Quality Safety People Delivery Environment Cost

Dr Rashmi Sharma & Dr Achyut Guleri

On behalf of COMMIT Team

Consultant Microbiologist: Lancashire Cardiac centre, Diabetic foot MDT clinic, COMMIT (OPAT)

Special Interests: Clinical Mycology Patient safety, HAIs & Antibiotic stewardship QIPP – transformational projects Antibacterial Resistance

Consultant Microbiologist

Clinical Director- Laboratory Medicine,

Blackpool Teaching Hospitals and

Hon. Senior Clinical Lecturer, University Central Lancashire

DISCLOSURES: Advisory board : MSD, Novartis, Schering –Plough, Astellas, AstraZeneca Conference sponsorship: Novartis, MSD, AstraZeneca, Janssen-Cilag, Astellas, BD, Carefusion UK Lectures for: Bayer AG, MSD, Novartis, Pfizer, Astellas & BD Preparing teaching video: Astellas, BD Diagnostics

OBJECTIVES

• Blackpool OPAT Model – a “pilot in its 3rd year”

• The “partnership” structure

• Key achievements, Challenges, Future

Blackpool Teaching Hospitals

• Large Acute Teaching Hospital FT with contract for community health services for residents within a large geographical area of Blackpool, Fylde & Wyre

• Local population of 440,000 plus 12 million visitors

• Annual Budget £335M; employ 6000 staff

• Tertiary centre for Cardiac and Haematology

• 91,000 A&E attendances, 99,850 day case and inpatients and 295,000 outpatients

• 844 beds across five sites

BLACKPOOL: Hub of 12 million holiday makers in North-west England

BLACKPOOL, FYLDE & WYRE

Quality Safety People Delivery Environment Cost

Elements of Balance

Clinical Care

Value for Money Savings

Tax Payer

Clinician

Management

CCG Commissioner

Courtesy: Sharon Rourke, ex CCG Senior Commissioning Manager

P

“Suitable patient” for Home/Clinic administered IV therapy:

• Medically stable patient • Any Infectious condition • Requiring intravenous antibiotic • Oral option: Non responsive or not optimal

COMMIT COMMunity/home Intravenous Therapy)

SUITABLE PATIENT

Hospital based: Consultant Microbiologist / ID

GP referral

Ward referral

GP led - Primary care Assessment Unit & ward 2

A & E referral

Any other hospital referral [B, F, W resident]

Community Clinic based: IV Nursing Team

E-referral; 1st Assessment; E-Management plan; E-prescription; Venous

access (cannula/PICC/mid); 1st dose in pcau/ward; follow up appointments

Diabetic Foot MDT Clinic

PHARMACIST

Medically stable, any infectious condition, unresponsive oral or IV optimal option

1. Locally developed E-tools: • E-referral (intranet & EMIS) • E – patient management plan • E – discharge prescription • E – Review & end of treatment report • PMS (pharmamix)

2. Primary Care Centre Community based clinic offering IV abx (8am-8pm) • CLINIC [30 appt slots/day] • HOME [12 appt slots/day]

3. Multi-disciplinary team working: • Clinic based IV nurse team with band 7

lead nurse • Hospital team (Microbiologists, ID,

pharmacist) • Thursday MDT to discuss all patients

4. Branding & advertisement – COMMIT; raising awareness for patients, GPs, wards, A&E

5. Regular steering committee & operational team meeting

COMMIT

With permission of estates

5 – IV stations 5 – infusion stations

Mrs. X: “P.S. the nurses are all lovely, nutters, but lovely!!"

Mr. Y: “A pleasure to attend, less like a chore and more

like meeting friends”.

Quality Safety People Delivery Environment Cost

April 14 – March 15: 242 patients (aver 20.1 patients/month)

14

5

18 17

21 23

22 22

33 32

15

20

0

5

10

15

20

25

30

35

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

An average of >400 days/month

Total Number of days of IV delivered outside of hospital

Bed Days Saved

367

292

339

374

559 547

501

465 455

417

311

355

0

100

200

300

400

500

600

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

INFECTIOUS CONDITIONS (% of 242 patients)

44.6

5.3

17.3

10.6

8.3

8.3

2 2 CELLULITIS

BRONCHIECTASIS/AE

DIABETIC FOOT / OM

UTI/STENT IX

DEEP/ORGAN ABSCESS

PJI/SA

ENDOCARDITIS

MALIG OE

COMMIT STEERING GROUP

BCN Alternative to Hospital /”Bridge to Home” Steering Group (every 2 wks)

Rehabilitation Working Group (weekly)

BCN Flow Steering Group (every 2 wks)

IV Therapy Working Group (fortnightly)

Better Care Now (BCN) Project Board (every 2 wks)

1. Eliminating delays in care, 2. Ensuring we have the right professionals with the right skills to deliver high quality care and 3. Improving patient pathways.

