Pauline Dobson, Hunter New England Health: Patients are doing it for Themselves: The Evidence for Self-care Home IV Therapy

50 %
50 %
Information about Pauline Dobson, Hunter New England Health: Patients are doing it for...
Health & Medicine

Published on March 10, 2014

Author: informaoz

Source: slideshare.net

Description

Pauline Dobson, Clinical Nurse Consultant & Dr Mark Loewenthal, Immunology & Infectious Diseases Unit, Hunter New England Health delivered this presentation at the 2013 Hospital in the Home conference. This 2-day event is a nurse oriented program to improve HITH services and maximise hospital efficiency. For more information about the annual event, please visit the conference website: http://www.communitycareconferences.com.au/hospitalinthehome

Patients are doing it for themselves The Evidence for Self-administration of Home IV Therapy Pauline Dobson & Dr Mark Loewenthal Immunology & Infectious Diseases Unit John Hunter Hospital, Newcastle NSW and Faculty of Health, University of Newcastle

• 40 years ago the first accounts of home IV antibiotic courses replacing inpatient stays were reported – the first HITH.1 – The antibiotics were self-administered • In 2013, the bulk of this treatment is still clinician administered • Recently evidence has been published to support self-administration as a model of care 2 of 47 1. Antoniskis A, Anderson BC, Van Volkinburg EJ, et al: Feasibility of outpatient selfadministration of parenteral antibiotics. West J Med 128:203-206, Mar 1978

• Today’s Nurses – Highly educated workforce – IV therapy commonplace – Skilled with Central venous catheters – Better knowledge about how to avoid infection – Clear guidelines and policies • Surely it follows that nurses would be much better than patients or carers self-administering 3 of 47

However we may be making assumptions… 4 of 47 Image from: Quarksandquirks.wordpress.com

Examples of some clinician managed PICCs in patients referred to our service from elsewhere 5 of 47

Multiple Opsite dressings Unsecured Excess External length 6 of 47

St Elsewhere’s a number of days post insertion Unsecured, bloody, two dressings 7 of 47

The long and winding road 8 of 47

Policy “…the dressing is changed on a weekly basis or immediately if the integrity of the dressing is compromised.” 9 of 47

Phlebitis Blood, Statlock Placement 10 of 47 Multiple Opsites Old spot bandage under Opsite Multiple Multiple Opsites Opsites

Grotty Double Bunger 11 of 47

Neat Neat Triple Bunger! Triple Bunger Bunger 12 of 47

13 of 47

• 1993-2005, 2059 admissions over 13 years; 473 episodes (24%) self administration • Catheter complications overall 1.5/1000 catheter days (lit) • Readmission Clinician 12.6%, Self 10.5% (no significant difference) 14 of 47

• 2001-2011, 2766 episodes, 42,238 days, 69% PIVCs & butterfly devices, 23% midlines, 5% tunnelled TCVC, 1.5% PICCs • For analysis 854 midline, PICC, & TCVC for 25,292 days • Line infection 0.8 / 1000 cds • Flucloxacillin use OR 3.0 for other line events (given q.i.d) 15 of 47

• Prospective cohort, paediatric & adult patients admitted to Out & About from 1/10/1995 – 31/12/12 • Only home parenteral antibiotic therapy included • Clinician administration – community nurse, RACF nurse, HITH nurse in clinic • Self-administration – either patient or their carer administers IV therapy 16 of 47

• Out & About Home IV Therapy Program • Home IV therapy, with parenteral antibiotics as majority of admissions • Infectious Diseases led • Commenced in 1995 • Paediatric and adult patients - co-located children's hospital • Clinical database recording outcomes 17 of 47

HITH Service Geographic boundaries ~6hrs 427km ~3hrs 198km 18 of 47

• Offered as option only • Patient / Carer must be willing to self-administer • Assessed for: – – – – – – – – 19 of 47 Cognition Hygiene Motor skills (dexterity, tremor) Compliance IDU history Ability to read written instructions (language) Hearing (alarms, telephone contact) Vision (pump controls)

• Teaching session • One usually adequate • May require more for CADD pumps, or multiple antibiotics • Extension set, to allow patients to flush PICC using both hands • Every patient, regardless of whether they are self or clinician administration, are contacted daily by phone • Check temp, PICC / pump status, complications, falls 20 of 47

• Early discharge – The patient does not complete the intended course of treatment due to a complication • Readmission – The patient is readmitted to hospital for more than 48 hours following a deterioration or new condition • On call use – The patient contacts the HITH team to resolve a problem, either in or after hours • Call Out – The patient requires HITH staff to meet the patient to troubleshoot their problem e.g. blocked catheter 21 of 47

• Bone & Joint Infection – Osteomyelitis, septic arthritis, prosthetic joint infection, orthopaedic hardware (pins, plates, screws, rods) infection, discitis & bursitis • Abscess – liver/splenic; spinal/epidural; cerebral; lung; psoas; & deep tissue • Cellulitis is serious or limb threatening • Multiple other includes: – malignant otitis media; encephalitis; ascending cholangitis; empyema; nocardia; meningitis; parotitis; leptospirosis; pyomyositis; pericarditis – infected devices e.g. pacemakers, permacaths, CVCs, cochlear implants, VP shunts, peritoneal dialysis catheters; 22 of 47

