Inotropic drug infusion provides one last dance

Procedure keeps patients out of hospital longer

The 78-year-old woman’s goal was to dance at her daughter’s wedding, but she suffered from end-stage heart failure and had been in and out of the hospital for months. By working with her physician, the home health agency was able to provide continuous inotropic drug infusion that kept her out of the hospital long enough to dance at the wedding.

Ann K. Frantz, BSN, RN, an independent health consultant and cardiac educator, sees the need for home care agencies that provide inotropic infusion growing.

"While there is still controversy among the medical community, the truth is that there is a population of patients for whom this provides time to resolve issues prior to death and to enjoy being at home with friends and family," she says.

Inotropic drug infusion is covered in the home by Medicare with noninvasive hemodynamic monitoring that measures parameters such as contractility, cardiac output, and fluid status, Frantz says.

"Our agency is high-tech, so we purchased our own mobile monitor, but patients can also be monitored in the physician office," she adds.

Inotropic drug infusion is not the first-choice treatment now because there have been many advances and there are better oral treatments than there were in previous years. But there is a need for the service, says Lisa A. Gorski, RN, MS, CS, CRNI, clinical nurse specialist for Covenant Home Health in Milwaukee.

"There is a small group of patients for whom other treatments don’t work and for whom transplants are not possible," she explains. "We began offering inotropic infusion in the home in 1988, and while we haven’t seen huge increases in the number of patients we treat, we have seen a steady volume."

Gorski adds that there is research that supports use of inotropic drug infusions as a way to reduce hospitalizations and keep patients at home.1

Risk of sudden death

The use of dobutamine and milrinone to stimulate an injured or weakened heart to pump harder and relieve the symptoms of heart failure does carry a risk of sudden death, Gorski says.

To minimize these risks, it’s important to assess patients thoroughly, chose patients carefully, and ensure that the nurse overseeing the patient’s care is appropriately trained, she adds.

The most important aspect of evaluating a patient for this treatment is to make sure there is a caregiver who is readily available to the patient, Frantz says.

For patients who cannot change IV bags or manage the pump on their own, a caregiver should be in the home, but that is not always required, she adds.

"I’ve had two patients who had their next-door neighbors act as caregivers, and I had one patient whose daughter was a RN who stopped by his house every day to check everything for him," Frantz says.

"If the patients’ goal is independence, you need to respect that goal and let them be as independent as they can safely be," she explains.

Consult best-practice recommendations

Frantz is a member of the Washington, DC-based Home Healthcare Nurses Association committee that has developed best-practice recommendations for inotropic drug infusion.

"We’ve written the recommendations, and they are currently under review," she says. "We took a look at everything that would contribute to the best possible outcome for these patients."

The proposed recommendations include:

• Presence of a central-line or peripherally inserted catheter

"Peripheral lines for infusion cause necrosis of soft tissue and aren’t appropriate for patients who will receive drug infusions over time," Frantz explains.

• Presence of a caregiver

"The caregiver is important because we teach our patients self-management techniques that may require assistance from a caregiver," Gorski says.

• First dose in hospital setting

"It’s important to make sure the first dose is given in the hospital because if the patient is going to have an adverse reaction to the medication, it will be with the first dose," Frantz points out.

• Careful physical assessment

"The nurse must listen to the patient’s lungs, check the IV site for infection, and assess any cardiac arrhythmias," Frantz says. This full assessment must be performed at every visit, she adds.

• Use of cardiac-trained nurse

"The best outcomes are found when the nurse has five or more years in a cardiac care unit," Frantz says. "

You must have a nurse [who] is proficient in cardiac assessment, understanding heart tones, listening to lungs, and understanding the effect of the drugs used for these patients," she adds.

If you are considering the addition of inotropic drug infusion to your services and you don’t have an expert on staff, consult with a specialist in this area to make sure you hire the right nurses, establish the best guidelines, and ensure good outcomes, Frantz suggests.

"You also need to make sure the patient understands that the treatment is palliative not curative," Gorski says. "The physician must make sure the patient understands all options, if any are appropriate, before allowing the patient to choose this treatment."

The patient also needs to understand that while the medications have the capability of improving his or her quality of life, they also can cause sudden death, Gorski says.

End-stage heart patients who are receiving ino-tropic infusions make up 5% to 10% of patients for the Fort Worth, TX-based Cardiovascular Home Care, says Bridgette Campbell, RNC, BSN, executive director of the agency.

Need for inotropic infusions could increase

The need for this service is likely to increase as the population ages, as heart failure patients stay alive longer, and as more people want to avoid hospitalizations, she says. "It is one way that you can help patients make the most of their lives."

[For more information about inotropic drug infusion in home health, contact:

  • Bridgette Campbell, RNC, BSN, Executive Director, Cardiovascular Home Care, 2501 Parkview Drive, Suite 303, Fort Worth, TX 76102.
  • Ann K. Frantz, BSN, RN, Independent Health Care Consultant & Cardiac Educator, 465 W. Northfield, Pontiac, MI 48340. Telephone: (248) 745-4882. E-mail: afrantz922@prodigy.com.
  • Lisa A. Gorski, RN, MS, CS, CRNI, Clinical Nurse Specialist, Covenant Home Health and Hospice, 10335 W. Oklahoma Ave., Milwaukee, WI 53227-4107. E-mail: ml_gorski@msn.com.]

Reference

1. Boger JE, DeLuca SL, Watkins DF, Vershave KK, et al. Infusion therapy with milrinone in the home care setting for patients who have advanced heart failure. J Intrav Nurs 1997; 20(30):148-154.