IV Therapy Steering Committee Membership • Commissioning Manager NHS Blackpool CCG

• Commissioning Support Officer NHS Fylde and Wyre CCG

• Acute Trust Board Executive Director & Director of Operations or DDOP

• Consultant Microbiologist – COMMIT Clinical Strategic Lead

• Consultant Microbiologist – COMMIT Clinical Operational Lead

• COMMIT Lead Nurse

• Antimicrobial Pharmacist

• Operational Lead - Head of Locality (Fylde and Wyre) Community Nursing

and Rehab Therapies

• Better Care Now Programme Manager

• Better Care Now Project Support

• CIP DIRECTOR

Monitoring Performance - KPI • Capacity Appointment Tracker: 12 home / 30 clinic slots • KPI spreadsheet:

– Referral source, CCG – B or F&W; Duration treatment; administrations, indication, clinic/home, outcomes, readmission

– Diagnosis, HRG code, HRG name, non-elective spell tariff (example below)

• Patient Feedback: – COMMIT questionnaire; patient forum; consultant web-profile

feedback from patients;

DIAGNOSIS DESCRIPTION HRG code HRG name Non-elective spell

tariff (£)

Osteomyelitis : Osteomyelitis HD25B Infections of Bones or Joints with CC

3,000

Cellulitis : Cellulitis JD03B Intermediate Skin Disorders category 2 with Intermediate CC

1,301

Genito Urinary-UTI LA04F Urinary Tract Infection 1,372

Endocrine-Diabetes KA08Z Other Endocrine Disorders 1,778

“After many weeks in hospital, I was made to feel less like a patient

and more like a person”.

“Am self employed. If I would have been admitted to

hospital, I would have been on benefits during the 12-

weeks of treatment”

“A very reassuring and professional service provided in comfortable

and accessible surroundings”.

“Without the IV team the only thing to look forward to would be more

time as an inpatient. This service gives even the poorliest of people

independence and the opportunity to be back home with loved

ones”

“P.S. the nurses are all lovely, nutters, but lovely!!"

PATIENT FEEDBACK & COMMENTS ON THE SERVICE = EXCELLENT TO VERY GOOD

Key challenges & future

• A pilot (commissioned) in its 3rd year – Phased nursing staff recruitment & training

– From “Home only” to “Clinic and Home” model

– Adopted by Trust PMO & Better Care Now in 2014

• Sub-pilots in 2015-16: – Ferrinject, Frusemide, TPN, Infliximab, Immunotherapy,

Bisphosphonates,

– Nurse led protocols for couple of uncomplicated conditions

• Challenges: – satellite clinics;

– OPAT to OPT;

– Shifting Sands (federation of regional services, hospitals, etc)

Clinical Care

Value for Money Savings

CLINICIAN

1. All infectious conditions

2. GP & ward referrals

3. Consultant – suitability assessment

4. Team working: Consultant Infection

specialist, Pharmacist, Nursing

5. Weekly MDT

6. User friendly E-tools: referral,

Prescription, Management/

monitoring plan, Review/end of

treatment report,

MANAGEMENT

1. Better care Now – Alternative to

hospital Project

2. Savings – QIPP/CIP

3. Early facilitated discharge

4. Closing beds; Reducing re-

admissions / avoidable admissions

5. Optimisation of bed use

P

PATIENT

1. Hospital, Community Clinic or

home

2. Flexibility of appt (8am-8pm)

3. Prompt access to consultant

care

4. 24/7 Helpline

5. Patient feedback, forum

CCG commissioner

1. Aligned to NHS vision

2. Performance monitoring to

ensure financially sustainable

3. Patient centred, quality care,

Excellent patient feedback &

press

4. Acute lead service delivery in

community

Tax Payer: value for money for a truly patient centred service

CEO, Lead GP-Primary Care Assessment Unit, Pharmacist, COMMIT Nursing team, Microbiologists

There’s no place like home