CHAPTER 8. Infusion Therapy Across the Continuum
Lisa Gorski, MS, HHCNS-BC, CRNI®, FAAN, Crystal Miller, BSN, MA, RN, CRNI® and Nancy Mortlock, BSN, CRNI®, OCN® ∗
Acute Care, 109
Alternative Site: Outpatient and Long-Term Care Settings, 115
Alternative Site: Home Care, 120
Summary, 125
Infusion therapy is administered in every patient care setting. This chapter is divided into three sections with an overview presenting issues related to acute care and non–acute care settings such as outpatient and long-term care. In the acute care section, the focus is on the implementation of the infusion therapy team. The history of alternative sites for infusion delivery is explored in the alternative site and home care sections. Options for, and advantages of, alternative site infusion administration as well as criteria for safe infusion delivery are addressed.
ACUTE CARE
The challenge in the health care industry in the United States is to deliver the highest quality of care to the greatest number of people, using all available resources in the most cost-effective manner. With each advance in technology and each breakthrough in health care intervention, the challenge becomes greater and the solution more complex. In the past, budget management of a facility was often a matter of determining where and how to use the available funds. Payment was based on charges and fees for services, so attention to volume and operational costs was primary. Higher operational costs and decreased payment have changed the focus of management. As in the past, it is mandatory to the success of an organization for managers to be astute in all aspects of health industry standards. The emphasis for nurse managers has expanded from managing not only care delivery but also the fiscal aspects of health care delivery.
A health care worker from 50 years ago would likely find the current health care system barely recognizable. We have seen a gradual decrease in the number of hospitals in this country. With projected closures, increased expenditures, and dwindling resources, reform was inevitable. The delivery of nursing care has been affected dramatically. One aspect that has felt the greatest impact is the delivery of infusion therapy. Maintaining quality and cost-effectiveness in delivering this aspect of care alone is of great concern. Criteria for the justification of hospital admission often include the clinical necessity for a venous access device (VAD) or an infusion medication. Although it is not a criterion for remaining in the hospital after the acute phase of illness as it once was, it is rare to find a patient who has not had infusion therapy by the end of a hospital stay.
Because registered nurses (RNs) manage most aspects of infusion therapy administration and infusion access, shortages in the RN workforce have led to changes in the way nursing care is delivered. Primary nursing and patient-focused care have placed more demands on the generalist nurse. Many services that were once delivered by specialists, such as infusion therapy, are now the responsibility of generalist staff nurses. The use of nursing assistive personnel (NAP) to assist in tasks has also expanded. In addition to assessing and providing direct patient care needs in the hospital, RNs serve also in the role of case managers, planning for safe and appropriate care beyond the hospital environment. High costs and decreasing reimbursement make earlier discharge to alternative settings a necessity. The demand for providing complicated infusion therapies outside the zones of acute care has expanded the role of the infusion therapy nurse. A high quality of care requires infusion nursing expertise. Clearly in the acute care environment, the specialized skills of an infusion team enhance the process for managing patient care.
Formerly, acute care facilities were reimbursed for the ancillary (versus routine) services provided by an infusion team. This reimbursement provided an incentive for implementing hospital infusion teams. Another impetus to establish such teams was the cost savings realized when infusion care was managed by specialists; there were fewer clinical complications, fewer supplies were used, and procedures were performed more quickly. With the institution of the prospective payment system, direct reimbursement for infusion therapy teams could no longer be assumed and teams were at risk with justification for their services under the close scrutiny of cost-benefit analyses. Maintaining existing infusion teams has often been a challenge for institutions, and establishing new teams even more so, despite evidence of the potential benefits infusion teams provide to patients and facilities.
FOCUS ON EVIDENCE
Impact of Infusion Teams in the Acute Care Setting
• Specialized “IV teams” have shown unequivocal effectiveness in reducing the incidence of catheter–related infections and associated complications and costs (O’Grady et al, 2002).
• A randomized controlled trial examined the incidence of infection when an intravenous team provided infusion services. There were significantly less local and infectious-related complications in peripheral catheters started and maintained by an IV team. The occurrence rate of local complications was 21.7% in catheters inserted by medical housestaff and maintained by floor nurses and 7.9% in catheters inserted by the IV team. There was a 35% overall decrease in infection (Soifer et al, 1998).
