Are you qualified for pediatric referrals?

They are not little adults’

Infusion therapy is infusion therapy no matter who the patient is, right?

Wrong. Add pediatric patients to the mix and you’re dealing with a unique situation. Although at first glance it may seem that little differentiates home infusion therapy provided to an adult from therapy provided to a young child, those who specialize in pediatric services says there’s a world of difference.

Mark McConnell, MD, CEO and medical director of Newport Beach, CA-based pediatric home care provider Building Blocks, understands pediatric-specific infusion therapy both as a professional and a parent.

"My company was started because my own son needed home care services to receive 30 days of antibiotic infusion," says McConnell. The ensuing experience pointed to the need for pediatric-specific home health providers.

"A pediatric nurse initially came out and did all the teaching and education, but after that an adult [non-pediatric experienced] nurse came out," says McConnell. "My son initially had to have an IV started every two to three days until he got a longer line in him, and they were unable to start IVs in him. They were trying to poke my son, and eventually I had to take over and start the IV myself because the nurse that came out was not competent to do that."

McConnell adds that the home care company also sent out adult IV supplies: catheters that were 18 gauge rather than 22 or 24 gauge, as well as an adult-size wrist splint rather than a splint for a 15-month old infant.

"That’s how my company got started," says McConnell. "I believe that if he had specialized pediatric care in the hospital, he should have specialized pediatric care in the home, too."

McConnell cites numerous instances in which pediatric-specific care has saved money — and, more importantly, saved patients’ lives.

One pediatric patient, who was under a capitated contract with another payer, was forced to receive care from an adult home care company for enteral feedings at night. However, for the first seven nights in a row, the tube came out and the nursing company was forced to send out a nurse to replace the tube. Eventually, the pediatrician asked the payer to allow Building Blocks — which did not have a contract with the payer — to send one of its nurses out.

"We sent one nurse out who was a pediatric nurse, and knew how to fasten the tube to the patient’s nose and behind the patient’s ear so the patient couldn’t pull it out," says McConnell. "The patient received the rest of the month of enteral nutrition without another home nursing visit."

In another situation, Building Blocks was subcontracted to provide care for an infant just released from a neonatal intensive care unit to receive antibiotics in the home. Building Blocks would provide the care and another nursing company would provide the supplies.

"On the first visit, our nurse looked at the supplies and the pharmacy had mixed the drugs in 150cc of fluid," says McConnell. "This infant weighed 3kg, maybe even less, and 150cc of fluid is enough to drown an infant that weighs 3kg."

The nurse called the pharmacy and refused to infuse the infant. The pharmacist would not budge on his position that the mixture was safe and called his medical director, who agreed that the infant was not at risk.

"So as the medical director of our home care company, I got involved and told him, You could kill this child if you give the child this much fluid,’" says McConnell. "He called one of their neonatologists in the group, who agreed with me. Only then was it changed so the child received the appropriate dose of antibiotics mixed in the right volume of fluids."

While there is no gold standard designating a nurse as qualified to care for a pediatric patient in the home, pediatric home care companies have their own requirements before hiring a nurse.

Catherine Prophet, RN, BSN, PHN, vice president of clinical operations for Building Blocks, says hiring people with pediatric experience is especially important for nurses working in the home.

"In the hospital setting, there may be other nurses they can touch base with and have them look at a patient, but we don’t have that same ability in the home health arena," she says. "We have support by phone, but you can’t send multiple nurses out to the home to see the patients."

Just as important as the ability to provide infusion therapy is the ability to assess children properly.

"We like our nurses to have at least a year of acute-care pediatric experience or neonatal ICU experience, or at least two years of pediatric neonatal home care experience," says Prophet. "The ideal nurse has both, and as a result, understands what it is like to be in the home care arena as well as having the latest clinical knowledge."

She adds that seeing a nurse with Pediatric Advance Life Support or Neonatal Advance Life Support certification through the nurse’s previous hospital is a big plus.

Why the emphasis on pediatric experience?

"In my opinion you need pediatric nurses for pediatric cases," says Judy Gay, RNC, CCRN, CRNI, pediatric service coordinator for CareSouth of Macon, GA. "They are not little adults, and they cannot be treated as such."

"Our home care company sees a lot of severely ill children, so we want to make sure our nurses have been around sick kids and they know what to look for," says McConnell. "If you send an adult nurse out, does she know the normal respiratory rate for a six-month old may be 30, vs. 20 for an adult being normal?"

When it comes to providing home infusion for pediatric patients, Gay adds that the CRNI certification is helpful, but that the pediatric and neonatal critical care certification is very important as well.

"I am both neonatal pediatric critical care- certified and CRNI-certified. The pediatric critical care certification is most important to me because it is totally pediatric-focused," she says.

While the CRNI exam does include questions on pediatric patients, they account for only 7.5% of the exam. And even if the exam was all-encompassing regarding pediatric care, such classroom knowledge cannot replace experience. That’s why pediatric home care providers look for neonatal and pediatric experience rather than certain credentials.

Building Blocks puts such a high emphasis on hiring competent, pediatric-specific staff, it has created its own exam to evaluate potential hires during its lengthy interview process.

"Before they even interview, they have to complete two examinations," says Prophet. "One is a medication examination for both oral and IV medications in terms of administration for pediatrics, and there is also a comprehensive pediatric exam. They have to pass those with 80% or better or they don’t even go to the interview process."

Once the candidate passes the exams and enters the interview process, Prophet looks for several key pieces of information relating to dealing with family dynamics and psychosocial skills, as well as education principles.

"It’s very important for us to provide proper education for the family in that first visit while the nurse is present, so we can get them comfortable in the home and show them what issues to look for," she says. Therefore, her company requires that nurses be able to educate family caregivers.

Regardless of a candidate’s experience, a thorough orientation process finalizes the hiring process. This validates the individual’s competency and ensures that the new hire is familiar with all of Building Blocks’ policies, procedures, and equipment, and has the skills necessary to take care of patients.