Hospital Discharge and Outpatient Parenteral Antimicrobial Therapy (OPAT)

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Hospital Discharge and Outpatient Parenteral
Antimicrobial Therapy (OPAT)

• Sandy Nelson, M.D.

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What is OPAT?

• Hospital stays have become shorter, and patients
  often do not complete their antibiotic courses as
  inpatients.
• Some patients will continue on IV antibiotic
  therapy after hospital discharge
• OPAT Outpatient Parenteral Antimicrobial
  Therapy
• Yet the antimicrobial treatment still carries
  risks
• Drug related adverse effects
• Superinfections (e.g. C difficile)
• PICC line complications (thrombosis, infection,
  occlusion)
• Antibiotic intolerances are common
• Points of transition are error-prone
• Electronic and personal communications minimize
  errors

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What is OPAT?

• At MGH, OPAT is a system that assists ID
  physicians in caring for their outpatients on IV
  antibiotic therapy
• OPAT does not replace the care of ID and other
  physicians, but facilitates it
• Active lab tracking and communication of abnormal
  results
• Communication with home infusion services and
  VNAs
• Prompt access to care for problems (NP)
• Proactive followup coordination
• OPAT cares for approximately 700 patients yearly

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Preparing for ID signoff

• Decide on antimicrobial plan
• Determine what care providers will be supervising
  antimicrobials after hospital discharge ID (with
  OPAT) or other
• Considerations (see suggestions in handout and
  online)
• duration of therapy, toxicity of antibiotic
  regimen, risk of antimicrobial failure,
  comorbidities, involvement of primary or
  specialist team
• Followup in ID is required if OPAT system involved

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Preparing for ID signoff

• First, ask Karen Manning to schedule the followup
  ID appointment (kmanning3_at_partners.org)
• Appointment will be scheduled preferentially with
  MGH fellow or any provider who can provide
  inpatient-to-outpatient continuity
• In your appointment request, please also include
  the desired time frame for the appointment and
  the anticipated antibiotic stop date
• Please note the ideal followup appointment is
  usually 1-2 weeks after hospital discharge (not
  at the end of a six week course)
• Some patients may be scheduled to be seen by one
  of our clinic NPs

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ID Discharge Form

• Any patient being discharged on IV antibiotic
  therapy needs an ID discharge note in the chart
  and in the electronic record
• Templates under Fellow Resources on ID Intranet
• Two forms, depending on whether ID/OPAT will be
  following the patient after discharge
• Be succinct but relay information relevant for
  decision making, particularly if you will not be
  following the patient after discharge
• Include laboratory monitoring (and goal drug
  levels if relevant). Suggestions for laboratory
  monitoring are included in your orientation
  handouts and online. Be succinct avoid
  requesting a BMP if all you want is a BUN and
  creatinine
• Include studies that are still pending and need
  followup
• Avoid cutting/pasting

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Communicating the Plan

• Post the note electronically in LMR/CAS
• Print the note and put into the hospital chart
• Communicate the plan verbally and electronically
  to the primary inpatient team and case manager
• Discuss the plan with the patient. If possible
  provide the patient with your team card
  including the appointment information
• Email the note to the outpatient team (ID fellow
  and outpatient attending, and kmanning3_at_partners.o
  rg)

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Special Considerations

• OPAT does not take over antimicrobial supervision
  until after hospital discharge
• If there are important pending results or
  monitoring after ID signoff but before hospital
  discharge, please ensure primary team is aware to
  follow, alternatively keep a less active list
  to check on periodically
• Patients going to SNF or rehab
• OPAT will help with the care of these patients if
  otherwise appropriate for OPAT care
• Patients going home on oral antibiotics
• With rare exceptions (e.g. high risk patients on
  linezolid) OPAT will not monitor patients going
  home on only oral meds

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Special Considerations

• Patients who do not otherwise need ID followup
• OPAT will only monitor patients who will be seen
  in ID followup
• Fellow does not have clinic availability in the
  time frame in which the patient needs to be seen
• Discuss with your preceptor, move other patients,
  utilize NPs at a time you are in clinic
• Avoid conflicts over who will supervise
  antimicrobials
• Involve your attending if you sense any issues
• Please page or email me with any questions
  (sbnelson_at_partners.org)