Home Infusion Providers Research Articles

605. Rates of Patient Satisfaction with Home-Based Outpatient Antimicrobial Therapy (OPAT)

Abstract Background The use of home-based outpatient parenteral antimicrobial therapy (OPAT) is well established. Studies by the National Home Infusion Foundation (NHIF) show that 1.4 million patients receive OPAT each year.1 With patient satisfaction a priority, NHIF developed, validated, and reliability tested the Uniform Patient Satisfaction Survey for Home Infusion Providers in 2017.2 Medicare patients are the fasting growing segment in the US and account for a disproportionate share of health care usage. Determining older patient satisfaction is imperative because patients who are more satisfied are more compliant with treatment3 and tend to return for continued care.4 Accordingly, the purpose of this study was to determine the level of home-based OPAT patient satisfaction and if a significant difference (p = ≤ .05) exists between the 0-64 and 65+ age groups. Methods 2019 and 2020 OPAT survey data (n=5,559) was used in this study. Top box percent, typically used in health care patient satisfaction, was calculated for each survey question. Data was summarized using 7 composite categories formed from the 22 survey questions. Differences (p = ≤ .05) between the age groups was also calculated. Results Mean patient age was 64.31 (SD=14.78), 54.99% were 65+ years old, and 58.85% were male. OPAT patients gave high marks to their home infusion service (Table 1). The highest top box % for the composite scores was “Patient instructions” which averaged 98.91%. The most common healthcare satisfaction question “I was satisfied with the overall quality of the services provided” showed significant difference between the age groups (p = .002) with the 0-64 groups being more satisfied than the 65+ (Exhibit 1). Table 1. OPAT Patient Satisfaction Survey Composite Scores: Percent of Patients Selecting Top-Box Score (n= 5,559) Exhibit 1. Level (%) of Agreement to “I was satisfied with the overall quality of the services provided” by Age Group (n = 5,559) Conclusion Analysis of each survey question shows the 65+ patients are less satisfied than younger patients on the following: being informed of side effects, explanation of financial responsibilities, and the helpfulness of the billing staff. Even though the scores are high for both age groups, additional research needs to be conducted to determine why scores for the 65+ age group are lower, and changes needed for improvement. Knowing the level of OPAT patient satisfaction will benefit infectious disease physicians, providers, prescribers, payers, and regulators as they evaluate how to expand home-based services. Disclosures All Authors: No reported disclosures

Case Study: Daily Review of Telemonitoring Data by a Critical Care Nurse Improves Outcomes in a Patient with Class IV, Stage D Heart Failure with Reduced Ejection Fraction Receiving Home Intravenous Dobutamine for Palliation.

Purpose The purpose of this case study is to demonstrate how a robust telemonitoring program, which includes daily critical care nurse review of heart failure symptoms, vital signs, oxygen saturation, weight, and blood glucose levels, prompts clinical interventions that result in overall improved symptom management and decreased hospital readmissions for a patient requiring home inotrope infusion. Objectives 1. To summarize particular telemonitoring data that triggered nursing telephonic outreach for further patient evaluation 2. To summarize clinical interventions resulting from data and nursing telephonic outreach 3. To report patient outcomes (symptom improvement and avoidance of hospitalizations) Methods A retrospective review of this patient's medical record was performed, which consisted of telemonitoring data, physician order changes, and clinical assessments performed by critical care nurses. Results This 50-year-old male with Class IV, Stage D heart failure with reduced ejection fraction was admitted to this home infusion provider on 03/26/2015 to receive palliative treatment with continuous intravenous dobutamine 2.5 mcg/kg/min and daily telemonitoring. He was not a candidate for advanced heart failure therapies, such as left ventricular assist device or heart transplant, due to prior noncompliance with his treatment plan. The first telemonitoring data was transmitted on 03/28/2015. The patient was largely compliant with daily data transmissions throughout the course of care, which ended 06/03/2015 when the patient's insurance changed and the payor mandated transfer of care to another home infusion provider. A telephonic assessment performed by a critical care nurse occurred each day the transmitted data triggered an alert. A total of 25 alerts were received and are summarized as follows: 1 increased lower extremity edema, 5 weight increased more than 2 pounds in 24 hours, 7 heart rate and blood pressure elevations, 2 blood glucose elevations, 1 increased orthopnea, 1 significant weight loss in 24 hours, and 8 missing daily data transmissions. These alerts and resulting telephonic assessments prompted 61 clinical interventions, which included: 32 nursing visits for IV furosemide administration, 7 patient education sessions, 1 additional dose of oral furosemide, 7 rechecks of blood pressure and heart rate, 6 physician contacts, and 8 patient contacts requesting health check/data transmission. Conclusions Daily critical care nurse telemonitoring resulted in nearly daily interventions with gradual stabilization of weight and vital signs, no decline in respiratory status, and no hospitalizations throughout 69 days of service. Of particular significance is the fact that telemonitoring improved the patient's compliance to his treatment plan, which resulted in an evaluation for a left ventricular assist device placement. Results

Implementation of Smart Pump Technology With Home Infusion Providers: An Assessment of Clinician Workflow and Patient Satisfaction.

