3As an important aspect of U.S. health care reform, health care provided outside of the hospital setting continues to grow, and this growth is also apparent across the globe. Contributing factors include an aging population, the increasing incidence of chronic illnesses, and the continued pressure to reduce cost through reducing the incidence of hospitalizations and the length of hospital stay. The overarching goal of home care is to maintain patients safely in the home setting and prevent rehospitalization. The provision of infusion therapies in the home is a common practice that allows patients to be discharged earlier from the hospital or, potentially, to avoid hospitalizations.
Although the overall safety of home infusion therapy has been established over the past 30-some years, infusion therapy is still a “high risk” area of practice for patients who require an invasive device and may be receiving high-risk drug infusions such as antineoplastics, opioids, and inotropes. Even home intravenous (IV) antibiotic therapy can result in significant adverse events such as nephrotoxicity or ototoxicity associated with medications such as the aminoglycoside antibiotics (Gorski, 2017). Safe and effective delivery of home infusion therapy is ensured when the home care agency provides knowledgeable and qualified home care nurses and when there are structures and processes in place to ensure quality patient care.
After reading this chapter, the reader will be able to:
■ 4Discuss four aspects of care that impact home infusion therapy outcomes
■ Identify components of a successful home infusion therapy program
■ Describe characteristics of a competent home infusion nurse
■ Identify professional organizations relevant to home infusion therapy
Fast Facts in a Nutshell
Infusion therapy refers to the administration of solutions or medications via the IV, subcutaneous, intraosseous, and intraspinal route. The most common route is the IV route via either a peripheral or a central vascular access device (VAD). Subcutaneous and intraspinal infusions are less common routes but are also performed in the home setting. Intraosseous infusion is currently not a route for home infusion and thus not addressed in this book. Home-administered infusion therapies include antimicrobials, hydration solutions, parenteral nutrition, antineoplastic infusions, analgesics, cardiac infusion therapies for heart failure management, and immunoglobulins. A variety of other medications may be home administered as addressed in the final chapter of this book. Home infusion therapy is provided to patients across the life span.
EVIDENCE-BASED PRACTICE AND STANDARDS OF PRACTICE
The Home Health Nursing: Scope and Standards of Practice (American Nurses Association [ANA], 2014) provides standards for professional performance. Standard 9—Evidence-Based Practice and Research—requires the home health care nurse to “integrate evidence and research findings into practice and use current evidence-based nursing knowledge, including research findings, to guide practice” (ANA, 2014, p. 64). Although a comprehensive discussion of evidence-based practice is beyond the scope of this handbook, the concept is briefly defined and addressed. Evidence-based practice is defined as a problem-solving approach to clinical practice and administrative issues that integrates:
5■ A systematic search for and critical appraisal of the most relevant evidence to answer a burning clinical question
■ One’s own clinical expertise
■ Patient preferences and values (Melnyk & Fineout-Overholt, 2014)
The Infusion Nurses Society (INS) publishes evidence-based infusion therapy practice standards approximately every 5 years. These standards are widely used and cited in the United States and across the globe (Gorski et al., 2016). The references used to support the INS recommendations are rated according to the level of evidence. The reader is referred to the standards for a discussion on the methodology and rating scale used to support the references for each recommendation. The Infusion Therapy Standards of Practice are intended to be used by clinicians in any setting where infusion therapy is administered and the standards will be frequently cited throughout this book.
THE GORSKI MODEL FOR SAFE HOME INFUSION THERAPY
The Gorski Model for Safe Home Infusion Therapy (Figure 1.1) predicts that positive outcomes, which include the absence of infusion therapy–related complications, patient satisfaction, and health care provider satisfaction, are maximized when four aspects of care are addressed during the home care planning process and during the process of providing care. This model provides a framework for Parts II and III of this book.
Fast Facts in a Nutshell
Four aspects of care that impact clinical outcomes in home infusion therapy are (a) appropriate patient selection; (b) effective patient education; (c) meticulous patient care and comprehensive assessment, and monitoring; and (d) interprofessional communication and collaboration.
Figure 1.1 Gorski Model for Safe Home Infusion Therapy. Source: Copyright © Lisa Gorski.
The first aspect of care is appropriate patient selection. Patient selection criteria specific to VADs, infusion administration methods, and the type of infusion therapy are addressed in Parts II and III of this book. Some general questions to ask in terms of patient selection include:
6■ Can the infusion therapy be safely administered in the home setting?
■ Is the patient and/or caregiver(s) accepting of the home care plan?
■ Is the VAD (or subcutaneous or intraspinal route) and the infusion administration method appropriate for the patient and the prescribed infusion therapy?
■ Does the home agency have competent nurses and up-to-date policies and procedures, including admission criteria, related to the type of infusion therapy that the patient requires (e.g., inotropic infusions, intraspinal infusions, and parenteral nutrition)?
■ 7Is attention paid to the transitioning of the patient from acute to home care (e.g., patient is tolerating prescribed infusion without adverse reaction, caregiver availability as appropriate, orders for appropriate laboratory studies, and reimbursement verified and explained to the patient)?
The second aspect of care is effective patient/caregiver education. Patient education is especially critical to the outcome of safe infusion therapy. In most cases, the patient, or a competent caregiver, is expected to learn how to administer infusion therapy. Even in cases where most of the infusion administration–related skills are performed by the nurse (e.g., antineoplastic infusions initiated via an implanted port), the patient still must safely live with a running infusion and VAD. As addressed in the INS standards, patient education includes some level of care and maintenance of the VAD, precautions for preventing infection and other complications, use and troubleshooting of an infusion pump, and how to live with a VAD including activity limitations and activities of daily living (Gorski et al., 2016, pp. S25–S26). Patient education strategies are covered in Chapter 2 and specific topics for patient education are identified in subsequent chapters.
The third aspect of care includes meticulous patient care and comprehensive assessment and monitoring. Infusion administration and access device care is provided utilizing aseptic technique and sound, evidence-based procedures. This requires competent nurses, as addressed later in this chapter, with excellent assessment skills as well as expert home infusion pharmacists. The competency under the “Assessment” standard from the Home Health Nursing: Scope and Standards of Practice states that the nurse collects comprehensive data in a systematic and ongoing process (ANA, 2014, p. 44). A thorough baseline assessment is conducted at the first home visit. For Medicare-certified home care agencies, this will include data required on the Outcome Assessment and Information Set (OASIS). Although assessment data specific to VADs, infusion administration methods, and the type of infusion therapy are addressed in Parts II and III of this book, some general areas of assessment and monitoring during both the initial and ongoing home visits include:
■ Environmental assessment including safety (e.g., electrical), structural (e.g., stairways and barriers to bedside infusion pump), and sanitation hazards (e.g., running water and refrigeration)
■ 8Functional limitations and cognitive ability in relation to ability to learn infusion procedures, how patient best learns, caregiver/family support, and involvement in learning infusion therapy
■ Vital signs, infusion access device site and patency, other signs and symptoms as appropriate to patient condition, progress toward self-care, therapeutic response, and presence of any side effects/adverse reactions
■ Consideration for and attention to risks with certain patient populations; for example, physiologic differences or changes associated with pediatrics or older adults, which impact drug dosage and risk for adverse reactions
Fast Facts in a Nutshell
