Without gathering enough information, the agency accepted a 66-year-old woman with a fungal pneumonia, human immunodeficiency viral infection, and renal insufficiency who was scheduled to receive Ambisome (amphotericin B, liposome) for 14 days. The recommended infusion time for this medication is 120 minutes (Astellas Pharma, 2007a). The orders on the referral were as follows:
- Premedications: acetaminophen 325 mg PO and diphenhydramine 50 mg PO.
- Flush peripherally inserted central catheter (PICC) with 10 mL normal saline (NS).
- Administer 500 mL bolus 0.9 NS over 90 minutes.
- Flush PICC with 10 mL 5% dextrose/water.
- Administer Ambisome (amphotericin B liposome) 250 mg in 250 mL 5% dextrose/water at 125 mL/hr.
- Flush PICC with 10 mL 5% dextrose/water.
- Administer 500 mL bolus 0.9 NS over 90 minutes.
- Flush PICC with 10 mL NS followed by 5 mL of heparin 100 units/mL.
The drug is high risk. Potentially life-threatening adverse events, including dyspnea, hypoxia, hypotension, tachycardia, chest pain, sepsis, gastrointestinal tract hemorrhage, and pleural effusion can occur in clients receiving amphotericin B (conventional or liposome preparations) (Astellas Pharma, 2007a, 2007b). Therefore, it would have been inappropriate to leave the client's home during administration on the first visit—even though the client received the first dose of the medication in the hospital. In order to provide care in a safe and prudent manner for this client, a minimum of 5 hours was required to administer the boluses and medication. Additional time was needed for teaching and the admission process—the initial visit lasted a total of 6.2 hours
This case was further complicated by the fact that the capable, willing caregiver (the client's daughter) was quite ill herself, so it was necessary to teach the client's 16-year-old granddaughter to administer the intravenous (IV) infusion as well. The agency was not aware that the adult caregiver was ill until the admission was in progress.
Four additional, lengthy follow-up visits were required (for a total of 14 hours) to ensure safe/competent caregiver performance and client safety. At $40 per hour in salary and benefits, the direct care cost for this client was $808 for the first 5 days of treatment. Thirteen client visits (at a total cost of $180 per visit) had to be reassigned to other RNs. The total cost of care for the first 5 days was $2,340. During the admission assessment, the nurse found the client to be very weak and debilitated—and several additional comorbidities were identified. Despite this, she was able to demonstrate independence in activities of daily living and her overall functional status was high, so therapy was not ordered or needed. Projected reimbursement based on the Medicare prospective payment system case mix classification, home health resource group code was not consistent with the patient's needs. The cost of care exceeded Medicare reimbursement for the case before the first week was finished.
The Benefits of Infusion Cases
The purpose of the above case history is not to discourage agencies from accepting IV infusion cases, but rather to assist agency personnel in evaluating the appropriateness of each referral. Home infusion therapy is a wonderful alternative for clients who would otherwise require ongoing facility-based nursing care or daily travel to an infusion center. In addition, clients who are extremely ill due to an infection often get well quickly and seldom require intense care for long periods. For the most part, providing client support for infusion therapy is a win-win situation for client and agency.
Sophisticated technologies, such as elastomeric infusion pumps, make it simple for clients and caregivers to learn the skills (Skryabina & Dunn, 2006). Even the more complicated electric pumps used in home health can usually be mastered by caregivers with relative ease. In addition, nurses typically enjoy the challenge of teaching clients and caregivers to perform these high-level tasks. So, in most cases, accepting a client requiring home infusion is an easy and good decision.
Providing home infusion therapy is high risk, especially if clients/caregivers and staff members are not appropriately educated to address possible complications. And complications do occur; Cox et al. (2007) reported that 57 (27.8%) of the 205 clients in a study of IV antibiotic home infusions with PICC lines or peripheral IV lines experienced catheter-related complications, including occlusion, accidental removal, irritation from the dressing, site infection, bacteremia, and phlebitis. In another study that was designed to evaluate the impact of IV therapy on ability of 92 home care clients to self-perform activities of daily living, the authors reported that 40.2% of patients with PICC lines or peripheral IV lines experienced a complication, such as infiltration, phlebitis, embolism, leaking at the insertion site, accidental disconnection, catheter occlusion, dislodgement, or loss of dressing occlusion (O'Halloran et al., 2008).
