Download - Pauline Dobson, Hunter New England Health - The Evidence for Self-administration of Home IV Therapy
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
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• 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
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• 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…
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Examples of some
clinician managed
PICCs in patients
referred to our
service from
elsewhere
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Unsecured
Multiple
Opsite
dressings
Excess
External
length
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St Elsewhere’s a number of days post insertion
Unsecured,
bloody,
two
dressings
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The long
and
winding
road
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Policy “…the dressing is changed on a weekly basis or immediately if the
integrity of the dressing is compromised.”
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Phlebitis
Multiple
Opsites
Multiple
Opsites
Multiple
Opsites
Multiple
Opsites
Blood,
Statlock
Placement
Old spot
bandage
under Opsite
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Grotty
Double Bunger
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Neat
Triple Bunger
Neat
Triple Bunger
Neat
Triple Bunger!
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• 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)
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• 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)
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• 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
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• 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
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~3hrs
198km
HITH Service Geographic boundaries
~6hrs
427km
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• 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)
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• 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
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• 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
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• 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;
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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.
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• 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
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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%)
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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
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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
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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
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Clinician Administered
Self Administered
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• The proportion of those
who self-administer
has steadily increased
• And remains the case
when Cystic Fibrosis is
excluded
50%
40%
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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.
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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)
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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
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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.)
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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
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Clinician lines
have a slightly
higher
cumulative
hazard at all
times
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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
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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
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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).
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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.
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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)
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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)
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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
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• 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
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• 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