Infusion therapy moves into the community

Intravenous (IV) therapy as we know it today is a highly specialised form of treatment that provides a quick and effective method of delivering medication, fluids, total parenteral nutrition and blood products. 

Although the practice of using veins to inject substances essentially began in the 17th century, the major advances in IV therapy occurred during the past 150 years – evolving from an extreme measure used only on the most critically ill to a therapy used for almost 90% of all hospitalised patients.

However, IV drug infusion therapy is not confined solely to the hospital setting. Demands for acute hospital beds, advances in treatment regimens, changes in government policy and greater patient participation in treatment decisions are challenging the traditional perception that infusion therapy should be confined to the hospital environment.

Increased IV use in community care

IV therapies are now increasingly being delivered in community settings, including skilled nursing facilities, health clinics and patients’ homes. Indeed, the practice settings for IV therapy delivery are as varied as the patient populations served by this speciality; from the hospitalised neonatal patient to the geriatric patient in a nursing home, all patients assessed by their doctors as being unable to have oral medication, or where medication via the intravenous route is deemed to be the treatment of choice. 

The Infusion Nurse Society (INS), which is the recognised global authority in infusion therapy, encapsulates the diversity of IV therapy settings and treatments: “In a clinical setting one might find the nurse transfusing blood products and interpreting haemodynamic data gained from IV monitoring. Another nurse may be training a mother to administer total parenteral nutrition to her toddler in a suburban home. A colleague is fighting downtown traffic to reach a working executive in time to change a cassette on an ambulatory antibiotic pump, while yet another is recommending vascular access devices to the new oncology patient in the physician’s office.” 

Bernadette Carter, who is one of the founding members of the Irish and UK International Affiliate of the INS, says tens of thousands of patients across a range of diseases such as cancer, rheumatology, respiratory, cystic fibrosis, gastro disorders and many infectious diseases rely on infusion treatment.

“The list of innovative medications is growing, patients have more medical options than ever before and our nurses play a vital role in getting these medicines to them,” she remarks.

Infusion therapy may be provided for patients who need:

• Medication for chronic illnesses such as Crohn’s disease, bronchial asthma and diabetes 
• Pain management 
• IV hydration therapy 
• Blood products such as platelets, red cells or plasma 
• Low-dose chemotherapy 
• IV antibiotics for an infection 
• Post-transplant IV medications 
• Immunomodulators (drugs that stimulate the immune system) 
• Biological response modifiers (substances made by living cells that stimulate the body’s response to infection and disease; used for rheumatoid arthritis and other conditions) 
• IV anti-emetics for nausea and vomiting 
• IV immune globulin to boost the body’s natural defence system against infection 
• Monoclonal antibodies to suppress the immune system or to kill/inhibit cancer cells 
• Therapeutic phlebotomy, which involves withdrawing a prescribed amount of blood to improve the symptoms of a blood disorder.

Infusion teams typically include a doctor who writes a prescription and develops a schedule for infusions, and infusion therapy nurses who actually perform the treatments and monitor the patients while treatment is ongoing. The medication can be delivered directly into the body via a blood vessel, the spinal cord or a muscle. 

Ms Carter explains that, up until recent years, the management of this highly specialised treatment area has been under the care of individual hospitals rather than one overarching body. 

However, the arrival of the INS in Ireland in 2010 supports nurses and healthcare professionals through establishing standards, educational programmes, publications and access to experts in infusion care. 

MRI is the most effective way of showing whether a patient’s back pain is amenable to minimally invasive surgery, according to neurosurgeon Mr Steven Young(click to enlarge)

Specialised IV therapy courses

The INS offers a Certified Registered Nurse of Infusion (CRNI) course, which is the recognised accredited educational standard for infusion therapy for over 10 years in the US. INS UK and Ireland is now developing and running this course in Ireland. Several INS members are currently studying for the CRNI and will take their exam in September 2011. These will be the first Irish nurses to take this post-diploma accredited certification.

“This is a course offered by INS and we will be the first group of nurses outside of America to take the course,” says Ms Carter, who is a course instructor and will be providing web-based study for the CRNI students.

“IV nursing is now a technical, highly specialised field that requires advanced clinical knowledge and technical expertise. The CRNI is a very intensive and highly specialised course that will cover nine core areas, which nurses involved in the practice of IV therapy need to be knowledgeable in,” says Ms Carter. 

These are: 

• IV therapy in paediatrics, such as fluid replacement
• IV antibiotics, immunotherapy etc
• Infection control
• Fluid and electrolytes
• Practice and quality assurance
• Transfusion therapy
• Chemotherapy
• Pharmacology
• Total parenteral nutrition
• Clinical applications and technology around IV therapy. 

Clinical applications and technology around IV therapy is a crucial part of the course and covers a broad area including peripheral venous catheters, central venous catheters, and the complications of IV therapy.

Infusion therapy is rapidly becoming a more specialised area primarily due to the development of innovative new drugs, such as biologic drugs and a new range of antibiotics and chemotherapy drugs. However, with these new drugs comes increased risk of adverse drug interactions and the need to understand the correct method of delivery for each medication.

Complications of infusion therapy

Infiltration and extravasation are all-too-common complications of IV infusion therapy, especially therapy involving peripheral IV sites. According to the Infusion Nursing Standards of Practice, infiltration is the inadvertent administration of non-
vesicant (non-blistering) medication or fluid into the surrounding tissue instead of into the intended vascular pathway, which can cause discomfort or pain at the venipuncture site. Extravasation is infiltration with a vesicant medication or fluid. When these highly irritating fluids leak out of a vein, they cause blisters and can even damage or destroy surrounding tissue.

“Because of these concerns, some drugs aren’t appropriate for peripheral delivery,” says Ms Carter. “Therefore it is vital that the IV nurse chooses the type of vascular access according to the pH and osmolarity of the infusion. A lot of nurses wouldn’t be aware of this risk and that is why it is so important for infusion therapy to become more specialised.”

Reduction in hospital visits 

The delivery of community-based infusion services is gradually gaining pace in Ireland. A myriad of international research has shown that providing IV therapy in a community setting resulted in a reduced number of hospital patient days and related savings for the healthcare system.

Ms Carter is a cancer nurse specialist and nurse educator with Point of Care, an Irish firm that has a network of private clinics around the country and works with acute hospitals to provide specialist infusion services in the community. 

Both Quinn Health and Hibernian Aviva cover a range of community-based IV treatments for the sole purpose of reducing the expense and hassle to their customers who can now avoid unnecessary trips to hospital. 

The patient is referred for community infusion therapy by their hospital consultant. Patients remain under the care of their hospital consultant at all times and will receive their infusion treatments in the comfort of a primary care clinic, specialist nursing facility or their own home.

“Doctors in Ireland are using community infusion services more often these days as they see the many benefits for their patients and that it’s something that their patients want. 

“Whether we are administering infusions in a community clinic, teaching a client in the home how to administer their antibiotics via IV access or teaching someone how to administer their own medication for their rheumatoid arthritis we are making a significant difference to the patient. We are helping the walking get better – people who don’t need to sit around in a hospital waiting for an infusion, taking up nursing time, using hospital services. 

“There are so many infusions that can be given in a home or clinic setting in the community, I believe this will be biggest growth area for infusion therapy in the future,” says Ms Carter.