Variable Clinician Administered Self-Administered Combined Admissions 2739 1913 4652 Patients 2204 1091 3295 59,983 42,920 102,903 21 20 21 1758 (64.2%) 1107 (57.9%) 2865 (61.6%) 58.8 (3 months - 96yrs) 40.0 (3 weeks – 92yrs) 51.1 140 377 477 Patient days Median Length of stay Gender – Male Age – (mean, range) Paediatric Females are less likely to utilise selfadministration, Odds Ratio 0.65 (95% CI 0.47 to 0.89). Note: self is often carer. 23 of 47

• 2705 (82%) patients admitted once only • 391 (12%) had two admissions • 199 patients (6%) from 3 – 33 admissions • Small numbers of patients have repeated admissions 24 of 47 Admissions Per patient Number of Patients Percent 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 18 19 20 21 22 27 33 Total 2,705 391 91 35 14 12 5 4 6 5 5 5 2 2 3 1 3 1 1 1 2 1 3,295 82.1 11.9 2.76 1.06 0.42 0.36 0.15 0.12 0.18 0.15 0.15 0.15 0.06 0.06 0.09 0.03 0.09 0.03 0.03 0.03 0.06 0.03 100

Variable Clinician Self Combined 1552 (57%) 854 (45%) 2406 (51.7%) 81 (3%) 497 (26%) 578 (12.4%) Infective Endocarditis 208 (8%) 61 (3%) 269 (5.8%) Abscess 168 (6%) 83 (4%) 251 (5.4%) Sepsis/Bacteraemia 128 (5%) 83 (4%) 211 (4.5%) Wound Infection 138 (5%) 48 (3%) 186 (4%) Bronchiectasis 88 (3%) 75 (4%) 163 (3.5%) Cellulitis 92 (3%) 42 (2%) 134 (2.9%) 284 (10%) 170 (9%) 454 (9.8%) Bone & Joint infection Cystic Fibrosis Other 25 of 47

Vascular Device Clinician PICC Self Combined 2510 (88.6%) 1516 (76.8%) 4026 (83.7%) Implantable Port 73 (2.6%) 364 (18.4%) 437 (9%) CVC 197 (6.9%) 68 (3.4%) 265 (5.5%) 29 (1%) 22 (1.1%) 51 (1%) 25 (0.9%) 3 (0.15%) 28 (0.6%) 2,834 1973 4,807 Tunnelled Catheter Peripheral IVC Total Note: more lines than admissions, some lines need replacing during admission 26 of 47

Drug Flucloxacillin Vancomycin Benzylpenicillin Timentin Meropenem Ceftazidime Tobramycin Cephalothin Tazocin Ceftriaxone Gentamicin Teicoplanin Cephazolin Cefepime Piperacillin Total Clinician Self Total 835 503 398 290 91 76 51 192 30 88 57 57 55 16 5 2744 518 214 183 237 193 198 218 46 103 40 58 50 23 48 33 2162 1,353 717 581 527 284 274 269 238 133 128 115 107 78 64 38 4,906 Note: more drugs than admissions, some patients on dual or triple tx 27 of 47

Mode Clinician Self Total 2,599 (90%) 1,684 (75%) 4,283 Intermittent infusion 98 (3%) 119 (5%) 217 Bolus 190 (7%) 435 (20%) 625 Total 2,887 2,238 5,125 Continuous 24h 28 of 47

Clinician Administered Self Administered 29 of 47

50% • The proportion of those who self-administer has steadily increased • And remains the case when Cystic Fibrosis is excluded 30 of 47 40%

There was no difference in early discharge due a complication between Self and Clinician. Age, line type, and cystic fibrosis did not predict early discharge. 31 of 47

Female patients were more likely to be discharged early from HITH than males. On average early discharge occurred at a rate of 9.7 per 1000 patients days for females and 7.1 per 1000 patient days for males (HR 1.40 95%CI 1.17 to 1.68 P = 0.0002) 32 of 47

33 of 47

Predictor Haz. Ratio P-value [95% Conf.Interval] PICC CVC Port Tunneled Catheter 1 .82 .73 .65 reference 0.138 0.042 0.120 0.64 to 1.1 0.54 to .99 0.37 to.1.12 Child (<18) Female Cystic fibrosis Female with CF 1.4 1.3 .79 .58 <0.0001 <0.0001 0.195 0.015 1.2 to 1.8 1.1 to 1.4 0.55 to 1.1 0.37 to 0.90 34 of 47

There were 447 admissions resulting in at least one after-hours call-out. 278 (10.6%) of Clinician patients and 169 (9.3%) self administered (P-value 0.26 PPP test.) Predictor Haz. Ratio P-value [95% Conf. to Interval] CF 0.466 <0.0001 0.31 to 0.69 child 1.69 0.002 1.2 to 2.3 female 1.33 0.003 1.1 to 1.6 35 of 47

