Background: The opioid epidemic is a well-recognized, national public health emergency. Patients admitted to the hospital with complications of opioid use disorder (OUD) often have complex infections which frequently require lengthy courses of intravenous (IV) antimicrobial therapy (1). Many in the medical community have valid concerns about patient safety and risk of central line misuse in these situations; consequently, many patients remain hospitalized for the duration of their antibiotics courses, leading to high costs and dissatisfied patients (1). We developed criteria to determine if certain hospitalized patients with OUD could be safely discharged with outpatient parenteral antimicrobial therapy (OPAT).
Purpose: Project COMET (Caring for patients with Opioid Misuse through Evidence-based Treatment) is a comprehensive, multi-disciplinary program that seeks to improve care of hospitalized patients with opioid use disorder (OUD). Within the framework of this program, we sought to identify criteria which would support earlier discharge from the hospital with OPAT.
Description: We launched Project COMET July 1, 2019 after obtaining funding from our health system and meeting with various key stakeholders, including Infectious Disease (ID). In collaboration with our ID colleagues and after reviewing relevant literature (2-4), we created a list of criteria for discharge home with IV antibiotics to be administered via a Peripherally Inserted Central Catheter (PICC) line under the supervision of a home health agency. These criteria included 1) stable living conditions; 2) supportive caregiver; 3) active engagement with providers while hospitalized; 4) readiness to change and stop substance use as determined by social worker; 5) no evidence of ongoing or suspected drug use during current hospitalization; 6) no transportation barriers to outpatient appointments; 7) willingness to sign a contract with home health providers for safe PICC use; 8) providers feel that patient will be safe with home IV antibiotics. Using these criteria, we have discharged seven patients home with OPAT in the four months since we started our project. Six of these patients have completed therapy with one still receiving OPAT. Among these seven patients, we have had no readmissions and there have been no concerns documented for antimicrobial treatment failure or PICC misuse. There is documentation of several missed antibiotic doses, one missed ID follow-up appointment, and one Emergency Room visit during the treatment period. These findings are consistent with other published literature showing high rates of OPAT completion, even in higher-risk populations (2, 5). In our cohort, a total of 184 hospital days were saved due to earlier discharge.
Conclusions: A collaborative approach is necessary for optimal care of hospitalized patients with OUD. Many patients with OUD are hospitalized with complex infections requiring lengthy courses of IV antibiotics. A risk assessment tool with eight simple criteria can identify patients who will likely be successful with OPAT with home health and outpatient ID supervision. We hope other institutions can use these criteria to identify patients who may be able to be discharged home earlier, leading to length of stay reductions. This can translate into significant cost savings and improved patient satisfaction. More research is needed to determine the longer-term outcomes of this approach.