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Transition from Hospital to Home
Outpatient Parenteral Antimicrobial Therapy (OPAT)
Karri A. Bauer, PharmD, BCPS
Specialty Practice Pharmacist Infectious Diseases
January 16, 2013
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
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
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
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
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
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.
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.
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.
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
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 vs CoPAT 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.
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.
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.
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.
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.
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.
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.
Transition from Hospital to Home
Outpatient Parenteral Antimicrobial Therapy (OPAT)
Karri Bauer, PharmD, BCPS
Jessica Johnston, MSPH
Debbie Goff, PharmD, FCCP
OSUWMC and University Optioncare
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
Nafcillin Piperacillin0
10
20
30
40
50
60
70
19
4
63
17
Incorrect/Ambiguous
Total
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
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
Resultsn=100
Age 48 (39-60)
Male 53
Service*--UH hospitalist--Colorectal surgery--Gen surgery--Inpatient ID--Urology
95555
Comorbidities--Diabetes--Chronic renal disease--Malignancy--Chronic respiratory disease--Immunosuppression--Liver disease
18151615103
*Top 5 services presentedData presented as % unless otherwise stated
Resultsn=100
Infectious diagnosis*--Osteomyelitis--Intra-abdominal--UTI/pyelonephritis--Pneumonia--Bacteremia
21211276
IV access--PICC--Groshong
991
ID follow-up upon discharge 60
Combination therapy 31
Median antibiotic duration, days 21 (14-42)
*Top 5 diagnoses presentedData presented as % unless otherwise stated
ResultsOrganism %
Polymicrobial 33
Culture negative 26
MRSA* 6
MSSA 5
Gram negatives** 52
*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
Antimicrobial Agent# %
Ertapenem 100
Vancomycin 15
Daptomycin 11
Penicillins 2
Fluoroquinolones 1
ResultsOutcome n=100
Line-related complication 0
Antibiotic-related complication--Intolerance*--Compatibility--Allergy
200
Change in antibiotic therapy 4
Post discharge antibiotic additions 12
Transition to oral therapy--Osteomyelitis
95
Clinical cure 80
Infection-related readmission** 19
*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
Results• 20 patients did not achieve a clinical cure• 19 patients had an infection-related readmission
Infectious Diagnosis n=20
Intraabdominal 6 (20)
Osteomyelitis 4 (20)
UTI/pyelonephritis 3 (15)
Soft tissue 3 (15)
Pneumonia 2 (10)
Bacteremia 1 (5)
LVAD 1 (5)
Organism n=20
Gram negative 14 (70)
Culture negative 5 (25)
Polymicrobial 5 (25)
MRSA 3 (15)
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
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”