The service is provided to adults over the age of 18 years who are registered with a Wirral GP.
Establishment of the service
The community nursing service at the authors' trust had already been providing IV antibiotic therapy within the community, although this had been restricted to provision within patients' own homes. Therefore, the equipment for the treatment was available. A number of meetings where held with the estates department in order to find suitable rooms with infection and prevention control standards required to deliver the service. The clinic rooms chosen came with the appropriate storage facilities and equipment required to carry out the procedure, as well as hygiene and clinical waste disposal facilities.
A service improvement and innovation day was held involving all community nurse team leaders and community matrons. From this, the OPAT workstream was developed. A number of meetings were held to discuss the possible ways of increasing capacity within the service to support larger numbers of patients requiring IV antibiotic therapy.
The community nursing service is divided into four neighbourhoods. As mentioned above, prior to the OPAT workstream, IV antibiotic therapy was only delivered to patients within their own homes. Following patient feedback, it was recognised that not all patients where housebound, and some patients were still attending work. Therefore, a hub IV clinic feasibility audit was carried out.
Hub IV clinic feasibility audit
Data were collected in September 2018 from patients at the point of referral when they were admitted into the OPAT service and before they were discharged into the community. These patients all attended a clinic within a single geographical area for IV therapy. Data were also collected using a combination of information recorded in SystmOne at weekly multidisciplinary team meetings. The results showed that 62% of 40 patients questioned at the point of referral were prepared and able to travel to a clinic for their IV antibiotic treatment.
In addition to the above, a further 24 patients were asked at the point of referral if they would be prepared to travel to a clinic to receive therapy. Thirteen were prepared to, while the remaining were not.
Of the total number of patients questioned (n=40), 62% (n=25) agreed to travel to a clinic for therapy, while 38% (n=15) refused. The patients who declined attending a clinic cited financial or travel limitations, which led to the trust looking into transport solutions through GP out-of-hours drivers or charities such as AgeUK.
Outcomes and benefits
Four IV antibiotic therapy clinics run by community nurses are now available in each hub. Thus, the community nursing team's capacity for treating patients requiring IV antibiotics has increased, whereby they treat 12 patients (three per clinic) Wirral-wide (three per hub) while continuing to see six patients requiring visits at home. Quality of life for patients improved with the increased availability of IV antibiotic therapy in the community for ambulant patients. The clinics have received excellent patient feedback:
‘The timings of my appointments were really convenient.’
‘The IV clinic very accessible and a few minutes' walk from my house.’
‘The concept of a community OPAT clinic was excellent and that all areas within Wirral should offer the service.’
‘The nurses were so pleasant and so nice.’
Importantly, the number of bed days saved between April 2018 and May 2019 was 7207.
Work at the clinic
Every month, the community trust provides a rolling mandatory training programme that features training for the administration of IV antibiotics and medication management. The IV antibiotic training is delivered by one of the community matrons jointly with the OPAT team.
During administration of IV antibiotic therapy, staff use aseptic non-touch technique (ANTT) at all times. A point of use disposal of sharps (POUDs) tray, trust-approved cleaning wipes and, if indicated, an open sterile dressing pack on a clean surface are used. All sterile single-use equipment is placed within the aseptic field, maintaining key-part protection at all times.
The main conditions treated include: osteomyelitis with a duration of up to and beyond 6 weeks, cellulitis with a duration of 7–10 days and stepdown onto oral antibiotics, complicated UTIs including those caused by extended-spectrum beta-lactamase (ESBL) producers of duration 3–5 days and exacerbation of COPD.
The patient's main point of contact remains the community nursing team, which liaises with the GP/OPAT team. Weekly multidisciplinary team (MDT) meetings are held with the OPAT team, microbiologists and pharmacists to review blood results and clinical photography if available and for decision-making on the dose, duration and frequency of treatment. Direction regarding discharge is provided following the MDT meeting. During discharge, patients are given ongoing clinical advice as required, any stepdown medication and guidance on how to take it is discussed. Additionally, an electronic discharge letter is sent to the patient's GP.
Conclusion
Having a close collaborative working partnership with primary and secondary care with a standard set list of appropriate and agreed IV antibiotics supports the NHS long-term plan around antimicrobial resistance (NHS England, 2019), by optimising antibiotic usage, close monitoring of all patients on the pathway and raising awareness of antimicrobial stewardship.
The community nursing IV therapy clinics run by community nursing staff enable patients to be seen closer to home. On the Wirral, the plan is to further expand the clinics to enable multiple appointments to run concordantly. Further investment is needed to support the expansion of the clinics to ensure staffing availability, that the environment is appropriate (adequate space is available for multiple occupants and that there is appropriate physical distancing between patients) and that any additional equipment is made available (IV stands and appropriate clinical chairs). Plans are also in place to explore the arrangement of transportation for patients who cannot organise this for themselves. Another potential addition to the service is the use of elastomeric devices for certain cohorts of community patients. Additionally, the team intends to implement a cellulitis pathway in secondary care supported by IV clinic appointments in the community run by community nurses. The cellulitis pathway would ensure that patients are not admitted to hospital with cellulitis but rather are seen promptly in the community in an IV clinic by community nurses. Lastly, a potential new key performance indicator (KPI) is being considered so that a microbiologist was available to speak to GPs in order to ensure a timely response and ensure that community patients can be supported promptly to reduce cellulitis-related admissions.
Key Points
- Personalised care can be delivered to patients in a variety of settings successfully in order to ensure they receive the correct treatment at the correct time and to prevent hospital admissions
- Increasing collaborative working between primary and secondary care improves place-based care and integrated working
- Community intravenous (IV) antibiotic therapy can be administered for various conditions, including cellulitis, exacerbations of chronic obstructive pulmonary disease (COPD), community-acquired pneumonia, and urinary tract infections (UTIs)
- Through community IV therapy clinics, patients can benefit from the right therapy at a convenient time and place.
CPD REFLECTIVE QUESTIONS
- What are the advantages of patients attending an intravenous (IV) therapy clinic?
- What are the reasons a patient may need a home visit for their IV treatment?
- How can you ensure antimicrobial stewardship is followed?
- Who would you need to contact if you had any concerns related to patients' IV therapy and treatment?
- Why is it important that blood levels are checked every week?