• A 12-month descriptive study was conducted to assess the value of services provided by an infusion resource team. Data were analyzed from the 789 consults received for infusion services from a randomized sample of 250 patients. Requests for venipuncture services were received from the noncritical medicine and surgical wards, with 31% requested from the general and vascular surgery wards. Vascular access was fair to good for 50% of the consults, but 39% of consults had poor access. Most consults (81%) resulted in the optimal initiation of peripheral catheters in areas of nonflexion and a 96% overall successful insertion of peripheral catheters (Bosma and Jewesson, 2002).
• A prevalence study was undertaken to assess the impact of a dedicated infusion therapy team on the reduction of catheter-related nosocomial infections. Before establishing an IV team, the total number of bloodstream infections annually was 47; the number of infections decreased to 18 per year after formation of the IV team (Brunelle, 2003).
• A 2-year study conducted at a 300-bed acute care facility supported previous data that personnel specially trained to maintain intravascular devices provide a service that effectively reduces catheter-related infections and overall costs. The implementation of an IV team on medical-surgical units resulted in a decrease in infusion-related bacteremias from 4.6% to 1.5% per 1000 patient discharges, decreased morbidity, and an estimated cost savings of $124,906 (Miller et al, 1996).
• This prospective study explored the impact of a dedicated infusion team on nosocomial bloodstream infection rates in an acute care setting. Before the introduction of an infusion team, the bloodstream infection rate was 1.1 infections per 1000 patient days (p < .01). After the introduction of the infusion team, there was a 35% reduction in nosocomial infections (1.1 to 0.7 infections per 1000 patient days, p < .01), which included a 51% decrease in infections caused by Staphylococcus aureus (Meier et al, 1998).
Acute care organizations are again facing significant changes in reimbursement as a “pay for performance” strategy is being implemented for hospitalized patients whose care is reimbursed under Medicare (i.e., Centers for Medicare & Medicaid Services [CMS]). Effective in October 2008, CMS implemented a plan that limits reimbursement for certain preventable complications. This includes vascular catheter–associated infections. This major change in reimbursement will compel organizations to reconsider the infusion team. Improved outcomes of care including decreased risk of infection led to CDC support for infusion teams in their 2002 practice guidelines (O’Grady et al, 2002).
ORGANIZATIONAL STRUCTURE
To maintain their viability, hospitals have been forced to become more knowledgeable and strategic in business plan development. While some facilities have become casualties, unable to maintain financial solvency with implementation of the reforms, other institutions, recognizing the economic necessity and the potential benefit of changes, have merged to form multifacility health systems. Controlling cost expenditure has forced hospitals to implement strategies that may compromise the quality of care they deliver.
Infusion care delivery models
Advances in health care delivery and related technologies, along with the adoption of more healthful lifestyles, have led to an increase in life expectancy with a subsequent increase in the average age of the hospitalized patient. This older population has frequent acute and chronic illnesses, often requiring complicated therapies, increasing the need for complex care and nursing interventions. Models of care that offer relief for some routine, high-volume tasks that nurses perform are often implemented. Such models often incorporate the use of NAP to provide routine care under the direction of the RN. Of note, while the Infusion Nurses Society (INS) supports the assistance of NAP in routine care, INS does not support the use of NAP in the direct provision of infusion therapy (e.g., catheter insertion, site care, drug/solution administration) (INS, 2009). Computerized systems help the nurse document and communicate aspects of unit management and patient care coordination. Specialized nursing management of infusion therapy has often been delegated to teams of infusion nurse specialists. Infusion specialists offer the means for maintaining consistency and quality in infusion nursing care throughout the acute care facility. Their early assessments and interventions have an impact on the discharge planning of infusion therapy needs. Even the most complicated infusion therapy needs can be met in the outpatient and home settings by these specialists.
With decreased lengths of stay, streamlined resources, and a reduced workforce, nursing is challenged to develop a care model that maintains both cost-effectiveness and quality of care. Reengineering and decentralization continue the transition of many services to the unit level. Skill-mix staffing has moved care delivery from the primary-care model to a patient-focused model.
Today’s professional practice models focus on enhanced efficiency, improved quality, and desired patient outcomes. It is important for the infusion team to function within these models to have the most positive impact on patient care outcomes. The mode of practice is setting and service dependent and contributes to the success of the infusion team and the organization. When the focus of care is quality and patient satisfaction, hospitals operate cost-effectively and safely, reducing the incidence of litigation.
