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Home care issues and challenges
I would like input from all nurses working in home care about the issues and challenges you face in caring for all types of vascular access devices, the best practice interventions that you find to work for preventing any and all catheter complications specific to patients in home care. Thanks for your feedback, Lynn
Gwen Irwin
I don't work for home care,

I don't work for home care, but definitely notice some issues that should not be issues in our area.  We are really trying to educate home care, but it is an overwhelming effort.  With our very limited staff, we can't tackle this one effectively.

The issues that are the most often occuring are:

1.  Not declotting with tPA (quotes it is a dangerous drug.  Send the patient to ER)

2.  Cannot discontinue a PICC (quotes we don't have nurses "certified" to remove a PICC).

3.  Cannot troubleshoot problems, so send the patient to ER.

 Gwen Irwin

Austin, Texas


Mari Cordes, BS RN  Nurse
Mari Cordes, BS RN 
Nurse Educator IV Therapy
Fletcher Allen Health Care
We have a major quality initiative now in the implementation phase which was triggered by home infusion issues, particularly pedi.  We have a list of problems that we associated different factors to in the FMEA process, and from there applied to pedi and adults in in and outpatient settings.  Email me off line, and I can send you an outline of our process, including the issues that started the QA process.

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Angela Lee
I see the same issues as
I see the same issues as Gwen.  Many of the reports come from the patients (or in my case, the patient's parents).  In addition, I see inappropriate dressing materials,  PICCs actually pushed in or pulled out either on purpose or with dressing change and clear problems not been recognized or being discounted when parents identify them.  Most of the issues I see are regarding PICC care only.
Ann Williams RN CRNI
I find the responses

I find the responses interesting, and a stark contrast from our nurses.  The problem WE run into is the hospital staff does not yet see a withdrawal occlusion as a problem, even to the point of telling patients, "that medicine is expensive and your medicine goes in just fine."  The Home Care nurses then get to the home to do an admission and are having to call for Cathflo! 

Everything done in the home must have time taken into consideration as it is not a case that you can run down a floor between patients while allowing cathflo to dwell, etc.  Also, you must be diligent on supply delivery as a mistake could again be very time involved if you need to make a trip for a forgotten item.

Other home considerations include timing of doses.  There is not a nurse to administer a dose at 4am, so we have to get patients off those night hours of BID doses that they were getting in the hospital. 

Appropriate line placement isn't the problem it once was, as most have PICCs now.  We do not like PIVs in the home, they never last, and they NEVER go bad during the day time!

Insurance issues arise in the the hospital the care goes the home, you have to get approval for extra visits, new drugs, etc.  things you don't think about in the hospital.

Meticulous teaching is a must and you need well trained nursing staff to pull this off.  As well as proper line care etc.  I am very fortunate to have a great team of nurses.  No fears of using Cathflo at home and they do meticulous care.  Our infection rates on central lines is almost non-existent.

In the home you also have to be aware of drug stability.  Some drugs might only be good for 24 or 48 hours once compounded.  In the hospital, that isn't an issue as they can be delivered as needed.  You have to get creative with supplies and drug delivery.  And to catch patients at home to take the delivery!

I am sure as I think I will come up with more to add.  But for now, this will do.  Please don't judge home care by the statements previously made.  I know those nurses do exist out there, but ours in Deaconess Home Services are top notch!! 

Ann Williams RN CRNI

Infusion Specialist, Deaconess Home Services

Evansville, IN

Angela Lee
I certainly agree about the
I certainly agree about the wide range in skill levels and the changes in home health.  We work primarily with two companies very comfortable with peds.  The problems come in when the patient is not local and these companies then contract with a nurse in that area for dressing changes, etc.  Depending upon reimbursement the local nurse may be with the public health department.  In many of these outlying areas (and not all of them rural) there is a definite lack of experience and comfort level working with pediatrics and their PICCs.  What I find disturbing is that instructions for care are provided and sometimes not followed because it is so different than what they usually do.  I think many times pediatric patients especially toddlers tend to "un-nerve" the nurse who has no problem with adults.  And that may be a completely different issue.
[quote=lynncrni]I would like

