Expanding horizons: A new therapy could eliminate unnecessary stays
Expanding horizons: A new therapy could eliminate unnecessary stays
Treatment highly cost-effective, comfortable for patients
An innovative treatment that could save taxpayers billions of dollars and deliver quality care to patients is getting a lot of support from health providers and others. The treatment, outpatient intravenous/intramuscular antibiotic therapy (OPAT), could save Medicare $1.5 billion over the next five years and almost $5 billion by 2010 through reducing or eliminating unnecessary hospital stays.
Eligible patients receiving the treatment for bacterial infections could choose to receive a standard of care comparable to that provided in a hospital, but in the comfort and convenience of their own home.
OPAT is considered by many experts to be an appropriate treatment choice for as many as 80% of all bacterial infections currently treated entirely on an inpatient basis. Those infections include cellulitis, pneumonia, osteomyelitis, and endocarditis. Currently, Medicare patients requiring intravenous or intramuscular antibiotic therapy, but who do not necessarily need to be hospitalized, are forced to find an alternative payment method for treatment. In 1995, 650,000 Medicare beneficiaries suffering from bacterial infections were not permitted to receive OPAT due to Medicare regulations, which mandated inpatient treatment.
OPAT patients can receive the same therapy from home-nurse administration, an outpatient clinic, or even self-administration. Physicians retain full patient care responsibility for the duration of therapy, making OPAT a safe method of care. By choosing home treatment, patients can enjoy flexibility and control over their daily schedules that is not possible as an inpatient. OPAT may be administered only to patients who are alert, medically stable (or improving), and don’t require close daily observation. The treatment is part of a national trend toward outpatient care that is increasing at a rate of 15% to 20% annually. In a recent study, 95% of the 400 OPAT patients surveyed said they would choose outpatient therapy again.
The most frequently prescribed injectable antibiotic for use in OPAT is ceftriaxone (Rocephin), because of its effectiveness, high patient tolerability, and dosing flexibility. Studies from 1991 through 1995 reviewed case histories of 137 patients, most of whom were hospitalized for a short time and then received OPAT with ceftriaxone in combination with other antibiotics. The clinical success rates ranged from 88% to 100%, and a statistical analysis of 30 of the patients involved in the studies showed that OPAT reduced hospital stays by 380 hospital days.
"Ceftriaxone is an effective choice for OPAT therapy because of its unique once-daily dosing and intramuscular delivery," says Larry Eron, MD,an infectious disease consultant at Kaiser Permanente Medical Center in Honolulu. "Its broad antibacterial application and good tolerability also put it at the head of the class."
Adverse clinical effects occur at levels similar to those of other cephalosporins — in adults: diarrhea (2.7%), rash (1.7%), and local reactions (less than or equal to 1%); in pediatric patients treated for serious infections: diarrhea (5.6%), rash (less than 2%), and fever (1.1%). Rocephin is contraindicated in patients with a known allergy to cephalosporins and should be used cautiously in penicillin-sensitive patients.
Document, document, document
Developments in home infusion therapy management, such as OPAT, bring with them additional responsibilities for the home infusion therapy manager. Making sure your patient fully understands the vascular access device (VAD) procedure relieves you, the home IV therapy manager, of worry about possible charges of educational negligence should problems arise with the patient’s procedures.
Scott Gilbert, CRNI, of the Queen’s Medical Center in Honolulu, has designed the following educational form (below), to improve patient understanding of IV procedures:
Educational Information about the Insertion and Use of Extended Dwell Intravenous Catheters Peripheral Intravenous Catheters — Midline Catheters — Peripherally Inserted Central Catheters
You have the right to information regarding the use of all medical devices that are used in the performance of medical and nursing care. You also have the right and an obligation to participate in the decisions concerning your health care treatments. Medical use of intravenous fluids, antibiotics, pain medications, or blood products that may be ordered by your physician or health care provider will require the insertion of vascular access devices (IV catheters). Several options are available in vascular access devices, insertion locations, and methods of insertion. The information about each of those options and devices is provided in writing to you. Additionally, a vascular access nurse is available to answer your questions. You should always discuss all health care decisions with a physician.
1. I, _______________________________ (patient’s name), agree to have intravenous therapy via a vascular access device placed into my arm.
2. I understand that my physician, _______________, has ordered the insertion, catheter tip location, and use of this intravenous catheter.
• Peripheral Intravenous Catheters
I understand that a Peripheral Intravenous Catheter is a temporary device that must be changed regularly to reduce the irritation to my skin and veins (usually every 2-3 days), and can be inserted by a trained nurse. This short 1-to 2-inch intravenous catheter can be placed into the hand, wrist, lower or upper forearm, foot, or neck. I agree to report any vein or site tenderness, swelling, pain, or redness at the insertion point or along the arm immediately to the nursing staff.
• Extended-dwell Midline Catheter
I understand that a Midline Catheter is a medium-term device that may remain in place for up to two to four weeks. This type of intravenous catheter is 5-6 inches in length, is placed into the bend of my arm, and can be used for normal intravenous fluids and blood products.
