Paediatric OPAT provision the challenges and …...1. Van Winkle P et al. PIDJ 2008 2. Hussain S et...
Transcript of Paediatric OPAT provision the challenges and …...1. Van Winkle P et al. PIDJ 2008 2. Hussain S et...
Paediatric OPAT provision – the challenges and opportunities
Dr Sanjay Patel
Consultant in Paediatric Infectious Diseases
Contents
• Challenges:-
– Economies of scale
– Where can p-OPAT be delivered?
– Risk averse behaviour
– Practical issues: IV access
– Paucity of evidence
• Opportunities:-
– Tertiary p-OPAT: the Southampton experience
– Expanding p-OPAT beyond tertiary hospitals
Challenges in introducing a p-OPAT service: economies of scale
920 adult beds
124 paediatric beds
Challenges in introducing a p-OPAT service: where can it be delivered?
versus
Unique challenges in introducing a p-OPAT service: overcoming risk averse
behaviour
1. Van Winkle P et al. PIDJ 2008 2. Hussain S et al. Clinical Pediatrics. 2007
Van Winkle
(2003-06)
Hussain
(1995-99)
Number of PICCs 39 (5 midlines) 104
Mean age (years) 4.4 7.5
Duration (days) 21.7 +-14.1
(mean and SD)
Mean 41
(range 0-80)
Mechanical
complications 11 (28%) 28 (27%)
Time to mechanical
complication (days) N/A 54
Infective complications 2 (5%) 13 (12.5%)
Time to infective
complication (days) N/A 42
Total complication rate 33% 39.5%
Challenges in p-OPAT: IV access
0
5
10
15
20
25
30
35
Challenges in introducing a p-OPAT service: paucity of evidence
31
2 Adult OPAT
papers published in 2014 P-OPAT papers
published in 2014
The Southampton p-OPAT journey
• Tertiary Children’s Hospital
• Serves a population of 500,000 children
• 124 in-patient beds
• 9000 admissions per year
Geographical area covered
• Introduced July 2012
Southampton tertiary p-OPAT service
Period Patient episodes Bed days saved
Year 1 (July 12 – July 13) 48 497
Year 2 (July 13 – July 14) 42 641
Year 3 (July 14 – Dec 14) 20 278
Total: 30 months 110 1416
Impact over a 30 month period:-
Diagnosis Number of Patients
Osteomyelitis 28
Septic arthritis 24
Respiratory 12
Bacteraemia 10
CNS infection 9
Mastoiditis / sinusitis 8
Infected prosthetic material 7
Deep seated wound 2
Skin and soft tissue 3
Infective endocarditis 3
Pyomyositis 3
Intra-abdominal 1
Total 110
IV Access
81%
13%
6%
PICC (91)
Cannula (15)
Tunnelled CVC (7)
Mechanical complications 10% Infective complications 2%
pOPAT Outcomes (BSAC definitions)
Success: Completed therapy in OPAT with no
change in antimicrobial agent, no
adverse events, cure or improvement of
infection and no readmission.
Partial success: Completed therapy in OPAT with
either change in antimicrobial
agent or adverse event not
requiring admission.
Failure: Readmitted due to infection worsening
or due to adverse event. Death due to
any cause during OPAT.
Indeterminate: Readmission due to unrelated
event eg. Chest pain.
85%
6% 5%
4%
Success (93)
Partial Success (7)
Failure (6)
Indeterminate (4)
Patient Infection Outcomes Cure: Completed +/- oral step down for defined duration with resolution of infection and no requirement for long term antibiotic therapy. Improved:
i. Complete +/- oral step down with partial resolution of infection but need for further follow up OR
ii. Completed but required escalation of antimicrobial therapy during OPAT (without admission) +/- oral step down with ultimate cure or partial improvement (as above).
Failure: Progression or non-response of infection despite OPAT, required admission, surgical intervention or died for any reason. Indeterminate: There was a non-infective pathology responsible for persisting symptoms.
81%
11%
5%
3%
Cured (89)
Improved (12)
Failure (6)
Indeterminate (3)
Opportunities – expanding p-OPAT to other tertiary hospitals
Expanding p-OPAT beyond tertiary hospitals
Expanding p-OPAT beyond tertiary hospitals Diagnostic category Number bed days saved
Pyrexia 62
UTI 37
ENT 33
Skin & Soft tissue 30
Bacteremia 27
Lymphadenitis 15
Periorbital / pre-septal cellulitis 12
Osteoarticular 11
Respiratory 11
Other 11
Gastrointestinal 10
Rashes 7
Total 266 6 month period
Opportunities and challenges– prospective data collection
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