Keywords: IV therapy/Service/ Community This article has been double-blind peer reviewed

Nursing Practice Innovation IV therapy

Community IV therapy can benefit both patients and the NHS and the number of services is increasing. These require clear policies and staff training and support

IV therapy in the community

In this article...
The benefits of providing IV therapy in the community Considerations for setting up a community IV therapy service Types of IV therapy appropriate for delivery in the community Training and support needed by community nurses Patient choice; Government policies; Growth of private home IV companies.

Author Jill Kayley is an independent nurse consultant, community IV therapy UK wide. Abstract Kayley J (2011) IV therapy in the community. Nursing Times; 107: 19/20, 15-18. Community IV therapy services can be of significant benefit to both patients and the NHS. They can prevent hospital admissions and facilitate early discharge, improve patient safety by reducing the risk of infection and improve choice by enabling patients to stay in their homes. However, the availability, standard and uniformity of these services varies throughout the UK. This article describes the benefits of delivering IV therapy in the community and provides guidance for nurses on setting up aservice.

ntravenous (IV) therapy is routine practice in UK hospitals, and the need for IV therapy is often a reason for hospital admission. However, community IV therapy services have seen significant developments over the past decade, and now deliver a wider and more complex range of treatments. Factors that have influenced this change include: Expansion in the range of skills among community nurses; Improvements in technology; Drugs with pharmacokinetic profiling that allows once and twice daily dosing; Constant pressure on acute hospital beds;

Despite these developments, not all provider services have established community IV therapy services, and the availability, standard and uniformity of services varies throughout the UK. The previous government focused on reducing acute admissions and length of hospital stay, providing care closer to patients homes and greater patient choice (Department of Health, 2009; 2006; 2002). The latest white paper, Equity and Excellence: Liberating the NHS aims to put patients at the heart of everything the NHS does. It seeks to liberate clinicians to innovate, giving them the freedom to focus on improving healthcare services (DH, 2010). Community IV therapy lends itself well to these aims, and there is considerable demand for further work and development in this area. The time is right for community services to build on existing work and press ahead with this innovative area.

immediate (OHanlon et al, 2008). It also requires a GP with a special interest who is willing to prescribe the therapy, cannulate and then monitor the patient (OHanlon et al, 2008). Facilitating early discharge requires a multidisciplinary approach, and good communication between hospital and community staff is essential (Kayley, 2008). Early discharge helps to relieve pressure on hospital beds, and good communication allows more time to plan the IV therapy treatment and length of medical and nursing input in the community. For senior community nurses looking to develop an IV service, facilitating early discharge provides a more controlled and manageable starting point than seeking to prevent hospital admissions. Recent developments in community IV therapy services include walk-in IV clinics. Because patients are treated in one place, these clinics reduce travel time and costs for community nurses (OHanlon et al, 2008). As well as being time and cost effective, this type of service gives patients more independence as they are not waiting at home for the community nurse to visit.

Administration of IV therapy

Background

The aim of a community IV therapy service is to prevent hospital admissions and/or facilitate early discharge. Preventing admissions requires a more intensive infrastructure in terms of nursing and medical input because the need for vascular access and IV therapy is

A number of health professionals can be involved in the administration of IV therapy (Table 1). In many areas it is carried out by community nurses. Patients and carers can be involved in the care of the vascular access device (VAD) and IV therapy administration. For patients or carers who have been properly assessed and trained, this is safe and feasible (Matthews et al, 2007). According to Tice et al (2004), the majority of patients or carers who self-administer IV therapy are highly motivated, understand the importance of the treatment and have a sense of autonomy.

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Providing IV therapy in the community can increase patient choice and reduce infection risks Community IV therapy can prevent hospital admissions and promote early discharge Early discharge is a good starting point for new services Excellent multidisciplinary communication and collaboration are essential Community nurses undertaking IV therapy need both education and access to skilled professional support

5 key points

Table 1. Practitioners who can administer intravenous therapy

Advantages Works in the community Able to monitor patients Works seven days a week Flexible hours (am and pm) in many areas Rapid response/ Flexible hours intermediate care May be able to prevent hospital admission or team facilitate early discharge Intensive input Able to monitor patients Private home IV Flexible service company Experienced nurses Able to monitor patients 24-hour back-up support Practice nurse Limited number of nurses involved (one or two) Able to monitor patients Enables patient independence Lead nurse/specialist Experienced nurses community IV nurse Able to monitor patients GP May be prepared to cannulate (if needed) Would increase their knowledge and experience of community IV therapy Community nurse Source: Kayley (2008) Disadvantages Requires training and support Several nurses may be involved in administration Requires training and support Several nurses may be involved in administration Period of input may be time limited Cost Fragmented care for patients as they could have care from several different agencies Requires training and support Restricted to surgery opening hours Not feasible for long distances, large numbers of patients or frequent dosing Requires training and support for all GPs in the practice Limited knowledge about vascular access devices and community IV therapies Not enough time or resources

