Engaging Patients and Caregivers in a Transdisciplinary Effort to Improve Outpatient Parenteral Antimicrobial Therapy.
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ABSTRACT:
SUBMITTER: Keller SC
PROVIDER: S-EPMC7314581 | biostudies-literature | 2020 Jun
REPOSITORIES: biostudies-literature
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Engaging Patients and Caregivers in a Transdisciplinary Effort to Improve Outpatient Parenteral Antimicrobial Therapy.
Keller Sara C SC Tamma Pranita P Salinas Alejandra A Williams Deborah D Cosgrove Sara E SE Gurses Ayse P AP
Open forum infectious diseases 20200521 6
We worked with patients, caregivers, and healthcare workers to prioritize barriers and propose solutions to outpatient parenteral antimicrobial therapy (OPAT) care. Unclear communication channels, rushed instruction, safe bathing with an intravenous catheter, and lack of standardized instructions were highly ranked barriers. Outpatient parenteral antimicrobial therapy programs should focus on mitigating barriers to OPAT care. ...[more]
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Project description:BackgroundPatients discharged from the hospital on outpatient parenteral antimicrobial therapy (OPAT) require close monitoring, including weekly blood tests and an early posthospital follow-up visit. However, because patients often receive OPAT in a separate healthcare system from where they received inpatient care, the OPAT plan often fails, with less than 75% of OPAT patients receiving the recommended laboratory monitoring. We sought to determine whether changing our inpatient OPAT documentation method would improve postdischarge care.MethodsAs a quality improvement initiative, we conducted 2 Plan-Do-Study-Act interventions on our OPAT documentation. Our first intervention was to create a standardized OPAT Progress Note, and our second was to turn that note into a SmartForm (Epic) with discrete fields for the key information. We examined the effects of these changes on the rate of completion of recommended laboratory monitoring, attendance at outpatient follow-up visits, and 30-day readmission rates.ResultsChanging our documentation to a standardized Progress Note and then to a SmartForm with discrete fields led to an increase in the proportion of patients with a serum creatinine checked within 10 days of discharge (from 63% to 71% to 73%) and who attended an infectious disease clinic visit within 3 weeks of discharge (from 21% to 36% to 47%). However, the rate of readmissions for OPAT-related problems did not change, nor did a composite outcome of 30-day mortality/unplanned readmission.ConclusionsChanges in how and where care plans are documented in the inpatient medical record can have significant effects on patient care outcomes after discharge.
| S-EPMC9251666 | biostudies-literature
Project description:Outpatient parenteral antimicrobial therapy (OPAT) is overused in cases where highly bioavailable oral alternatives would be equally effective. However, the scope of OPAT use for children nationwide is poorly understood. Our objective was to characterize OPAT use and clinical outcomes for a large population of pediatric Medicaid enrollees treated with OPAT.We analyzed the Truven MarketScan Medicaid claims database between 2009 and 2012. An OPAT episode was identified by capturing children with claims data indicating home infusion therapy for an intravenous antimicrobial. We characterized OPAT use by describing patient demographics, diagnoses, and antimicrobials prescribed. We categorized an antimicrobial as highly bioavailable if ?80% systemic exposure was expected from the peroral dose. We also determined the percentage of OPAT recipients in whom a follow-up healthcare encounter occurred during the OPAT episode in either the emergency department or as a hospital admission. We reviewed the primary diagnoses associated with these healthcare encounters to determine whether it was related to OPAT.We identified 3433 OPAT episodes in 2687 patients. A total of 4774 antimicrobials were prescribed during these episodes. Ceftriaxone and vancomycin were the most commonly prescribed antimicrobials. Highly bioavailable antimicrobials accounted for 34% of antimicrobials used for OPAT. An emergency department visit or hospital admission occurred during 38% of OPAT episodes, among which 61% were OPAT-related.The high rate of medical encounters associated with OPAT in this cohort and the common prescribing of highly bioavailable antimicrobials underscore the opportunities for antimicrobial stewardship of pediatric OPAT.
