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Outpatient treatment in the University Hospital Utrecht: organization and infrastructure
INTERNPTIONI\L,(ILRNII.“F
Antimicrobial Agents International Journal of Antimicrobial Agents 5 (1995) 59-61
Outpatient treatment in the University Hospital Utrecht: organization and infrastructure P.O. Witteveen* Department of Internal Medicine, University Hospital Utrecht, E! 0. Box 85500, 3508 GA Utrecht, Netherlands
Received 26 July 1994; accepted 4 October 1994
Abstract
Interest in home care for patients with serious infections is increasing. Home care technology needs reliable equipment that can be operated by the patient without constant supervision. To achieve long-term home treatment requires the establishment of protocols, education programmes, patient support and easy hospital admission. In the present study 185 patients, with cancer or a variety of infections, were treated at home over a 2-year period. Nineteen patients who had to receive antimicrobial agents were educated for self-administration and could contact a health professional with any problems. No serious complications due to home treatment with parenteral medication were observed. Keywords: Home care; Self-administration;
Outpatient
parenteral antibiotic therapy (OPAT)
1. Introduction During the past several years, increasing interest has been generated in the role of home care for patients with advanced cancer or serious infections. Several factors have contributed to this change, including technological innovations, patient and family preference and the need for cost-containment programmes [IA]. Home-care technology is one of the tools in strategies to promote early discharge, to prevent re-admissions and to relocate treatments from the outpatient clinic to the home situation. Home-care technology demands reliable, easy-tooperate equipment that can function without constant supervision [5]. The increasing number of patients with cancer or AIDS has stimulated research in this field and the use of pump devices to administer parenteral medication and fluids in the home-care setting is increasing. Skilled hospital doctors and nurses can assist general practitioners in coping with pump and access devices by providing protocols, teaching sessions, and a 24 h information and support service. In 1992, the University Hospital Utrecht started a
*Tel. (+31-30) 509 111; Fax (+31.,30) 518 328. 0924-8579/95/$29.00 0 1995 Elsevier Science B.V. All rights reserved SSDI
0924-8579(94)00059-X
home-care technology programme for patients with cancer or serious infections. Treatment included parenteral administration of cytostatics, antimicrobial agents, antiviral agents, morphine, nutrition and blood products as well as paracentesis of malignant ascites. The aim of the programme is to manage the patient at home for the complete period that they require these treatments. For most patients, this implies home care until death.
2. Technology To achieve this aim, the following requirements have to be met: written protocols, educational programmes, 24 h support service for patients, their families and professional carers, the availability of easy and quick admission to the hospital, and clear logistic guidelines. Patients were considered for entry into the programme only if their GP was willing to participate, even when patients were completely self-supporting. The patients also had to live no further than 50 km away from the hospital. In The Netherlands, the GP is a key person in medical care at home. He or she is the first person who will be called in case of problems. When cytotoxic drugs were given continuously with a portable pump, the patient was edu-
60
PO.
Witteveenilnternational
Journal of Antimicrobial
cated in coping with pump alarms and toxicity. Due to national guidelines for handling these drugs, the drug cassettes with medication were only renewed inside the hospital during a visit to the outpatient clinic. The first time paracentesis of ascites was performed, the medical oncologist instructed the GP. From then on, all the GPs were able to perform the paracentesis alone. Blood products were delivered by the hospital blood bank and taken home by the clinical nurse specialist who started the infusion together with the GP. The patient’s family took over during the administration and the district nurse concluded the treatment by removing the needle. It took the team about 15 min to instruct everybody. Patients who received antibiotics or antiviral medication were always self-supporting after instruction during the admission for the acute phase of their infection. The GP and the district nurse were available for trouble shooting. Morphine was given via spinal or intravenous administration with a portable patient-controlled analgesia pump that permits control of medication by the patient. All the catheters were connected to a subcutaneous port. Changing of the needles and renewing of medication cassettes was performed by the GP and/or district nurse, again after instruction by the team. Intravenous administration of fluid started inside the hospital. Changing of fluid bags, prepared by the local pharmacist, was done by the family. Central venous catheters, with or without a port system, were taken care of by the GP or district nurse. When total parenteral
Table 1 Characteristics of patients with serious infections enrolled on the OPAT programme Number of patients Age (years) Karnofsky performance status Home distance (km) Diagnosis
Treatment
Treatment period
Median Range Median Range Median Range CMV-retinitis Cryptococcal meningitis Lyme disease Other viral infections Other bacterial infections Ganciclovir Foscavir Amphotericin B Cephalosporin AIDS
Other infections
19 43 30-69 90 50-100 20 5-55 10 3 4 5
6
median 12 months (range 1.5-I 6 months) median 3 weeks (range 1 week-22 months)
“In one patient, Foscavir was replaced by Ganciclovir because of impaired renal function.