Risks include excessive bleeding, pain at the site of insertion, swelling of my arm and vein thrombosis. I agree to report any vein or site tenderness, swelling, pain or redness at the insertion point or along the arm immediately to the nursing staff. The insertion of a MIDLINE CATHETER will only be performed by a specially trained and certified Intravenous Nurse Specialist or physician.
• Peripherally Inserted Central Catheter (PICC)
I understand that a Peripherally Inserted Central Catheter (PICC) is a longer term device that may remain in place for several weeks or months and, if necessary, it may be used at home for continuation of my intravenous therapy. This type of intravenous catheter is measure to fit my specific arm length and the end of the catheter will come to rest in my chest at an area near my heart but not in my heart. The insertion of a PICC will only be performed by a specially trained and certified Intravenous Nurse Specialist or physician.
3. I realize that placement of those devices is an invasive procedure and has certain risks. They may include arterial puncture, local infection, irregular heartbeat, air, or catheter embolism. All appropriate measures to eliminate or reduce the chances of those or others from occurring will be taken.
4. I realize that there is also a chance that the insertion of intravenous devices may not be successful for me, though the procedure will only be attempted if I seem to be a good candidate for the catheter chosen or selected. Should attempts to place a MIDLINE or PICC line fail, I will again be offered the other options that are available in order to receive my medication.
5. I understand that my physician may also discuss other VASCULAR ACCESS DEVICE OPTIONS, including a multilumen catheter, a tunneled catheter, an implanted port, or others. I understand that my physician has determined the intravenous route to be the safest and most effective means of giving my medications at this time. I have chosen to have a _______________________ catheter placed at this time.
6. I have had the opportunity to ask any questions I may have about this INTRAVENOUS CATHETER and this procedure, and will continue to ask for additional information as I find necessary.
7. I have received this education from a VASCULAR ACCESS/INTRAVENOUS NURSE.
on this date: _____________________________
SIGNATURE__________________________(patient or family member)
SIGNATURE_________________________ INTRAVENOUS NURSE/RN
Gilbert designed the following VAD Assessment form and request for physician orders, as well. Obtaining and documenting this information can be time-consuming, but it’s every bit as important for a provider of home infusion therapy services to have evidence that supports actions taken as it is for a hospital.
Criteria for VAD Selection
Primary Diagnosis____________________
Secondary Diagnosis _________________
Circle one:
• Vascular Condition: Excellent - Good - Poor - Very Poor
• Condition: Excellent - Fair - Eccymotic - Fragile/Tears
• Patient Needs: T/PPN - Vesicant - Irritant - Isotonic
• Expected VAD USE/LOS: 1-4 Days - 5-9 Days - 10-14 Days >15 Days
• Alternate Setting Home: - PCU - OPO - SNF/Conv
• Patient Desires: PIV - Midline - PICC - MLC - Port
• Other: ________________________________
• VAD Recommendations: ____________________
DATE: ______________
VASCULAR ACCESS NURSE:__________________
Physician Order Request
Doctor__________________: Please select the appropriate VAD Protocol Orders
Check:
- VAD Selection: VASCULAR ACCESS NURSE to select and insert the most appropriate intravenous catheter (Insyte Vialon IV Catheter, Arrow Twin-Cath IV Catheter, Bard 20 cm Peripheral Midline, Bard PICC).
- May only insert peripheral IV Catheter into (circle): Upper Extremity - Foot - External - Jugular
- Insert Midline for intravenous use per QMC Procedures. IV Therapy RN to obtain verbal consent from Patient. Enter standard Midline care orders into CLIQ. Provide nursing and patient education on Midline Care and Management. (Usually two-four week limitation for these extended-dwell peripheral catheters.)
- Insert PICC Line for intravenous use per QMC Procedures. MD to obtain written consent from Patient. Provide nursing and patient education on PICC Care and Management. Enter standard PICC care orders into CLIQ. Obtain chest X-ray verification of central tip placement PRIOR TO USE.
-Site Rotation: Intravenous Therapy RN to assess site for rotation PRN based upon patency, site complications, potential for phlebitis, and patient specific needs. Protocol restarts and rotation of intravenous site should normally occur at three-day intervals with tubing changes and catheter site dressing changes with a "good or excellent" vascular integrity rating.
- For catheter or implanted port occlusion: Enter standing orders for catheter occlusion clearance. Order and instill urokinase for catheter clearance using Abbokinase or urokinase (5,000 units/mL) per each occluded lumen. Follow QMC procedure to re-establish patency. Reinforce education with nursing staff and patient related to catheter flushing techniques and practices.
- Blood Draws for lab specimen:
___ RN to draw specimens via Catheter.
___ Phlebotomy to draw all specimens percutaneously.
- Flushing Orders: Use the SASH method with turbulent flushing technique and the following (using the Standard QMC flushing protocol) for specific / appropriate catheter or 0:
___ Normal Saline 1mL 3mL 5mL 10mL 20mL q8hr q12hr
___ Heparin (10units/mL) 1mL 3mL 5mL 10mL 20mL q8hr q12hr
___ Heparin (100units.mL) 1mL 3mL 5mL 10mL 20mL q8hr q12hr
Need More Information?
% Scott Gilbert, CRNI, 1330 Wilder Ave., No. 310, Honolulu, HI 96822. E-mail: [email protected].
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