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The OPAT experience in Leicester Amandip Sahota

The OPAT experience in Leicester Amandip Sahota. READY, STEADY, GO…? The challenge of creating a pilot OPAT service in Leicester. Amandip Sahota ST7 Infectious Diseases, University Hospitals of Leicester NHS Trust Specialty Registrar Lead for OPAT

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The OPAT experience in Leicester Amandip Sahota

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  1. The OPAT experience in Leicester Amandip Sahota

  2. READY, STEADY,GO…?The challenge of creating a pilot OPAT service in Leicester Amandip Sahota ST7 Infectious Diseases, University Hospitals of Leicester NHS Trust Specialty Registrar Lead for OPAT Clinical Leadership Fellow, NHS Leadership Academy

  3. Where we’re at, and how we got there • What currently happens at UHL • Creating our Pilot OPAT – a collaboration of minds • Who gave us the money? • Early challenges and changes • Starting the service • Sustainability – Our vision and planning for the future

  4. Who we are • UHL – 3 sites across Leicester • ≈1700 bed, ≈1million people served • Leicestershire’s only A&E (LRI) • Tertiary cardio-respiratory centre (GGH) • Urology / Renal / Renal translant (LGH) • Haem-Onc (inc. BMT) / General surgery / O&G / Vascular / T&O / HPB / Paediatrics • ID – Purpose built unit, 18 beds , 10 negative pressure rooms

  5. Community IV delivery – the current set-up In-patients • Vascular access service • Dedicated team • Mon-Fri, working hours, across 2/3 sites • PICC, Mid-lines • Abx / Chemo / TPN • 24-72 hr turnaround time • Priority basis

  6. Respiratory CF, bronchiectasis Haem-Onc Diabetic foot infections (MDT/Micro led) Day-case medical ward Administer infusions (Rheum / Gastro); observation post liver biopsy, etc. Used ad-hoc for giving IV antimicrobials (up to bd) Disadvantages often gets used as Medical Ward with  bed pressures No Infection Specialist input Patient must be ambulatory Small services led by individual departments:

  7. Intermediate Care Team (ICT) • Group of community nurses funded by PCT/CCG • Good, competent service, additional healthcare input • Can be accessed by all departments and GPs • Essentially – DNs being asked to give IVs • Butfragmented service: • IV service limited by lack of staffing / mixed skill-set • 5 days / week only • No specific Infection Specialist input • No clear lines of referral for problems / monitoring • Patients have fallen through holes in system • District Nurses

  8. “Cellulitis pathway” Prevent admission (GPs / A&E) Early discharge (AMU) 4-5/7 Teicoplanin (if no response to PO) Use ICT / DNs Disadvantages Dependent on availability of nurses No Infection Specialist input Do they need IVs at all?? AMU – “Bed Bureau Clinic” GP referral system for ambulatory patients Prevent admission Cellulitis / ESBL-UTI Can give 1st dose Abx then discharge (with cannula) F/U with ICT / DNs Disadvantages As for Cellulitis pathway Out-patients

  9. UHL Data for 2011 - bed days saved for patients being discharged on IV antibiotics Potential for expansion, including more departments, with dedicated OPAT service

  10. “We Need OPAT!” • ID/Micro • Advantages of OPAT at UHL recognised for years • Wiselka MJ, Nicholson KG. Outpatient Parenteral Antimicrobial Therapy: Experience in a Large Teaching Hospital. J. Infect. (1997), Jul; 35(1):73-6. • Difficulty convincing “the right people” • Acute Medicine • Increased demand on AMU to accept/discharge cellulitis / ESBL-UTI from community • Unprecedented perennial bed pressure • Limited infra-structure to manage • Vascular Access • Increasing demand on service - lines needed to get patients home quickly • Need for more staff – planned toput in own funding bid

  11. The Catalyst • Head of Operations • Working jointly in Acute Care Division • Frustrations • Recognised many pts that could have IVs at home • Lack of community nurse capacity • GP complaint letter • Unable to get patients onto community IV service • Request for hospital to offer consistent service for IV therapy • Became aware of existence of OPAT model

  12. Request sent across departments to gauge interest for a community-based IV delivery service • ID • Micro • Acute Care • Vascular access • GPs / ICT • Bid put in for funding from Transformation Fund

  13. The Transformation Fund • Funding programme provided by PCT/CCG • Enable service transformation / improvement • Main drivers • Improving the quality of patient care / experience • Reducing on-going costs • All organisations in health community can bid; panel decision • Provides • “Pump Priming” – resources to get a service/project off the ground • “Double Running Costs” – money to run existing service/pathway alongside new; old taken down when new fully established • Non-recurrent • Available for 1 financial year only • Service must be affordable / sustainable for subsequent years

  14. Is it available elsewhere? • Operating Framework for NHS 2011/12: • “All PCTs should set aside 2% of income to invest non-recurrently in supporting service transformation” • All health organisations should have access • May differ between PCTs / CCGs

  15. The Application • “Scheme Overview” • Pilot service for 2 models of delivering IV in the community • Nurse-administered / self-administered at home • Use of community hospitals as “infusion centres” • “Strategic Context” • Does it meet national / regional priorities as set out by NHS Operating Framework / CCG √ • Does it meet QIPP agenda (Quality / Innovation / Productivity / Prevention) √

