Home intravenous therapy: Accessibility for Canadian children and youth

Question 1

What are indications for home IV therapy?

Answer 1

1. Infection requiring IV antibiotic therapy - esp. skin and soft tissue, bone and joint, occasionally pneumonia, menignitis, endocarditis, sepsis, CMV, fungal if stable
2. Parental nutrition
3. Administration of clotting factors for hemophilia
4. Chemotherapy
5. Therapy for immunodeficiencies
6. palliative care medications
7. anti-inflammatory mediators
8. Biologics

Question 2

What are complications of home IV therapy?

Answer 2

1. Mechanical during IV insertion
2. Thrombosis
3. Dislodgement
4. Occlusion
5. Leakage
6. Infections (rare)
7. Adverse reactions to therapy incld. metabolic and hepatic complications with long term PN

Question 3

What infrastructure is required for home IV therapy?

Answer 3

1. Home IV therapy team
2. Facilities for insertion of VADs
3. Availability of infusion pumps and other devices

Question 4

Who should be a part of the home IV therapy?

Answer 4

1. Physician incld. one knowledgeable about ID available 24h/d
2. Patient’s PCP and referring MD
3. An infusion nurse specialist who is knowledgeable about home IV therapy and care of children
4. Representation from the community home care service, if applicable
5. Collaboration with surgeons, interventional radiologists, vascular access nurses or other personnel skilled in the insertion of VADs in children
6. A pharmacist who is knowledgeable about home IV therapy
7. Access to other specialists, as appropriate, for the underlying condition
8. A social worker if indicated
9. A case manager if this role is not performed by the home IV therapy team physician or infusion nurse

Question 5

What are clinical factors to consider in the selection of patients for home IV therapy?

Answer 5

1. Is IV therapy necessary?
2. Does the child require hospitalization at this time for any other purpose?
3. Is the condition stable and the risk of sudden or life-threatening event rare (unless palliative)?
4. Is the IV medication used an acceptable standard of treatment and of comparable efficacy to alternative therapy that would have to be given in hospital?
5. Is the child at higher risk of central catheter-related complications (eg, vascular thrombosis and bleeding) because of underlying coagulopathy or other disease?

Question 6

What are patient and family factors to consider in the selection of patients for home IV therapy?

Answer 6

1. Are the patient and primary caregiver willing to participate in home IV treatment?
2. Do the caregiver, and the patient if old enough, fully understand the importance of compliance with therapy?
3. Do the caregiver, and the patient if old enough, fully understand the potential adjustments to routine schedules and the limitations on sports and other activities that may be required until the therapy has been completed?
4. Is the caregiver able to understand the benefits and risks of home treatment, to anticipate and solve problems related to the medication, infusion or access device, and to know when to call for help?
5. Is the caregiver able to learn and perform the necessary skills reliably?
6. Are there physical factors or cognitive or psychological factors that could impede care?
7. Does the family understand the economic implications of the therapy?
8. Does at least one caregiver have the time and flexibility of schedule required to provide the therapy?
9. For prolonged PN therapy, is skilled home help available to permit parents some respite time?
10. If problems occur, is rapid communication with the home IV therapy team possible?
11. Does the home have adequate conditions for provision of IV therapy?
12. Is the home environment safe for provision of IV therapy?

Question 7

Determining the appropriate vascular access device based on duration of therapy?

Answer 7

1. PIV 1-2 weeks
2. Midline cathether 2-4 weeks
3. PIC catheter weeks to months
4. Tunnelled central catheters e.g. Broviac or Hickman months to years
5. Implanted port month to years

Question 8

What should pediatricians and other PCP ensure?

Answer 8

1. Be aware of indications for and contraindications to home IV therapy.
2. Be aware of programs available to their patients and how to access them.
3. Advocate for the development of home IV therapy programs for children and youth, including appropriately trained personnel and equipment, where these are not currently available.
4. Advocate for adequate funding, by provincial health care programs or alternative sources, of all aspects of home IV programs and appropriate reimbursement mechanisms to ensure that children and youth are not denied home IV therapy because their families cannot afford the cost.
5. Advocate for skilled home help to provide respite for parents providing home PN and other therapies that require IV infusion 24 h/day for prolonged periods.

Question 9

What are other recommendations regarding home IV therapy?

Answer 9

1, Children and youth should have access to appropriate home IV therapy in situations where it is indicated, given the following:

2. Home IV therapy for children and youth with infections, those needing long-term PN, and for selected other conditions is at least as effective and as safe as IV therapy in hospital.
3. Home IV therapy for children is cost effective.
4. Home IV therapy for children provides improved quality of life and greater satisfaction to patients and families.
5. Those responsible for providing home IV therapy to children and youth should have expertise in the treatment of children and youth, should receive appropriate training and should be knowledgeable about relevant paediatric issues.
6. Appropriate training should be provided to patients and their families.
7. Home IV programs should have written protocols for assessment and selection of patients, VAD insertion and care, patient education and monitoring, outcome assessment and documentation.
8. Specialists responsible for home IV programs should liaise with paediatricians and other physicians providing primary care to children and youth, and should promote the involvement of these primary caregivers in the follow-up of their patients.