Intravenous (IV) therapy in patients' homes is a relatively new procedure in community nursing. Most services have only started offering it in the last 10 years, although it was first piloted back in 1974 (O'Hanlon et al, 2008).
Among the many benefits of administering IV therapy in the home, it is well known that fewer resources are needed to nurse a patient in their own home. The BBC (2017) reports that the average daily cost of an NHS bed is £400. In 2 years, Guys and Thomas' Home IV service saved 5000 hospital bed days, and saved the Trust about £1.5 million (Dean, 2014). A Cochrane study also found that IV therapy at home is just as safe as IV therapy in hospital (Balaguer and González de Dios, 2012), although it also found that there was not a lot of research in this area. Very few nursing articles have been published about home IV therapy, and the majority of them are about setting up a service (Lees and Sonkor, 2006; O'Hanlon et al, 2008; Regan and Morgan, 2015).
Administering IV therapy in a patient's home is very different to administering it in a hospital ward. In a hospital, there are colleagues and equipment readily at hand, especially if something of concern happens; in the home, it is just the nurse and the patient, and the nurse needs to be able to rely upon their clinical skills and judgement, as well as the equipment they have with them. However, this should not be seen as a barrier to performing home IV therapy, which can be beneficial to both patients and the healthcare service: patients can remain in the comfort of their homes and avoid the isolation and cross-infection risks in hospital. They can manage their own days and not be away from their friends and family. Additionally, home IV therapy is an economic alternative to in-patient care.
This article looks at the practical side of administering IV therapy in a patient's home. It is based primarily on the author's many years of experience of administering home IV therapy, as well as teaching and assisting colleagues to perform home IV therapy.
Hand hygiene
Nurses should always observe hand hygiene before performing any aseptic technique (NICE, 2014), and home IV therapy must always be an aseptic technique. Hands should be washed with soap and warm water to remove any contamination from them. Unfortunately, the sinks in most patients' homes are not of the same standard as hand hygiene sinks in clinical areas, liquid soap may not always be available, and the related facilities may be unsuitable. Sanitising hand rub should only be used on visibly clean hands (WHO, 2009), but where hand hygiene facilities are poor, it can be used to supplement washing hands with soap and water.
Hands should always be washed using the six-stage hand washing technique to ensure that all areas of hands are covered (WHO, 2009). This will ensure that hands are visibly clean. If they are not, they should be rewashed, after which sanitising hand rub can be used to remove any transient microorganisms from the hands (Hillier, 2015) and provide the extra level of hand hygiene that the facilities available may not allow. IV devices give direct access to a patient's bloodstream (Scales, 2011), through which microorganisms may enter and cause bacteraemia. Therefore, this level of hand hygiene is essential and cannot be emphasised enough.
Nurses also need to consider what their hands could have been contaminated with prior to visiting a patient needing IV therapy. They should try not to visit a patient for IV administration immediately after seeing a patient who carries a high risk for cross-contamination (Infusion Nurses Society (INS), 2011), for example, those with heavily weeping leg ulcers, those who required manual bowel evacuation and those with an active infection such as flu or diarrhoea. Since the nursing care for such patients carries a high risk of contaminating the nurse, they should ideally be seen after the patient requiring IV therapy, to reduce the risk of cross-contamination.
Care of the IV site
Local policy will dictate which IV access device is used, and it is important to follow local policies when performing home IV therapy. Whether it is a cannula, a long line or central venous access device (CVAD), it is always important to ensure that the patient's IV access is patent and is being safely looked after.
As in the case of the device, local policy often dictates the type of dressing to be used. If the policy is not explicit, nurses should use a dressing that has been specifically manufactured for use with that device (i.e. a cannula dressing should be used with a cannula device and a peripherally inserted central catheter (PICC) line dressing should be used with a PICC line device). The IV device should always be covered, and the dressing must be clear to allow inspection of the insertion site; it should maintain a sterile environment around the IV device and help stabilise the IV device and prevent it moving, both of which will help reduce the risk of infection. Additionally, it should be easily removable so as not to dislodge the IV device at dressing change and be comfortable for the patient because they will have to have the dressing in place for some time (Gabriel, 2010). Using just any dressing may not provide a sterile environment, stability, ease of removal and comfort. Further, nurses should ensure that they have an adequate supply of the required dressing in the patient's home, as it is when the supply runs out that they may use an inappropriate dressing. The epic2 guidelines (Pratt et al, 2007) recommend that the dressing on a long line or CVAD be changed every 7 days if it is intact and as soon as possible if it is not intact. Many of the dressings available for long lines or CVADs have space on them to write the date they were applied, which greatly helps with their timely changing if filled in correctly.