Infusion therapy has moved beyond the realm of technical skills. Today’s infusion nurse provides clinical knowledge and serves as the primary resource for infusion therapy education. What better way to ensure positive outcomes than with a group of specialized nurses whose expertise benefits both the patients and the organization.
Operational designs
Each organizational structural design is associated with distinct advantages and disadvantages that must be evaluated carefully. A major consideration is to enhance the ability of the infusion team to meet its own established goals, objectives, and standards of care while remaining cost-effective. The ability to positively affect the maximum number of patient outcomes must be preserved. The positive impact of an infusion team directly relates to the scope of services offered and the commitment to providing exceptional service while obtaining quality outcomes. Autonomy, accountability, and collaboration are vital for the existence of an infusion department.
For the infusion team to perform at an optimal level and to derive maximum benefit from the infusion nurse’s specialty skills to the patient and the organization, the infusion nurse should be assigned exclusively to infusion-related functions, without crossover into general nursing activities. It is important to note that successful high-quality infusion teams are operating as closed staff units reporting within nursing departments. Advantages may be seen in maximizing the infusion nurse specialist’s collaboration and working in partnership with peers to meet established goals and strategic initiatives. It is important that collaborative relationships be maintained with other departments, such as nursing, infection prevention, case management, and pharmacy. The infusion nurse should be an active participant in the interdisciplinary health care team, and is essential in meeting the patient care objectives of providing timely and effective infusion therapy in the most appropriate setting, without complications.
Some infusion teams are placed under the pharmacy department because of the relationship between infusion therapy and the administration aspects of IV admixtures, solutions, and medications. Delivering IV medications and solutions is an integral function of all infusion teams. An association with the pharmacy affects the organizational structure and the workload responsibilities of the infusion team in various ways. There are other benefits afforded to the team reporting to pharmacy; for example, infusion team nurses gain knowledge about the safe administration of IV medications. An infusion nurse working within the pharmacy department can be an invaluable liaison between two major health care departments.
There are many instances in IV drug and solution administration in which drug compatibilities, characteristics, interactions, and filtration needs require specific administration supplies or venous access. The pharmacy staff benefits from the infusion nurse’s expertise with access devices and their use and maintenance requirements. Knowledge of proper, safe IV medication administration prevents infusion drug–related complications. Interaction with the infusion nurse gives the pharmacy staff the opportunity to participate more directly in infusion-related patient care. The pharmacy director’s membership on the pharmacy and therapeutics committee is an asset to the infusion therapy team, because the committee is often the hospital’s approval body for policies and procedures.
Establishing a collaborative partnership with other hospital departments is essential for an infusion team. In many hospital environments, establishing the communication necessary to ensure this close relationship may not be accomplished easily. In recent years, professional practice models based on shared or collaborative governance have provided an alternative to the hierarchical management structures of most institutions. These practice models provide staff nurses with the opportunity to share the responsibility and accountability for the nursing organization. Committees are established in which nurses from the various areas of the hospital are responsible for activities such as setting standards for their practice, developing policies and procedures, and evaluating the quality of practice and its outcomes. Collaborative governance offers potential advantages for infusion teams inside and outside the nursing department.
The infusion team that actively participates in shared governance models benefits from a strong communication system that would otherwise not be available to an ancillary department. Such involvement offers decision-making opportunities at the unit level and the ability to address hospital-wide concerns. Participation in shared governance activities strengthens the infusion nurse’s ties to the nursing structure, allows increased visibility, and enhances the team’s value to the organization. It provides infusion nurses with the opportunity to have a voice not just about infusion-related issues, but about all facets of nursing. The viability of an infusion team rests on the value the organization places on the department’s contribution to hospital goals, and on meeting department-specific goals.
The Infusion Nurses Society (INS) encourages infusion nurses to collaborate with or participate in committees that regulate the practice of infusion nursing and interact with the members of the health care team to provide safe, quality infusion therapy and care (INS, 2006). Representatives from the infusion therapy department should be active participants in committees such as pharmacy and therapeutics, infection control and prevention, nutritional support, transfusion therapy, safety, quality assurance, and risk management.