While hospitals have adopted smart pump technology (SPT) featuring drug libraries and medication safety software, most home infusion providers (HIPs) continue to use traditional infusion pumps that don't offer drug libraries or medication safety software. As infusion delivery is moving from the hospital to the home, the purpose of this study was to determine whether SPT was a feasible alternative at both a hospital-based and a rural HIP. HIP personnel were trained on an ambulatory infusion pump. Patients requiring home infusion used the pump and recorded daily pump interactions for 5 to 7 days. After the creation of a drug library, clinicians felt comfortable programming pumps after 7 uses. Patients reported 100% overall satisfaction, and the majority of alarms were resolved without contacting the HIP. Ambulatory SPT can be implemented successfully by HIPs and can be used effectively by patients.

Incidence and Management of Infusion Reactions to Infliximab in an Alternate Care Setting

BackgroundInfliximab is a chimeric anti-tumor necrosis factor alpha (TNF-α) monoclonal antibody that ameliorates inflammation when it binds to and neutralizes TNF-α. It is often used in patients with Crohn’s disease and ulcerative colitis to reduce the severity of disease symptoms and induce disease remission. Infusions are generally administered in the hospital setting due to concerns over patient safety, and limited data exist regarding the incidence and management of infusion reactions (IRs) in an alternate care setting without direct physician oversight.AimsThe aim of this study was to evaluate the incidence of IRs following administration of infliximab and associated management approaches in an alternate care setting.MethodsA retrospective chart review of 796 patients with Crohn’s disease or ulcerative colitis that received a combined 5581 infusions with one home infusion provider between January 2014 and November 2016 was conducted. Timing, severity, management approach, and outcomes of IRs were abstracted and analyzed.ResultsA total of 109 infusion reactions (2.0% of all infusions) were recorded in 62 patients (7.8% of all patients). The majority of these reactions were acute and mild or moderate in severity and resolved with rate adjustments and/or medication. Emergency room visits were required in 0.1% of all infusions, and 0.3% of all infusions were not completed due to a reaction.ConclusionsIRs to infliximab were uncommon and mostly mild or moderate in severity. Resolution of the IR and continuation of therapy was achieved in most patients through a management approach that included prompt recognition and initial treatment via rate adjustments and medications according to physician’s orders.

Prevalence of Home Parenteral and Enteral Nutrition in the United States.

Malnutrition is highly prevalent and associated with increased morbidity and mortality. Studies continue to reveal significant clinical benefits with nutrition support, including improved wound healing, reduction in complications and length of stay, and mortality. Due to these benefits, the prevalence of home parenteral and enteral nutrition (HPEN) continues to increase worldwide. In the United States, given our healthcare insurance landscape, it has been very difficult to ascertain the true prevalence of HPEN. Medicare beneficiary data for 2013 were obtained from Centers for Medicare and Medicaid Services. Commonly used Healthcare Common Procedure Coding System codes were used for home enteral nutrition (HEN) and home parenteral nutrition (HPN). Data regarding number of patients and insurance providers were also obtained from 3 of the largest home infusion providers in the United States (Coram CVS, Option Care Enterprises, and BioScrip Inc). Based on the ratio of Medicare to non-Medicare billing, an estimate of HPEN prevalence was obtained. For 2013, there were 6778 Medicare beneficiaries for HPN and 114,287 for HEN. The ratio of Medicare to non-Medicare was 0.271 for HPN and 0.261 for HEN, leading to an estimated prevalence of 25,011 patients receiving HPN (79 per million U.S. inhabitants) and 437,882 patients receiving HEN (1385 per million U.S. inhabitants). There are an estimated 4129 pediatric patients and 20,883 adult patients receiving HPN; for HEN, 189,036 pediatric patients and 248,846 adult patients. Compared with results from 1992, the prevalence of HEN has increased dramatically, while the prevalence of HPN has declined.

