Patient-Directed Healthcare

Nurses teach patients to self-administer IV medications at home

After a lengthy hospital stay, patients want nothing more than to go home. For some patients, depending on their diagnosis, home may not be the next stop. Patients with endocarditis, an infection of the heart, or osteomyelitis, a bone infection, among other pathologies, require 2 to 6 weeks of IV antibiotics after they have been declared medically stable.

Insured patients are discharged either to a nursing home or to their own home for H-OPAT-healthcare-administered outpatient parenteral antimicrobial therapy. A healthcare worker, such as nurse, will make sure they get the needed medications. Uninsured patients cannot afford nursing home or home health care. They must remain in the hospital, usually so-called “safety-net” facilities that care for high populations of uninsured, low-income patients, for those weeks.

This is not an ideal situation. Patients want to get home to their spouses, children, jobs and other responsibilities. In the hospital, they are taking up beds that could be used for the more acutely ill. Knowing this,Parkland Memorial Hospital in Dallas tested the feasibility of S-OPAT, aka self-administered outpatient parenteral antimicrobial therapy. What would the outcomes be if patients themselves administered IV medications in their homes?

The hospital ran a four-year study from 2009-2013 under the direction of Kavita Bhavan, MD, Medical Director of the Infectious Diseases OPAT Clinic at Parkland and Assistant Professor of Internal Medicine at UT Southwestern Medical Center, to test the effectiveness of the program. At the launch of the study, there was not dedicated staff members for S-OPAT; now there are nurses, case managers, pharmacists, and physicians dedicated to guiding the patients through the educational process. “It takes a lot of time and education,” explained Jillian Dorsey, RN, BSN, nurse navigator in Parkland’s OPAT clinic.

Consistent Patient Education

When the program launched, an interdisciplinary team of Parkland nurses, case managers, physicians and infectious disease pharmacists, along with Bhavan, devised the patient training. Dorsey remarked, “We saw the need for more consistency across the board. Everything needed to be done the same way. Having a dedicated nurse makes sure the patient gets the education they need.”

Traditionally, nurses are the ones who set up IV medications at the bedside. They also play a large part in discharge education, so the profession is a natural fit to train patients on the administration of their medications.

Maria Sierra, RN, transitional care nurse in S-OPAT said, “At first, patients are scared because they don’t know what they are getting into.” Dorsey continued, “Patients think only a nurse can do this.”

Patients might not know what a central line is, for example, and nurses answer any questions. In order to be a part of the program patients or their family members must prove a minimum of three times that they can administer an IV antibiotic through a peripherally inserted central catheter line. They must know how to prepare the antibiotic, hang the bag, flush the catheter line and administer the antibiotic. The process is repeated countless times over a four- to six-week antibiotic treatment.

One of the teaching tools is an instructional DVD outlining the process. “Watching it answers and helps to relieve any anxiety they might have,” noted Sierra. They can download the video onto their smartphone to watch as many times as they need or can access it on YouTube.

Nurses as Teachers

Of course, hands-on instruction is the best teaching tool. The goal is to make sure the patients are confident and competent, which can take multiple teaching sessions in the hospital. At first, they practice using saline in the IV. Later, Sierra explained, “We teach them with the medication they are going home with. It needs to be used at least once so they learn the entire process.”

Nurses teach the patients how to use their IV tubing. At home, patients will use a coat hanger to hang the IV bag. They learn how to count the drops of IV antibiotic and to adjust for the drip rate indicated on the medication label. “If they don’t have their PICC line or central line yet, we use a dummy arm,” said Sierra.

Throughout the whole process, even when the patients have been discharged, nurses are available to provide bilingual support. Sierra remarked, “Sometimes at home, they freak out being alone the first time. We ask them to relax and watch the video.”

Dorsey noted, “Teaching them gives them a sense of control. By the end, they are confident.” Empowering patients to take charge of their own healthcare needs goes a long way towards getting them back to their everyday routines. The patients are happy to be home.

Getting Home Sooner

Results are positive for the hospital too.  In Parkland’s study, 944 patients went through the S-OPAT program and 224 received H-OPAT. The 30-day readmission rate for the S-OPAT group was 47% lower than their H-OPAT counterparts. One-year mortality rates between the two groups were statistically similar. Ove the four years, the hospital saved 27,666 inpatient days because patients were discharged sooner.

The program continues to have positive results today. Dorsey advised nurses at other hospitals, “They have to realize patients can do this.” She recognized, “It’s a scary thing to send a patient home with IV access. It’s a learning process for nurses as well.”

Parkland Health & Hospital System set out to test the safety and efficiency of teaching patients to administer their own IV-based antibiotics. Through the efforts of their nursing staff, they proved that was possible.

Bhavan also credits the patients with the clinic’s success. “Yes, we have developed an innovative approach to healthcare delivery in this clinic, but it’s the patients who have shown the greater impact of tapping into human potential by being  empowered to do something that many didn’t think they could do,” Bhavan said. “They are the true heroes here – we just gave them the opportunity to shine.”

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