Although I didn't know it at the time, in 2015 I was fortunate enough to land my ‘dream job’: setting up an outpatient parenteral antimicrobial therapy (OPAT) service along with two medical consultants at Wythenshawe Hospital, a large tertiary hospital in Manchester. The project was initially a 6-month pilot to see whether there was a place for this type of service in the organisation, so the pressure was on from the beginning to ensure that we did things right! The purpose of OPAT is to treat patients with infections as close to their own home as possible and, although there are various ways in which treatments can be offered, the majority of OPAT patients require intravenous (IV) therapy and therefore IV access.
The vascular access options available to our OPAT patients in 2015 were limited to either peripheral cannula or peripherally inserted central catheters (PICC), which were inserted by the interventional radiology (IR) department. Although, in theory, these choices seemed perfectly acceptable, the reality was that many medications prescribed by the OPAT service required central venous access (due to pH, osmolarity, requirement for frequent blood sampling, duration of treatment etc) and, in a large tertiary hospital with multiple specialist services, the demand for PICC insertions was high. This invariably resulted in lengthy delays for PICC insertions, which had implications for our new service.
These delays affected the OPAT service in a number of ways. For inpatients, it could delay their discharge from the acute care setting to home, resulting in an increased risk of exposure to hospital-acquired infections and prolonged separation from home/work/loved ones. For OPAT patients referred from the community setting, the delay in PICC placement could mean a delay in starting treatment.
Because neither of these scenarios seemed acceptable, I asked myself the following questions: What was already in place? What works and, perhaps more importantly, what does not work? What is the quickest and most cost-effective solution and, finally, what does the guidance say?
The answer to these questions led me to the conclusion that I needed to learn to insert PICCs myself, so I set about developing a service that was responsive to the needs of the OPAT patient. As the only nurse in our new service I felt it was my duty, and responsibility, to identify what the OPAT patient needed and to safely fill the gaps. From previous roles I was aware that learning a new skill was only one part of the solution—I needed to ensure that I had robust guidance, policies and protocols in place to underpin this extended role and to ensure/demonstrate governance.
Reducing risks
The hospital already used BARD vascular access devices (VADs) and I was fortunate enough to be able to access the free support and training package the company offered, so I set about developing a robust vascular access service for the OPAT patients. A service that did not rely on another team helped reduce treatment and discharge delays and strengthened the links between the OPAT nurse and the OPAT patient. It also significantly increased my job satisfaction because the solution to the problem was something that I could influence: I could be the change that the service needed—and, although this can be a weighty responsibility, it was also extremely rewarding.
‘This collaborative way of working has been a great example of multidisciplinary teams working together to pool resources and expertise for the benefit of the patient, reducing waiting times and increasing choice’
Another huge advantage of developing the vascular access side of the OPAT service was that I could ensure all the recommendations advocated in the literature, such as epic3 (Loveday et al, 2014) and the Royal College of Nursing (2016)Standards for Infusion Therapy, could be implemented and incorporated into the standard practices of the OPAT service from the very beginning. I had the opportunity to design a service that was patient focused and nurse led, and to embed practices underpinned by the literature. All these qualities were, and still are, extremely important to me, especially as the service quickly started to grow. By 6 months the organisation acknowledged that there was a place for OPAT and the service was made substantive, with support to expand the team. Since 2015, the team has exponentially grown from one nurse and two unpaid medical consultants to five nurses, one antimicrobial pharmacist, one admin assistant and 0.2 whole-time equivalent medical cover.
Working in the NHS it is essential to be dynamic. I am always looking for an opportunity to improve and diversify the OPAT service and its ability to meet the ever-changing needs of the patient and organisation. Over the past few years this has included the introduction of chest X-ray free/ECG-guided PICC insertions, which has reduced radiation exposure for patients, reduced treatment times further and improved the OPAT pathway considerably. Other innovations I have led on include the introduction of elastomeric devices for delivering antimicrobials in the outpatient setting and developing a comprehensive support and training package for patients and/or next of kin to learn how to self-administer IV therapies at home.
More recently, I was involved in developing and managing a COVID-19 ‘virtual ward’ to facilitate the early supported discharges of COVID-19-positive patients from the acute setting to home and, because of the expertise of the OPAT team in managing complex patients in the community, we were perfectly placed to adapt our skills to this emerging health crisis.
Benchmarking
From the very beginning I have always thought it vital to audit and monitor outcomes, whether that is how the patient has responded to their OPAT treatment or recording the incidence of line complications. Regardless of how busy the service has been, a continuous cycle of audit has always been on the agenda; it allows me to benchmark our practice against the published literature and provides reassurance to the hospital and patients that they are in safe hands. It also gives me the opportunity to showcase the team and OPAT service as the beacon of exemplary practice that it is.
From a clinical point of view, I have always thought that it is important to ‘know the journey’ of the patient and their VAD, from insertion of the device to removal. A VAD complication can happen at any point during this time and, in my experience, the majority of VAD issues tend to happen long after insertion. Therefore, I think that it is essential to know where your devices are, who is providing care (and that the care is evidence based) and that there is some form of active surveillance.
As a practitioner, if you know the true infection/complication rate associated with your devices, then you can target your resources to address them. In a small and dedicated team this is something that can be done—I think that this has been part of the success of the service and has definitely built the OPAT team at Wythenshawe a reputation as a valuable resource for the wider hospital to call on when managing VADs.
In 2019, we were approached by the IR department to support their team to provide a more robust and sustainable vascular access service for the wider hospital. This was my opportunity to instil the wrap-around service that the OPAT team provides to its patients to the wider hospital population. This collaborative way of working has been a great example of multidisciplinary teams working together to pool resources and expertise for the benefit of the patient, and together we have reduced waiting times, increased choice and access to VADs and provided valuable support to ward teams across the hospital.
The involvement of the OPAT team in providing a vascular access service for the hospital has facilitated bedside placement, and ECG/chest X-ray-free PICC insertions across the hospital site, leading to improved access to care. We have improved knowledge surrounding complications associated with VADs, and subsequently formal reporting, and have introduced a VAD link worker role to improve theory–practice gaps. All patients referred for a VAD now receive a standardised, thorough assessment that promotes informed consent and appropriate device selection, taking into account the needs of the patient, their lifestyle and proposed treatment plan.
I think I have always been a bit of a ‘number cruncher’ and this has allowed me to critique the statistics for our service, which in turn allows me to benchmark our practice against the literature and similar services. For example, I am very proud to say that the OPAT service at Wythenshawe Hospital has ‘saved’ in excess of 20 000 bed days since 2015, has a VAD infection rate of 0.04 per 1000 catheter days and has a team accuracy rate for inserting ECG-guided PICCs of 99.4%.
I have been fortunate to have had people around me who have encouraged me to share my experiences and data with a larger audience, and this has led to wonderful opportunities to speak about the fabulous OPAT service at Wythenshawe Hospital at local, national and European conferences. I am the only nurse on the national OPAT steering group run by the British Society of Antimicrobial Chemotherapy (BSAC) and was involved in the publication of the recently updated good practice recommendations for OPAT services in the UK (Chapman et al, 2019).
The OPAT team has also been crowned Clinical Team of the Year 2020 for Manchester University NHS Hospitals, which is a great honour indeed and testament to every member of the fabulous team!