Update on Scottish OPAT work

Dr R. Andrew Seaton Infectious Diseases Consultant & Lead Doctor NHS GG&C Antimicrobial Management Team, Chair, Scottish Antimicrobial Prescribing Group Co-lead, BSAC OPAT Initiative @raseaton66 SAPG event May 2021 What’s been happening in OPAT?

• Scottish OPAT practice and impact of COVID-19 • SHTG review of clinical and economic effectiveness of OPAT • SAPG OPAT group • OPAT and Interface care Current Scottish Estimates of OPAT Practice

9000 900

8000 800

7000 700

6000 600 5000 Nurses 500 4000 400 7 4 2 1.7 2 3 2 1 2 Numbers 3000 300

2000 200

1000 100

0 0 Lothian GGC Lanark Tayside Highland Forth V Fife Grampian Dumfries Number 800 520 200 150 150 150 150 140 100 Days 8000 4500 2500 3000 2700 2000 1500 3000 1200

Medical – sessional Ad hoc – Borders, Ayrshire and Arran, Island boards Pharm – sessional GJNH – feeding boards Admin – Nil except one board 0.2 R A Seaton, email survey December 2019 Current Scottish Estimates of OPAT Practice

9000 900

8000 800

7000 700

6000 600 5000 Nurses 500 4000 400 7 4 2 1.7 2 3 2 1 2 Numbers 3000 300

2000 200

1000 100

0 0 Lothian GGC Lanark Tayside Highland Forth V Fife Grampian Dumfries Number 800 520 200 150 150 150 150 140 100 Days 8000 4500 2500 3000 2700 2000 1500 3000 1200

Medical – sessional Ad hoc – Borders, Ayrshire and Arran, Island boards Pharm – sessional GJNH – feeding boards Admin – Nil except one board 0.2 R A Seaton, email survey December 2019 OPAT Delivery in Scotland – no single model of care

Borders DG Fife FV GGC Grampian Highland Lanark Lothian Tayside OPAT clinic MAU Self admin OPAT nurse at home Community Nurse at home Community Hospital HCITH link

Most frequent (or HCITH link) to least frequent and service not available (or no HCITH link)

*Infusion pumps: DG, Highland, Grampian (Elastomeric), Lothian (Elect) R A Seaton, email survey October/November 2020 Discovery: Cellulitis in Scotland (2019) with admission <8 days (n= 6837): unmet need

Scotland: 19.4% zero day admission 70.5% <4 day admission

14.4% 19.1% 32.2% 23% 14% 20.5% 30.8% 11.9% 22.1% 6.3% 8.6%

*adjusted zero days for QEUH Bronchiectasis admissions (2019) and mean LoS (n= 1097): unmet need

Smaller patient population but mean of 6-7 days admission and potential for further focus on OPAT management would reduce LoS Scottish Health Technology Assessment:

Clinical Effectiveness and Health Economic Assessment modelled on BSAC NORs data

Jointly commissioned by BSAC and SAPG

Recommendations for Scottish HBs

Reported Feb 2021 Cost of OPAT models of care vs inpatient stay for short-term skin and soft tissue infections

3000

2476 2500

2000 Cost (£) 100% 25% 34% 25% 51%

1500 1266

1000 831

631 611

500 *Assumes elastomeric IV ceftriaxone 2g OD **Dalbavancin 1g once 0 Inpatient OPAT daily Home visit Self admin* Dalbavancin ** SHTG report, 2021 Cost of OPAT models of care vs inpatient stay for Bone-Joint/Orthopaedic infections

100% 30% 41% 22% 29% 21%

SHTG report, 2021 Cost of OPAT models of care vs inpatient stay for Bronchiectasis