| S-EPMC5907854 | biostudies-other
Project description:BackgroundAlthough widely accepted for adults, the safety of outpatient parenteral antimicrobial therapy (OPAT) in very old patients has not been examined.MethodsNonagenarians (age ≥90 years) discharged from the hospital on OPAT over a 5-year period were identified from the Cleveland Clinic OPAT Registry. Three matched controls (<90 years) were selected for each nonagenarian. Times to OPAT-related emergency department (ED) visit and OPAT-related readmission were compared across the 2 groups in multivariable subdistribution proportional hazards competing risks regression models. Incidence of adverse drug events and vascular access complications were compared using negative binomial regression.ResultsOf 126 nonagenarians and 378 controls, 7 were excluded for various reasons. Among the remaining 497 subjects, 306 (62%) were male, 311 (63%) were treated for cardiovascular or osteoarticular infections, and 363 (73%) were discharged to a residential health care facility. The mean (SD) ages of nonagenarians and controls were 92 (2) and 62 (16) years, respectively. Compared with matched controls, being a nonagenarian was not associated with increased risk of OPAT-related ED visit (hazard ratio [HR], 0.77; 95% CI, 0.33-1.80; P = .55), OPAT-related readmission (HR, 0.78; 95% CI, 0.28-2.16; P = .63), adverse drug event from OPAT medications (incidence rate ratio [IRR], 1.00; 95% CI, 0.43-2.17; P = .99), or vascular access complications (IRR, 0.66; 95% CI, 0.27-1.51; P = .32). Nonagenarians had a higher risk of death overall (HR, 2.64; 95% CI, 1.52-4.58; P < .001), but deaths were not from OPAT complications.ConclusionsCompared with younger patients, OPAT in nonagenarians is not associated with higher risk of OPAT-related complications. OPAT can be provided as safely to nonagenarians as to younger patients.
| S-EPMC7532659 | biostudies-literature
Project description:A cluster of cefepime-induced neutropenia (CIN) was identified from June 2017 to May 2018 in a regional outpatient parenteral antimicrobial therapy population. Our data suggest prolonged courses of cefepime (≥2 weeks), administered by rapid intravenous push, were associated with a higher risk of CIN.
| S-EPMC6637276 | biostudies-literature
Project description:BackgroundPatients increasingly receive home-based outpatient parenteral antimicrobial therapy (OPAT). Understanding which patients might be at higher risk of complications is critical in effectively triaging resources upon and after hospital discharge.MethodsA prospective cohort of patients discharged from 1 of 2 academic medical centers in Baltimore, Maryland, between March 2015 and December 2018 were consented and randomly divided into derivation and validation cohorts for development of a risk score for adverse OPAT outcomes. Data from the derivation cohort with the primary outcome of a serious adverse outcome (infection relapse, serious adverse drug event, serious catheter complication, readmission, or death) were analyzed to derive the risk score equation using logistic regression, which was then validated in the validation cohort for performance of predicting a serious adverse outcome.ResultsOf 664 patients in the total cohort, half (332) experienced a serious adverse outcome. The model predicting having a serious adverse outcome included type of catheter, time on OPAT, using a catheter for chemotherapy, using a catheter for home parenteral nutrition, being treated for septic arthritis, being on vancomycin, being treated for Enterococcus, being treated for a fungal infection, and being treated empirically. A score??2 on the serious adverse outcome score had a 94.0% and 90.9% sensitivity for having a serious adverse outcome in the derivation and validation cohorts, respectively.ConclusionsA risk score can be implemented to detect who may be at high risk of serious adverse outcomes, but all patients on OPAT may require monitoring to prevent or detect adverse events.
