Home infusion from A to Z

Creating interventions for use on laptops

Wouldn’t it be nice if everything your staff did for each patient was immediately recorded in that patient’s medical record, from providing the therapy to teaching the caregiver how to discard used IV tubing?

Pamela Johnson, MSN, MBA, CNS, an infusion nurse for SharpHealthcare/Sharp Grossmont Hospital Homecare and Hospice in San Diego, thought so. To that end, she and her colleague, Sally Parenti, RN, CRNI, created all-encompassing home infusion practice guidelines.

Entered into staff laptop computers, the guidelines prompt a nurse through the entire home infusion visit and record each step in the patient’s chart.

Johnson says she believes the lengthy process of defining each step of every nursing intervention, only recently implemented at Sharp, will reap big benefits in the long run. Nurses will not only be reminded of the essential components of a visit; they also will have the nursing visit record completed when they walk out the door.

Eliminating writing from the visit

Realizing that you want a software package that has every step of a home infusion process is one thing; finding such a program is quite another. As Johnson and her staff evaluated programs, they knew exactly what they were looking for.

"We wanted every intervention in the computer so all the nurse had to do was click on it, and they would not have to do any writing," says Johnson. "We wanted the nurse to be able to walk into the home, turn on the computer, and have care steps and a care map."

With nothing available on the market that fit its specific needs, Sharp Home Care was left to develop its own program.

"Creating the guidelines was time-consuming because we input interventions that not only addressed each parenteral therapy, but that delineated the care required for each vascular access device and each delivery method," says Johnson.

She notes that she and her staff used a number of resources in preparing the guidelines, such as:

• IV therapy textbooks;

• Intravenous Nurses Society and Oncology Nurses Society standards;

• policies and procedures from national infusion companies;

• articles written by experts in the field of infectious disease, infection control, oncology, hematology, and others.

The process, while time-consuming, wasn’t necessarily complex.

"One approach that helped us get started was to picture oneself actually doing a home visit for a patient on a particular therapy," notes Johnson. "Once we were able to detail one or two various therapies, a format emerged that was useful as we described other therapies."

Laptops provide specific guidance

For example, all visits entailed teaching the patient or caregiver what to watch for and when to call for help, as well as infection control guidelines. Once finished, these guidelines could be used for every diagnosis.

Although the product is not complete and will be revised pending input from the nurses, Johnson says the text is user-friendly.

"For each patient, the nurse simply selects a pump, a therapy, a vascular access device, and a diagnosis," says Johnson.

From there, the computer prompts the nurse through the visit. As the nurse clicks on each completed task, the task is entered into that day’s visit record. Johnson says it was necessary to have the laptops provide such specific guidance and to record visit events in the patient file.

Many home care nurses are not familiar with the wide variety of home infusion devices now available. Sharp’s program helps such nurses go through every step required during a thorough home infusion visit.

"Home care is just recently coming into home infusion technology, so many home care nurses may not know the specific differences between an ambulatory and a stationary pump, and even some of the therapies like IVIG are new to home infusion," says Johnson.

Complete documentation is another huge benefit of the program.

"It comes down to good charting," says Johnson. "We wanted there to be ticklers for the nurse, who would be able to put down everything that was done without having to write or type text. This provides a lot more information than having to write or type in a patient’s file, and it also gives a nurse guidelines to make sure they don’t miss things."

Implementation and training have taken time

Obviously, such an endeavor isn’t completed overnight. In fact, Sharps is looking at its move to laptops as a three-year project. In the first year, about a third of the nurses were trained to use laptops in the home.

"We put some basic information in the laptops and then put the nurses from one of our two offices on the system," says Johnson. "That took about a year."

In the second year, it became clear that more specific guidelines were needed, so Johnson and her staff set about developing specific interventions for home infusion, as well as nearly 100 additional guidelines for general home care visits.

With the process now entering its third year, Johnson says the remainder of the staff will receive training on the computers. But the process still won’t be complete once that training has been accomplished.

"When the nurses first started, it took longer for visits," says Johnson. "They like the system better now, but it is a very long, slow learning curve. Because some nurses don’t even type, for some nurses we had to start with typing tutorials."

Johnson notes that each employee is allotted 60 hours of training time, and the training curve is steep even after that.

"We know it’s a big step and cost, but it is the direction to go," she says. "We don’t want paper around, everyone else is going to computers, it’s a lot easier manipulating data, and nurses will only be entering data one time, whereas before, nurses were entering names and start dates on every set of paper they worked with."

Training made the move much easier for Cheryl Cass, RN, a home health nurse for SharpHealthcare.

"They gave us a full week in class to learn it before we went out and used it during any home care visits," she says. "During training, they covered everything, from admissions, care plans, visit notes, and orders, to how to hook up and download information. I had two good trainers and a week in class, which made a big difference."

Another benefit of the training, according to Cass, was that the instructors were also nurses who knew how to apply the software to actual home care visits.

"I’m at the same number of visits, and I don’t think it took me even a month to get to where I was before the switch," says Cass. "I think it’s great. It allows you to access patients’ charts in the home so you don’t have to go looking for them, so your access to information is great."