Agents 5 (1995) 5941
Table 2 Outcome of patients on OPAT programme Died from progressive disease (AIDS) Still on therapy Recovered, no longer requirement of i.v. medication Total
7 4 8 19
.-
nutrition was given, all nutrients were mixed in one bag, the so-called ‘all in one’ system. Delivery of material and medication was done by the local pharmacist, when necessary, in cooperation with the hospital pharmacist or facilitary agency. In all circumstances, patients, their families and health professionals were informed about the support team and clear descriptions were given about their responsibilities. The support team, which consists of a consultant medical oncologist and two clinical nurse specialists, is on standby for 24 h/day and prepared for home visits. Education is given as bedside teaching preferably following a course on basic theory. Because of their time schedule this was not always feasible for general practitioners. For legal reasons, district nurses have to pass through a theoretical and practical examination before they are allowed to support the involved medical actions.
3. Results and discussion Between June 1992 and June 1994, 185 patients took part in this programme. Of these, 19 were patients with serious infections requiring intravenous antimicrobial agents for a long period. Eleven of the 19 patients (60%) had AIDS and received antiviral or antifungal medication for a median period of 12 months (range 1.5-16 months). The remaining eight patients with other serious infections received intravenous antibiotics for a median period of 3 weeks (range 1 week-22 months). Fifteen patients had tunnelled central venous catheters, preferably connected to a port system. The remaining four patients received antibiotics with a peripheral catheter. Medication was administered with electronic infusion pumps or disposable elastomeric infusers. This latter device is easy to handle and most appropriate in the case of a short infusion time. All but three patients had been admitted to the hospital during the diagnostic or acute phase of the infection and were sent home during maintenance treatment. Three patients with Lyme disease were seen in the outpatient clinic and received the first administration of antibiotics at home. The patients’ age ranged from 30 to 69 years, 12 patients were male (Table 1). Patients were educated for self-administration and relied on the general practitioner or district nurse in the case of problems. Patients were allowed to contact the support team directly when they were not on duty. During a total of 3600 administration days, six patients called the support team 13 times. All these cases could
RO. Witteveenllnternational Journal of Antimicrobial Agents 5 (1995) 5941
be handled by telephone. No serious complications caused by home treatment were observed; the outcome is given in Table 2: seven patients with AIDS died due to progressive disease, four are still on therapy and eight patients recovered and finished their treatment. To obtain materials and medication at home, in time and in the right volume, was not always easy. Most pharmacists do not find it commercially attractive to deliver small volumes of materials to patients. Doing business with one or two pharmacists in a city or region makes it possible to achieve a larger area of distribution and therefore a more effective and uniform delivery.
4. Conclusion It was concluded that, under certain conditions, parenteral administration of medication at home is feasible. The advanced technology and reliable infusion pumps ensure a low incidence of technical problems. A multidisciplinary approach including a hospital-based home-care
61
team, general practitioners, district nurses and pharmacists, may provide high-quality home care for patients with cancer or serious infectious diseases.
References PI Gezondheidsraad. Thuiszorg voor patienten met kanker. Advies uitgebracht door de Gezondheidscommissie Thuiszorg voor pat&ten met kanker aan de minister en de staatssecretaris van Welzijn, Volksgezondheid en Cultuur. Den Haag, No. 1991/02, 1991. PI Ferris FD, Wodinsky HB, Kerr IG, Sone M, Hume S, Coons C. A cost-minimization study of cancer patients requiring a narcotic infusion in hospital and at home. .I Clin Epid 1991;44(3):313-327. [31 Vinciguerra V, Degnan TJ, Sciortino A et al. A comparative assessment of home versus hospital comprehensive treatment for advanced cancer patients. J Clin Oncol 1986;4(10):1521-1528. 141Eisenberg JM, Kitz DS. Savings from outpatient antibiotic therapy for osteomyelitis. JAMA 1986;255(12):1584-1588. PI Portenoy RK, Moulin DE, Rogers A, Inturrisi CE, Foley KM. IV infusion of opioids for cancer pain: clinical review and guidelines for use. Cancer Treat Rep 1986;70:575-581.