100% 46% 56% 40% 49%

SHTG report, 2021 SAPG OPAT group

• Formed September 2020 • Multidisciplinary group with NHS Scotland-wide representation • Aims • Realistic Medicine approach to variation in service and practice • Promote best antimicrobial prescribing practice/ AMS in NHS Scotland OPAT • Develop a national approach to accurate and unified recording and reporting • Resource recommendations to address lack of uniformity in OPAT service staffing, including administrative support, nursing and pharmacy provision for existing services. • Define and promote role of OPAT in context of the COVID-19 pandemic: response and recovery SAPG OPAT group – key planned outputs • Evidence review – post BSAC GPRs -> including staffing • Development of key performance indicators (BSAC template) • Aiming for c.15 KPIs to capture best practice/governance • Development of survey of practice and outcomes • Post BSAC NORS • OPAT baseline to national prospective data collection • Capture gatekeeping function including CoPAT • Patient/infection/management information and clinical outcomes • Development of antimicrobial monographs • Share and unify Scottish OPAT practice • Key drugs including guidance on dosing and administration (Ceftriaxone, Ertapenem, Daptomycin, Teicoplanin, Dalbavancin, “CoPAT”) Redesign of Urgent Care: Interface care

“‘Delivery of high-quality care for defined groups of patients, that safely provides an alternative to avoid hospital admission or leads to early front door discharge and reduces length of stay. ‘Interface Care’ will provide care for the complete patient journey, from point of contact to conclusion of need, optimising staff and patient experience.” Interface care

• Will support care nearer to home • Safely reduce hospital admissions and shorten length of stay for defined groups of patients • Supports COVID remobilisation • The RUC will be designed to deliver improvement and innovation at scale for Scotland. • Includes supporting front line staff, optimising pathways and exploring the role of technology as an enabler, which could include emerging technologies. Acknowledgement: Milla Marinova OPAT Target Operating Model for NHS Boards

• Describes the future state/ vision of OPAT across all NHS Scotland boards that aligns operating capacity and strategic objectives • Vision is to provide a service that meets population health needs timeously, effectively, efficiently regardless of location ensuring health inequalities are not widened. OPAT should dovetail/collaborate at board level with other aspects of Interface Care.

Summary

• Variation and opportunities in OPAT practice, data and funding • SHTG review: • clinical and economic effectiveness of OPAT • recommends national patient focussed OPAT development • SAPG OPAT group central to development of national governance • OPAT central to SG Interface care initiative Acknowledgements

SAPG OPAT group membership: Additional OPAT Data: Jacqueline Sneddon, Project Lead, SAPG William Malcolm, Clinical Lead for SONAAR programme, Ayrshire and Arran: Sam Allen , Borders: Anne Duguid, National ARHAI Scotland Dumfries and Galloway: Melinda Munang and Shirley Lesley Cooper, Data scientist, SAPG Buchan, Fife: David Griffith Grampian: Sharon Falconer, Robbie Weir, Consultant Microbiologist and AMT Lead, NHS FV Highland: Alison Macdonald, Orkney: Wendy Lycett, Claire Mackintosh, Clinical Director, RIDU, NHS Lothian Shetland: Mary Macfarlane, Tayside: Nik Rae and Busi Niketa Platt, Antimicrobial Pharmacist, NHS Fife Mooka GJNH: Rebecca Houston Heather Kennedy, Lead Antimicrobial Pharmacist, NHS Tayside Interface care group: Emer Friel, Antimicrobial Pharmacist, NHS Western Isles Derek Bell, Milla Marinova, Amanda Trolland, Alex Royal Jayne Walden, Antimicrobial/OPAT Nurse, NHS DG Wendy Beadles, Consultant Infectious Diseases, NHS Highland SHTG: Sharon Watson, Charge Nurse, OPAT service, NHS Lothian Maria Dimitrova, Health Economist Stephanie Dundas, Consultant ID, NHS Lanarkshire Amy Baggott, Consultant Infectious Disease, NHS Forth Valley BSAC: Liz Collison/Lynn O’Reilly, Specialist OPAT Nurses NHS GGC Mark Gilchrist, Felicity Drummond Hazel Dodds and Stuart Baird, SNAP, PHS