  16. “Key Performance Indicators” • Reduction in admissions • Reduction in length of stay / bed days • Care closer to home • ↑ patient satisfaction • Implementation • Creation of OPAT team (Community IV Therapy team) • Regular meetings: CIVTT, UHL, CCG, GPs • “Engagement” • Advertise to hospital specialties (ID / Diabetes / MSK) • Advertise to GPs based near to chosen community hospital • “Exit strategy” • Prove that pilot service is more effective than current approach • Continue service via contracting process / business case to CCG

  17. Scheme Timeline – 2012/13(Application placed Oct 2011)

  18. Financial Plan – monthly costs • Staffing (per month) • OPAT (ID/Micro) Consultant: 0.5 = £5,000 • Specialist pharmacist (Band 8A): 0.5 = £2,115 • Nurse Team Leader (Band 7): 1 = £3,661 • Community nurses (Band 6): 6 = £26,729 • Admin support (Band 4): 1 = £2,028 • Non-staff • Recruitment • Travel • Other capital ~ £10,000 (over 1 year) • Drugs / consumables • Initially from Fund budget • Eventually from continuation bids / CCG • VAT saving (home delivery)

  19. Show me the money! Granted £358,000 (May 2012)

  20. The Community IV Therapy Team (CIVTT) • Head of Operations / Project Manager • Project Lead / Co-ordinator • Infectious Diseases Consultant Lead • Microbiology Consultant Lead • OPAT Consultant (Locum) • Specialty Registrar Lead • Antimicrobial Pharmacist • Vascular Access Lead • Community representatives (Leicester Partnership Trust) - Nursing and GPs • (Hospital nursing division leads / matrons) • Meeting fortnightly since May 2012 • Recruitment occurring along the way • Trying to work within timeline(!)

  21. Early challenges & solutions CHALLENGE • RECRUITMENT: • Community nurses initially to be recruited full-time and work in-conjunction with existing ICT team • Aim to expand ICT service; optimise staffing when OPAT workload low • Unable to recruit enough nurses in time • ICT no longer involved SOLUTION • Community nursing tendered out to private companies • Good experience in other trusts/depts. (Healthcare At Home) • Contract won by BUPA – already a National Framework Provider for E. Midlands • OPAT experienced, extensive service with clear governance • Arrange home delivery of drugs • Can teach self-admin of IVs • Pay-as-you-use system • £90 per visit (~£120 with overheads) – works out as similar costs

  22. CHALLENGE • Infusion centre model at 3 sites unsustainable • Not enough community nurses at each site • No guarantee of rooms • Confusion between role of ICT, OPAT & existing “Cellulitis pathway” • 2 GP services running in parallel ?overlap ?may cause confusion if pilot not successful 4) Difficulty recruiting OPAT specialist nurse as Project Lead / Co-ordinator SOLUTION • Infusion centre model abandoned – concentration on IV delivery at home • Allow GPs to decide which service to refer to prevent admission • Continue Cellulitis Pathway • Not to be incorporated into OPAT 4) Recruitment of Ex-site lead with managerial and service development experience • Amalgamation of Band 7 nurse and Admin posts

  23. CHALLENGE 5) Delays in commencing service; did not start in Aug as planned • Recruitment delay • Acquisition of database (our IT!) • Confirming GP referral pathway • Many IT systems to consider/amalgamate for service; could get confusing • OPAT database • ICE (discharge summaries) • Community / GP IT system • Introduction of e-prescribing! SOLUTION • All delays being dealt with • Start date planned for October • BUPA nurses ready to go • OPAT Consultant will be employed full-time for 6 months (equivalent cost) 6) Still a work in progress!

  24. Current work & progress • Confirming referral pathways • Creation of consensus treatment guidelines between ID / Micro (difficult cases) • Planning clinic space/time/MDT composition for weekly clinic and virtual round • Clarifying prescription pathway with BUPA

  25. Producing referral proformas / hand-held records (in conjunction with BUPA requirements) • Emergency contacts / re-admission pathways • OPAT database acquired (Pharma-Mix) – learn how to use it! • Communications Team • Branding – Logo / Catchprase • Advertising service within hospital and to GPs

  26. On your marks, get set… • OPAT service (hopefully!) starts on 01/10/12 • Lots of interest from many departments • In-patient cases already identified • Trial with 1-2 patients initially • GP referral process may be more complex

  27. Our future vision… • Draft Business Case produced for Commissioners 2013-14; requesting ~£500,000 • Deadline: end of Sep; decision in up to 6/12 • Taken elements from “Business Case Toolkit” (inc. published data on success of OPAT) • Utilises estimated projections of service use / cost savings from pilot scheme (1 year): • Total no patients: 707 • Total daily cost of IV delivery (£90/day): £800,000 • Overheads (inc. salaries): £200,000 • Bed days saved: 8820 = £2.6 million (£300 / bed day) • 24 “empty” beds each day

  28. Emphasis will be on reduction in bed-days (and resultant saving of HCG income) • Aiming to produce local OPAT tariff • Also – patient satisfaction surveys • Cost savings from patient experience CQUINs • Important to help gain FT status • If rejected by Commissioners (as already saving trust money) • Present to individual departments; request funding from their budgets

  29. Fellow of NHS Leadership Academy • Academic and experiential modules on clinical leadership and service improvement • Manchester Business School / Kings Fund • PGC • Pilot OPAT – service development project for Fellowship

  30. Summary • Be creative with funding / ask around • Find a passionate, forward-thinking manager who knows where the money is! • Work together with interested parties • Business cases are daunting – a pilot may help to boost your case • Leave plenty of time for bids, and bid to plenty • Use the patient OPAT experience to sell your case

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