Ensuring the provision and development of a high-quality COPAT service

Reviewing and reflecting on the performance of the COPAT team on a regular basis is essential for the evolution and development of a service.

The weekly MDT meeting, which is mandatory in our opinion, is an excellent opportunity to discuss, and learn from, arising clinical and organisational issues that may impact the quality of the patient care provided. Time should be set aside for such discussions. The presence of at least two (preferably three) healthcare professionals of different training backgrounds (i.e. nurse, doctor and pharmacist) at such meetings provides what we consider to be real-time clinical governance by, for example, discussing each other’s approach to management leading to consensus and an agreed clinical or organisational decision.

A good example of this in our own team’s practice is the prescribing of Tedizolid, which, because of the cost, requires approval by at least two infection consultants (this could be two senior prescribers) within an MDT setting to ensure use is appropriate and alternative antibiotic regimens with equivalent efficacy and safety cannot be used instead. Also, when the service is close to capacity, we discuss how such situations can be managed without impacting patient outcomes, safety or experience.

More formal clinical governance is also required through regular collection and analysis of data, which, to be done well, is time-consuming and requires considerable human resource.

Consideration and discussion of team learning needs and audit, quality improvement and research to be prioritised is also important. In our own service, because of a lack of such resource we find this challenging – but we ensure at least a yearly report is produced and presented to our clinical and non-clinical managers (see resource in the downloads section below).

COPAT services should aspire to regular collection of informative data, even if only minimal, however, perhaps at the weekly MDT meeting, in the same way as for OPAT. Minimal patient-level data-sets are suggested below, but these may need to be adapted to local circumstances and available resources. The potential for OPAT, or other prior interventions including surgery, to influence, for example, the clinical outcomes of COPAT must be considered. Avoid collecting data that will not subsequently be used for either audit, quality improvement or research.

Finally, it is vital that the patient is allowed to provide feedback in some way and that this is collated and fed-back to all members of the COPAT team. In the UK, the Friends and Family Test and I Want Great Care are two ways of doing this.

Minimum patient-level data-set:

• Age

• Sex

• Route of referral

• Whether admission to hospital was avoided by COPAT

• Diagnosis

• Positive microbiology (including resistances)

• Allergies

• Comorbidities that impact oral antibiotic prescribing (e.g. epilepsy and fluoroquinolones)

• Medications that impact oral antibiotic prescribing (e.g. warfarin)

• Creatinine clearance (at start and end of COPAT)

• For oxazolidinones, haemoglobin, platelet and white cell counts at start and end of therapy

• Receipt of prior intravenous antibiotics

• Oral antibiotic(s) prescribed

• Length of COPAT in days; reason(s) for stopping

• Adverse effects that required cessation of therapy prior to planned duration

• Serious adverse effects that occurred after stopping COPAT (e.g. Clostridium difficile infection)

• Unexpected complications/events (e.g. acquisition of MRSA, deep venous thrombosis, etc.)

• Clinical outcome at end of COPAT (e.g. improved, no change, worse, died (and cause) compared to onset)

• Readmission to hospital within 90 days of the end of COPAT (related to the treated infection or an adverse effect of COPAT)

• Recrudescence of the treated infection within 90 days of the end of COPAT (longer follow-up may be required for infections such as chronic osteomyelitis and prosthetic joint infections that may recrudesce later than 90 days)