SCOPE OF SERVICES
With the majority of acute care patients receiving infusion therapy at any given time, the infusion nurse is an integral part of the nursing process for each patient. The infusion nurse’s role is no longer viewed as a technical position but is one that consolidates knowledge regarding infusion therapy and incorporates sound clinical assessment and intervention into the patient’s care plan. It is essential that the infusion nurse be given time for thorough patient assessment before preparing the patient’s infusion plan of care. When establishing the scope of practice of the infusion therapy department, it is important to evaluate the practice setting carefully, looking at current and potential demands for infusion services. The present scope of services for infusion therapies must be reviewed, the current demand for services and how that demand is being met must be ascertained, and the future demand for services must be carefully estimated. It is important to remember that as the infusion therapy concept gains acceptance from medical and nursing staffs, the demand for services is likely to increase. This increase will affect the demand for existing services and will include requests for more sophisticated technological procedures. Quality management data related to infusion therapy are critical, providing valuable information for determining the essential functions needed to improve infusion care. While infusion teams deliver infusion therapy with a high level of expertise and have a positive impact on the quality of care, it can be difficult to quantify the impact this has on the organization. Quality assurance data for evaluating infusion care are not consistently kept in hospitals without infusion teams and often must be estimated from random checks of individual units or obtained from other facilities of comparable size. Consideration also needs to be given to the scope of pharmacy services currently in place and changes anticipated with the addition of the infusion team. Once these have been determined, the desired team functions and service hours can be better defined.
The ideal infusion therapy department should be staffed to provide the total spectrum of infusion therapy services 24 hours a day, every day of the week. The infusion nurse performs all functions connected with the administration of IV solutions, medications, chemotherapeutic agents, blood and blood components, and parenteral nutrition. Specific responsibilities performed by infusion nursing teams are listed in Box 8-1. Benchmarking statistics to quantify infusion therapy department services, productivity, and patient outcomes are an important function of the infusion team staff. There are compelling data that specialized education lowers the risk of infection and complications associated with vascular catheters (Sheretz, 1999 and Catney, 2001).
Box 8-1
INFUSION NURSING TEAM SERVICES
While many possible services are listed, any combination of services may be provided:
• Venipuncture (as needed)
• Routine peripheral catheter site changes
• Initiation of blood components
• Assistance to physicians in central venous access device (CVAD) insertion
• Routine and as-needed CVAD dressing care
• CVAD blood withdrawals
• Daily peripheral site checks
• Implanted port access
• Declotting of CVADs and peripherally inserted central catheters (PICCs)
• Insertion and maintenance of PICCs
• Insertion and maintenance of specialty peripheral catheters
• Consultation and teaching for long-term CVADs
• Preparation of selected large-volume parenteral solutions and IV medications
• Administration of intraspinal medications
• Care of intraspinal catheters
• Therapeutic phlebotomies
• Participation as member of code team
• Chemotherapy administration
• Care and maintenance of arterial catheters; obtaining blood gases
• Administration of parenteral nutrition
• Evaluation of infusion therapy–related equipment
• Data collection of infusion-related statistics
• In coordination with the pharmacist, consultation on pharmacokinetics scheduling and compatibility issues
• Staff education through clinical validation and inservice training
• Patient teaching for catheter care and home or outpatient infusion therapies
• Provision of outpatient infusion therapies, patient monitoring, and education
In addition to providing a full spectrum of infusion therapy services, the ideal team provides these services to all areas of the hospital. If this is not possible, a realistic alternative is for critical care, emergency department, and other high-volume areas of the facility to provide their own infusion-related care. However, it remains important for the infusion team to be as involved as possible with these areas to provide whatever support is necessary and feasible.
An infusion team’s functions include some type of routine patient service rounds to designated areas of the institution. Rounds by the infusion team may be made routinely, at specific intervals, or a set number of times per shift or day, depending on such factors as the size of the facility, the workload type and volume, and staffing resources.
If the infusion team’s staffing is limited, it may be necessary to designate some of the more routine technical aspects of initiating and maintaining infusion care to the staff nurse. The nursing staff must be educated regarding the functions of the infusion therapy department and be clear as to their own responsibilities regarding their patients’ infusion therapy needs. Regardless of functions performed by the infusion team, every nurse is responsible for routine monitoring of a patient’s IV site and infusions, and for ongoing patient assessment of the response to the therapies delivered. This monitoring, as described in the Infusion Nursing Standards of Practice, should be related to the patient’s condition, age, and practice setting and should follow established infusion therapy policy and procedure. An infusion team’s functions may include routine site checks performed on each shift or selected shifts, but the staff nurse must perform site checks in the interim, and initiate appropriate nursing interventions as necessary.
