Discharge and follow-up arrangements

Patients are discharged when:

• The planned complex antibiotic therapy course has been completed and the patient does not require further therapy

• The patient is established and stable enough on the complex regimen for standard outpatient monitoring (this might apply to a patient taking Co-trimoxazole, for example, but not Linezolid)

• The patient is switched to a longer-term regimen requiring less monitoring (i.e. can be safely monitored via a general or specialty clinic or by the patient’s primary care doctor)

• Recent blood (or other tests) are satisfactory

• Their infection is cured or improved to a point of clinical stability that does not require enhanced monitoring

It is important to remember that whilst only some antimicrobial regimens require frequent attendance at a COPAT or other similar service, many antimicrobials do not, but all antimicrobials prescribed for prolonged use do need at least occasional oversight. A robust plan for follow-up is therefore required for patients prescribed ongoing therapy and, for example, those requiring follow-up tests to ensure cure/improvement.

Challenge

One challenge for COPAT services is to avoid ‘holding’ onto patients longer than is clinically necessary thereby ‘stressing’ the service and reducing the services ability to take on new patients and/or consistently provide a high-quality service to all patients.

It is therefore necessary to proactively discharge patients to either a general or sub-speciality clinic (e.g. a bone and joint infection clinic) or, if ongoing specialist input is not required, the patient’s primary care doctor with or without involvement of other key healthcare professionals such as a community podiatrist or district nurse.

Important

Key components of high-quality COPAT discharge planning include early discussion at the weekly MDT meeting (follow-up appointments are booked well before discharge) and good communication with patients, administrative staff and other hospital or community-based clinical teams prior to discharge.

Documentation of follow-up arrangements is also important. Patients may also need to take a higher degree of personal responsibility for their own health at this stage and need to be informed about, for example, attending or arranging a practice nurse appointment for ongoing wound management or who to contact should their condition deteriorate or if the planned clinic appointment is not subsequently confirmed.

Patients may also have anxieties/concerns that may need to be addressed in the run-up to discharge as they realise the level of hospital-based oversight is to stop or decrease.

The primary care doctors of all patients are sent a COPAT discharge letter (please find in the downloads section below), which is provided additionally to any discharge letter completed at the time of discharge from hospital and copied to any other relevant healthcare professionals involved in the patient’s care (e.g. an orthopaedic surgeon who may want to know the antibiotic course has been completed prior to the second-stage prosthetic joint revision procedure). Specific important information may also be communicated verbally in selected patients.

Discuss with fellow learners in the comments below:

• What are your experiences with similar services? Have you experienced any problems?
• If you are developing a service do you anticipate any problems with discharging patients?