Catheter-related bloodstream infection (CRBSI) is one of the most serious possible complications for any client with an intravascular device. In an Australian study of 273 oncology clients with a Hickman catheter, 61 (22.3%) developed a CRBSI (Chee et al., 2008). In a Spanish study of 1,018 episodes of bloodstream infection with a documented cause, 14% were due to an intravascular device (Valles et al., 2008). A U.S. study identified that presence of a central venous catheter in a hospital/acute care setting was one of the top five risk factors for nosocomial bloodstream infection and that once bloodstream infection did occur, 20.6% died (Al-Rawajfah et al., 2009).
In the home environment, unskilled and exhausted caregivers are sometimes injecting solutions into ports. Thorough teaching is clearly a priority. In spite of the complicating factors, relatively low rates of CRBSI in home care have been reported. Leone and Dillon (2008) recorded an infection rate of only 0.24 per 1,000 patient days in a retrospective study of 2.4 million home infusion catheter days. In a study of 231 cases of antibiotic infusions in 205 patients, Cox et al. (2007) reported a rate of 0.76 per 1,000 IV days for clients over 60 years old and 0.23 per 1,000 days for those under 60.
The serious and life-threatening consequences of CRBSI, however, mean that it is important that we strive for an infection rate of zero. Before accepting an infusion referral, the agency should assure that all staff members assigned have been appropriately educated and are competent to perform the skills and client teaching necessary (McGoldrick, 2009).
The nurse should also be thoroughly familiar with the drug and complications that may occur. In the Cox study, 24 of the 205 patients experienced blood dyscrasias, 10 developed nephrotoxicity, and 8 demonstrated a rash (Cox et al., 2007). The nurse should always assure that the client is able to tolerate the medication without adverse effects before leaving the home. As some reactions occur after infusion, teaching on possible complications and appropriate interventions is imperative. With drugs administered directly into the vascular system, there is little warning when allergic reactions and serious adverse effects occur. Clients and caregivers need to know what can happen and exactly what they should do if an adverse event occurs.
The nurse assigned to an IV case needs to be prepared to provide intensive, planned, organized, and effective teaching during the admission visit. Client teaching materials should be made available to the client and caregiver at that time and reviewed regularly on subsequent visits. A client teaching sheet containing critical information (Figure 1) and a drug-specific handout should be reviewed during initial visits. Until the nurse can document that the caregiver has safely and correctly demonstrated these skills without reminders or prompting, the nurse should be present to directly observe NS and heparin flushes, reconstitution of medications, addition of additives, and initiation of IV medication or parenteral nutrition. The nurse should also be present to observe disconnection until safety with that skill set is documented. For a 12-hour, overnight total parenteral nutrition (TPN) case, that may mean visits at start-up and disconnect for a couple of days. Client/caregiver teaching and response to instruction should be documented using a form similar to that found in Figure 2.
Issues to Consider Before Accepting a Client Referral
Adequate information is needed from the referral source before the agency makes a decision on any particular infusion referral. Follow-up calls and playing telephone tag wastes everyone's time, so a systematic method for obtaining all of the necessary information at first contact is invaluable. If a screening process is not already in place, consider adapting the form shown in Figure 3, for IV referrals, used in combination with the agency's standard referral form. The following considerations are likely to assist agency decision makers to accept or reject a specific IV infusion case.
- Does the agency have the RN expertise necessary to intensively teach this particular client and/or caregiver to safely and correctly administer the given drug or infusion?
- Will all staff who will care for the client or be on-call be prepared to address the needs of the client should a complication occur?
- Is all staff familiar with the type of IV access and equipment?
- Can all on-call staff insert a peripheral IV line (if appropriate) should something happen to the central line, so that therapy is not interrupted?
- Are appropriate policies/procedures and CRBSI surveillance methods in place? See McGoldrick (2009) for further guidance.
- Have all staff been appropriately educated on policies and procedures to prevent CRBSI and has competency been documented?
- How will this case affect agency resources? How will accepting this case affect care for other clients and the ability to accept other cases?
- What are the real costs for this case? Include salary, benefits, driving time, additional time required for labs (long visits for peak and trough levels, time to transport labs), case coordination time, and costs of reassigning other clients.
- Will the insurance authorized visits allow the client's needs to be met safely? Is it possible to negotiate with the insurance company to pay for two visits for the same day to start and discontinue a medication if the infusion requires that the nurse be in the home for several hours?
