By Jean McCaslin, RN, IgCN.
Home health care continues to be the fastest growing segment of the health care industry. Many patients prefer the convenience and comfort of receiving care in the home. While the infusion of immune globulin (IG) requires specialty knowledge and precaution, the home infusion environment itself requires thoughtful consideration and accommodation.
It is critical a thorough assessment be conducted on the patient being considered for home infusion. While co-morbidities and the pharmaceutical specifics of the therapy are important, there are also many environmental and patient-specific considerations. Each plan of care should be customized to overcome many of the unique challenges of the home environment. These accommodations and precautions are important for the provision of care and safety of both patients and nursing staff.
Perception: For nurses, the hospital, clinic, or infusion suite is a primary setting. The environment is controlled, constant, and regulated. For patients, the setting is considered secondary; for them there is little control or contribution to the dynamics of their surroundings.
In the home care setting the opposite is true. It is a primary setting for the patient and a secondary setting for the nurse. Oftentimes dynamics exist that present challenges for the nurse. The nurse may be overly scrutinized. A patient or family member may not agree with the nurse’s work style and may be critical. Conflicting personality types may necessitate a change in staffing. The role of the nurse should be set by the nurse. The nurse is there to deliver infusion nursing care for the home infusion patient. Requests outside of nursing should not be performed by the nurse. The patient and family should be encouraged to express any concerns they have about having home nursing services.
Poor Venous Access: Since intravenous immunoglobulin (IVIG) is often administered regularly for chronic conditions, venous access may become difficult over time. Nurses with above average venipuncture skills are critical for this patient population. Adequate hydration can help with obtaining venous access as well as minimizing side effects. The oral intake of 64 ounces of water each day should be encouraged; starting 1-2 days before, each day of, and 1-2 days post-infusion. Exceptions to this are reserved for patients with cardiac or renal conditions. Leaving an angiocatheter locked should be considered for a multiple-day infusion course. As access issues progress, subcutaneous route of administration may need to be considered. Proactive communication of access issues with the specialty pharmacy and physicians is important.
Barriers to Learning or Communication: Any factors that may contribute to the ability of a patient to comprehend, communicate or learn can compromise the quality of home infusion services nurses provide. When a patient is incapable of contributing to his/her own care in a meaningful way, appropriate accommodations must be considered.
- Cultural: Cultural differences may affect the provision of care. There are often requests for nurses of specific religious or cultural affiliations. When available, these requests are honored. There may be barriers to communication for non-English speaking patients. An English speaking family member or friend can act as the primary contact. Translation phone services are available for most languages. When available, a same-language nurse is selected.
- Cognitive: Cognitive deficits may develop in aging patients. Some may suffer from psychological or neurological disorders that affect their cognition or ability to express themselves. If a patient is unable to provide self-care, it is important to identify a caregiver willing to accept responsibility to assist in communicating all aspects of care.
- Visual Acuity/ Manual Dexterity: Some patients receiving subcutaneous immunoglobulin (SCIG) may not be capable of administering therapy unassisted due to deficits of vision, strength, or dexterity. Barriers to self-administration should be identified at the onset of therapy so a caregiver can be selected to learn and administer therapy. If this is not possible, IVIG may be an alternative.
Scheduling: Many patients have limited availability in their busy schedules to accommodate multiple-day, long infusion therapy. Some patients are fearful their jobs are already in jeopardy due to missed work days associated with their illness. It is important for nurses and specialty pharmacy to be sensitive to individual patient time constraints. Evening and weekend appointments should be considered.
Compliance: Typically patients receiving home infusion therapy are compliant initially, but over time, they sometimes become complacent. Patients may be less likely to return calls for scheduling nursing visits or medication delivery. At times they are less proactive in their care with regard to oral hydration, pre-medication, bringing IG to room temperature or avoiding excessive alcohol intake prior to infusing IG. It is important nurses and pharmacy staff reinforces compliance periodically to avoid interruptions in therapy. Nurses should report non-compliance to the specialty pharmacy.
IV drug abuse: On occasion, it may be discovered a patient (or family member/caregiver) suffers from IV drug addiction/abuse. Once discovered it is important to report this finding to the physician and specialty pharmacy if not already known. If the patient has an abuse problem, angiocatheters should not be left in place after the completion of each infusion. Supplies are usually delivered to patients ahead of the scheduled dose and typically may include angiocatheters, syringes and needles. Having these available to an abuser before the dose could be problematic and may require accommodation such as delivering to someone other than the patient at an alternate address.
Health Hazards: Because the home care environment is unregulated, hazards may exist. Examples include poor air quality (lead paint, toxic substances, cigarette smoke, dust, mold, pet hair/odors), poor climate control (excessive heat or cold), unsanitary conditions (insects, rodents, hoarding, filth) and exposure to infection (hepatitis, HIV, virus, bacteria) due to poor hygiene.
An environment identified as a potential health risk must be addressed. Some corrections may be made quickly, such as making a home environment smoke, rodent or insect free. Some hazards may require action by a landlord. When an imminent life-threatening situation is identified, the patient must be moved to a safe environment until an alternative solution is found. It may necessitate moving the site of care to a physician’s office, an infusion suite or to a friend or family members home. Close communication between specialty pharmacy, physician, patient/care giver, and nursing agency should be ongoing as the hazard is corrected/ removed.
Threats: Nurses may be exposed to real or perceived threats such as aggressive pets, suspected inappropriate drug or alcohol use in the home, verbal abuse, ethnic discrimination and threatening language or stance by patients, family or neighbors. A nurse may see drugs, drug paraphernalia or guns in a home.
When a nurse’s well-being is in jeopardy due to hazards or threats in the home, accommodations should be made when possible, or the site of care relocated. Abuse and threats should not be tolerated by nurses. Dangerous situations should be reported to the nurse’s employer, police physician and specialty pharmacy.
Dangerous Neighborhoods: Some areas are known to have high crime rates and there may be an increased risk to the safety of a nurse, particularly after dark. If a threat is perceived upon arriving to the home, the nurse should not leave his or her vehicle. Instead, the nurse should drive away and notify the specialty pharmacy. Daytime infusion or an alternative site of infusion should be considered. Some apartment complexes have security guards willing to walk a nurse to his/her vehicle.
Fall Risk: Physical hazards increase the risk for falls and may include poor lighting, floor mats, throw rugs, excessive clutter and icy walkways or steps into a home. Some patients are unsteady on their feet and lack the assistance of mobility devices.
Nurses should perform a thorough evaluation of fall risks and discuss with the family/caregivers. Any dangerous or complex fall risks should be discussed with the specialty pharmacy and physician when minor reasonable accommodations are unable to minimize the fall risk.
Patient Neglect or Abuse: Patients are sometimes found in poor condition in their homes. It may be a result of disease process, refusal of care, or neglect or abuse from family members or caregivers. If abuse or neglect is suspected, it must be reported to the appropriate government agency, specialty pharmacy and physician.
While the home environment can present unique challenges for patient and caregiver, a nurse performing a thorough assessment can identify issues, make accommodations and overcome challenges while providing quality care.