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"The conventional wisdom has always been you stick and you stick and you stick peripherally until everything is exhausted. By the time you’ve tried to do a week or two of peripheral therapy, there are no more peripheral veins left to use. Then, if therapy is to continue you have put in a central venous catheter," says Lynn Hadaway, principal of Hadaway and Associates in Milner, GA. "That’s still the common practice in most hospitals today. We’re to the point, in many institutions and agencies, where patients’ arms are battered and abused and they have peripheral complications like phlebitis and infiltration. In some patients, peripheral catheters don’t last longer than 24 hours."
Hadaway says that home infusion therapy care suffers from the result of this practice. The goal now, she says, is that when the patients are admitted to any health care environment — whether they begin their therapy through an outpatient clinic or are referred immediately by the doctor’s service to home care — all the clinical components of this decision are reviewed. Then the infusion experts can choose the device that has the greatest likelihood of reaching the end of therapy, with the minimal number of vascular access devices (VAD) used, be that a midline or a PICC, tunnel catheter, or implanted port.
"Regardless of which avenue is used, the very minute that it’s recognized that IV therapy is needed," Hadaway says, "that critical proactive assessment needs to be made when the patient enters the infusion therapy health care system."
Whether home infusion therapy is the best choice depends on reimbursement structures that have come from the prospective payment system, Hadaway says. "There are some patients for whom it’s cost-effective to infuse in the home. Knowing how to assess your patients so that you choose the right ones for home care is paramount. Assessing and choosing the patients who can derive the most benefit in a cost-effective way from home care is the single best thing a home infusion company can do. The goal, in my opinion, should not be to provide more home infusion services, but to provide services for the most appropriate group of patients."
Smooth transition to home
If patients have begun infusion therapy in a hospital, they will generally have a VAD in place when they are sent home. "But if they come to home infusion through some other means, they may not already have a VAD inserted," Hadaway says. "Things have changed in home care now. Home infusion nurses used to freely insert mid-clavicular catheters. Because of practice standards changes, home care doesn’t do those insertions much anymore because they do require a chest X-ray to determine the correct location, so the insertion of these is flowing back to an institution, not to the home care service."
She adds that putting in a PICC line in the mid-clavicular region without first doing a chest X-ray never was established as a safe practice. "Home care adopted it because two nurses went around the country teaching it, but there was never any research supporting safe outcomes with it. A few of our voices were saying, No, wait a minute — this is not safe,’ and then we finally got research that backs us up. This support came via two studies that documented a four- to five-time increase in catheter-related thrombosis from a mid-clavicular tip location. Both the Intravenous Nurses Society and the National Association of Venous Access Nurses [NAVAN] opposed home mid-clavicular catheter insertions."
In fact, Hadaway says, "NAVAN wrote a position paper stating that mid-clavicular catheters should never be a conscious choice because of the complications associated with them."
There are still a few home infusion companies that continue to insert mid-clavicular catheters without an X-ray, but Hadaway points out that they are running a tremendous liability. "I can tell you that there is technology coming that may change that, but it isn’t here yet," she says. "We’ll always need to determine tip location, but the chest X-ray may be replaced with other technology that is more convenient to use in the home."
On-line courses are one of Hadaway’s educational specialties. "The on-line course offers an opportunity to share your experiences with other health care professionals all over the world — anytime of the day, from anywhere you wish."
The on-line course Hadaway’s teaches has short reading assignments posted on her Web site. Each week there are assignments to perform, such as reviewing your organization’s policies and procedures, discussing vascular access choices with co-workers and patients, and using case studies to discuss your recommendations. Students post their responses at the designated page on the Web site, read the messages of others and respond to their messages if they desire. "The more experiences, ideas, and comments you share, the richer the learning experience for everyone."
Lynn C. Hadaway, M.Ed., RNC, CRNI, Hadaway & Associates, P.O. Box 10, Milner, GA 30257. Telephone: (770) 358-7861. Fax: (770) 358-6793.