2 3

4 5

Suitable therapies A range of IV therapies can be administered in the community, including: Antimicrobials; Ambulatory chemotherapy; Bisphosphonates; Iron sucrose; Immunoglobulins; Parenteral nutrition (PN); Blood products; Rehydration fluid. The main area of growth in recent years has been delivering short-term and longterm IV antimicrobial therapy for acute and chronic infections (Seaton et al, 2005; Cooper et al, 2003; Deagle, 2001; Nathwani and Morrison, 2001; Kayley, 2000). Although a number of antimicrobial drugs can be given once daily, some microbiologists are reluctant to prescribe them because of concerns about causing drug resistance, and prescribe therapy to be administered three or four times a day (OHanlon et al, 2008). Most community nursing teams are unable to visit three or four times a day, so service provision could be outsourced

to a private home IV company that can visit several times a day. Anecdotal evidence suggests this is already happening, but it results in fragmented care for patients and a loss of skills for community nurses. When establishing a community IV therapy service, it is crucial to involve the microbiologist at an early stage to ensure a common understanding of what IV antimicrobial treatments can be effectively managed in the community and by whom. Vascular access devices Patients receiving community IV therapy need a reliable VAD, which can be placed peripherally or centrally. Types of VADs include: Peripheral cannula; Midline catheter; Peripherally inserted central catheter (PICC); Tunnelled cuffed central catheter; Implanted port. Patients can have courses of IV treatment in the short term (days), medium term (weeks) or long term (months or years). Different VADs have advantages and disadvantages, but the choice of device must meet the individual patients clinical needs, give reliable and sustainable access for the course of IV therapy and be acceptable to the patient (Dougherty, 2006; Kayley and Finlay, 2003).

Role of the lead nurse

It is well documented that a multidisciplinary team approach and a lead nurse with experience in IV therapy are pivotal to the success of any IV service (Depledge and Gracie, 2006; Tice et al, 2004; Cooper et al, 2003; Nathwani and Conlon, 1998; Kayley et al, 1996). Community IV services in the UK are quite diverse, as are the roles of the lead nurse. The lead nurse is essential to the day-today running and overall management of the service and, most importantly, in acting as a bridge between acute and community settings (Kayley, 2008). Since many areas of the UK do not have lead nurses for community IV therapy services, community nurses are taking on this role. This can be time consuming, putting additional pressure on other work commitments. Community IV therapy services run more smoothly and effectively when there is a designated lead nurse, particularly as they become experienced in the role (Depledge and Gracie, 2006).

Training and education

Delivering IV therapy in the community requires appropriately trained health professionals. To provide the necessary level of care and support, nurses need access to community focused theoretical and skillsbased IV training.

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Nursing Practice Innovation

box 1. key recommendations
When setting up and developing a community intravenous therapy service: Identify local need and demand Develop links with the acute sector andGPs Establish a multidisciplinary team Discuss and establish drug regimens with microbiologists Decide and be clear about which IV therapies and venous access devices are manageable Set out policies, procedures and guidelines Provide training and education for community nurses

to an experienced practitioner who can provide practical support and guidance.

Policies and procedures

box 2. Benefits of a community IV therapy service

Enables early discharge and frees up acute hospital beds Prevents hospital admissions Patients recover more quickly in their own home environment and can return to home life, work and school more quickly Reduced risk to patients of developing nosocomial infections Encourages patient choice

To provide effective IV therapy services in the community it is necessary to have documented policies, procedures and guidelines. These must be clear, robust, evidence-based, up to date and functional. It is not uncommon for community nurses to take referrals from several units within one hospital, or from a number of hospitals, which may all have their own procedures and guidelines. This array of information can be confusing for community nurses, who need to be able to provide standardised care for all patients based on national guidance (RCN, 2010; NPSA, 2007; Pratt et al, 2007; DH, 2005; 2003; NICE, 2003). Because community nurses often work in isolation in their patients homes, policies, procedures and guidelines have to be consistent, clear and unambiguous (OHanlon et al, 2008).

