Dissemination of the Guidelines
The contributors to these guidelines considered what could be done to optimize their understanding and use. Timely publication of the guidelines or their abstracts in the various society journals is possible. In addition, the Internet offers the ability to disseminate information and support it through links to documents from other societies and to patient education materials.
The potential exists for continual updating and close cooperative activities among the societies represented in these guidelines. Many of these resources are available through the Web page of the Infectious Diseases Society of America (http://www.idsociety.org). Additional information about outpatient parenteral antimicrobial therapy (OPAT) can be found at the OPAT Outcomes Registry Web site (http://www.opat.com) and at the Web pages of the contributing societies listed in Table 9 in the original guideline document.
OPAT Outcomes and Patient Safety
The measurement of outcomes by an OPAT program is a part of the continuous performance improvement process through which health care providers attempt to improve and assure the quality of their care and service. Parameters are chosen to assess the safety, efficacy, and cost of the OPAT program. The best-studied OPAT outcomes indicators have been those related to cost savings and financial analyses. Results of outcomes analyses may also be useful for marketing and contracting with payors. Accrediting bodies such as the Joint Commission for the Accreditation of Health Care Organizations (JCAHO) and the National Committee for Quality Assurance require outcomes measurements as a part of their certification process but do not specify the parameters or indicators to use. The JCAHO requires reporting and root cause analysis of "sentinel events" resulting in unexpected death or permanent injury arising from therapy. As the financial pressures mount for earlier hospital discharge of sicker patients, the importance of monitoring outcomes to assure patient safety increases.
Since the 1997 OPAT guidelines were published, some progress has been made in defining the appropriate outcomes to monitor and the techniques for their measurement; however, available data are sparse and rarely prospective. The articles referenced in the Appendix of the original guideline document support the effectiveness of OPAT for many indications.
OPAT centers should have an active performance improvement program that can track clinical and program outcomes. Limited data are available to allow for comparison of a program’s performance with a national database for benchmarking purposes. The OPAT Outcomes Registry is a national database that is accumulating data that can help compare a program’s performance with that of an aggregate of 130 centers with over 14,000 cases. An OPAT center collects data on outcomes for the patients and can monitor its own clinical performance over time. This is particularly useful in the absence of published outcomes standards for infections treated with OPAT. Parameters which are monitored in the OPAT
Outcomes Registry are listed in table below.
Patient safety and health care–related infections are of particular concern with OPAT. The home environment is rarely constructed for safety; hence, application of hospital infection control polices may not be appropriate. Fortunately, the risk of infection related to home care appears to be much less than the risk of hospital-acquired infection and the chances of acquiring an antimicrobial-resistant organism from the home environment appear to be lower. Long-term care facilities are challenged with a concentrated population of debilitated but mobile patients, many of whom are recovering from hospital-acquired infections.
Patient safety issues with OPAT are similar to the hospital with potential medication errors, adverse drug effects, and complications from infusion devices. Patients and staff should be educated with regard to these risks and be immediately available if they occur. OSHA standards for health care worker safety and needle stick prevention are to be incorporated into the patient’s plan of care in the outpatient setting.
Outcome Measures for Outpatient Parenteral Antimicrobial Therapy (OPAT)
- Clinical status (as reported by the responsible physician)
- Improved
- Clinical failure
- No change
- Bacterial infection status (if a pathogen was identified and repeat culture was done)
- Culture negative for pathogen
- Persistent pathogen
- New pathogen
- Program outcome (i.e., end of therapy)
- Therapy completed as planned
- Therapy not completed because of patient’s death, noncompliance with therapy, complication, patient’s preference, hospitalization (give reason), or other
- Antibiotic use (i.e., end of treatment course)
- Course completed as planned
- Course not completed because of adverse drug reaction (note type), resistant organism, persistent organism, patient’s preference, clinical failure
- Vascular access complications, such as phlebitis, infection, thrombosis, infiltration, or becoming dislodged
- Additional outcome measurements
- Patient returned to work or school during OPAT (if applicable)
- Did outcome meet physician expectations?
- Survival status (patient alive, died of infection, died of other causes, lost to follow-up, or status unknown)
