Ambulatory intravenous antibiotic therapy in Quebec : The Hôpital Charles LeMoyne experience in 1996

Department of Infectious Diseases, Hôpital Charles Le Moyne, Greenfield Park, Quebec Correspondance and reprints: Dr Laurent Delorme, Département de Microbiologie Infectiologie, Hôpital Charles LeMoyne, 3120 boul Taschereau, Greenfield Park, Québec G4V 2H1. Telephone 450-466-5000 ext 2835, fax 450-466-5778, e-mail laurent.delorme@videotron.ca L Delorme, C Frenette, I Le Corre, J Duchesne, C Delorme, P Plourde. Ambulatory intravenous antibiotic therapy in Quebec: The Hôpital Charles LeMoyne experience in 1996. Can J Infect Dis 2000;11(Suppl A):6A-10A.

O utpatient intravenous antibiotic therapy was introduced to the province of Quebec through pilot studies initiated in Quebec City from 1984 to 1987 (1)(2)(3).The pilot studies were set in university hospitals, using multidisciplinary teams comprising an infectious disease specialist, a pharmacist, a nurse trained in venous access and a hospital administrator.The infections most commonly treated were osteomyelitis and septic arthritis, and great cost savings were achieved.However, new alternatives to hospitalization were slow to be developed because of fixed budget rules and no incentive to support outpatient services.
In 1995, a major health care reform called 'défi qualitéperformance' (4) was initiated by each regional health board.This initiative planned to decrease public hospitals' budgets and the number of beds to liberate new funds and achieve a major medical/surgical 'virage ambulatoire'.This reform allowed the promotion of less costly alternatives to hospitalization, such as outpatient intravenous antibiotic therapy.In the Monteregie region, a large area of 1,307,423 people, situated on the south shore of Montreal, this health reform was applied to 10 community hospitals located in the region.Almost every community hospital initiated a local outpatient intravenous antibiotic program as part of their hospital reform.We present the experience of the largest hospital in Monteregie, the Hôpital Charles LeMoyne.

PROGRAM DESCRIPTION
The Hôpital Charles LeMoyne is a 436-bed, acute care hospital with a major emergency centre and a regional trauma centre.It provides basic care to a population of 450,000 people and receives 60,856 visits per year to the emergency department; 80% of the 14,856 admissions went through the emergency department in the 1994/95 fiscal year.Pressure to access care is very strong for patients who are cared for by 64 general physicians and 136 active surgical/medical specialists.In 1994/95, the hospital per diem cost was $412/day, and the annual closed budget envelope for Hôpital Charles Le Moyne was $93 million.
To generate a rapid and significant impact on cost, infectious disease specialists and organizers of the outpatient antibiotic intravenous therapy program requested the participation of a large proportion of the medical/surgical staff.Infectious disease specialists thought that outpatient antibiotic intravenous therapy had been well studied and successful results had been published (5)(6)(7)(8)(9).They also thought that the Canadian guidelines (10) could be used to teach active medical/surgical staff at Hôpital Charles LeMoyne.The infectious disease specialists asked for the same professional support from hospital nursing and pharmacy for outpatients as received by inpatients.The infectious disease specialists also believed that with proper professional support and simple, locally established guidelines, medical/surgical staff would participate together as a group in the 'virage ambulatoire' as primary providers of an alternative to hospitalization and promote the early release of patients from hospital beds or stretchers in emergency corridors.
An ad hoc committee was created to prepare the program and establish local guidelines.Nurses prepared a venous access program.Pharmacists prepared written information for patients on intravenous antibiotics, and safety and preparation procedures for each intravenous antibiotic.Infectious disease specialists defined indications (eg, a stable patient) and contraindications (eg, an intravenous drug user) for outpatient intravenous antibiotic therapy.They prepared a list of the antibiotics of choice, with recommended dosage and dosing intervals.For example, they selected cefazoline every 12 h with probenecid (Benemid, Merck Sharpe & Dohme Canada, Kirkland, Quebec) (11), use of once daily aminosides (12), the use of clindamycin (Dalacin C, Pharmacia & Upjohn Inc, Mississauga, Ontario) 1200 mg every 12 h (13) if minimum inhibitory concentrations of isolate bacteria were low.As another example, intravenous use of ciprofloxacin (Cipro, Bayer Inc, Toronto, Ontario) and metronidazol were restricted because of good bioavilability (more than 80%) (14).Infectious disease specialists prepared a routine set of blood tests for toxicity surveillance and recommended drug dosages for each order of intravenous antibiotics (15).
Within three months of the decision to begin the program, an intrahospital ambulatory unit, which occupied a two-bed room in the hospital, was staffed by a nurse seven days/week from 7:00 to 21:00.The unit was supported by a part-time pharmacist and a part-time pharmacist technical assistant.A telephone number for the program was given to each patient admitted to the program.Calls were handled directly by the nurse.The objective of the intrahospital ambulatory unit was to provide an alternative to hospitalization equivalent to 4.5 beds/year and 1.5 stretchers in emergency corridors/year (the equivalent to 2190 bed days/year).
The admitting physician was the acting physician unless another physician had agreed to take charge of the patient on the following day.Nurses evaluated each patient referred to the unit for mobility, learning ability and past medical history, such as intravenous drug use.Nurses attended to venous access, on-site perfusion, self-administration teaching, and surveillance of bloods tests and side effects.Pharmacists gave information to patients about medications and side effects, and looked for allergies and drug interactions.Pharmacists also checked drug dosages and prepared antibiotics.They also called admitting physicians for verification or a change of prescription when the prescriptions did not conform to locally established guidelines.The program followed differed depending on whether short (two to five days) or long term intravenous antibiotic therapy was prescribed.With short term treatment, the unit served more as an infusion unit and antibiotics were administered in the unit.For long term treatment, the unit provided education and support, and antibiotics were self-administered at home.For patients on long term therapy, vascular radiologists inserted peripherally inserted central catheter (PICC) lines (mainly Groshong, Bard Canada Inc, Mississauga, Ontario) to allow selfadministration of medication with mechanical pumps or programmable pumps.