Antimicrobial Agents International Journal of Antimicrobial Agents 5 (1995) 59-61
Outpatient treatment in the University Hospital Utrecht: organization and infrastructure P.O. Witteveen* Department of Internal Medicine, University Hospital Utrecht, E! 0. Box 85500, 3508 GA Utrecht, Netherlands
Received 26 July 1994; accepted 4 October 1994
Abstract
Interest in home care for patients with serious infections is increasing. Home care technology needs reliable equipment that can be operated by the patient without constant supervision. To achieve long-term home treatment requires the establishment of protocols, education programmes, patient support and easy hospital admission. In the present study 185 patients, with cancer or a variety of infections, were treated at home over a 2-year period. Nineteen patients who had to receive antimicrobial agents were educated for self-administration and could contact a health professional with any problems. No serious complications due to home treatment with parenteral medication were observed. Keywords: Home care; Self-administration;
Outpatient
parenteral antibiotic therapy (OPAT)
1. Introduction During the past several years, increasing interest has been generated in the role of home care for patients with advanced cancer or serious infections. Several factors have contributed to this change, including technological innovations, patient and family preference and the need for cost-containment programmes [IA]. Home-care technology is one of the tools in strategies to promote early discharge, to prevent re-admissions and to relocate treatments from the outpatient clinic to the home situation. Home-care technology demands reliable, easy-tooperate equipment that can function without constant supervision [5]. The increasing number of patients with cancer or AIDS has stimulated research in this field and the use of pump devices to administer parenteral medication and fluids in the home-care setting is increasing. Skilled hospital doctors and nurses can assist general practitioners in coping with pump and access devices by providing protocols, teaching sessions, and a 24 h information and support service. In 1992, the University Hospital Utrecht started a
*Tel. (+31-30) 509 111; Fax (+31.,30) 518 328. 0924-8579/95/$29.00 0 1995 Elsevier Science B.V. All rights reserved SSDI
0924-8579(94)00059-X
home-care technology programme for patients with cancer or serious infections. Treatment included parenteral administration of cytostatics, antimicrobial agents, antiviral agents, morphine, nutrition and blood products as well as paracentesis of malignant ascites. The aim of the programme is to manage the patient at home for the complete period that they require these treatments. For most patients, this implies home care until death.
2. Technology To achieve this aim, the following requirements have to be met: written protocols, educational programmes, 24 h support service for patients, their families and professional carers, the availability of easy and quick admission to the hospital, and clear logistic guidelines. Patients were considered for entry into the programme only if their GP was willing to participate, even when patients were completely self-supporting. The patients also had to live no further than 50 km away from the hospital. In The Netherlands, the GP is a key person in medical care at home. He or she is the first person who will be called in case of problems. When cytotoxic drugs were given continuously with a portable pump, the patient was edu-
60
PO.
Witteveenilnternational
Journal of Antimicrobial
cated in coping with pump alarms and toxicity. Due to national guidelines for handling these drugs, the drug cassettes with medication were only renewed inside the hospital during a visit to the outpatient clinic. The first time paracentesis of ascites was performed, the medical oncologist instructed the GP. From then on, all the GPs were able to perform the paracentesis alone. Blood products were delivered by the hospital blood bank and taken home by the clinical nurse specialist who started the infusion together with the GP. The patient’s family took over during the administration and the district nurse concluded the treatment by removing the needle. It took the team about 15 min to instruct everybody. Patients who received antibiotics or antiviral medication were always self-supporting after instruction during the admission for the acute phase of their infection. The GP and the district nurse were available for trouble shooting. Morphine was given via spinal or intravenous administration with a portable patient-controlled analgesia pump that permits control of medication by the patient. All the catheters were connected to a subcutaneous port. Changing of the needles and renewing of medication cassettes was performed by the GP and/or district nurse, again after instruction by the team. Intravenous administration of fluid started inside the hospital. Changing of fluid bags, prepared by the local pharmacist, was done by the family. Central venous catheters, with or without a port system, were taken care of by the GP or district nurse. When total parenteral
Table 1 Characteristics of patients with serious infections enrolled on the OPAT programme Number of patients Age (years) Karnofsky performance status Home distance (km) Diagnosis
Treatment
Treatment period
Median Range Median Range Median Range CMV-retinitis Cryptococcal meningitis Lyme disease Other viral infections Other bacterial infections Ganciclovir Foscavir Amphotericin B Cephalosporin AIDS
Other infections
19 43 30-69 90 50-100 20 5-55 10 3 4 5
6
median 12 months (range 1.5-I 6 months) median 3 weeks (range 1 week-22 months)
“In one patient, Foscavir was replaced by Ganciclovir because of impaired renal function.
