Sara Keller remembers the concern she felt when patients who were receiving long-term intravenous antibiotic therapy at home for infections after heart valve surgeries and joint replacements would be readmitted because of communication slipups.

“In the hospital, some of these patients got daily blood draws and had very frequent monitoring of the levels of drug in their body,” says the Johns Hopkins infectious diseases physician. “At home, some of their weekly labs could be missed because they were not being received by the appropriate teams in this timely fashion.”

She believes that without the structure and safety procedures of the inpatient world, treatment outside the hospital requires a multidisciplinary team of health-care professionals to ensure patients are getting the appropriate care.

Designed to meet this goal, the Outpatient Parenteral [Intravenous] Antimicrobial Therapy (OPAT) Service was launched at Johns Hopkins in 2021. Since then, it has treated more than 3,700 patients, mostly from East Baltimore, according to Keller, who serves as its medical director. In three years, the OPAT team has lowered hospital readmissions from nearly 30% to 18%.

The program is a collaborative effort among The Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, the Department of Medicine’s Division of Infectious Diseases and Johns Hopkins Care at Home. The program's success lies in evidence-based practices founded in a decade of Keller's research on health care quality improvement, which has been largely supported by more than $25 million in grants from the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality at the U.S. Department of Health and Human Services.

“In addition to physicians, our team members include nurses and infectious diseases-trained pharmacists who can help with things like therapeutic drug monitoring and adjusting drug levels,” Keller says. “We also have members of the team who are medical office coordinators and pharmacy technicians.”

Such supervised collaboration allows patients to recover safely at home or at a skilled nursing facility while avoiding the cost of longer hospitalization and the risk of acquiring other infections.

Keller has spent years studying ways to improve this process. After completing her residency in internal medicine at Johns Hopkins, she completed fellowships in infectious diseases at the University of Pennsylvania and at the Penn Center for Healthcare Improvement & Patient Safety. When she returned to Johns Hopkins, she started building a team of physicians, nurses and pharmacists who could work together in post-discharge follow-up care, monitoring medication toxicity and adjusting therapy if needed.

“Our patients have many different comorbidities — everything from heart failure, necessitating ventricular assist devices, to very poorly controlled diabetes,” she says. “About 10% also have a history of substance use disorders, and we have collaborations with addiction medicine about how best to manage them.”

Patients discharged to skilled nursing facilities also require attentive care coordination, points out Paul Auwaerter, Johns Hopkins’ clinical director of infectious diseases. “We don’t really have privileges at these facilities, yet care is being rendered there by in-house physicians who don’t have our expertise as infectious disease physicians. Fundamental to the success of OPAT is excellent communication among clinicians and nursing and pharmacists, regardless of the treatment location.”

Auwaerter says the service has also removed some of the physicians’ workload by providing highly skilled nurses and pharmacists who can quickly review test results and respond to calls.

“The improved communication and the ability to help supervise treatment on all levels really complement one another for the patient.”

Affiliated with the Armstrong Institute for Patient Safety and Quality, Keller also directs the Patient Safety and Quality Improvement pathway for the Department of Medicine’s residency program.

As part of OPAT’s ongoing quality improvement efforts, Keller is researching how to prevent central line-associated bloodstream infections in patients needing antimicrobial therapy. Additionally, she is evaluating the experience of patients who are discharged and have to continue complicated regimens of oral antibiotics outside of the hospital setting.

“We’re looking into how to incorporate those people into the program, as well as continuing to work with addiction medicine and case management to build additional supports for our patients,” she says.