Roles and Role Ambiguity in Patient- and Caregiver-Performed Outpatient Parenteral Antimicrobial Therapy

Community-based Intravenous Treatment and Central Venous Access Devices: A Scoping Review of the Consumer and Caregiver Experience, Information Preferences, and Supportive Care Needs

PURPOSE

Map existing research and describe the consumer/caregiver experience of community-based intravenous treatment, central venous access devices (CVADs), supportive care needs, and information preferences.

DESIGN

Scoping review.

METHODS

Five databases (Joanna Briggs Institute, Cochrane library, Emcare, Embase, and Medline) were searched. Screening and data extraction were performed independently by two reviewers.

FINDINGS

Forty-eight studies were included.

CONCLUSIONS

Although community-based intravenous treatment and CVADs have a significant impact on consumers and caregivers, there is scant research on their supportive care needs and information preferences.

CLINICAL EVIDENCE

Some consumers and caregivers may require additional support while undergoing community-based intravenous treatment.

Comparing peripherally inserted central catheter-related practices across hospitals with different insertion models: a multisite qualitative study

BACKGROUND

Peripherally inserted central catheters (PICCs) provide reliable intravenous access for delivery of parenteral therapy. Yet, little is known about PICC care practices or how they vary across hospitals. We compared PICC-related processes across hospitals with different insertion delivery models.

METHODS

We used a descriptive qualitative methodology and a naturalist philosophy, with site visits to conduct semistructured interviews completed between August 2018 and January 2019. Study sites included five Veterans Affairs Medical Centres, two with vascular access teams (VATs), two with PICC insertion primarily by interventional radiology (IR) and one without on-site PICC insertion capability. Interview participants were healthcare personnel (n=56), including physicians, bedside and vascular access nurses, and IR clinicians. Data collection focused on four PICC domains: use and decision-making process, insertion, in-hospital management and patient discharge education. We used rapid analysis and a summary matrix to compare practices across sites within each domain.

RESULTS

Our findings highlight the benefits of dedicated VATs across all PICC-related process domains, including implementation of criteria to guide PICC placement decisions, timely PICC insertion, more robust management practices and well-defined patient discharge education. We also found areas with potential for improvement, such as clinician awareness of PICC appropriateness criteria and alternative devices, deployment of VATs and patient discharge education.

CONCLUSION

Vascular access nurses play critical roles in all aspects of PICC-related care. There is variation in PICC decision-making, care and maintenance, and patient education across hospitals. Quality and safety improvement opportunities to reduce this variation are highlighted.

Engaging Patients and Caregivers in a Transdisciplinary Effort to Improve Outpatient Parenteral Antimicrobial Therapy

We worked with patients, caregivers, and healthcare workers to prioritize barriers and propose solutions to outpatient parenteral antimicrobial therapy (OPAT) care. Unclear communication channels, rushed instruction, safe bathing with an intravenous catheter, and lack of standardized instructions were highly ranked barriers. Outpatient parenteral antimicrobial therapy programs should focus on mitigating barriers to OPAT care.

Which Patients Discharged to Home-Based Outpatient Parenteral Antimicrobial Therapy Are at High Risk of Adverse Outcomes?

Background

Patients increasingly receive home-based outpatient parenteral antimicrobial therapy (OPAT). Understanding which patients might be at higher risk of complications is critical in effectively triaging resources upon and after hospital discharge.

Methods

A prospective cohort of patients discharged from 1 of 2 academic medical centers in Baltimore, Maryland, between March 2015 and December 2018 were consented and randomly divided into derivation and validation cohorts for development of a risk score for adverse OPAT outcomes. Data from the derivation cohort with the primary outcome of a serious adverse outcome (infection relapse, serious adverse drug event, serious catheter complication, readmission, or death) were analyzed to derive the risk score equation using logistic regression, which was then validated in the validation cohort for performance of predicting a serious adverse outcome.

Results

Of 664 patients in the total cohort, half (332) experienced a serious adverse outcome. The model predicting having a serious adverse outcome included type of catheter, time on OPAT, using a catheter for chemotherapy, using a catheter for home parenteral nutrition, being treated for septic arthritis, being on vancomycin, being treated for Enterococcus, being treated for a fungal infection, and being treated empirically. A score ≥2 on the serious adverse outcome score had a 94.0% and 90.9% sensitivity for having a serious adverse outcome in the derivation and validation cohorts, respectively.

Conclusions

A risk score can be implemented to detect who may be at high risk of serious adverse outcomes, but all patients on OPAT may require monitoring to prevent or detect adverse events.