The IV access site must be carefully examined, whatever type it is, before administering any IV medication (INS, 2011). If there are problems with the IV access site, then it may not be possible to administer the IV medication. If there are signs of phlebitis (see Table 1), the site should not be used and advice should be sought before proceeding. If a cannula is to be inserted, then re-siting may be necessary. If a long line or CVAD are to be inserted, then the patient may need to return to the hospital/clinic that is managing their care. In case of any uncertainty, further advice must be sought (Box 1).
| 0 | No signs of phlebitis | |
| 1 | Possible first sign of phlebitis, observe cannula | |
| Symptoms: |
Slight pain at IV
|
|
| 2 | Early stage of phlebitis, re-site cannula | |
| Symptoms: |
Pain
|
|
| 3 | Medium stage of phlebitis, re-site cannula and consider treatment | |
| Symptoms: |
Pain along the path of the cannula
|
|
| 4 | Advanced stage of phlebitis or start of thrombophlebitis, re-site cannula and consider treatment | |
| Symptoms: |
Pain along the path of the cannula
|
|
| 5 | Advanced stage of thrombophlebitis, re-site cannula and start treatment (may require hospital treatment for this) | |
| Symptoms: |
Pain along the path of the cannula
|
|
Many local policies require that cannulas be routinely changed, usually after 72 hours. Some local policies require that the patient be cannulated before administration of IV medication, and that the cannula then be removed after the medication is administered. Even though there is debate on how long a cannula can be left in place, Webster et al (2010) found no difference between routine cannula changing and changing when clinically indicated. Nonetheless, cannulas should always be changed when the visual infusion phlebitis score is 2 or above (Table 1). When cannulating a patient, the skin should always be cleaned with an antiseptic preparation to reduce the chances of contamination from skin flora, and the epic2 guidelines recommend that 2% chlorhexidine in 70% isopropyl alcohol be used (Pratt et al, 2007).
Maintaining a safe environment
When administering IV therapy at home, nurses are often unable to control the environment in which it is performed as they would had they been in a hospital or clinic environment. Nonetheless, there are steps that they can take to ensure that the environment is as appropriate as possible.
IV medication must be prepared on a hard, flat, wipeable surface that can be easily cleaned (Rowley, 2015). Treatment trays are ideal for this, but if these are unavailable, a hard-plastic tray, which patients often have in their homes, should be used. These trays can also be used to transport prepared medicines to the patient and to dispose of used equipment. They should be used for IV administration only and cleaned before each use with an appropriate surface wipe (Rowley, 2015).
Local policies for IV administration must always be followed. Some trusts require that IV administration be performed as an aseptic procedure using sterile fields and sterile gloves, while others require for it to be performed as a non-touch technique. Nonetheless, clean gloves should always be worn when preparing any IV medications (Pratt et al, 2007; Scales, 2011). Clean gloves prevent accidental contamination of IV medications and also prevent the medications from contaminating the nurse's hands.
IV medications must be prepared according to the instructions. Many IV medications, especially several commonly used IV antibiotics, can damage the veins, so they may need to be diluted before administration. The manufacturer's instructions must always be followed for the solution to be used for dilution, as the wrong diluent could affect medication patency (INS, 2011).
Before administration, the giving port of the IV access device must be cleaned a suitable alcohol wipe (Scales, 2011). If a long line is being used, then the cleaned port should not be allowed to come in contact with the patient's skin, to prevent it from becoming contaminated.
The line must be flushed with normal saline before any IV medication is administered (Hamilton, 2006), per local policy. This ensures that the line is patent. Pre-filled, 10 ml syringes of normal saline may be used for this purpose. Although their use may be viewed as laziness, they are in fact one way to prevent contamination in a high-risk stage of the procedure. Pre-filled syringes reduce the need to decant normal saline from an ampule to a syringe and consequently, the chances of contamination.
Patient safety should be foremost when administering IV medication. If the medication has to be delivered as an infusion and an IV pump is available, nurses should use it if they have been trained for it (INS, 2011). A pump regulates the flow of the infusion, ensuring that the infusion is delivered at an even rate, and it can help with any positional problems with the IV access device. If no pump is available, then the infusion should be monitored closely to ensure that it does not run too quickly or too slowly.
Once the administration is completed, the IV access device should again be flushed with normal saline (Hamilton, 2006). This is to ensure that no medication is left in the IV access device's line, that the patient receives all the required medication and that the medication does not cause any patency issues with the IV access device (INS, 2011).
All used equipment should be disposed of as appropriate. Sharps should be disposed in a sharps bin as soon after use as possible (Pratt et al, 2007). Equipment provided with the medication, such as IV lines and bottles/containers, should also be placed in a yellow-lidded sharps bin (Department of Health (DH), 2013). IV medication-contaminated waste should never go into domestic waste (DH, 2013).
