April 18, 2012

IV hydration – a cure all?

As nurses and healthcare providers, we have seen the dramatic effects of infusing IV fluids to patients who are dehydrated, needing fluid replacement/supplement or those with symptoms resulting in electrolyte imbalance, and other cases when taking oral intake of foods/fluids is not enough, and the list goes on….

Now that list includes…HANGOVER! The movie? Well, just like in the movie…it’s that dreaded feeling of  headache, nausea, and vomiting the morning after a long night of drinking too much alcoholic beverages. There is a mobile clinic is Las Vegas (no surprise there) that will provide treatment to  ”hangover ” patients  by hydrating them with IV fluids and along with (as indicated) doses of anti-nausea and anti-inflammatory medications. This clinic is operated by a physician who is a board certified anesthesiologist. Click here for more info.

As an infusion nurse, I get it and the concept of infusing IV fluids, with nutrients, vitamins to patients with a hangover makes total sense and to be honest, it’s not a new nor a far fetched concept at all. We’ve all seen and know what IV fluid hydration can do but no one has really thought out of the “box” and marketed this as a treatment for hangover. On the other hand, I can also see where this service might be perceived as ‘encouraging” people to drink excessively or morally offensive by others.  It is a business and the founder of the clinic doesn’t hide that at all. And one important thing to note, this is a cash/credit card business – no insurance billing.

So here’s my two cents…. I will admit, there were times  I wished this service existed to get me through my ‘partying” years – those IV fluids would have helped. Now that I am older, boring and an infusion nurse, my advice to those considering this, make sure to tell the truth about your medical history. Yes, you are in Vegas but omitting important medical information might cause more problems. Make sure the technique and procedure used during venipuncture and fluid administration is in compliance with the standards of practice for infusion nursing and/or federal/regulatory standards . While it is just a simple IV stick, it is still a opening in your skin and into your veins and blood stream.  Make sure they have experienced licensed professionals who perform the infusions. And when in Vegas, think “moderation” and don’t let that ‘common sense” out the window so you won’t end up needing these services.

One last note – which is really a disclaimer –  I am in no way involved or endorsing this company or it’s services. I got a chuckle when I saw this news article as I was searching for things to do while I am in Vegas for the INS convention in a few weeks. I thought I’d blog about this because it does make sense and it’s an “out of the box” thinking when it comes to using IV hydration.

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April 17, 2012

Cheaper at the Doctor’s Office

I came across this interesting article on a study that shows chemo costs less in doctor’s offices.

Chemotherapy Treatment in Hospitals Costs 24% more than Treatment in Physician’s Offices

The study found that care for patients treated in a physician’s office is less expensive regardless of the length of the chemotherapy duration. The average chemotherapy treatment lasted 3.8 months for patients treated in a physician’s office versus 3.4 months for patients treated in a hospital outpatient setting. For chemotherapy therapy lasting only one month, patients treated in a hospital outpatient setting cost 28 percent more than patients managed in a physician’s office. For patients receiving a full 12 months of chemotherapy, hospital outpatient care costs 53 percent more than in the physician office-based setting. These results are adjusted for the effect of age, sex, and prior history of cancer, but do not reflect other patient acuity factors that could influence total costs of care.

Our study documents that chemotherapy treatment in an oncologist’s office costs less than in a hospital regardless of the length of treatment,” said Eric Hammelman, Avalere vice president and a study author. “At a time when the healthcare community is focused on managing costs, these findings show the importance of where care is delivered, and raise important questions about how best to manage cancer treatment.”

Click here for more info.

This is good news for the private payers and for the physician’s offices offering chemotherapy treatments. For the patients, there are certainly advantages to having treatments done at their physician’s offices. Most patients like the ‘cozy” environment with familiar faces and in certain places, free parking or infusion services conveniently and easily accessible is a plus. A lot of physician’s offices offering infusion services like chemotherapy or biologic infusions have designated an area in their offices for this purpose. Many have installed flat screen TV’s, free wi-fi , provide comfortable reclining chairs and delicious snacks. The infusion/chemotherapy services are provided by experienced and credentialed chemo/infusion registered nurses and the office is equipped with hoods for proper preparation of chemotherapy agents.

Aside from chemotherapy, infusion services at physician’s offices is growing because of the newer biologic agents indicated for autoimmune disorders like rheumatoid arthritis, psoriatic arthritis, gout, ulcerative colitis, Crohn’s disease, multiple sclerosis, to name a few.  The study above focused on chemotherapy, but perhaps the same might be true for these non-chemo infusions, who knows.

