Guest Columns
Guest Columns
Data collection tool offered for catheter outcomes
By Ann Williams, RN, CRNI
Deaconess Home Services
Evansville, IN
I have created a tool that we use in following our Infusion Lines in the Home Services patients. In order to accurately collect and collate your data, you must:
• Define your complications so that you are always using the same judgment criteria from month to month and person to person.
• Determine what data you are interested in gathering. For each patient, I include who placed the line, the type of line, when it was placed, as well as when it is discontinued. I track the reason for discontinuance (i.e., goals met, etc.), any complications, the cath make and gauge, which vein was used, patient’s sex, diagnosis, therapy, and method of infusion. I then have an area where I can elaborate on the complications, as well as a column for comments.
At the end of the month, after having collected and recorded all my data, I color-code my lines to make them easier to assess later. Then I count my lines to determine how many there are of each type. Next, I count and highlight my complications. At this time, I assess any trends that might explain a complication and help focus on a process improvement that needs to be implemented.
Recording and plotting
The next step involves recording and plotting the data into graphs or whatever form you feel best shows your data results. You will also notice on the lower portion of the data collection tool that my program counts the total lines, the line days, and the average days/line.
This information is used at the end of the month when you want to calculate percentage of patients that completed therapy with goals met, percentage of lines that completed therapy without infection, and percentage of lines that completed therapy without need for de-clotting.
You can individualize this to whatever your needs are. You can use paper and pencil or a personal computer (see example, p. 138). You can make it however simple or complex you wish to make it. It is just a matter of collecting what you want and having an organized way to review it. Remember: It is a waste of your time to collect the data if you never go back to analyze it and follow that up with improvements!
(Editor’s Note: Information from Ann Williams’ data tool has been compressed to fit on one page, thereby eliminating an excess of empty boxes. If you would like to receive a copy of the Excel file from which this is derived, please contact her directly at the e-mail address above, and include the version of Excel you will use.)
Need More Information?
Ann Williams, Deaconess Home Services, 600 Mary St., Evansville, IN 47747. Telephone: (812) 450-3828. Fax: (812) 450-7393. E-mail: [email protected].
Helping the hemophilia client gain independence
By Beth Stover, RN
Clinical Education Coordinator
Hemophilia Health Services
Forest Hill, MD
(Editor’s note: This is the second story in a two-part series about hemophilia and the importance of independence for the client with this disorder.)
The lifelong nature of hemophilia, paired with the extremely high cost of management, makes it a disease state that is ideal for self-management and independence. Clients must be educated about their disorder and its management so that safe and effective care can be used. The move to independence often occurs in stages, and eligibility for home care and ultimately, self-care is based upon quite a few different factors. Some clients may never reach independence.
There are many participants in a client’s decision to move into home care. Just after being diagnosed, most clients are seen repeatedly by members of a hemophilia treatment center (HTC). There are approximately 140 centers throughout the United States.
The HTC team will usually include a hematologist, nurse specialist, social worker, orthopedic physician, dentist, and physical therapist. As patients become more educated about their disorder, higher levels of independence are gained. This team, along with the client, family members, a pharmaceutical supplier, and a home nursing provider work together to move the client toward home care and independence. Even after clients are in home care, they need to be seen at least once a year by the HTC.
Independence arrives in stages
The first stage of independence usually consists of the client having a supply of clotting factor at their home that they manage while still going to the clinic or emergency department for evaluation and treatment of bleeding episodes. They maintain a home inventory and carry it with them as needed for emergency visits or for out of town travel. During this time, education regarding basic hemophilia care and treatment options are reviewed with the patient and family. The home-based inventory helps to assure the availability of the preferred brand with the right assay (number of units per bottle). Clients usually prefer to be exposed to as few lot numbers as possible to decrease their exposure risks. Also, there is usually a decrease in wait time and expense if the client’s own inventory is used as opposed to that of the hospital’s blood bank or pharmacy.
Once the clinic staff feels that the patient or family members are making appropriate decisions about identifying and treating bleeding episodes, they may recommend that the client consider home therapy. This means the patient or caregiver must make a preliminary decision on whether the patient needs to have treatment that can wait for a home care nurse.
Home nursing agencies are instructed that home visits must be made within two hours of notification of the need for a visit. Delaying treatment more than two hours will significantly alter the amount of damage and pain the client will occur. Delayed treatment frequently results in the need for repeated consecutive treatments for the bleeding episode, resulting in higher treatment costs and higher demands on the nursing agency’s staffing. Emergency situations will require the use of the 911 or emergency medical system.
