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