- Does this type of visit impact nurse satisfaction positively or negatively and how will nurse satisfaction impact the agency overall? Do the nurses enjoy complex, challenging visits where extensive teaching is needed? Do they feel adequately prepared to meet client/family needs for this type of visit? Are they frustrated because long, involved teaching visits make it harder to meet weekly visit quotas? Can the agency realistically address staff concerns in time to appropriately care for the referred client?
- How important is it to maintain or develop a relationship with the referral source? If this is the top referral source and the client can safely be cared for, the cost of care may be less important than keeping the referral source happy.
- Is there a capable and willing caregiver who will be able to learn? Is the agency prepared to address the client's care needs if the caregiver turns out to be neither capable nor willing? If possible meet with the caregiver while the client is still in the facility.
- What are the obstacles to learning? Can the client/caregiver read, write, hear, see, and understand complex information?
- Are there cultural and language considerations that will impact whether client needs can be met at home? Can these factors become obstacles to compliance if not addressed?
- Given the client's overall condition, will it be safe to administer the specific medication in the specified volume of fluid at the rate prescribed, within the home?
- Should preexisting chronic diseases such as diabetes mellitus or congestive heart failure be considered when decisions are made related to the brand of drug, volume to be administered, and solution the drug is prepared in? For example, there are a number of IV immunoglobulin (IVIG) preparations available. Brand names that do not contain sugars may be more appropriate for those with diabetes than those that use sugars to stabilize the drug. Brands that are more concentrated may be more appropriate for clients on fluid restrictions than those that are more diluted (Kirmse, 2009). Is a conversation with the dispensing pharmacist needed?
- Is the home setting appropriate for this type of care? Is it unusually dirty? Is there insect or rodent infestation? Is running water available? Is adequate lighting available? Is there a clean area for supply storage? Is appropriate refrigeration available?
- When and where were prior doses given and were there any adverse events identified?
- Request information related to the dosage and obtain prescribing information for the specific brand name before accepting the case. Do not depend on the referral source to provide all of the information accurately as individuals in discharge planning roles have varying skill levels and credentials. For some drugs it is best to speak directly with the pharmacist from the infusion company.
- How long will the infusion be administered for this client? For example, IVIG is typically administered over 2 to 4 hours, depending upon the dose, the client's previous tolerance to the infusions (Kirmse, 2009), and the recommended rates for the given brand of IVIG. Will it be a 2-hour infusion or a 4-hour infusion for this client?
- Are there other issues to consider with this infusion? For example, when teaching the client/caregiver to administer TPN, the nurse will also need to assure that the client has a glucometer and is capable of using it at the frequency prescribed and that insulin coverage can be administered safely and correctly as well.
- Is it safe to administer this medication via the proposed route (peripheral IV or central venous line) in the home? In this case? For example, peripheral IVs are very cost-effective and safe for therapy lasting 7 days or less (Gorski, 2009a). There are, however, other times when the obstacles to reinsertion (such as extreme obesity) and subsequent risk of missed doses and infection (due to inability to change sites, previously identified compliance issues, etc.) exceed the potential benefits.
- Is there a risk of tissue damage due to extravasation? Has documentation of central line tip location via chest X-ray been provided (Gorski, 2009b)? Extravasation can occur if the tip of a PICC migrates (Hertzog & Waybill, 2008), so it is important to check the site to make sure that the catheter has not been displaced before each infusion.
- Will a blood pressure cuff and stethoscope allow for adequate monitoring or is a cardiac monitor/electrocardiograph machine required to be safe? Is a pulse oximeter needed and do all of the staff members have them?
- What type of rate regulation device will be used? Based on verbal feedback from practicing home care nurses, elastomeric pumps are the easiest type of device for clients to learn to use, whereas dial-a-flow/minibag systems and electric pumps take longer to learn. Is it possible to change to an easier device?
- Are the client and caregiver capable of identifying and addressing potentially life-threatening side effects for this medication in a timely manner?
- Will the client require immediate transfer to a hospital if equipment failure prevents continuous drug infusion? Can the local emergency medical system respond in an appropriate period?
Providing in-home infusion therapy can be a win-win situation for both client and agency, but these cases should not be accepted without careful consideration of all of the above factors. Asking the questions that need to be answered before accepting the case is important in determining whether or not the agency can provide safe, cost-effective, high-quality care to any given client in a fiscally responsible manner.
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