MANAGEMENT CONSIDERATIONS
The organizational structure and the roles of the various managers and staff members who constitute the infusion team vary depending on the size of the department and hospital, functions and services provided by the team, hours of service, and budgetary constraints. It is critical to ensure that an infusion team has precisely the right staff and is the right size to perform its services. Typically, infusion teams consist of a management or supervisory position, nursing staff, and an educational coordinator. However the team is organized, concise position descriptions for all members of the team are essential and should be reviewed annually and revised when necessary.
Staff qualifications
Entry-level requirements for the RN entering the infusion nursing specialty include current licensure and successful completion of an organized program of study on infusion therapy, including the opportunity to apply principles and practices of infusion therapy (INS, 2006). INS also recommends, but does not require, the bachelor of science degree in nursing. For nurses to be called an “Infusion Nurse Specialist,” according to the Infusion Nursing Standards of Practice (2006), the nurse must be certified in infusion nursing. It is important for all infusion team members to obtain national certification in the specialty of infusion nursing through the Infusion Nurses Certification Corporation (INCC). Although most professional nursing certification programs are voluntary, certified team members validate the competency and advanced skill level of the staff; they are often used as a marketing tool by institutions. Certification enhances the professional credibility of the nurses and demonstrates their high level of commitment to their specialty practice. In a consumer-driven marketplace, credentialed professionals demonstrate an organization’s dedication to professional development through continuing nursing education.
Because of the types of invasive procedures performed by infusion nurses, infusion teams are primarily staffed with registered nurses. Infusion-related procedures and activities require the level of theoretical and clinical knowledge and expert technical skill provided by RNs. The use of RNs on infusion teams has been an especially important component of the patient care delivery models implemented by many institutions in response to changes in the health care reimbursement structure. With much of direct patient bedside care often being delivered by unlicensed personnel, the extra support of an infusion RN can be very valuable to the generalist RN who now has to manage many more patients than in the past. The knowledge and expert skills of the infusion RN are needed more than ever to ensure quality of care in the delivery of infusion therapies.
Although the use of RNs may be optimal, to provide cost-effective services many infusion teams have also found it beneficial and necessary to use licensed vocational nurses (LVNs) or licensed practical nurses (LPNs). Consideration must be given to limitations in job functions of LVNs/LPNs when using them in the role of the infusion nurse. Infusion therapy–related practice guidelines for the LVN/LPN vary by state and may be further restricted by institutional policy. When an LVN/LPN is a member of the infusion team, all functions must, as defined in their licensure, be under the supervision of an RN. The supervising RN may be on the infusion team or on the patient care unit where the LVN/LPN is performing infusion care. LVNs/LPNs are limited in their role regarding infusion therapy and may not perform advanced technical procedures such as peripherally inserted central catheter (PICC) insertions. After completing education and training requirements and depending on the scope of practice as defined by the state’s Nurse Practice Act, the LVN/LPN may be permitted to perform venipunctures, monitor solution administration and VAD sites, and administer certain solutions and blood products.
An infusion therapy team should be managed by a licensed RN. Five years of recent experience in an acute care hospital setting is preferred, with a minimum of 2 years of experience in nursing management. Experience preparing and managing budgets is desirable. Certification in infusion therapy (CRNI®) should be required, or a candidate should at least meet the eligibility criteria for certification in the specialty of infusion therapy. The individual must demonstrate good organizational and communication skills. To establish and maintain a successful infusion team, the manager must have a high degree of interest and experience in the delivery of infusion therapy. Maintaining skills and expertise in all aspects of the specialty is necessary for recognizing needs and implementing appropriate adjustments in services. The infusion manager is held accountable for his or her own practice and work performed under his or her supervision. The infusion nurse manager should be well respected in the organization and be capable of dealing effectively with all hospital departments. The title for this position (e.g., manager, director, supervisor) may vary, depending on the department to which the team reports and the responsibilities of the position.