Administration Lines Line Days Failures Rate per 1000 line days Clinician 2721 57445 225 3.9 Self 1896 40693 125 3.1 Total 4617 98138 350 3.6 36 of 47

Clinician lines have a slightly higher cumulative hazard at all times 37 of 47

Predictor Hazard Ratio P-value [95% Conf. Interval] 0.684 0.001 0.54 - 0.86 PICC 1 - reference CVC 1.67 0.003 1.2- 2.4 Implanted Port 0.0467 <0.001 0.011 - 0.19 Tunneled Catheter 0.445 0.168 0.14 - 1.4 Age (per year) 0.98 <0.0001 0.975 - 0.986 Self administering Each variable above is independent of the other The important predictors of line failure are: (1) Clinician-administration do worse after controlling for age and catheter (2) Compared to PICCs; CVC are worse and ports are better (3) Age: the older the better 38 of 47

Hazard Ratio P-value [95% Conf. Interval] Self 0.273 <0.0001 0.14 to 0.53 Age (per year) 0.975 <0.0001 0.96 to 0.99 39 of 47

There was a trend toward less thrombosis in the Self group after adjustment for the finding that thrombosis is more likely to occur in children but the small numbers made the results imprecise (Pvalue 0.086 PPP test). Lines Line Days Events Rate per 1000 line days Clinician PICC 2427 51874 23 0.443 Self PICC 1447 32770 8 0.244 193 3715 2 0.538 65 1499 2 1.33 4132 89858 35 0.390 Clinician CVC Self CVC Total 40 of 47

17 PICCs, 15 CVCs, and 1 tunneled line were accidently removed by patients or fell out. 27 of these were in the Clinician group (P <0.024 PPP test). It can happen at any time in the life of the line. 41 of 47

There were only 8 definite infections in 98,528 line days of observation. There was no significant difference between Self & Clinician (P=0.12 PPP test) 42 of 47

No significant difference between Self & Clinician (P=0.43 PPP test) Device PICC CVC Total 43 of 47 Line Days 84611 5214 89836 Rate per 1000 line days 0.31 1.1 0.089

72 lines needed removal for blockage. No significant difference between Self and Clinician (P = 0.39, PPP test). The only significant risk factor was age under 18 years. May be due to smaller lumen size Factor P-value [95% Conf. Interval] Self PICC CVC Port Age <18 44 of 47 Haz. Ratio 1.31 1 0.767 0.661 3.85 0.275 0.81 to 2.1 reference 0.24 to 2.4 0.24 to 1.9 2.0 to 7.5 0.654 0.428 <0.0001

• Self-administration survey of Out & About Patients – Advantages • “not tied down”; “control over situation” “family life normal”, “get back to work”, “helps understanding of disease” – Choose self-administration again: 93% • Service Advantages – Suitable for rural areas where limited numbers of nursing staff working 7 days / week & evenings – Capacity of service is not as affected by number of HITH team staff – Costs lower: fewer staff, cars & transport • Service Disadvantages – Requires thorough assessment prior to acceptance 45 of 47

• In selected patients, self-administration is safe, and equivalent or better in outcomes to clinician administered home parenteral antibiotic therapy • Gender and age were important factors in HITH success, independent of who administered the HPAT 46 of 47

Questions? Corresponding author: pauline.dobson@hnehealth.nsw.gov.au 47 of 47

Add a comment

Related presentations

Related pages

Care Home | LinkedIn

Care Home Articles, experts, jobs, and more: get all the professional insights you need on LinkedIn
Read more

www.slidesearch.org

Helga Merl, Nurse Practitioner, Hunter Medicare Local delivered this presentation at the 2014 National Dementia Congress. The event examined dementia case ...
Read more

Jessica Fung - BMO Capital Markets - Iron ore trends in 2015

... Jessica Fung - BMO Capital Markets ... Pauline Dobson, Hunter New England Health: Patients are doing it for Themselves: The Evidence for Self-care Home ...
Read more

Writing for Publication: Part Two | Kathleen Fahy ...

50 Writing for Publication: Part Two Kathleen Fahy Abstract The rules for writing a research report for ... The purpose of this paper is to enable new ...
Read more

Mental Health and Drug & Alcohol - Ministry of Health

Responsible for developing, managing and coordinating NSW Ministry of Health policy, strategy and program funding relating to mental health and the ...
Read more

Dialysis - Advantages and disadvantages - NHSChoices Home Page

... Advantages and disadvantages . Share: Save: ... Advice for new patients with kidney disease. ... Department of Health; NHS England; About the NHS.
Read more

HIV and AIDS - NHS Choices - NHSChoices Home Page

According to statistics from Public Health England, 95% of those diagnosed with HIV in the ... The World Health Organization ... Request content evidence ...
Read more

The Dark Side of Linus Pauling's Legacy - Quackwatch

... gives additional evidence of Pauling's defense of vitamin C ... therapy to benefit patients with ... New England Journal of ...
Read more