Incidence of and factors associated with catheter-related bloodstream infection in patients with advanced solid tumors on home parenteral nutrition managed using a standardized catheter care protocol

BackgroundCatheter-related bloodstream infections (CRBSIs) are associated with high morbidity and mortality as well as increased medical costs. Cancer patients, who are often immunocompromised, are susceptible to CRBSI while receiving home parenteral nutrition (HPN). We evaluated the incidence of and factors associated with CRBSIs in cancer patients undergoing HPN managed using a standardized catheter care protocol.MethodsThis is a retrospective cohort study of 335 cancer patients receiving HPN between January 2012 and July 2015. The primary outcome of interest was the incidence of CRBSI expressed as events per 1000 HPN days. HPN days were calculated from the start date with the home infusion provider until the discontinuation of HPN, or the removal of the venous access device (VAD), or the death of the patient. The VADs used were either peripherally inserted central catheters (PICCs) or a subcutaneous implanted port or tunneled central catheters (TCCs). Univariate Poisson regression analyses were used to determine the variables associated with CRBSIs.ResultsOf 335 patients, 193 were females and 142 were males. The most common cancer types were colorectal, pancreatic, ovarian and stomach. A total of 408 VADs in 335 patients were studied, covering a total of 29,403 HPN days. Of 408 VADs, 206 (50.5%) were ports, 191 (46.8%) were PICCs, and 7 (2.7%) were TCCs. The median duration of HPN was 54 days. A total of 16 CRBSI episodes were recorded (8 in ports, 7 in PICCs and 1 in TCCs). The median duration from the start of HPN to the development of CRBSI episodes was 43.5 days. The overall incidence of CRBSI per 1000 HPN days was 0.54 (95% confidence interval: 0.32–0.86). Upon univariate analysis, no variables were found to be statistically significantly associated with CRBSI incidence.ConclusionsWe found a low rate of CRBSI following a standardized catheter maintenance protocol in a high-risk oncology population undergoing HPN.

Intravenous Home Infusion Therapy Instituted From a 24-Hour Clinical Decision Unit For Patients With Cellulitis

ObjectivesThe objective of the study is to evaluate whether patients with cellulitis can be safely discharged from a 24-hour clinical decision unit (CDU) with home infusion of intravenous (IV) antibiotics. MethodsClinical decision unit patients receiving IV antibiotics for cellulitis were screened for enrollment in a home infusion therapy (HIT) program. Inclusion criteria were patient ability and willingness to administer IV antibiotics at home and insurers' approval of home infusion services. Patients were discharged home with a peripheral IV and care coordinated with a home infusion provider. ResultsOf 213 patients with cellulitis transferred from the emergency department to the CDU over an 8-month study period, a total of 32 (15%) were discharged from the CDU with HIT. The average duration of home IV antibiotic treatment was 3.4 days. There were a total of 9 complications (28%), including IV infiltration (n = 5), allergic reactions (n = 2), nontolerance to the antibiotic (n = 1, this patient developed severe nausea and was switched to oral antibiotics after 2 days of HIT), and 1 patient required readmission for lack of clinical improvement. Among the 181 patients with cellulitis who did not receive HIT, 39 (22%) were hospitalized from the CDU, and 1 additional patient refused admission. ConclusionsWe avoided admission for 31 (97%) of 32 patients who were enrolled in HIT. Home infusion therapy has the potential to prevent hospitalizations, alleviate overcrowding of hospital beds, and decrease health care costs. Further studies are needed to determine the full impact of HIT on CDU patients with acute cellulitis.

Managing Multidrug-Resistant Organisms in Home Care and Hospice

Multidrug-resistant organisms (MDROs), including methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and certain gram-negative bacilli, are transmitted most frequently in acute care facilities. However, these MDROs have important infection control implications for care provided in the home setting. Little is known about the actual occurrence of MDROs among home care and hospice patients. To date, no published reports have described transmission of an MDRO from care provided in the home setting. Nonetheless, all providers of care in the home should be aware of MDROs and the potential for their transmission from one patient to another. The Centers for Disease Control and Prevention's (CDC) Guideline on the Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006 provides recommendations for preventing and controlling the transmission of MDROs. This article discusses the Guideline's recommendations and how they may be implemented in the home setting by home health agencies, home infusion providers, hospices, and providers of durable medical equipment.

Management of the Home Parenteral Nutrition Patient

Parenteral nutrition (PN) support can be managed in the home setting for both a short-term and long-term period or for a lifetime, permitting individuals who cannot adequately absorb nutrients enterally to achieve a normal lifestyle. Nutrition support professionals must be aware of home PN (HPN) management principles before discharge to ensure a smooth transition to home with all requisite monitoring. This article will discuss the initiation and monitoring of patients on HPN, the prevention and treatment of potential complications, the contributions of the home infusion provider, and the home nutrition support team and the outcomes of HPN.

