Pauline Dobson, Hunter New England Health - The Evidence for Self-administration of Home IV Therapy
Upcoming SlideShare
Loading in...5
×
 

Pauline Dobson, Hunter New England Health - The Evidence for Self-administration of Home IV Therapy

on

  • 238 views

Pauline Dobson, Hunter New England Health delivered the presentation at the 2013 Hospital in the Home Conference. ...

Pauline Dobson, Hunter New England Health delivered the presentation at the 2013 Hospital in the Home Conference.

The Hospital in the Home Conference is a nurse oriented program packed with comprehensive case studies to improve HITH services and maximise hospital efficiency throughout Australia.

For more information about the event, please visit: http://www.communitycareconferences.com.au/HITHevent

Statistics

Views

Total Views
238
Views on SlideShare
238
Embed Views
0

Actions

Likes
0
Downloads
0
Comments
0

0 Embeds 0

No embeds

Accessibility

Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

Pauline Dobson, Hunter New England Health - The Evidence for Self-administration of Home IV Therapy Pauline Dobson, Hunter New England Health - The Evidence for Self-administration of Home IV Therapy Presentation Transcript

  • 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
  • 2 of 47 • 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 1. Antoniskis A, Anderson BC, Van Volkinburg EJ, et al: Feasibility of outpatient self- administration of parenteral antibiotics. West J Med 128:203-206, Mar 1978
  • 3 of 47 • 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
  • 4 of 47 Image from: Quarksandquirks.wordpress.com However we may be making assumptions…
  • 5 of 47 Examples of some clinician managed PICCs in patients referred to our service from elsewhere
  • 6 of 47 Unsecured Multiple Opsite dressings Excess External length
  • 7 of 47 St Elsewhere’s a number of days post insertion Unsecured, bloody, two dressings
  • 8 of 47 The long and winding road
  • 9 of 47 Policy “…the dressing is changed on a weekly basis or immediately if the integrity of the dressing is compromised.”
  • 10 of 47 Phlebitis Multiple Opsites Multiple Opsites Multiple Opsites Multiple Opsites Blood, Statlock Placement Old spot bandage under Opsite
  • 11 of 47 Grotty Double Bunger
  • 12 of 47 Neat Triple Bunger Neat Triple Bunger Neat Triple Bunger!
  • 13 of 47
  • 14 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)
  • 15 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)
  • 16 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
  • 17 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
  • 18 of 47 ~3hrs 198km HITH Service Geographic boundaries ~6hrs 427km
  • 19 of 47 • Offered as option only • Patient / Carer must be willing to self-administer • Assessed for: – Cognition – Hygiene – Motor skills (dexterity, tremor) – Compliance – IDU history – Ability to read written instructions (language) – Hearing (alarms, telephone contact) – Vision (pump controls)
  • 20 of 47 • 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
  • 21 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
  • 22 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;
  • 23 of 47 Variable Clinician Administered Self-Administered Combined Admissions 2739 1913 4652 Patients 2204 1091 3295 Patient days 59,983 42,920 102,903 Median Length of stay 21 20 21 Gender – Male 1758 (64.2%) 1107 (57.9%) 2865 (61.6%) Age – (mean, range) 58.8 (3 months - 96yrs) 40.0 (3 weeks – 92yrs) 51.1 Paediatric 140 377 477 Females are less likely to utilise self- administration, Odds Ratio 0.65 (95% CI 0.47 to 0.89). Note: self is often carer.
  • 24 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 Admissions Per patient Number of Patients Percent 1 2,705 82.1 2 391 11.9 3 91 2.76 4 35 1.06 5 14 0.42 6 12 0.36 7 5 0.15 8 4 0.12 9 6 0.18 10 5 0.15 11 5 0.15 12 5 0.15 13 2 0.06 14 2 0.06 15 3 0.09 18 1 0.03 19 3 0.09 20 1 0.03 21 1 0.03 22 1 0.03 27 2 0.06 33 1 0.03 Total 3,295 100
  • 25 of 47 Variable Clinician Self Combined Bone & Joint infection 1552 (57%) 854 (45%) 2406 (51.7%) Cystic Fibrosis 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%) Other 284 (10%) 170 (9%) 454 (9.8%)
  • 26 of 47 Vascular Device Clinician Self Combined PICC 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%) Tunnelled Catheter 29 (1%) 22 (1.1%) 51 (1%) Peripheral IVC 25 (0.9%) 3 (0.15%) 28 (0.6%) Total 2,834 1973 4,807 Note: more lines than admissions, some lines need replacing during admission
  • 27 of 47 Drug Clinician Self Total Flucloxacillin 835 518 1,353 Vancomycin 503 214 717 Benzylpenicillin 398 183 581 Timentin 290 237 527 Meropenem 91 193 284 Ceftazidime 76 198 274 Tobramycin 51 218 269 Cephalothin 192 46 238 Tazocin 30 103 133 Ceftriaxone 88 40 128 Gentamicin 57 58 115 Teicoplanin 57 50 107 Cephazolin 55 23 78 Cefepime 16 48 64 Piperacillin 5 33 38 Total 2744 2162 4,906 Note: more drugs than admissions, some patients on dual or triple tx
  • 28 of 47 Mode Clinician Self Total Continuous 24h 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
  • 29 of 47 Clinician Administered Self Administered
  • 30 of 47 • The proportion of those who self-administer has steadily increased • And remains the case when Cystic Fibrosis is excluded 50% 40%
  • 31 of 47 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.
  • 32 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)
  • 33 of 47
  • 34 of 47 Predictor Haz. Ratio P-value [95% Conf.Interval] PICC 1 reference CVC .82 0.138 0.64 to 1.1 Port .73 0.042 0.54 to .99 Tunneled Catheter .65 0.120 0.37 to.1.12 Child (<18) 1.4 <0.0001 1.2 to 1.8 Female 1.3 <0.0001 1.1 to 1.4 Cystic fibrosis .79 0.195 0.55 to 1.1 Female with CF .58 0.015 0.37 to 0.90
  • 35 of 47 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 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.)
  • 36 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
  • 37 of 47 Clinician lines have a slightly higher cumulative hazard at all times
  • 38 of 47 Predictor Hazard Ratio P-value [95% Conf. Interval] Self administering 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 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
  • 39 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
  • 40 of 47 Lines Line Days Events Rate per 1000 line days Clinician PICC 2427 51874 23 0.443 Self PICC 1447 32770 8 0.244 Clinician CVC 193 3715 2 0.538 Self CVC 65 1499 2 1.33 Total 4132 89858 35 0.390 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 (P- value 0.086 PPP test).
  • 41 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.
  • 42 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)
  • 43 of 47 Device Line Days Rate per 1000 line days PICC 84611 0.31 CVC 5214 1.1 Total 89836 0.089 No significant difference between Self & Clinician (P=0.43 PPP test)
  • 44 of 47 Factor Haz. Ratio P-value [95% Conf. Interval] Self 1.31 0.275 0.81 to 2.1 PICC 1 reference CVC 0.767 0.654 0.24 to 2.4 Port 0.661 0.428 0.24 to 1.9 Age <18 3.85 <0.0001 2.0 to 7.5 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
  • 45 of 47 • 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
  • 46 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
  • 47 of 47 Questions? Corresponding author: pauline.dobson@hnehealth.nsw.gov.au