Healthcare services are increasingly moving from hospital to outpatient and community settings.
Chris McKernan, MSc, BSc, BA, RGN, was formerly senior staff nurse, intermediate care team, and sister, out-of-hours service, Sefton PCT, and is now retired.
McKernan, C. (2008) Exploring the literature on delivering home IV therapy. This is an extended version of the article published in Nursing Times; 104: 34, 28-29.
BACKGROUND: Healthcare services are increasingly moving from hospital to outpatient and community settings.
AIM: To help policymakers formulate guidelines on treatment strategies for patients with infective conditions that can be treated with IV antibiotic therapy at home.
METHOD: Several databases were searched for published and unpublished studies in English on home IV therapy from 1995 onwards.
RESULTS AND DISCUSSION: The US has an already well-established non-hospital based service for home IV antibiotic therapy. Patients, relatives and carers are satisfied with the option of having a traditionally hospital-based treatment carried out at home. The review found no evidence that the initial two doses of therapy must be administered in a hospital environment, as was once standard practice.
CONCLUSION: Patients are satisfied with home treatment, it improves their quality of life and choice. Advanced nurse practitioners’ skills could be enhanced by introducing this service.
Over 90% of patient contacts in the NHS currently take place in primary care (Gorski, 2005). The UK’s population is ageing and healthcare delivery has shifted significantly from acute to primary care settings. This has resulted in an environment in which the roles of those providing care are changing rapidly (Department of Health, 2006a).
Hospital inpatient services are often at full capacity due to reduced availability of acute beds, and demand on resources continues to rise in an attempt to meet requirements (DH, 2006b). As much as £400m could be saved each year and diverted to other health services (DH, 2006c). A prime target for this investment could be primary care, which has seen the introduction of advanced nursing roles involving diagnostic and assessment skills with the aim of preventing hospital admission (Nielsen, 2000). Kayley (2003) stated that traditional nurses’ roles have expanded and many treatments once conceived as inpatient ones can now be performed successfully in patients’ own homes.
The DH (2002) advocated the introduction of first-contact care practitioners able to diagnose, assess and treat patients. It placed an emphasis on nurses with advanced clinical skills that are transferable from hospital to community settings (Gorski, 2005). Some treatments have until very recently only been offered in hospital (Esmond, 2006). IV therapy is one such treatment suitable for what has become known as ‘hospital-at-home’ or ‘hospital home care’ (Kayley, 1996).
These schemes are not unique to the UK and have been introduced in response to several issues. First, the increased demand for fewer hospital beds has led to a shift towards community rather than hospital-based care (DH, 1989). Second, Montgomery (1993) observed that hospital admission can have a physical, social and psychological effect on patients, particularly older people. Third, the number of acute inpatient beds has reduced drastically in recent years (Gorski, 2005). This, combined with an increasing older population, has forced healthcare services to reconsider how best to use hospital beds for acute care due to limited funds and government waiting-time targets. Lane (2000) noted that government initiatives promote provision of healthcare in the community rather than in medical institutions. This researcher also highlighted a growing number of early discharge hospital-at-home initiatives, providing nursing care that would have previously been given in hospital.
Both UK and international qualitative studies demonstrate that IV therapy can be delivered safely and effectively in patients’ own homes (Smego, 2005; Esposito, 2000; Tice, 1995). Literature from Rwanda described a successful programme of families being supported and taught to care for relatives with Aids in their own homes with the administration of IV therapies (Schietinger, 1993). Italy has long been at the forefront of carrying out antibiotic therapy in community settings (Esposito, 2000). Home therapy services in Italy appear to be focused on instructing patients and their families in techniques of self-administration of prescribed drug treatment.
Several databases were searched for published and unpublished studies in English on home IV therapy from 1995 onwards. These were Medline, CINAHL, Policy Hub, the British Library, the RCN, the Cochrane Collaboration, the York Centre for Dissemination and Review and EMBASE. Keywords included the following: home therapy; intravenous therapy; primary care; admission prevention/avoidance; first-contact care; advanced practitioner. An additional search of bibliographies and reviews was made and contact was made to key authors for additional unpublished information where necessary.
