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Referral to first dose: mapping the handoffs where OPAT patients get stuck

The interval between referral and first outpatient dose is the cleanest measure of whether an OPAT program works. A map of where the days go.

6 min readGrowInfectiousDisease editorial

A pharmacy compounding hood with a sterile preparation tray, empty and lit from within.

The short version

  1. 1Each handoff is a queue; queues are where days accumulate.
  2. 2Coverage determination should happen at intake, not after a therapy plan is built.
  3. 3Vascular access and pharmacy readiness are frequently the binding constraints.
  4. 4Measure the median and the tail — the worst decile is where the clinical risk sits.

Referral to first dose is the OPAT metric that captures almost everything: coverage, authorisation, access, pharmacy, nursing and communication. When it drifts, one of those is failing — and the interval tells you to look before a patient event does.

The handoffs

  1. Referral received → triaged. Who reviews, within what window, and what happens out of hours.
  2. Triage → coverage determination. Insurance verification and site-of-care eligibility. This must come early: a therapy plan built before coverage is understood frequently has to be rebuilt, and that rework is where whole days go.
  3. Coverage → authorisation. Submission, criteria documentation, and escalation to peer-to-peer where required.
  4. Authorisation → vascular access. Arranged, placed, confirmed. Commonly a binding constraint, and dependent on a service you may not control.
  5. Access → pharmacy readiness. Drug sourced, compounded or delivered, supplies in place.
  6. Pharmacy → nursing. Home nursing scheduled, facility slot confirmed, or infusion chair booked.
  7. Nursing → first dose. Delivered, documented, monitoring schedule started.

How to find your constraint

Timestamp each handoff for twenty consecutive referrals. Do not estimate; measure. The step with the longest median wait is your constraint, and the step with the widest variance is your reliability problem. They are often different, and they need different remedies — capacity for the first, process for the second.

Measure the tail

Report median and the ninetieth percentile. A program with a good median and a long tail is a program where a small number of patients wait a clinically meaningful time, and those are the patients most likely to be readmitted or lost. The tail is where the safety story lives.

The intake rule worth adopting

Determine coverage and site-of-care eligibility at intake, before the therapy plan is finalised. This single sequencing change removes the most common source of rework in OPAT, because it stops the program from designing plans that the patient's insurance was never going to support.

Sources & further reading

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