Anaphylaxis
Anaphylaxis is rare, and according to Resuscitation Council (UK), only 1 in 1333 of the English population have had an anaphylactic reaction, with an associated mortality rate of 1% (2012). Nonetheless, the possibility of analphylaxis when administering IV treatment at home cannot be ignored. The mortality rate is low because of prompt diagnosis and treatment, and deaths caused by an anaphylactic reaction to IV medication mostly occur within 5 minutes of administration (Resuscitation Council (UK), 2012). Further, the incidence of anaphylaxis is on the rise—a 700% increase was observed in the years between 1990 and 2004—and 12.67% of anaphylactic reactions in the UK were found to be caused by oral and IV antibiotics (Resuscitation Council (UK), 2012).
The council has identified five symptoms/factors to identify an anaphylactic reaction, which they have designated ‘ABCDE’:
These symptoms have a sudden onset and rapid progression, and treatment must be started as soon as they are identified. Nurses must stop the IV therapy and administer adrenaline as per the local trust's policy.
Adrenaline is the most important drug in the treatment of anaphylaxis (Resuscitation Council (UK), 2012). It should be administered via the intramuscular (IM) route, not the IV route, unless the practitioner has had specific training, because of the higher risk of harmful side-effects in the case of the latter.
The Resuscitation Council (UK) (2012) recommends the following adrenaline doses:
In case of an analphylactic reaction, nurses should administer the appropriate dose of adrenaline and then call 999, as this is a medical emergency. The Resuscitation Council (UK) (2012) recommends repeating the dose of adrenaline if there is no improvement in the patient's symptoms after 5 minutes.
Evaluation
Once the medication has been administered and all used equipment has been safely disposed of, the patient's needs should be evaluated and their next episode of care prepared for.
Patient notes, whether patient held or digital, should always be filled out as per the Nursing and Midwifery Council (NMC) guidelines (NMC, 2015). All the batch numbers and expiry dates of the IV medications used (including saline flushes) must be recorded, as this will act as a reference if the patient has a reaction to or complications from the IV therapy.
A housekeeping check should be performed to ensure that adequate medication and equipment are available for the next 2 or 3 days of care. This time period should be extended if a weekend or bank holiday is upcoming. This will ensure that there are no interruptions to the care.
Ladenheim (2018) states that nurses play a unique role in antimicrobial stewardship, whereby antibiotic usage is monitored carefully to ensure their future effectiveness. During evaluation, antimicrobial stewardship should also be taken into consideration. Nurses should determine whether the patient's IV therapy is being monitored by a clinic, home IV service and/or the antibiotic prescriber. As with all antibiotic treatment, home IV therapy should be seen as a treatment with an end date. Ladenheim (2018) recommends that the patient's progress, resolution or changes in symptoms and persistence of symptoms be reported back to the prescriber. Nurses should discuss the antibiotics with the prescriber and be actively involved in antimicrobial stewardship. Questions like ‘is the patient on the right anti-biotics for them’ and ‘are the antibiotics still required’ as well as discussing the patient's progress are an important part of this (Ladenheim, 2018).
Training and professional competence
Before administering IV therapy in a patient's home, nurses must be appropriately trained and have their competencies signed off (per local policy). If cannulas are used as IV access, the nurse also needs to be competent in cannulation. O'Hanlon et al (2008) recommend that nurses receive training dedicated for home IV therapy because it is such a different environment. Generic IV training usually focuses on hospital IV administration.
The NMC (2018) requires that nurses be appropriately trained before practicing a new task and that they work within their own competencies. The author's own trust requires that a nurse observes three home IV therapies and then performs three home IV therapies safely under supervision before practicing it themselves. In the past, the author has taken advantage of this ‘sign-off’ period to train colleagues in the difference between home IV therapy and it being carried out in hospital, thereby tailoring training to the needs of delivering home IV therapy.
The Resuscitation Council (UK) (2012) recommends at all clinical staff who administer parenteral medications receive anaphylaxis training. This is particularly important in the case of home IV therapy because nurses are away from a clinical environment and do not have access to support.
Conclusion
Home IV therapy can be very helpful for patients, and there is no evidence that it poses any greater risk to them than therapy received in a clinical environment does.
With the appropriate training, competencies and time allocated, community nurses should not hesitate to taken on administration of home IV therapy. Time should always be taken with the preparation, administration and evaluation of home IV therapy, and infection control principles should always be at the heart of the procedure. Home IV therapy can also give a community nurse time to get to know the patient and their concerns, possibly enabling them to better meet their patient's needs.