Table 1. Key papers reviewed
|Author||Date||Title||Country of origin|
|Deagle||2001||Administering antibiotic therapy at home||US|
|Dubois and Santos-Eggimann||2001||Evaluation of patients’ satisfaction with hospital-at-home care||Switzerland|
|Esposito||2000||Outpatient therapy in Italy||Italy|
|Lawrence||2001||Outpatient parenteral antibiotic therapy||US|
|Smego||2005||A university- sponsored home health nursing programme||Pakistan|
|Tice||1995||Experience with a physician-directed, clinical-based programme for outpatient parenteral antibiotic therapy in the US||US|
|Trowbridge and Kralik||2006||Evidence for IV antibiotic therapy in the community||Australia|
|Wolter et al||2004||A randomised trial of home versus hospital IV antibiotic therapy in adults with infectious diseases||Australia|
|Schietinger||1993||Teaching Rwandan families to care for people with Aids at home||Rwanda|
Themes from the literature
Six main themes emerge from the literature on home antibiotic IV therapy. These are:
Safety of the procedure;
Preventing admission to hospital;
Skill mix – using the skills of advanced practitioners;
Patient satisfaction with home therapy;
Quality of life;
Prescribing habits for antibiotics in different countries.
Wolter et al (2004) conducted a randomised controlled trial (RCT) of home versus hospital IV antibiotic therapy in Australia. Their study included 129 patients who were referred for IV therapy. It is unclear how long the whole trial lasted but the authors drew several positive conclusions. The issue of safety was mentioned. There was evidence to indicate that antibiotic therapy given intravenously in the home carries no greater risk than when administered in hospital.
Further evidence of safety emerged from Australia when Trowbridge and Kralik (2006) reviewed the evidence for IV antibiotic therapy in the community. Their study was primarily concerned with safety in the administration of the first and second doses of antibiotics, yet several themes were common to other literature. The authors acknowledged that Australia is not as advanced in home therapies as the US but its health service is aiming to move healthcare into the community to relieve demand for hospital beds. This appears to be a commonly occurring theme internationally. Conclusions indicated there was no greater risk in administering the first and second doses of therapy in patients’ own homes and it was safe to do so. Previously, it was widely accepted in this country that first and second doses were administered in hospital due to the risk of adverse reaction and that a hospital was the safest place for this procedure (Nathwani and Morrison, 2001).
Further evidence on safety of IV drug administration at home is provided by an RCT from New Zealand; Corwin et al (2005) conducted a study of 200 patients with cellulitis, an infection of the deep dermis of the skin. The trial aimed to compare the safety, efficacy and acceptability of home treatment with hospital treatment where patients required IV antibiotics. They acknowledged that no clear guidelines exist for when cellulitis should be treated with IV antibiotics, other than in cases when oral antibiotics fail. The authors concluded that only about one-third of patients presenting at hospital for home treatment were considered suitable for this method but clear exclusion criteria were not discussed.
Smego (2005) also provided further evidence of safety in an article describing a university-sponsored home health nursing programme in a large urban centre in Pakistan. During the programme’s first 18 months, 316 patients were enrolled from a variety of hospital areas. This paper is different to those previously discussed due to methods of patient selection. The hospital in Karachi was the basis of the programme that assessed patients who had already been admitted for what may have been described as an ‘early discharge scheme’ (it is not described as such, however). The author described Pakistan as ‘resource limited’, yet it could be argued that the NHS also suffers from limited resources and so could perhaps be compared with this country. Smego (2005) said significant cost savings could potentially be made by delivering healthcare at home and, like previous studies, noted that home IV therapy is a safe procedure.
Kayley (1996), an English nurse specialist, published one of the earliest reviews of the subject in Britain. She has subsequently published several other articles on the subject and is still involved in community IV therapy services. Her then health authority developed an outpatient IV antibiotic therapy programme that evolved from the desire to provide high-quality IV therapy to patients with Aids. This programme wanted to capitalise on the strengths of the community nurse system and minimise the need for extra resources. As community nurses’ clinical skills are extended and enhanced, this type of treatment has become more widely used in the community setting in some regions.
Dubois and Santos-Eggimann (2001) conducted a qualitative study in Switzerland over two years to measure patient satisfaction with hospital-at-home care. This study recruited 174 patients for a pilot scheme at four sites in the Canton region. Only 107 patients were actually admitted onto the scheme during the two years, making it a relatively small-scale project. Only six people were transferred straight home from the hospital where they had been assessed to commence treatment immediately.
Semi-structured interviews were used to evaluate patient satisfaction with the service. Interviews were carried out mainly in patients’ homes by a neutral psychologist. However, the time-frame is questionable. Participants were given a self-administered questionnaire to complete six weeks after being admitted to the scheme and interviews took place another six weeks later. The freshness of the information in participants’ minds could be questioned. The authors said ‘few patients’ changed their minds between the questionnaire and the interview but exact figures are not quoted.