The infusion therapy department manager’s responsibilities are typically diverse and require good organizational and delegation skills. The manager’s responsibilities may include writing and reviewing policies and procedures based on evidence-based practice recommendations and current standards, keeping abreast of the latest developments in technology, budgeting, and conducting performance evaluations. The infusion therapy nurse manager provides infusion therapy–related orientation and continuing education programs within and often outside the organization, keeps the staff motivated, and develops and maintains a quality management program. It is also crucial for the infusion manager to serve on committees within the hospital related to infusion therapy, such as pharmacy and therapeutics, infection prevention, product evaluation, nutritional support, safety, tumor board, and transfusion. Along with the clinical specialty rationales for membership on these committees, it is important that the infusion therapy team participate in product evaluation, selection, and standardization and conduct inservice training.
An infusion therapy department manager must carefully design and implement an effective quality management program to ensure that acceptable care parameters are met. The program should address the delivery of necessary and appropriate care, while minimizing complications and ensuring that all complications are investigated. The program should evaluate negative outcomes to determine whether they are attributable to such factors as nurse practice, procedural or systems’ issues, equipment failure, or supply defects. The infusion team staff can provide the data from infusion therapy monitoring. The manager reports findings, assesses impact, and develops recommendations for corrective actions to improve outcomes.
An important and challenging responsibility for the infusion manager is ensuring technical and clinical expertise and maintaining staff morale in an arena in which most activities are carried out independently. It is crucial to hold regular staff meetings so that team members can openly share problems, raise questions, and identify educational needs. Staff meetings also provide an excellent opportunity for inservice training and review of procedures and equipment. Unit-based governing councils, which are part of a shared governance system, can also play an integral role in the success of the team and satisfaction of the staff. Through shared governance, nurses are empowered to make decisions that can impact their practice. The infusion therapy manager must be aware of the aspects of shared governance that enhance the philosophy and meet the objectives of the infusion team.
An important supplemental role to be considered for inclusion in the infusion therapy department is the educational coordinator. The educational coordinator’s job description should include creating and maintaining an orientation program for new staff and providing continuing education and staff development programs and ongoing infusion-related inservice training. The educational coordinator should also act as liaison to the medical and nursing staff and encourage staff to attend outside educational meetings and be active in their specialty organizations.
Teams in large facilities may find it appropriate to incorporate within the team infusion nurses who are dedicated to specific subspecialty areas of the discipline. The role could be defined as that of clinical resource person. For example, a staff member may be dedicated to all aspects of managing central venous catheters, nutritional support, or transfusion therapy or may be the nurse who places PICCs or administers chemotherapy. If there is a large and diverse pediatric population, there may be an infusion team specialist for all aspects of pediatric infusion therapy. It is important to recognize the specialist as a valuable resource available throughout the organization for consultation.
Staffing
To provide cost-effective patient care and reduce the incidence of complications related to infusion therapy, ideally an infusion therapy team should provide full-service coverage 24 hours a day, every day of the week. The number of registered nurses on the team is determined by the number of hospital beds or patients served by the organization or agency, the type and volume of hands-on procedures performed, and the infusion therapies delivered. The ideal infusion team is organized so that it consists of the management, educational, and infusion nurse full-time equivalents (FTEs) needed to provide optimal service levels to all patients receiving infusion therapy.
In reality, FTEs available for the infusion therapy team are not always adequate to meet the ideal situation, and infusion therapy department resources vary depending on the organization. Most infusion teams probably do not have sufficient staffing resources to provide all specialty services and the related levels of care for their specialty. Having to work within such limitations, a choice must be made regarding how best to use the expertise of the team within the facility. A good approach is the implementation of team functions over time. Initial services should address the most pressing needs and should be based on a realistic workload to establish the team. Once the team is organized, is operating smoothly, and is successfully performing designated functions, additional services can be proposed as needs are recognized and resources become available.
When a full-service team cannot be justified, a limited-service team, although not ideal, may be able to provide quality team services for some aspects of infusion care. Budget considerations will define the limited-service hours. Limited-service teams can vary widely in the allocation of service hours. Typical options include covering day and evening hours, with no coverage during the night shift. Time studies related to workload volume help define the greatest hours of need. Some teams can flex their shift coverage into the late night and early morning hours, leaving only a 4- to 6-hour period without infusion team coverage. This is obviously preferred when there are no resources for a full-service team because it offers the least interruption of service. Other teams may offer services only during expanded day-shift hours (i.e., early morning to early evening). This provides some consistent, quality care by infusion nurses but leaves primary responsibility related to infusion care to staff nurses during the hours when there is no infusion team coverage. This may lead to inaccurate data collection and inconsistent quality of care. When a limited-service infusion team is in place, responsibility for infusion functions during off-service hours must be clearly defined and understood to minimize the interruption of therapy. It is important to the ongoing collection of clinical data and to the workload management of the infusion team that services performed by the general nursing staff are clearly communicated.
