Hywel Dda University Health Board antimicrobial pharmacist input into implementation, clinical and outcome monitoring of outpatient parenteral antimicrobial therapy (OPAT)
Authors: Robinson R , Kennerley Z 
Published: November 2022

Abstract

Introduction
The finance team highlighted an increased spend on antibiotics used by the Acute Response Teams (ART) across Hywel Dda University Health Board (HDUHB). Antimicrobial pharmacists (AMPs) investigated the antibiotics issued to ART and their stock lists. A wide variety of antimicrobials including broad-spectrum, high-cost, and restricted antimicrobials were being prescribed as OPAT. A multi-disciplinary team (MDT) team was set up to implement and deliver good practice recommendations 1alongside providing care closer to home2.

Aim
To assess the number of patients accessing treatment through the service, evaluate uptake and adherence to OPAT guidelines, identify whether AMPs were having an impact on the service and evaluate patient outcomes.

Methods
The MDT included consultant microbiologists, AMPs, ART & infection control nurses, consultant anaesthetist and orthogeriatrician. A Standard Operating Procedure and guidelines were implemented. A data collection form was completed by nurses for each patient and monitored by AMPs. The data underwent descriptive statistical analysis. Ethical approval was not required for this service evaluation.

Results
The service saved 1685 bed days across two counties (Ceredigion and Carmarthenshire) over a 6-month period. Patients were treated with a variety of antimicrobial agents including ceftriaxone, ertapenem, teicoplanin and ceftazidime. Patients receiving OPAT received a clinical check by an AMP for clinical appropriateness, therapeutic drug monitoring and dosing according to blood results. AMPs undertook over 200 reviews, making 27 interventions, including advice on monitoring, when to take levels, bloods, or antibiotic choice. There were only 6 interventions on choice of antibiotic to include more stewardship wise options or options for reduced dosing frequency to increase the capacity of ART, highlighting good uptake and adherence to the guidelines. Outcome forms were collected for all 31 patients in Ceredigion 81% (26 patients) were cured of their infection. In 6% the treatment aim was not attained and required readmission, 6% had no information supplied, 3% were reviewed in clinic and switched to oral and 3% required readmission due to unrelated event.

Discussion/Conclusion
Collaboration within the MDT has led to an improvement in practice while delivering OPAT in HDUHB. Development of a working relationship between the ART nurses and AMPs has led to improved patient safety and monitoring whilst offering patients the opportunity to receive care closer to home. The availability of AMPs to provide answers and guidance in a timely manner to ART has made treatment in the community easier and safer. The guidelines launched at the beginning of the COVID-19 pandemic in an effort to reduce the number of patients occupying beds in secondary care however, this led to a reduced ability for education to be delivered on the guidelines compared to normal practice. Further work is needed to involve the Pembrokeshire team in the process and to increase awareness of the guidelines in both primary and secondary care. Discussions are also in place to investigate whether elastomeric devices offer better antimicrobial stewardship wise treatment options. The main limitation of this study is the inability to follow up long term outcomes.

References
1. Chapman A., Patel S., Horner C., Gilchrist M. and Seaton A. Outpatient parenteral antimicrobial therapy: updated recommendations from the UK. Journal of Antimicrobial Chemotherapy, Volume 74, Issue 11, November 2019, Pages 3125–3127, https://doi.org/10.1093/jac/dkz343
2. Welsh Government. A Healthier Wales: our Plan for Health and Social Care. 2021 A Healthier Wales (gov.wales)