Agencies begin 'pushing' their way to savings
Agencies begin pushing’ their way to savings
Push antibiotics gain momentum
As technology slowly advanced into the field of home infusion, some ways of treating patients fell by the wayside. But as agencies search for innovative ways to save money, push antibiotics are mounting a comeback as a way to cut costs and improve patient satisfaction.
It may come as a surprise that a method left for dead not too long ago is gaining more attention in the midst of the modernized world of health care. But there are numerous reasons push antibiotics are a viable alternative for many patients.
"We’ve been using it for three years," says Frank Keillor, RN, the general manager of Nations Healthcare in San Francisco. "We had read some information and decided to give it a try. The biggest thing is cost. It’s infinitely cheaper to give IV push than it is to do mini-bags and drips."
For example, Keillor notes that the syringe required to administer push IV costs about a dime. In contrast, a mini-bag will cost more than a dollar, with tubing costing another dollar, not to mention the expenses of other equipment, such as poles, that must be considered.
"Everything it takes to do a mini-bag is in the $3.50 range as opposed to a dime," notes Keillor. "It’s hard to argue with those economics."
Saving several dollars here and there can add up over the course of a year, particularly for a high-volume agency. But Keillor notes that supplies isn’t the only area in which his agency saves money each time a drug is administered by push IV. Most patients can easily be taught to administer push IV themselves, sharply reducing the number of visits your staff has to make.
"If you’re a traditional infusion company, you probably build the cost for nursing into the cost of your drug, so you want to keep nurses from going out to keep the profit on the drug," he says. "With the syringes we can teach patients in one visit and occasionally two. People are very clear on how a syringe works, so you don’t have to teach the technique of spiking a bag and creating air locks and counting drips. You just teach them to attach a 10 cc, syringe and when the second hand hits the 12, give themselves 1 cc."
Use of patient instruction sheet
When teaching a patient how to set up a mini-bag, Keillor notes that teaching usually requires two visits and occasionally three. He adds that when instructing patients how to administer push IV, nurses usually spend more time on flushing than teaching infusion. Nations Healthcare staff use a two-page sheet to help teach patients how to administer push IV and flush lines. (See patient teaching sheet, pp. 142-143.)
Ann Zonderman, BSN, CRNI, an independent home care nurse in Jacksonville, FL, who works exclusively on infusion cases, wishes more agencies had this perspective.
"One of the things that really upsets me, even as a taxpayer, is sending a nurse three or four times a day to administer even IV push," she says. "It costs Medicare dollars to send a nurse every visit, and a lot of agencies just don’t think patients should be taught, but if they’re capable and willing, this is a very simple thing. They can be taught about administration, complications, and back-up support."
While savings may be nice for your agency, don’t forget the potential patient benefits.
"If the patient feels it’s easy to give the drug, they’re going to give it on time and they’re going to finish their therapy," says Keillor. "If a drug is pushed over 10 minutes and the patient is getting the drug three times a day, they can wake up in the morning, get the medication, and be right back in bed in 15 minutes. It takes very little time out of their lives."
Also, because so few supplies are required, it’s much easier for those who may have to travel for business or a vacation.
"There are times when I’ve taught the school nurse to give a medication because the mother couldn’t get there for the child," says Zonderman.
Initial screenings look good
When Nations Healthcare began using push IV for cephalosporins, it did an initial screening to evaluate complications. In the end, there were no noticeable changes.
"We did an initial run for a month of looking at people who were doing mini-bags and giving them syringes," says Keillor. "I haven’t seen any more or less phlebitis, infections, or problems caused from doing this."
Push IV may have fallen by the wayside because of complications related to the method. But Lynn Hadaway, RNC, CRNI, president of Lynn Hadaway & Associates in Milner, GA, notes that such problems may have resulted from harried professionals rather than push IV itself.
"I think the difference between my experience years ago in the hospital and what is happening now is we had very limited time to infuse all these drugs," says Hadaway. "Now in home care it’s being admixed by a pharmacy, and the patient or family member has the time to push it over the required amount of time."
If a drug must be pushed over a certain amount of time, a busy nurse may try to cut a minute or so off the time, while the patient is likely to follow instructions to the letter.
"If you tell patients to push a drug over three minutes, they do it to the minute," says Zonderman. "They’re probably more compliant than the nurse."
When working for Coram, Zonderman oted that the company recommended placing a microbore extension on the tubing, which would prevent rapid infusion.
"Patients would be restricted by the bore of the tubing, and we were using 10 cc syringes so they wouldn’t place tremendous pressure on the line either," she says.
Pharmacists also always checked with physicians prior to placing a patient on push IV.
"If it was a drug I knew was on the approved list from the company, I would ask the physician if it was all right, or the pharmacist would ask," she says. "The physicians usually have no problems with it, and there’s usually a good relationship between the pharmacist and the physicians, and the pharmacist can explain the safety factors."
Those familiar with push IV say there are two areas that must be given careful consideration before using the method on any patient. First, ot all drugs can be administered this way. Keillor notes his agency mostly uses push IV on cephalosporins. Hadaway recommends your pharmacist look at the drug manufacturer’s literature to see if the drug can be administered via the push method.
"The question is the osmolality of the solution," says Hadaway. "When you mix drugs in very high concentrations, you’re going to have a solution that has a very high osmolality, and that’s what leads to damage of the vein and can cause phlebitis."
But for drugs with lower osmolality, the push method can actually speed the process and reduce complications.
"Because there is less exposure time for the drug going into the vein, you also have less potential for phlebitis," says Zonderman.
Evaluate patient ability
Hadaway says it’s important to assess the patient’s manual dexterity to control the syringes and push.
"If the patient has a catheter in the chest then they have both hands to work with, but if you’re dealing with a short vertical catheter in one hand, the patient has one hand to work with, so their manual dexterity has to be considered," she says.
In addition to physical ability, she also recommends making sure the patient/caregiver has the cognitive ability to learn the technique in addition to watching for signs of complications and knowing when to call the nurse.
Zonderman adds that patient teaching tools, such as written directions or diagrams, should be used to reinforce teaching and provide specific step-by-step instructions to the patient. Patients should also be given additional information.
"Troubleshooting and complications should be reviewed and patients provided with access to the nurse for assistance," she says. "Patients are not usually instructed in venipuncture but are for removal of catheters if it becomes necessary."
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