Agents 5 (1995) 5941
Table 2 Outcome of patients on OPAT programme Died from progressive disease (AIDS) Still on therapy Recovered, no longer requirement of i.v. medication Total
7 4 8 19
.-
nutrition was given, all nutrients were mixed in one bag, the so-called ‘all in one’ system. Delivery of material and medication was done by the local pharmacist, when necessary, in cooperation with the hospital pharmacist or facilitary agency. In all circumstances, patients, their families and health professionals were informed about the support team and clear descriptions were given about their responsibilities. The support team, which consists of a consultant medical oncologist and two clinical nurse specialists, is on standby for 24 h/day and prepared for home visits. Education is given as bedside teaching preferably following a course on basic theory. Because of their time schedule this was not always feasible for general practitioners. For legal reasons, district nurses have to pass through a theoretical and practical examination before they are allowed to support the involved medical actions.
3. Results and discussion Between June 1992 and June 1994, 185 patients took part in this programme. Of these, 19 were patients with serious infections requiring intravenous antimicrobial agents for a long period. Eleven of the 19 patients (60%) had AIDS and received antiviral or antifungal medication for a median period of 12 months (range 1.5-16 months). The remaining eight patients with other serious infections received intravenous antibiotics for a median period of 3 weeks (range 1 week-22 months). Fifteen patients had tunnelled central venous catheters, preferably connected to a port system. The remaining four patients received antibiotics with a peripheral catheter. Medication was administered with electronic infusion pumps or disposable elastomeric infusers. This latter device is easy to handle and most appropriate in the case of a short infusion time. All but three patients had been admitted to the hospital during the diagnostic or acute phase of the infection and were sent home during maintenance treatment. Three patients with Lyme disease were seen in the outpatient clinic and received the first administration of antibiotics at home. The patients’ age ranged from 30 to 69 years, 12 patients were male (Table 1). Patients were educated for self-administration and relied on the general practitioner or district nurse in the case of problems. Patients were allowed to contact the support team directly when they were not on duty. During a total of 3600 administration days, six patients called the support team 13 times. All these cases could
RO. Witteveenllnternational Journal of Antimicrobial Agents 5 (1995) 5941
be handled by telephone. No serious complications caused by home treatment were observed; the outcome is given in Table 2: seven patients with AIDS died due to progressive disease, four are still on therapy and eight patients recovered and finished their treatment. To obtain materials and medication at home, in time and in the right volume, was not always easy. Most pharmacists do not find it commercially attractive to deliver small volumes of materials to patients. Doing business with one or two pharmacists in a city or region makes it possible to achieve a larger area of distribution and therefore a more effective and uniform delivery.
4. Conclusion It was concluded that, under certain conditions, parenteral administration of medication at home is feasible. The advanced technology and reliable infusion pumps ensure a low incidence of technical problems. A multidisciplinary approach including a hospital-based home-care
61
team, general practitioners, district nurses and pharmacists, may provide high-quality home care for patients with cancer or serious infectious diseases.
References PI Gezondheidsraad. Thuiszorg voor patienten met kanker. Advies uitgebracht door de Gezondheidscommissie Thuiszorg voor pat&ten met kanker aan de minister en de staatssecretaris van Welzijn, Volksgezondheid en Cultuur. Den Haag, No. 1991/02, 1991. PI Ferris FD, Wodinsky HB, Kerr IG, Sone M, Hume S, Coons C. A cost-minimization study of cancer patients requiring a narcotic infusion in hospital and at home. .I Clin Epid 1991;44(3):313-327. [31 Vinciguerra V, Degnan TJ, Sciortino A et al. A comparative assessment of home versus hospital comprehensive treatment for advanced cancer patients. J Clin Oncol 1986;4(10):1521-1528. 141Eisenberg JM, Kitz DS. Savings from outpatient antibiotic therapy for osteomyelitis. JAMA 1986;255(12):1584-1588. PI Portenoy RK, Moulin DE, Rogers A, Inturrisi CE, Foley KM. IV infusion of opioids for cancer pain: clinical review and guidelines for use. Cancer Treat Rep 1986;70:575-581.