| S-EPMC7270705 | biostudies-literature
Project description:BackgroundOutpatient parenteral antimicrobial therapy (OPAT) prescribing has increased along with the trend toward early discharge of hospitalized patients who have infections. There is limited literature that assesses unplanned hospitalizations during OPAT. This study aims to elucidate the predictors of unplanned hospitalization in OPAT patients after discharge from acute-care facilities within Carolinas HealthCare System (CHS). Understanding these predictors may inform future interventions to improve treatment efficacy and patient outcomes.MethodsThe study cohort included hospitalized patients aged >19 years who initiated OPAT in an acute-care facility within CHS in 2014-2015. Patients who had OPAT prescribed at an ambulatory-care facility were excluded. The primary outcome was unplanned hospitalization anytime during the at-risk time from discharge through 90 days.ResultsThe unplanned hospitalization rate for the cohort was 18.5%. In adjusted analysis, having OPAT delivered at a skilled nursing facility was associated with a 46% (incident risk ratio = 1.46; 95% confidence interval = 1.04-2.06) increased risk of an unplanned hospitalization compared with patients receiving OPAT at home after adjustment for demographics, comorbidities, indication, treatment duration, and antimicrobial prescribed. Infusion, dialysis, and rehabilitation centers had the lowest rates of unplanned hospitalizations.ConclusionsThese results suggest that the location of OPAT delivery is associated with unplanned hospitalizations and that older patients need additional support during OPAT.
| S-EPMC5473366 | biostudies-literature
Project description:BACKGROUND:While outpatient parenteral antimicrobial therapy (OPAT) is generally considered safe, patients are at risk for complications and thus require close monitoring. The purpose of this study is to determine how OPAT programs are structured and how United States-based infectious diseases (ID) physicians perceive barriers to safe OPAT care. METHODS:We queried members of the Emerging Infections Network (EIN) between November and December 2018 about practice patterns and barriers to providing OPAT. RESULTS:672 members of the EIN (50%) responded to the survey. Seventy-five percent of respondents were actively involved in OPAT, although only 37% of respondents reported ID consultation was mandatory for OPAT. The most common location for OPAT care was at home with home-health support, followed by post-acute-care facilities. Outpatient and inpatient ID physicians were identified as being responsible for monitoring laboratory results (73% and 54% of respondents, respectively), but only 36% had a formal OPAT program. The majority of respondents reported a lack of support in data analysis (80%), information technology (66%), financial assistance (65%), and administrative assistance (60%). Perceived amount of support did not differ significantly across employment models. Inability to access laboratory results in a timely manner, lack of leadership awareness of OPAT value, and failure to communicate with other providers administering OPAT were reported as the most challenging aspects of OPAT care. CONCLUSION:ID providers are highly involved in OPAT, but only a third of respondents have a dedicated OPAT program. Lack of financial and institutional support are perceived as significant barriers to providing safe OPAT care.
| S-EPMC6765349 | biostudies-other
Project description:Abstract Background Outpatient parenteral antimicrobial therapy (OPAT) has shifted from being a novel concept to an accepted model of care for some conditions. However, concerns remain that have limited its broader roll out: the use of daily ceftriaxone regarding its efficacy and impact on antibiotic resistance, intravenous (IV) catheter complications, risk of treating an acute infection directly from the emergency room (ER), and concern that OPAT has shifted the burden of cost from hospitals to patients. We aimed to address these questions with the first randomized controlled trial (RCT) of OPAT efficacy in children: comparing OPAT directly from the ER using IV ceftriaxone with hospitalization using IV flucloxacillin for moderate/severe cellulitis. Methods The RCT was set at a tertiary pediatric hospital from January 2015 to June 2017. Inclusion criteria: children 6 months–18 years with uncomplicated cellulitis needing IV antibiotics. Patients were randomized to ceftriaxone via OPAT at home or flucloxacillin in hospital, using a peripheral catheter. Primary outcome: treatment failure within 48 hours due to lack of improvement or adverse events. Secondary outcomes: complications, readmission, acquisition of nasal and stool-resistant bacteria and costs. Results A total of 188 children were randomized: 93 to OPAT and 95 to hospital. In the intention-to-treat population, there was no difference in treatment failure between OPAT and hospital (2% vs. 7%, P = 0.09). Per protocol, OPAT had less failure (1% vs. 8%, P = 0.03). There was no increased acquisition of MRSA, ESBL, VRE or C. difficile with OPAT compared with in hospital at 1 week or 3 months (P > 0.05). Complication rates were similar (6% vs. 7%, P = 0.78), and repeat IV catheterization was less with OPAT (3% vs. 15%, P = 0.002). Readmission was 1% on OPAT. The cost to families was significantly less with OPAT (AUD213 vs. AUD733, P < 0.001). Conclusion Despite the acuity of the infection, OPAT with IV ceftriaxone for moderate/severe cellulitis in children is efficacious with complications and readmissions no different from hospital care with IV flucloxacillin. Short-term ceftriaxone use in healthy children on OPAT is not associated with increased acquisition of resistant organisms, and has reduced burden of costs to families (ClinicalTrials.gov NCT02334124). Disclosures All authors: No reported disclosures.