[quote=lynncrni]I would like input from all nurses working in home care about the issues and challenges you face in caring for all types of vascular access devices, the best practice interventions that you find to work for preventing any and all catheter complications specific to patients in home care. Thanks for your feedback, Lynn [/quote]

I have been a CRNI for 0ver 10 years and I work for the Homecare at a University Medical Center who employs many self appointed IV experts without certification or credentials who come up with outlandish techniques, non-evidence based, that they expect us to uphold in the home setting. However, those of us in the home setting are aware that rather than follow their techniques, it is more important to investigate the real cause leading to infection. For example, we have a two-year-old patient on TPN, Enteral feeds, and hydration who is constantly being readmitted for CR-BSIs. The TPN nurses are teaching to pull the CVAD over her shoulder and secure it down her back (so that the catheter hub is at the level of the top of the diaper) and then to cover the cap with an alcohol wipe and tape it over the cap and hub connection. As soon as the alcohol wipe drys this becomes a wick for the diaper overflow into the CVAD. We instead have requested the Fostermom loop the excess catheter on the upper chest with the cap pointing toward the patient’s head and secure it. While teaching the Fostermom to do this we observed the child, without washing her hands, flushing her own GT and then CVAD. She had been taught to do so at a previous Fosterhome. These are some of the challenges we face in homecare.


Additionally in homecare, we see too many people discharged with caregivers who are willing but not able, not willing, or are unable to safely provide care but are forced to simply because they have no other choice or resource. We also see caregivers who have little or no education who we are expecting to successfully do multiple therapies for their loved one. Patients in the hospital are sicker and Patients being sent home are sicker as well.


The best practice we encounter is starting teaching early (in the hospital), observing and correcting patients when they forget to wash their hands or work surface, and/or clean the end cap prior to using the line. Also, we find giving written instructions to follow when we can’t physically be there to give a therapy and calling the patient regularly to answer their questions prevents mistakes and poor practice. We find that as soon as a parent or patient becomes complacent about the line, infection occurs. We also emphasize to our home patients that they are no longer in a controlled setting so they must control the setting to reduce infections. We have a print out on how to do this that we review with them and then give them a copy. This is often difficult in our low-income service area where some families actually live in a relative’s garage. We emphasize to the Patient and caregiver to be their own advocates, if based upon the teaching they have received they see care being done incorrectly stop the person doing the care and question it after all it is their health in jeopardy. Unfortunately, when we follow up with these patients by phone we often hear their stories about how they are afraid to leave the bedside of their loved one because the nurse at home or at the hospital didn’t use anything to clean the end cap prior to accessing the CVAD. We emphasize to them that even one time of this poor technique can cause a CR-BSI and encourage them to advocate for the standard of practice.

Patti Atteberry
[quote=lynncrni]I would like

[quote=lynncrni]I would like input from all nurses working in home care about the issues and challenges you face in caring for all types of vascular access devices, the best practice interventions that you find to work for preventing any and all catheter complications specific to patients in home care. Thanks for your feedback, Lynn [/quote]

I am a CRNI nurse educator for a home infusion and home care services.  I educate pharmacist on Infusion care as well as all of the nurses in 6 markets.  I present a 2 day orientation to the nurses that includes, types of lines, complications, anatomy, pumps, line care and troubleshooting.  I also instruct on high risk medications and infusion there of.  I find as stated earlier one of the problems is, the nurse in the home has other issues and tends to rank infusion patients in the same acuity and education needed as all other patients.  We recently revised our high risk medications to include all infusion and injectable medications, in hope to keep this on a high level.  All of our nurses are expected to function on the same level (peds, adults, wounds, infusions, etc)  As we all know this is not always recommended.  I personally would like to see our agency have infusion nurses.  I am currently working on this. 

One other main issue I come across frequently is the physician and their staff not knowing the standards.  Many do not recommend checking for a blood return and become irritated when we tell them it is a standard and our protocol. 

I do believe with consist protocols and education and allowing for the nurses to have resources is the key.  The more printed educational material for the patient is also a plus.  As for the hospitals and physicians, we need to keep them informed and let them know what we are capable of.

Patti Atteberry, RN, CRNI
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