Evaluating the Effectiveness of a Micronutrient Assessment Tool for Long‐Term Total Parenteral Nutrition Patients

Monitoring parameters for patients receiving long-term home parenteral nutrition (HPN) should include assessment of micronutrient status to avoid deficiencies and potential excesses of any micronutrient. This evaluation examined the effectiveness of a standardized micronutrient assessment tool administered semiannually to long-term HPN consumers, for identifying signs/symptoms of a suspected deficiency or excess. All patients assessed were receiving long-term HPN from a single home-infusion provider. Of the 275 micronutrient assessments evaluated, 30 patients were found to have a suspected deficiency. Laboratory tests were ordered for 13 patients: deficiencies were confirmed in 6 patients, no deficiency was found in 4 patients, and 1 patient was not deficient in the suspected micronutrients but was found deficient in others. The micronutrient assessment tool is effective in determining the suspected presence of micronutrient deficiencies. All long-term HPN patients should receive ongoing monitoring by a home care clinician, including an assessment of micronutrient status, to ensure adequacy of the nutrition support regimen.

The Role of Advanced Practice Skills for Nutrition Support Dietitians in Home Care

Home care encompasses services such as the provision of supplies and durable medical equipment to the provision of high tech home infusion therapy (home chemotherapy and home nutrition support). The nutrition support dietitian (NS-RD) experienced in working with the hospital nutrition support team can be a valuable asset to the home infusion provider. We collated information from a large home infusion therapy provider (90 branches across the US) to provide insight into the qualifications, roles and responsibilities, and impact of the NS-RD in the provision of home nutrition support. More than half of the NS-RDs are certified nutrition support dietitians and all had been in practice greater than 2 years. The NS-RDs qualifications indicate that advanced practice skills are essential to performing the clinical management required for home nutrition support patients. The responsibilities of the NS-RD identified which would be considered advanced practice skills were: clinical management of home parenteral nutrition patients, participation on the home nutrition support team, and home visits to patients providing nutrition focused physical ^assessment. Other identified roles of the NS-RD were support and assistance to the reimbursement staff, sales support for joint sales calls, development of continuing education presentations for patients and customers, and community involvement in both professional and patient oriented activities. This information has assisted us in recognizing the need for the advanced level skills of a NS-RD in managing home nutrition support patients. By better identifying the contributions of the NS-RD, the clinical and sales staff to better utilize the NS-RD. Finally, this has demonstrated to senior management the valuable role the dietitian plays in the overall success of the business - by facilitating improved clinical outcomes with cost effective high quality care. Advanced level skills make the NS-RD a valuable asset to the home nutrition support provider and patient.

Adverse Drug Reactions: Communications and Reporting — Hospital and Home Health Care Perspectives

Emphasis on adverse drug reaction (ADR) monitoring and reporting in the hospital setting has spawned a number of model ADR programs across the country. Although the pharmacy department usually becomes the caretaker of such programs in the hospital, a multidisciplin ary approach may be the cornerstone to an effective and efficient program. In contrast, little information is available regarding ADR monitoring in the home setting. Developing and implementing an ADR monitoring program in the home health-care setting presents unique administrative and clinical challenges to home infusion providers. The decentralized nature of formalized home care emphasizes the need for open communication channels in all aspects of care, but particularly for the monitoring and reporting of ADRs. Establishing an effective ADR program in the home setting may optimize patient safety, and provide valuable information regarding the nature and significance of reactions that occur in this population. The University of Kansas has established a dedicated phone line which enables home health care professionals to monitor and report ADRs. The data collected in this pilot project is reviewed, with respect to the type of reaction and its degree of severity, patient outcome and the United States market life of drugs associated with these reactions.

Adverse Drug Reaction Monitoring and Reporting in Home Health Care

AbstractHome health care is one of the fastest growing segments of the health care delivery system in the United States. The scope of medications administered in the home setting have expanded from traditional TPNs and chronic pain manage-ment to include dopamine infusions and other medications previously reserved to the hospital setting. However, little information is available regarding the adverse drug reactions (ADRs) encountered in the home infusion environment, including the degree of severity, the incidence and the patient outcome. Establishing an effective ADR program in the home setting may optimize patient safety and provide valuable information regarding the nature and significance of reactions that occur in this population.The University of Rhode Island has established a dedicated phone line which enables home health care pharmacists to monitor and report ADRs. After 13 months of operation, 125 adverse drug reaction reports were received by the center from two national home infusion providers.