RESULTS
The results of the first year of operation of the ambulatory care unit, January 1, 1996 to December 31, 1996, are described below.Over that period, 343 patients received outpatient intravenous antibiotic therapy, accounting for 2660 outpatient therapy days (Table 1).This represented 15.9% (343 of 2157) of bed admissions and 29.8% (2660 of 8934) of bed therapy days for the infectious diseases department at the Hôpital Charles LeMoyne (Table 2).An impressive 81.6% (280 of 343) patients admitted to the program came directly from the emergency department, or from outpatient hospital clinics or private offices in the community.Hospitalized patients constituted only 18.4% (63 of 343) of admissions to the program.The mean duration of outpatient intravenous antibiotic therapy was 7.76 days.The youngest patient was three years old; the oldest patient was 95 years old (mean age 44.1 years).Cefazolin and gentamicin/tobramycin were the most commonly used antibiotics in short term therapy and in term of number of patients (Table 3).Second-line antibiotics such as ceftriaxone (Rocephin, Hoffmann-La Roche Ltd, Mississauga, Ontario) or vancomycin were used for long term therapy.Total drug acquisition cost was $73,117 and constituted 20% ($73,117 of $373,309) of the total cost of the program (Table 4).Over the first year, 40% of doctors (57 of 143) from the medical/surgical staff participated in the program (Table 5).Infectious disease specialists admitted only 35.6% of patients (122 of 343).Primary care physicians admitted 37.3% of patients (128 of 343).The initial goal of 2190 bed days saved was surpassed; 2660 equivalent bed days were saved.
The per diem outpatient cost was $140/day for the first year versus the hospital per diem cost of $412/day.A saving of

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Can J Infect Dis Vol 11 Suppl A January/February 2000    $272/day (66% of hospital per diem cost) was realized, and an annual saving of $725,000 was generated (Table 6).Nursing costs were $61/day.Pharmacists cost without drug acquisition cost was $22/day.Indirects costs were estimated at $30/day (Table 4).When the data were analyzed more closely, two types of patients were seen (Tables 7,8).One group of patients was admitted mainly by primary physicians for empirical, outpatient intravenous antibiotic therapy for skin or soft tissue, or urinary tract infections.The mean duration of intravenous antibiotic therapy for this group was 3.8 days, with an antibiotic acquisition cost per patient of $51.57(Table 3).This group was largest in terms of the number of patients (n=258), but generated the smallest days in hospital days saved (n=985).Primary physicians cared for 49.6% (128 of 258) of those patients.The other group of patients was admitted mainly by microbiology/infectious disease specialists, and underwent specific outpatient intravenous antibiotic therapy for bone or joint, deep organ or opportunistic infections.The mean duration of intravenous antibiotic therapy was 19.7 days for this group, with an antibiotic acquisition cost per patient of $707.49(Table 3).This group was the smallest in the number of patients (n=85) but generated the largest days in hospital saved (n=1675).Infectious disease specialists cared for 74% (64 of 85) of these patients.
The antibiotics used differed between the groups.The empirical, short term therapy group used mainly cefazolin and gentamicin/tobramycin.The specific, long term treatment group used mainly ceftriaxone and vancomycin.Clindamycin and piperacillin-tazobactam (Tazocin, Wyeth-Ayerst Canada Can J Infect Dis Vol 11 Suppl A January/February 2000 9A Ambulatory IV antibiotic therapy program in Quebec

CONCLUSIONS
At Hôpital Charles LeMoyne, in 1996, we were able to convince a large medical/surgical staff to make a significant change in the practice of intravenous antibiotic therapy.This change significantly affected the daily management of hospital beds and number of stretchers in emergency department corridors.These results confirmed the results of previous pilot studies in the province of Quebec regarding savings, even with different definitions of data.
Our experience showed that two types of patients can benefit from outpatient intravenous antibiotic therapy: a group on empirical, short term therapy, which can be switched to an oral antibiotic after an initial clinical response; and a group on specific long term therapy, for which the therapy results in significant cost savings and significant improvement in the quality of life of those patients.Our experience shows that primary physicians can accept responsibility for empirical, short term outpatient intravenous therapy with first-line antibiotics.Hospitals that want to make a significant impact on hospital bed resources or stretchers in emergency department corridors would be advised to develop an outpatient facility for both groups of patients.

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