However, they noted that in palliative care cases, interviews were often impossible to carry through. As this patient group represented 14% of the total sample, this may affect the overall accuracy of the results. The authors stated nearly 80% of patients were satisfied with their home care. Older men appeared to have support from their wives at home, yet older women were frequently alone or had family who work and therefore they tended to feel more isolated and preferred to stay in hospital. The authors acknowledged that the lack of a control group made it difficult to discuss other important outcomes measured but did not specify which outcomes. Dubois and Santos-Eggimann (2001) indicated that much research has been carried out on hospital-at-home care and cited literature from Australia, Canada, the US and the UK.
Wolter et al’s (2004) RCT in Australia aimed to demonstrate that home care is a feasible alternative to hospitalisation over a broad range of infections, without compromise to quality of life or clinical outcome. Clear inclusion and exclusion criteria are detailed but there is no indication of the trial’s length. The study recruited 129 patients with infectious diseases but only 82 were actually randomised to the two treatment arms. Of these, the split was uneven between hospital and home care: 44 to home and 38 to hospital. There is no explanation for the uneven balance.
The main focus of the study was to determine an improvement in quality-of-life issues in relation to hospital or home care. It is interesting to note that 33 people withdrew from the trial. Some did so immediately on being randomised to the hospital group because an alternative option involving modified home care was made available. Wolter et al (2004) feel that RCTs will become increasingly difficult to perform as home-based care becomes more widely available. It is suggested that patients prefer to receive treatment at home. Results indicated that home administration of IV antibiotic therapy is safe and offered improvements in patients’ quality of life.
Balinsky and Mollin (1998) undertook a literature review on home drug infusion therapy, which concentrated on cost-effectiveness studies of parenteral antibiotic therapy administered in an outpatient setting. They noted, however, that home healthcare typically appeals to quality-of-life arguments, and that most people prefer to recuperate in their own beds. Nonetheless, comments from participants in other studies indicated that not all people prefer to be at home while unwell; personal family dynamics are an important consideration so it is not possible to generalise.
Some US models of care involve patients being able to attend an outpatient department, within a hospital or doctor’s surgery. This kind of model is not planned in the UK, as there are different financial constraints here compared with the US. Most healthcare is provided by insurance companies in the US, whereas the NHS funds healthcare in this country.
The feasibility of home care for IV therapy has increased partly due to increasingly sophisticated infusion pumps, administration kits, therapy protocols and venous access devices, as well as drugs that only need to be administered once or twice a day (Gavin, 2004). It is important to consider the initial cost of purchasing (and maintaining) portable infusion pumps, and to ensure their suitability for easy transportation by nursing staff. Nonetheless, there is substantial desire to transfer patient care from more costly institutional care to cheaper outpatient settings and home care (Gavin, 2004).
Esposito (2000) presented a paper to the British Society for Antimicrobial Chemotherapy describing the Italian model for treatment. This largely focuses on self-administration of prescribed drugs. Patients and/or their relatives are taught how to safely administer the drugs and for treatment to be solely received at home. Esposito (2000) noted that home therapy has become widely accepted because of improvements in quality of life, which have been widely documented in the US. He also stated that the clear economic benefits – the main driver behind the service’s development in the US – have paradoxically played only a secondary role in Italy. These are only now receiving due consideration.
Skilled nurses – advanced practitioners
The RCN (2005) described advanced nurse practitioners as qualified nurses with a sound base in primary care. It also stated that nurse practitioners have moved into most healthcare settings. The NMC published a document on standards for post-registration nursing. It described those nurses as ‘highly experienced and educated members of the care team who are able to diagnose and treat your healthcare needs or refer you to an appropriate specialist if needed’ (NMC, 2005).
Deagle (2001) discussed administering antibiotic therapy at home and the benefits to patients. She discussed the skills required by nurses to perform this service effectively and drew on work carried out in Southampton. Like other authors, Deagle noted that in the US, outpatient IV antibiotic therapy is well established with advanced nurse practitioners in lead roles. This author also noted that outpatient antibiotic therapy pathways are underdeveloped in Europe and provided information on audit from the international ‘OPAT’ (outpatient antibiotic therapy) registry. Her department visited four other hospitals and compared services for delivering IV therapy. Nurses with advanced skills (nurse practitioners), run the outpatient antibiotic therapy service. These nurses have degrees or master’s degrees in nursing studies; yet despite IV drug administration being available for 30 years, some employers still consider the skill to be an extended role (Lawrence, 2001).