| S-EPMC6254697 | biostudies-literature
Project description:BackgroundThere has been little detailed systematic consideration of the delivery, setting and outcomes of paediatric Outpatient Parenteral Antimicrobial Therapy (OPAT), although individual studies report that it is a safe and effective treatment.ObjectiveThis scoping review aimed to examine what is known about the delivery, settings and outcomes of paediatric OPAT and to identify key knowledge deficits.DesignA scoping review using Arksey and O'Malley's framework was undertaken.Data sourcesKeywords were identified and used to search MEDLINE and CINAHL.Study appraisal methodsPrimary research studies were included if samples comprised children and young people 21 or under, who had received OPAT at home or in a day treatment centre. The Mixed Methods Appraisal Tool was used to review the methodological quality of the studies MAIN FINDINGS: From a preliminary pool of 157 articles, 51 papers were selected for full review. 19 studies fitted the inclusion criteria. Factors influencing delivery of OPAT were diverse and included child's condition, home environment, child-related factors, parental compliance, training and monitoring. There is little consensus as to what constitutes success of and adverse events in OPAT.ConclusionsFuture studies need to clearly define and use success indicators and adverse events in order to provide evidence that paediatric OPAT is safe and effective.ImplicationsConsensus outcomes that include child and parent perspectives need to be developed to allow a clearer appreciation of a successful paediatric OPAT service.
| S-EPMC6252693 | biostudies-literature
Project description:Background:To better monitor patients on outpatient parenteral antimicrobial therapy (OPAT), we need an improved understanding of risk factors for and timing of OPAT-associated adverse drug events (ADEs). Methods:We analyzed a prospective cohort of patients on OPAT discharged from 2 academic medical centers. Patients underwent chart abstraction and a telephone survey. Multivariable analyses estimated adjusted incident rate ratios (aIRR) between clinical and demographic risk factors and clinician-determined clinically significant ADEs. Descriptive data were used to present patient-reported ADEs. Results:Of 339 patients enrolled in the study, 18.0% experienced an ADE (N = 65), of which 49 were significant (14.5%, 2.24/1000 home-OPAT days). Patients with longer courses of therapy had lower rates of ADEs compared with patients treated for 0-13 days (14-27 days: aIRR, 0.44; 95% confidence interval [CI], 0.20-0.99; at least 28 days: aIRR, 0.11; 95% CI, 0.056-0.21). Risk factors for ADEs included female gender and receipt of daptomycin or vancomycin, while treatment for uncomplicated bacteremia and empiric treatment were associated with lower rates of ADEs. Conclusions:OPAT-related ADEs were common and often occurred within 2 weeks of hospital discharge. Patients on OPAT should be monitored more closely for ADEs, including clinical assessment and laboratory monitoring, especially within the first weeks after hospital discharge and particularly among women and patients who receive vancomycin.
| S-EPMC5848264 | biostudies-literature