As the client uses the home care agency, the hemophilia education continues with the home care nurse now taking the role of primary educator for the client and family. As the situation permits, the client will be considered for an even higher level of home care that consists of the patient or family member learning to perform the infusion. Once the client is skilled enough, the ultimate level of self-care and independence can be attained. This often relates to the client’s age and ability to self-infuse.
Prior to beginning home care, certain items are considered necessary. Some of these items are:
• Understanding the basics of hemophilia, including general hemophilia information, as well as bleed identification and treatment guidelines.
• Understanding the possible complications of therapy, including possible reactions, loss of access, and financial and physical considerations for delayed treatment.
• A sound understanding of the hemophilia treatment plan.
• Living in an area that can be accessed by support personnel; timelines and safety issues must be considered.
• Availability of a telephone. This may be in the home, with a neighbor, or on the street outside their door.
• A second caregiver must readily be available in case of emergency. This can be a relative, neighbor, or friend who is capable of calling for assistance, if needed.
• The ability to order, maintain, and store supplies appropriately.
• The ability and willingness to keep scheduled appointments.
• The knowledge of when to call the professionals for assistance.
As the home care nurse moves out of the care picture, the clients or their family will also need:
• A higher level of knowledge of bleed identification and treatment guidelines.
• Knowledge of how to properly administer the factor, including information relating to expiration and preparation.
• The ability to access the venous system.
Home care nurses are very important role models as they guide the client toward independence. It is extremely important that every visit be thorough and educational in nature. Here is a brief list of what should be covered at every visit:
• Environmental safety and universal precautions. The nurse should always use and enforce the proper use of supplies and medication and the disposal of contaminated and sharps waste.
• Vital signs, including blood pressure, so that possible reactions to the factor administration can be assessed.
• Bleed identification, including history of when and how the bleed occurred, what type of bleed is present, and investigations into any possible negative side effects of this type of bleed, such as loss of nerve function or blood flow due to swelling and constriction.
• Joint measurement if the bleed is in a joint. It is important to have baseline measurements of all extremities in the initial history and physical. If a joint bleed is suspected, bilateral measurements should be done and followed until the bleed is resolved and the client returns to baseline measurements.
• Range of motion assessment. Again, this should be performed on the initial history and physical as well as with each visit that pertains to a muscle or joint bleed.
• Review of safe handling and storage practices for medication and supplies.
• Documentation of the episode, including location and the medication administered, including factor lot number and assay and location of infusion.
• Expected follow-up for the client, including any planned phone calls, office visits or home nursing visits required or suggested.
Some information about clotting factor
Storage of the clotting factor should follow manufacturer’s recommendations. Most brands of factor can be stored at a controlled room temperature (less than approximately 85° F) for at least six months. However, if conditions are questionable or if longer storage is possible, refrigeration is recommended.
Factor should never be left in a hot car or in direct sunlight. It is important to note that room-temperature factor will go into solution more easily than cold factor. Some clients may like to keep a small amount of factor at room temperature at all times. If needed, the diluent can be brought to room temperature in a shallow, warmwater bath. The concentrate should never be refrigerated after it has been mixed. Use any factor concentrate within three hours of mixing. After this time, the solution may not be sterile. It is very rare that clotting factor is ever discarded. Before discarding factor of any type, contact the treatment center for further information.
The rate of factor administration is often patient-dependent. Although there are written administration guidelines in the package insert, it is often found that clients are tolerant of (and used to) a much faster administration. Rate-related reactions are among the most common untoward reactions to clotting factor. Symptoms often include dizziness, rapid heart rate, and a feeling of anxiety. These are normally short term in nature and can be avoided with a slower rate of infusion. Allergic and anaphylactic reactions are rare.
Home care nurses play a critical role in moving the patient with hemophilia toward physical and social well being and independence. A client with hemophilia, as any client with a chronic illness, will never be truly independent. However, the benefits that can be gained from the presence of well-educated home care nurses are immeasurable. I have been told many times that clients never forget their home hemophilia nurse. I am privileged to have been in that role many times in the past and still enjoy it thoroughly.
Need More Information?
Beth Stover, RN, 1818 Cosner Road, Forest Hill, MD 21050. Telephone: (410) 638-5867. E-mail: [email protected].
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