Transition from Hospital to Home

Outpatient Parenteral Antimicrobial Therapy (OPAT)

Karri A. Bauer, PharmD, BCPSSpecialty 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

Key Elements

ID Specialist

Primary care

NurseCase manager

ID Pharmacist

Patient

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

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, BCPSJessica 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/AmbiguousTotal

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 60Combination therapy 31Median antibiotic duration, days 21 (14-42)

*Top 5 diagnoses presentedData presented as % unless otherwise stated

ResultsOrganism %

Polymicrobial 33Culture negative 26MRSA* 6MSSA 5Gram 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 0Antibiotic-related complication--Intolerance*--Compatibility--Allergy

200

Change in antibiotic therapy 4Post discharge antibiotic additions 12Transition to oral therapy--Osteomyelitis

95

Clinical cure 80Infection-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=20Intraabdominal 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”

Transition from Hospital to Home

Outpatient Parenteral Antimicrobial Therapy (OPAT)

Karri A. Bauer, PharmD, BCPSSpecialty Practice Pharmacist Infectious Diseases

January 16, 2013