ABSTRACT
ContextA collaborative clinical pathway developed between North Bristol NHS Trust (NBT), University Hospitals Bristol and Weston NHS Foundation Trust (UHBW) and Sirona Care and Health under the umbrella of Healthier Together @Home, Bristol North Somerset, and South Gloucestershire Integrated Care System (ICS).Multi-professional team including project management, nursing, pharmacy, infectious disease/microbiology and medical leaders, operational managers, finance, and HR teams collaborated to implement a new system-wide outpatient parental antimicrobial therapy (OPAT) pathway.Issue/ChallengeIssue: System partners had variation in access to OPAT. This was due to the number of staff with appropriate clinical skills (due to turnover and vacancies) available to deliver intravenous (IV) antimicrobials in a person's usual place of care rather than in an acute hospital. System pressures due to capacity not meeting demand, issues with flow and a need to increase elective capacity were significant drivers for change.Challenge: To develop an OPAT pathway with a truly collaborative approach, recognising the different organisations have varying competing services and plans. To develop, through a test and learn approach, an appropriate workforce model and identify additional opportunities to widen the scope of delivery @Home.Assessment of issue and analysis of its causesSystem group formed building on relationships developed through Covid Virtual Ward. Driver diagram completed with clinical and operational leads from the system, developing a shared vision. Clinical audit data alongside pre-existing activity data used to scope demand.Key stakeholders included in the design phase including medical & nursing staff, pharmacy, venous access teams, community nurses, operational managers supporting flow in the hospitals and in the community, project managers, recruitment teams and digital colleagues.Communication plan evolved to support teams understanding of the new pathway and its benefits. Additionally, this supported promotion of the service and helped gain executive support.ImpactBetween November 2021 and June 2022 (8 months) the integrated OPAT model received 160 referrals requiring varied levels of interventions from once-a-day administration or elastomeric 24-hour devices to three times a day delivery. Over 1600 bed days (7 full beds). Representing a value for money saving (if beds were used for elective recovery as proposed) of £345,000.The project had a phased approach starting with step down from hospital. The second phase is development of a step-up model, providing alternatives to hospital admission.InterventionThis project has demonstrated how system leadership can work across organisations through collaboration, joint vision with no one organisation in a lead role. Clinical leads from had a clear remit to develop collaborative working and engage the appropriate stakeholders. Multiple styles of leadership were used by different people within the project group helping inclusivity. Diversity of thinking with a multi-professional group helped the project address issues raised during the testing and learning phase and subsequently. Project management has been key, bringing the right people together with good transformation tools.Leadership was demonstrated by different professionals with a less traditional hierarchical structure. This enabled effective challenge and communication to happen to support progression. The 3 nursing teams co-led development of shared pathways and Standard Operating Procedures, taking time to understand other ways of working, whilst sharing knowledge and supervision. This has been particularly useful when supporting some of the more ‘wicked' problems such as sharing of information, handover, and governance without a shared electronic patient recordInvolvement of stakeholders, such as patients, carers or family members:Patient reported experience (n=48 to date) highlights high levels of satisfaction:Based on the care you, received, how would you rate the service? (Scale 1 â€' 10 high) 9 4 meanHow likely are you to recommend the service? (Scale 1-5 high) 4.6 meanKey MessagesSupportive, Compassionate and collaborative leadership, not competitionPsychological safety harnesses trust and honestyCo-creation of pathways leads to trust, shared knowledge and trainingClinically led meetings support delivery and ensured focus on alignmentDevelopment of a shared governance approach ensures learning from eventsDevelopment of shared communication tools ensured visibility of the serviceMeasurement of improvementPatient satisfaction and increased number of days patients spent at homeStrategy for improvementAn iterative, collaborative process with regular meetings of the core leadership and delivery team to capture lessons learnt, highlighting success and agree actions to resolve challenges.
ABSTRACT
Macrolide antibiotics are well known for their antibacterial properties, but extensive research in the context of inflammatory lung disease has revealed that they also have powerful immunomodulatory properties. It has been demonstrated that these drugs are therapeutically beneficial in various lung diseases, with evidence they significantly reduce exacerbations in patients with COPD, asthma, bronchiectasis and cystic fibrosis. The efficacy demonstrated in patients infected with macrolide tolerant organisms such as Pseudomonas aeruginosa supports the concept that their efficacy is at least partly related to immunomodulatory rather than antibacterial effects. Inconsistent data and an incomplete understanding of their mechanisms of action hampers the use of macrolide antibiotics as immunomodulatory therapies. Macrolides recently demonstrated no clinically relevant immunomodulatory effects in the context of COVID-19 infection. This review provides an overview of macrolide antibiotics and discusses their immunomodulatory effects and mechanisms of action in the context of inflammatory lung disease.