I was glad to know that the cost to private insurance payers is less in doctor’s offices than the hospitals. This might encourage more patients to use the services at their physician’s offices. The question now is do the doctor’s offices make a profit? I would think they do in order to continue to provide this service to their patients. I don’t think they do this just because the patients prefer to come to their offices for infusions…. :-)

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April 5, 2012

Wouldn’t it be nice….

..if we see veins like we had X-ray vision and insert IV catheters with one stick in patients with difficult to find veins?? Well, now there are several devices that can make the “venipuncture” experience much more tolerable, improves patient satisfaction and eliminates sticking patient’s veins blindly. They are called “vein-detecting” devices that use different types of technology and design that allow you to find and locate veins for IV start or blood draw.

But before you get too excited about getting one, think about the following:

  1. Technology: Not all vein detecting devices are created equal. It is best to know and understand the technology the device uses and how it works.
    • Devices that use laser and/or infrared technology
    • Devices that Illuminates tissue using LED lights
    • Devices that use Doppler effect

2. Ask questions like:

    • Will it work on all skin types and pigmentation?
    • Do I need to turn the room lights off to use the device?
    • Is it safe and does it produce heat that the patient might feel on their skin?
    • Is it hands free so the nurse can perform the procedure while visualizing the vein?
    • Battery operated and what is the battery life?
    • Ease of cleaning/disinfection in between patient use.

3. Device Portability: what good would a vein locating device be if it’s mounted on the wall or takes up so much space in the patient’s room? In my opinion, the device will have to go where I go to start an IV and not the other way around where I have to take the patient where the device is.

3.  User friendly:  Keep it SIMPLE so nurses will use it and make sure to involve the end users when evaluating these devices prior to purchase.

4.  Cost:  technology is not cheap so the cost of these devices might be more than the cost of a tourniquet and vein palpation. Though the benefits and improved patient satisfaction could be enough justification.

So when the good old fashion finger tip manual vein palpation fails, these devices are great especially for starting IVs in patients with difficult to find veins,  pediatrics and older adults, and for other purposes that require locating veins.

Note: It is by design that I did not mention any brand names of these devices. If you are interested in any of these – google “vein detecting devices” and you will find them.

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March 25, 2012

A second look at Midline catheters

Midline catheters have been around since the 1950′s and with the increasing popularity of other venous access like PICCs, many have forgotten about this viable option for venous access. So let’s take a second look…

  • A midline catheter is approximately 3-8 inches long and is inserted in the antecubital area and advanced into the peripheral veins of the upper arm.
  • Yes, midlines are not central venous catheters because the tip of this catheter is at or below the axillary vein and not in the superior vena cava. For this reason, midlines are considered peripheral devices.
  • Consider a midline catheter for therapies anticipated to last 1-4 weeks
  • What can be given via a midline catheter? Hydration, IV solutions, pain medications, select antibiotics.
  • What should not be given via a midline catheter? Continuous vesicant therapy, parenteral solutions/infusates with pH <5 or >9,  and infusates with an osmolality >600mOsm/L
  • Midline catheters are reported to have lower infection rates compared to PICCs.
  • Most common complication reported is phlebitis (mechanical/chemical).
  • Midlines are suitable for both adults and pediatric patients.Ideal for the older adult with limited venous access.
  • Special considerations should be given to patient with risk of thrombosis, comprised circulation, lymphedema, or those requiring vein preservation (patients with end stage renal disease)
  • Midlines are inserted by trained nurses, using strict aseptic technique and maximal barrier precautions. and ideally with ultrasound technology.
  • Midlines do not require x-ray for tip confirmation unless indicated for complications experienced during insertion.
  • There are several brands of midline catheters available in the US with varying configurations and materials.

It is best to assess your patients in order to determine the appropriateness of midline catheters. The midline catheter has its limitations. It is a peripheral device but it has an advantage over a short peripheral catheters because the larger diameter of the vessels in the upper arm allow for better flow rate.  It is not a substitute for a PICC or other central venous access devices because the tip is not in the SVC.

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March 19, 2012

Today is….National Certified Nurses Day

March 19 every year is a day to recognize board certified nurses in many nursing specialties.  Certification is a profession’s official recognition of achievement, expertise, and clinical judgment. It is a mark of excellence that requires continued learning and skill development to maintain.