Initially, to secure the hours needed for core or basic staffing, many of the nurses and nursing hours can be transferred from the general nursing department and dedicated to infusion therapy services. This eliminates the need for massive recruiting and hiring. There is a period of orientation and inservice education required during the initial phase. Ongoing monitoring of staff and systems at this time is crucial to address any problems that might arise. To determine staffing requirements, time studies must be completed for each infusion function, keeping in mind that productivity and efficiency improve after implementation. A time study should collect data on the average number of infusion patients, the number of VADs per patient, infusion functions performed on each shift, and admixtures prepared for each nursing unit. With the average time for each activity determined from current literature or for each facility, staffing needs can be estimated. Subsequently, the number of hours spent to perform infusion therapy can be determined, as can the number of FTEs. Using time study estimates and estimated volume data to define distribution of the workload, staffing levels for each shift can be determined. For greater accuracy, provisions for fatigue, delays, and travel time can be estimated when determining staffing levels. Orientation, vacation, holiday, and sick time relief can be estimated based on the benefits provided to team members and on historical data for even more accurate staffing estimates.
Infusion teams that are also responsible for outpatient therapy need to plan for additional staffing hours. Outpatient services may be provided in a dedicated room in the hospital setting or in an alternative setting. For smaller, hospital-based outpatient service operations, in-hospital infusion nurses may be able to cover staffing needs, especially for scheduled services. Ideally, an infusion nurse should be assigned exclusively to cover outpatient and home settings. To be cost-effective, all members of the infusion team, whether in the hospital or an outpatient setting, should be able to function when needed in either environment. Twenty-four-hour service departments can also use their evening and night shifts in a cost-effective manner to cover off-hour calls from outpatients. They can be a valuable resource for the home health staff in problem solving when they are managing the patient in the home setting, and for the staff of skilled nursing facilities. Coordinating with the home health agency to make the necessary interventions in the home when the patient cannot visit the infusion nurse is an acceptable option. The initial contact and assessment for infusion therapy-related issues should remain with the infusion nurse.
One problem encountered in staffing for the infusion team is meeting emergency needs. How to cover that last-minute sick call or the extended illness of an employee is a dilemma that needs careful consideration by the infusion team manager before it happens. It is more difficult for smaller teams that offer specialized services to maintain flexible staffing. For such teams, it is difficult to draw qualified staff from the general nursing population or even from outside agencies. Thought must be given to maintaining reliable on-call RN resources. One solution is to cross-train interested nurses from the critical care specialty or the emergency department, where venipuncture skills are most likely to be maintained. The workload distribution may need to be adjusted temporarily to integrate nonspecialist staff. For example, routine IV restarts should be assigned to the per diem staff and care of central line dressings to the infusion nurse. In areas where there are a number of infusion teams or home infusion organizations that might provide infusion nurses, those resources could be used and shared. This practice will give infusion nurses a wide experience base to meet the community’s needs. The possibility for establishing community-wide adherence to standards in infusion care becomes more realistic with large numbers of specialists involved in the practice.
Of course, for organizations with 24-hour infusion team coverage, staffing problems are magnified. Without careful attention to maintaining resources, the cost in overtime and the decline in levels of quality or service could be detrimental to the objectives of the infusion team. Smaller teams should plan carefully for meeting staffing needs in many situations. Crisis staffing has a decidedly negative effect on the operations of the infusion team.
ADDITIONAL CONSIDERATIONS
Fiscal restraints and organizational redesign necessitate that hospitals consider both internal and external environmental factors. An analysis of internal factors should begin by identifying the institution’s priorities and then demonstrating how the infusion team relates to those priorities. For example, if the facility has placed a high priority on improving the quality of infusion care because of current deficiencies, the justification should focus on the advantages brought to the institution by the specialized knowledge and skill of the infusion team. A complete internal analysis should also include the institution’s financial status, political structure, and the attitudes and perceptions of physicians, floor nurses, and patients. The external analysis should examine the effect of regulatory and demographic changes, changes in third-party payer reimbursement, competitor activities, limited human resources (e.g., shortage of nurses in the community), changes in availability or cost of supplies, and new technology.