Trowbridge and Kralik (2006) provided further evidence from Australia on the increasing complexity of community nursing procedures provided to patients at home, and how the nurse’s role is changing to meet needs. These researchers focused on first and second doses of medication, which have traditionally been administered in a hospital setting. They aimed to establish a process of safe and effective medication management in a community nurse setting for first and second doses of IV antibiotic therapy. Trowbridge and Kralik (2006) sought to discover the risks and safe practices when administering them. The extensive literature review concluded that administering these doses in a hospital environment appears to have little merit.
Wilson et al (1999) conducted what they claim was the first RCT directly to evaluate a hospital avoidance scheme. The eight-month trial randomised 199 consecutive patients to either hospital or hospital-at-home treatment. Six per cent of patients randomised to the hospital-at-home group refused to be admitted to it. However, of greater importance is the fact that 24% of those randomised to the hospital group refused as they preferred to be treated at home. This provides strong evidence that many patients prefer home to hospital treatment.
Kayley (2000) noted that although home IV antibiotic therapy is not a new concept, it is not routine practice and most infections requiring parenteral therapy are still treated in hospital. She detailed infective conditions that may require treatment for two weeks or longer and stated that the drive to perform these therapies outside the hospital setting is increasing patient choice.
Preventing hospital admission
Wilson et al’s (1999) RCT compared the effectiveness of hospital-at-home care with hospital care. They noted that such schemes provide treatment in patients’ homes that would otherwise require inpatient care. It is acknowledged that these schemes have been developed to prevent hospital admission and to enable early discharge, as well as reduce costs. Wilson et al (1999) concluded that hospital-at-home care resulted in significantly shorter lengths of stay in the scheme and did not lead to higher rates of subsequent readmission.
Nathwani and Morrison (2001) reviewed the evidence and evaluated future prospects for IV therapy at home. They acknowledged studies by Esposito (2000) and Wilson et al (1999) and noted that considerable savings in hospital costs can be made, as well as reducing the risk of contracting a healthcare-associated infection. Hospital-at-home schemes originated in the US primarily as a means of cost reduction but have subsequently evolved into the recognised pathway to treat patients who simply require IV antibiotic therapy.
The hospital environment can be a ‘dangerous place’, and it is not uncommon for patients to develop new problems as a result of admission (Balinsky and Mollin, 1998). These researchers believe the risk of acquiring serious secondary infection is probably lower when patients are at home than in hospital but disappointingly do not report actual statistical evidence for this statement.
Esposito (2000) considered that the variation in prescribing habits may result from difficulty in identifying standard criteria that would unequivocally indicate the necessity of oral or parenteral administration. However, the decision is influenced by three main factors: reduced gastric absorption; specific disease and related severity; and lack of appropriate oral antibiotics (Hallis, 1993).
Patient choice has been at the forefront of service provision for some time, as initiatives such as ‘Choose and Book’ have been introduced. It could be argued, however, that there is only limited choice regarding where some patients receive IV antibiotics due to lack of suitably trained nurses or some trusts’ financial constraints.
As there have been relatively few qualitative studies concerning home IV antibiotic therapy in the UK, it seems prudent to suggest further large-scale studies be undertaken. Developing countries appear to be making advances in using nurses with enhanced skills such as insertion and maintenance of peripheral lines – a skill only possessed by a small number of UK practitioners. While it may be difficult to transfer findings from studies undertaken in developing countries (Pakistan and Rwanda), if it can be done there under such geographical and economic limitations, it could be assumed the NHS can provide similar enhanced community services.
Additional research can identify how many hospital patients, on average, could be treated successfully by a community-based team. Data analysis therefore will indicate the skill mix required for the initiative.
I recommend an additional series of training packages for community nurse specialists that will enable them to insert and maintain peripheral cannula as well as PICC lines for antibiotic therapy. Frequently, manufacturers of the necessary equipment are willing to fund ongoing training and education for such occasions, which will ease the financial burden on creating a new or enhanced nursing service.
There can be little doubt that the introduction of IV antibiotic therapy in patients’ own homes by community nurses can be beneficial in numerous ways. Cost savings due to preventing hospital admission could be massive, or it could maintain an efficient early discharge scheme for suitable patients. This review has indicated that administering the initial doses of IV therapy in a non-hospital environment is safe. Patients are satisfied by home treatment, they have improved quality of life and benefit from being offered more choice.
In this current climate of stretched services, advanced nurse practitioners’ skills could perhaps be enhanced with the introduction of such a service.
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