Prolonged hospitalizations for complicated patients with severe infections who need long courses of intravenous antibiotics, are common in many institutions.
Outpatient parenteral antimicrobial therapy (OPAT) is a safe and cost-effective way to administer intravenous (IV) antimicrobial therapy to patients with the potential to decrease hospital length of stay (LOS). OPAT programs train motivated patients in self-administration of IV medications at home, in a stable environment. Ideally, infectious disease (ID) consultation should be involved to determine appropriate candidates for OPAT as well as a suitable drug regimen and duration of therapy.
Alison Beieler
A potential barrier to successful utilization of OPAT programs is the need for stable housing at discharge for home infusion services.
Challenge facing homeless patients
There is very little published data regarding the use of OPAT at a medical respite facility for homeless patients. This may be due to perceived concerns of difficulty in administering OPAT to these disadvantaged patients for multiple reasons such as unstable or no housing, inability to stay engaged in medical care, and underlying mental illness and substance abuse problems. In particular, active substance abuse, specifically injection drug use (IDU), is a significant problem.
Traditionally, homeless patients requiring ongoing parenteral therapy have remained inpatient for the duration of their course, which can cause significant inpatient discharge delays and increased LOS. Recommending long-term parenteral therapy as an inpatient for all patients who are homeless or have a history of IDU can lead to prolonged hospitalizations, increased health care costs and contribute to conflicts between patients and staff.
Our study, recently published in the Journal of Hospital Medicine (J Hosp Med. 2016 Apr 27. doi: 10.1002/jhm.2597), aimed to evaluate our experience with administering OPAT to homeless patients at a medical respite facility and to determine if patients could complete a successful treatment course of antibiotics for a variety of illnesses.
We demonstrated that 87% of homeless patients were able to complete a defined course of antibiotic therapy, and 64% were successfully treated with OPAT at medical respite. To our knowledge this is the first study evaluating this specific population (including those with homelessness, mental illness, substance abuse) in which OPAT was received at medical respite.
Our rate of adverse events was 7%, similar to other OPAT studies in the published literature. Our total readmission rate of 30% was similar to what current literature suggests. Our data suggest that providing OPAT to homeless patients is feasible at a medical respite facility with care coordination between members of a multidisciplinary team, including nursing, home infusion pharmacist, and ID clinic.
Partnering with medical respite programs is important, as home infusion services are not available otherwise to homeless patients. The recommendation for ID consultation is beneficial to determine candidacy for OPAT, including close scrutiny of social behaviors in the OPAT patient selection process, and can assist with transitions in care from inpatient to outpatient setting.
Homeless IDU patients remain a challenging population to treat with long term IV antibiotics. However, in certain circumstances, IDU alone may not be a reason to fully exclude someone from OPAT candidacy. Careful review of substance abuse history and evaluation of psychosocial factors are needed. Furthermore, an evaluation of the patient’s willingness to comply with care agreements while inpatient and at medical respite, and ensuring appropriate resources for chemical dependency treatment are needed. Early consideration of oral antimicrobial options if the patient is readmitted for complications/non-adherence should be encouraged.
Medical respite programs
Treating homeless IDU patients with OPAT is possible under close supervision at medical respite. Our patients sign an agreement to refrain from using their IV access for drug use. Security seals are used on all connections and tubing to prevent tampering. The IV access sites are inspected daily, and ID providers are contacted to discuss any patients suspicious of tampering with their IV to determine plan of care – either readmission or transition to oral antibiotics.
Medical respite programs are gaining in popularity in the United States. Medical respite can help engage patients in follow-up care and provide linkage to housing, mental health, and chemical dependency services. Many programs support harm reduction IDU practices and offer referrals for substance abuse treatment programs, which are not typically offered during inpatient admission in most hospitals.
Medical respite may continue to be a site of OPAT expansion, as there is continued pressure to discharge nonacute patients from the hospital. Moving forward, it may be beneficial for hospitals, public health departments, and communities to support these programs, which can assist with close monitoring of homeless patients receiving OPAT.