The justification for an infusion team centers on the benefits associated with delivering infusion therapy by a team of specially educated nurses. Benefits inherent in the use of infusion teams include standardization of equipment, improved productivity with better utilization of nursing resources, fewer patient complications, and improved risk management because an expert is monitoring care. To justify the importance of maintaining infusion teams or of creating infusion teams based on enhanced patient care and cost savings, infusion supervisors and managers should build their case on a foundation that addresses the environment, demand, costs, and benefits. Each area must be thoroughly researched and carefully analyzed, and the findings of this study must be skillfully presented to the organization’s decision-makers. It is important to remember the reasons the team was established; those reasons should be assessed again when justifying the team’s continued operation. Refer to Chapter 9 for additional information on validating and maintaining an infusion therapy team.
The future of infusion teams continues to depend on the issues of quality care and allocation of resources. Commitment to quality in any setting also requires careful analysis of how close adherence to standards of practice affects patient outcomes. For those committed to the philosophy of the infusion therapy specialty, the challenge remains to provide rationale and data-driven justification to support their services. It is the challenge of the infusion nurses to provide this expertise efficiently and cost-effectively within a carefully managed health care system.
ALTERNATIVE SITE: OUTPATIENT AND LONG-TERM CARE SETTINGS
The high cost of health care and decreasing reimbursement have made earlier discharge to alternative sites for infusion administration a necessity. In some cases hospitalization for uncomplicated conditions can be avoided by delivery of needed infusion therapy in an alternative site. It is now the norm for chemotherapy to be given in an alternative infusion setting, whether in an oncologist’s office or a free-standing infusion clinic, or with an ambulatory infusion pump at home for those receiving continuous infusions. The durability and dependability of long-term central venous catheters and ambulatory infusion pumps and a greater knowledge of the stability of chemotherapeutic agents have allowed tremendous freedom and flexibility for patients with cancer. Infusion centers with private examination rooms provide an ideal alternative setting for immunocompromised patients. They are safe places to be examined by the physician, visit with the pharmacist, and have dressing changes, pump refills, or assessments performed by the nurse. Like chemotherapy, the outpatient use of infusion antimicrobials has proven to be an efficacious, safe, and preferred delivery modality for infectious diseases. Common diagnoses associated with home and outpatient antimicrobial administration include skin and soft tissue infections, osteomyelitis, endocarditis, bacteremia, and wound infections (Tice et al, 2004).
Outpatient infusion therapy is successfully delivered in sites such as infusion departments or centers, physicians’ offices, extended and long-term care facilities, and the home setting. Each setting has its own advantages and disadvantages. Because of the uniqueness of the home as the only non–institution-based setting, it is addressed separately in the final section of this chapter.
Patients treated outside the hospital, whether in an outpatient facility, long-term care facility, or at home, avoid problems inherent in the hospital system, including unfamiliar, sometimes frightening surroundings; isolation from friends and family; and lack of privacy. Avoiding or leaving the hospital setting also may facilitate the transition from the role of “sick patient” back to the familiar, functioning self, thus speeding adaptation and recovery (Tice et al, 2004). While patient safety is the primary consideration of clinicians administering infusion therapy in all practice settings, safety is magnified because of the intermittent nature of patient contacts and care in alternative settings.
HISTORY AND EVOLUTION OF OUTPATIENT INFUSION ADMINISTRATION
Since the first reporting of outpatient intravenous infusion therapy in the 1970s, outpatient antimicrobial therapy has grown into an industry affecting millions of Americans and generating billions of dollars annually. It has demonstrated that infusion therapies can be safely and effectively delivered in alternative settings while overall reducing health care expenditures. Bernard and colleagues (2001) showed an average cost savings of $4732 per week for treatment of osteomyelitis, while another study with varying infection diagnoses demonstrated average cost savings of $4130 per week (Dalavisio et al, 2000). Reasons for this rapid growth include the many benefits outpatient therapy provides to patients, new technologies that make it possible, and well-documented cost savings (Tice et al, 2004). Factors accounting for the shift in the delivery of infusion therapies to alternative settings are listed in Box 8-2.
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