In infusion nursing,  many are confused with the terms “certification”  and“certificate”.  These two terms are not the same and shouldn’t be used interchangeably. Read about the difference in a previous blog called“Yes, I am IV certified”. Still many use the terms interchangeably creating continuous confusion. Perhaps, we should begin to use the term” Board certified” when referring to our specialty nursing certification awarded by certification corporations of nursing boards or nursing organizations.

For all the certified nurses, we salute you!! Celebrate your success and enjoy the day.

For more information about “Certified Nurses Day” click here!

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March 8, 2012

Outsource or In House?

I’m sure no one will be surprised to hear that many services in acute care and outpatient settings are outsourced to individuals or organizations who specialized in certain tasks or services. One of these outsourced services include vascular access device insertion, in particular PICC insertions.

There are several independent companies and/or  individuals who provide PICC insertion service, many of them are my nursing colleagues. PICC insertion services/companies are usually nursing based organizations and are (or employ) nurses with  excellent technical knowledge and skills in PICC insertion. They use state of the art ultrasound equipment and catheter technology giving them a high success rates of insertion and positive patient satisfaction. . They are experts in what they do and no doubt can easily give a hospital and other healthcare organization a “turn key” PICC service.

On the other hand, there are numerous in house PICC teams, comprised of nurses who are employed by the hospitals/healthcare organizations. They are nurses who are experts in infusion therapy and vascular access and have the same excellent technical knowledge and skills in PICC insertion.  You will find that large hospital systems have dedicated PICC teams with the same ultrasound equipment and insertion success rates as the external PICC service. Small to medium hospitals also have PICC experts but their responsibilities may include other nursing or patient care related activities. In some areas, these PICC teams or nurses are under nursing services while others are part of radiology services. One of the biggest challenges in establishing an in house PICC team is finding qualified PICC  nurses and the financial ability to purchase expensive equipment such as ultrasound machine. Hospitals are not the only ones who utilize outsourced services, many home health agencies, home infusion companies, nursing homes and long term care facilities do as well. They have successfully outsourced their PICC insertion service which affords them the ability to accept patients with infusion therapy needs to their service.

The question I often get from managers  and CNOs is..which is more cost-effective – outsourcing or in house? A very tough question to answer and of course, it’s always about the bottom line. Expertise and experience comes with a high price and outsourced services are not cheap. On the flip side, employing highly skilled nurses and purchasing expensive equipment may not be cost effective  either. Many external PICC insertion  services claim they have saved  hospitals large sums of money using their service. (no public data available)  The cost (and or savings) will have to be analyzed and determine what’s best for your organization and your patients. Patients are happy when they get an expert who can insert then IVs in one stick!

So to the managers and CNOs – do your homework and understand what your short and long term goals are for your PICC service. Using a readily available service is very tempting because it is so easy. Sometimes it is cost effective to use a PICC service, sometimes it is not depending on your organization. Identify who has the best quality, good outcomes, and prompt service. Establish an honest working relationship with the PICC service  especially if outsourcing is only temporary and  your goal is to build you own PICC team. PICC insertion service is a business and no one wants to lose income.  If you have a PICC team, establish performance measures that will help you justify the team and monitor your contribution to patient care and oh, of course….the bottom line.

NOTE: While I insert and train nurses on PICC insertion, I am not in the PICC insertion business nor am I encouraging or discouraging the use of their services.

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February 29, 2012

Leap Year Day….

February 29, 2012…I just can’t let this day go without posting here. After all, this is the first leap year day since I’ve started this blog.

So will this be a post about what leap year is or the “leaplings” whose birthdays come only every 4 years or if a woman should propose marriage to a man…well…you can always Google these.

This date on the calendar will always remind me of  a patient of mine who was dying from brain metastasis from colon cancer. Throughout her life, my patient was gifted with the ultimate organization skills. She planned, prepared and practiced in her head everything she did, whether it was for work, family events, outings with her friends and even her cancer treatments. Everyone loved her as she would do everything for them and friends lovingly called her “Martha Stewart” on steroids!

Her battle with colon cancer lasted a year to date when she got the horrible diagnosis. In that year, as she would normally do, she planned, prepared and practiced everything she wanted to do before she “left”. And that included the date she will depart. That year happened to be a leap year. She had left strict instructions with her husband and doctors that if ever she slipped into a coma that life support be terminated on leap day….yes, that day …not sooner or later. And so February 29 came…and she left.

I will always remember her, her remarkable life and battle with cancer and most especially when this extra day comes every four years.

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