Conclusion

The Royal College of Nursing Standards for Infusion Therapy provides clear guidance on what should be covered in theoretical and skills-based training (RCN, 2010). The Nursing and Midwifery Council code states: You must take part in appropriate learning and practice activities that maintain and develop your competence and performance (NMC, 2008). Employers are also responsible for supporting and providing staff with training and education (RCN, 2010). Community nurses can come across a range of IV therapies and VADs, which will require specific knowledge and practical skills. The variable provision of community IV therapy services means some community nurses may encounter IV therapy rather infrequently, which can make it difficult for them to maintain their practical skills and have the confidence to use them. To develop and maintain the skills of nurses already working in the community, service providers and educational establishments need to invest in good-quality, community-focused IV training programmes. Community nurses should also have access

Based on the growth of community IV therapy services in the last few years, there is no doubt that this area of healthcare provision will continue to expand. However, to ensure it is managed safely and effectively, there needs to be appropriate training and support for health professionals in the community. It also requires a multidisciplinary team approach and good communication between acute and community settings. A considerable amount of work needs to be done on a national level in relation to the uniformity, standard and availability of IV therapy services. It is hoped that the governments recent white paper (DH, 2010) will provide the encouragement and the support for this to happen. NT
References Cooper C et al (2003) An outpatient/home parenteral antibiotic service. Primary Health Care; 13: 8, 20-22. Deagle J (2001) Administering antibiotic therapy at home. Nursing Times; 97: 38, 62-63. Department of Health (2010) Equity and Excellence: Liberating the NHS. London: DH. tinyurl.

com/excellence-NHS Department of Health (2009) Transforming Community Services: Enabling New Patterns of Provision. London: DH. tinyurl.com/transformcommunity Department of Health (2006) Our Health, Our Care, Our Say: a New Direction for Community Services. London: DH. tinyurl.com/our-care Department of Health (2005) Saving Lives. A Delivery Programme to Reduce Healthcare Associated Infection (HCAI) including MRSA. London: DH. tinyurl.com/reduce-HCAI Department of Health (2003) Winning Ways: Working together to Reduce HealthcareAssociated Infection in England. London: DH. tinyurl.com/reduce-HCAIs Department of Health (2002) Liberating the Talents: Helping Primary Care Trusts and Nurses to Deliver the NHS Plan. London: DH. tinyurl.com/ liberating-nurses Depledge J, Gracie F (2006) Developing a strategic approach for IV therapy in the community. British Journal of Community Nursing; 11: 11, 462-468 Dougherty L (2006) Central Venous Access Devices. Care and Management. Essential Clinical Skills for Nursing. Oxford: Blackwell Publishing Kayley J (2008) Intravenous therapy in the community. In: Dougherty L, Lamb J, (eds) Intravenous Therapy in Nursing Practice. Oxford: Blackwell Publishing. Kayley J (2000) Home IV antibiotic therapy. Primary Health Care; 10: 6, 25-30. Kayley J et al (1996) Safe intravenous antibiotic therapy at home: experience of a UK based programme. Journal of Antimicrobial Chemotherapy; 37: 5, 1023-1029. Kayley J, Finlay T (2003) Vascular access devices used for patients in the community. Community Practitioner; 76: 6, 228-231. Matthews PC et al (2007) Outpatient parenteral antimicrobial therapy (OPAT): is it safe for selected patients to self-administer at home? A retrospective analysis of a large cohort over 13 years. Journal of Antimicrobial Chemotherapy; 60: 356-362. Nathwani D, Conlon C (1998) Outpatient and home parenteral antibiotic therapy (OHPAT) in the UK: a consensus statement by a working party. Clinical Microbiology and Infection; 4: 537-551. Nathwani D, Morrison J (2001) Parenteral therapy in the outpatient or home setting: evidence, evaluation and future prospects. Journal of Infection; 42: 173-175. National Institute for Health and Clinical Excellence (2003) Infection Control: Prevention of HealthcareAssociated Infection in Primary and Community Care. London: NICE. www.nice.org.uk/cg2 National Patient Safety Agency (2007) Alert 20: Promoting Safer Use of Injectable Medicines. London: NPSA. tinyurl.com/safer-meds Nursing and Midwifery Council (2008) The Code Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC. tinyurl.com/ NMC-code OHanlon et al (2008) Delivering intravenous therapy in the community setting. Nursing Standard; 22: 31, 44-48. Pratt RJ et al (2007) epic 2: national evidencebased guidelines for preventing healthcareassociated infections in NHS hospitals in England. Journal of Hospital Infection; 655: S1-S64. Royal College of Nursing (2010) Standards for Infusion Therapy. London: RCN. tinyurl.com/ infusion-standards Seaton AR et al (2005) Management of cellulitis on the community: evaluation of a protocol incorporating a patient group direction for intravenous antibiotic therapy. Journal of Antimicrobial Chemotherapy; 55: 764-767. Tice A et al (2004) Practice guidelines for outpatient parenteral antimicrobial therapy. Journal of Infusion Nursing; 27: 5, 338-359.

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